DESCRIPTION	CPT / HCPCS 	Service Type	Lafayette General Medical Center Price	Inpatient or Outpatient	Uninsured Discount Price	BCBS Reimbursement	Aetna Reimbursement	Cigna Reimbursement	Humana Reimbursement	United Healthcare Reimbursement	Verity Reimbursment	PHCS Reimbursement	Deidentified Contract Minimum	Deidentified Contract Maximum
30237-8900-06 - sipuleucel-T - Susp	Q2043	PHARMACY	"$314,255.00"	Outpatient	"$157,127.50"	"$52,784.94"	"$171,897.49"	"$209,608.09"	"$125,702.00"	Not Applicable	"$109,989.25"	"$219,978.50"	"$52,784.94"	"$219,978.50"
5.5 LITTER IMPELLA 0550-0008		SUPPLY/IMPLANTS	"$203,322.00"	Outpatient	"$101,661.00"	Not Applicable	"$111,217.13"	"$135,615.77"	"$81,328.80"	Not Applicable	"$71,162.70"	"$142,325.40"	"$71,162.70"	"$142,325.40"
00003-2328-22 - ipilimumab 5 mg/mL Soln	J9228	PHARMACY	"$159,510.00"	Outpatient	"$79,755.00"	$149.88	"$103,681.50"	"$106,393.17"	"$63,804.00"	Not Applicable	"$55,828.50"	"$111,657.00"	$149.88	"$111,657.00"
VALVE AORTIC SAPIEN 3 COMMANDER EDWARDS OD20 MM TRANSCATHETE S3UCM220A		SUPPLY/IMPLANTS	"$188,799.00"	Outpatient	"$94,399.50"	Not Applicable	"$103,273.05"	"$125,928.93"	"$75,519.60"	Not Applicable	"$66,079.65"	"$132,159.30"	"$66,079.65"	"$132,159.30"
VALVE AORTIC SAPIEN 3 COMMANDER EDWARDS OD23 MM TRANSCATHETE S3UCM223A		SUPPLY/IMPLANTS	"$188,799.00"	Outpatient	"$94,399.50"	Not Applicable	"$103,273.05"	"$125,928.93"	"$75,519.60"	Not Applicable	"$66,079.65"	"$132,159.30"	"$66,079.65"	"$132,159.30"
VALVE AORTIC SAPIEN 3 COMMANDER EDWARDS OD26 MM TRANSCATHETE S3UCM226A		SUPPLY/IMPLANTS	"$188,799.00"	Outpatient	"$94,399.50"	Not Applicable	"$103,273.05"	"$125,928.93"	"$75,519.60"	Not Applicable	"$66,079.65"	"$132,159.30"	"$66,079.65"	"$132,159.30"
KIT AOR VLV 26FR ASCENDRA+ SAPIEN XT ATRION 29MM TRANSAPICAL 9355ASP29A		STERILE SUPPLY	"$188,722.00"	Outpatient	"$94,361.00"	Not Applicable	"$103,230.93"	"$125,877.57"	"$75,488.80"	Not Applicable	"$66,052.70"	"$132,105.40"	"$66,052.70"	"$132,105.40"
KIT AOR VLV 24FR ASCENDRA+ SAPIEN XT ATRION 26MM TRANSAPICAL 9355ASP26A		STERILE SUPPLY	"$188,722.00"	Outpatient	"$94,361.00"	Not Applicable	"$103,230.93"	"$125,877.57"	"$75,488.80"	Not Applicable	"$66,052.70"	"$132,105.40"	"$66,052.70"	"$132,105.40"
KIT AOR VLV 24FR ASCENDRA+ SAPIEN XT ATRION 23MM TRANSAPICAL 9355ASP23A		STERILE SUPPLY	"$188,722.00"	Outpatient	"$94,361.00"	Not Applicable	"$103,230.93"	"$125,877.57"	"$75,488.80"	Not Applicable	"$66,052.70"	"$132,105.40"	"$66,052.70"	"$132,105.40"
KIT AOR VLV CMNDR SAPIEN 3 ATRION 29MM TRANSCATHETER BLN 9600CM29A		STERILE SUPPLY	"$188,722.00"	Outpatient	"$94,361.00"	Not Applicable	"$103,230.93"	"$125,877.57"	"$75,488.80"	Not Applicable	"$66,052.70"	"$132,105.40"	"$66,052.70"	"$132,105.40"
KIT AOR VLV 14FR CMNDR SAPIEN 3 ATRION 26MM TRANSCATHETER 9600CM26A		STERILE SUPPLY	"$188,722.00"	Outpatient	"$94,361.00"	Not Applicable	"$103,230.93"	"$125,877.57"	"$75,488.80"	Not Applicable	"$66,052.70"	"$132,105.40"	"$66,052.70"	"$132,105.40"
KIT AOR VLV 14FR CMNDR SAPIEN 3 ATRION 23MM TRANSCATHETER 9600CM23A		STERILE SUPPLY	"$188,722.00"	Outpatient	"$94,361.00"	Not Applicable	"$103,230.93"	"$125,877.57"	"$75,488.80"	Not Applicable	"$66,052.70"	"$132,105.40"	"$66,052.70"	"$132,105.40"
KIT AOR VLV 14FR CMNDR SAPIEN 3 20MM TRANSCATHETER INTRO BLN 9600CM20A		STERILE SUPPLY	"$188,722.00"	Outpatient	"$94,361.00"	Not Applicable	"$103,230.93"	"$125,877.57"	"$75,488.80"	Not Applicable	"$66,052.70"	"$132,105.40"	"$66,052.70"	"$132,105.40"
KIT AOR VLV 18FR CERTITUDE SAPIEN 3 ATRION ASCENDRA 23MM 9600CT23A		SUPPLY/IMPLANTS	"$188,685.00"	Outpatient	"$94,342.50"	Not Applicable	"$103,210.70"	"$125,852.90"	"$75,474.00"	Not Applicable	"$66,039.75"	"$132,079.50"	"$66,039.75"	"$132,079.50"
KIT AOR VLV 21FR CERTITUDE SAPIEN 3 ATRION ASCENDRA 29MM 9600CT29A		SUPPLY/IMPLANTS	"$188,685.00"	Outpatient	"$94,342.50"	Not Applicable	"$103,210.70"	"$125,852.90"	"$75,474.00"	Not Applicable	"$66,039.75"	"$132,079.50"	"$66,039.75"	"$132,079.50"
SYSTEM NEUROSTIMULATOR IMPLANTABLE ELECTRICAL PULSE GENERATO 1000	C1767	SUPPLY/IMPLANTS	"$184,408.00"	Outpatient	"$92,204.00"	Not Applicable	"$100,871.18"	"$123,000.14"	"$73,763.20"	Not Applicable	"$64,542.80"	"$129,085.60"	"$64,542.80"	"$129,085.60"
SYS CRD MNTR DLV PA SNSR CARDIOMEMS CM2000	C2624	SUPPLY/IMPLANTS	"$180,710.00"	Outpatient	"$90,355.00"	Not Applicable	"$98,848.37"	"$120,533.57"	"$72,284.00"	Not Applicable	"$63,248.50"	"$126,497.00"	"$63,248.50"	"$126,497.00"
DFBR CRD THK14MM 41X76MM QD ASR TAILOREDTHERAPY SHOCKGUARD CD3265-40Q	C1882	PACE MAKER	"$179,231.00"	Outpatient	"$89,615.50"	Not Applicable	"$98,039.36"	"$119,547.08"	"$71,692.40"	Not Applicable	"$62,730.85"	"$125,461.70"	"$62,730.85"	"$125,461.70"
VALVE AORTIC EVOLUT PRO PLUS 34MM EVPROPLUS-34-US		SUPPLY/IMPLANTS	"$174,276.00"	Outpatient	"$87,138.00"	Not Applicable	"$95,328.97"	"$116,242.09"	"$69,710.40"	Not Applicable	"$60,996.60"	"$121,993.20"	"$60,996.60"	"$121,993.20"
VALVE AORTIC EVOLUT R PORCINE PERICARDIUM 34 MM SELF EXPAND EVOLUTR-34-US		NON-STER SUPPLY	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 1 CDS0601 NTR MBR0101		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 2 CDS0601 NTR MBR0102		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 3 CDS0601 NTR MBR0103		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 1 CDS0601 XTR MBR0201		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 2 CDS0601 XTR MBR0202		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 3 CDS0601 XTR MBR0203		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 1 CDS0601 NTR 1 CDS0601 XTR MBR0301		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE SGC0301 2 CDS0601 NTR 1 CDS0601 XTR MBR0302		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE MITRAL MITRACLIP BUNDLE 1 SGC0301 1 CDS0601 NTR 2 CDS0601 XTR MBR0303		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE AORTIC EVOLUT PRO 26 MM EVOLUTPRO-26-US		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE AORTIC EVOLUT PRO 23 MM EVOLUTPRO-23-US		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
VALVE AORTIC COREVALVE EVOLUT PRO PORCINE PERICARDIUM 29 MM EVOLUTPRO-29-US		SUPPLY/IMPLANTS	"$174,094.00"	Outpatient	"$87,047.00"	Not Applicable	"$95,229.42"	"$116,120.70"	"$69,637.60"	Not Applicable	"$60,932.90"	"$121,865.80"	"$60,932.90"	"$121,865.80"
KIT ANLPLS MITRACLIP NT STRBL GD CATH CLIP DLV SYS NTMSK0101		STERILE SUPPLY	"$174,072.00"	Outpatient	"$87,036.00"	Not Applicable	"$95,217.38"	"$116,106.02"	"$69,628.80"	Not Applicable	"$60,925.20"	"$121,850.40"	"$60,925.20"	"$121,850.40"
KIT ANLPLS MITRACLIP NT STRBL GD CATH 2 CLIP DLV SYS NTMSK0102		STERILE SUPPLY	"$174,072.00"	Outpatient	"$87,036.00"	Not Applicable	"$95,217.38"	"$116,106.02"	"$69,628.80"	Not Applicable	"$60,925.20"	"$121,850.40"	"$60,925.20"	"$121,850.40"
KIT ANLPLS MITRACLIP NT SGC0301 CDS0501 NTMSK0103		STERILE SUPPLY	"$174,072.00"	Outpatient	"$87,036.00"	Not Applicable	"$95,217.38"	"$116,106.02"	"$69,628.80"	Not Applicable	"$60,925.20"	"$121,850.40"	"$60,925.20"	"$121,850.40"
Insert/Replace Permanent SQ Defib	33270	CARDIAC CATH LAB	"$171,275.00"	Outpatient	"$85,637.50"	"$154,176.28"	"$93,687.43"	"$114,240.43"	"$68,510.00"	"$23,583.00"	"$59,946.25"	"$119,892.50"	"$23,583.00"	"$154,176.28"
DFBR CRD THK15MM 51X69MM PROTECTA XT TI PU SIL RBR DF-1 D314TRG	C1882	PACE MAKER	"$167,210.00"	Outpatient	"$83,605.00"	Not Applicable	"$91,463.87"	"$111,529.07"	"$66,884.00"	Not Applicable	"$58,523.50"	"$117,047.00"	"$58,523.50"	"$117,047.00"
PUMP IAB IMPELLA 5L/MIN CATH MICROAXIAL 5062		STERILE SUPPLY	"$162,636.00"	Outpatient	"$81,318.00"	Not Applicable	"$88,961.89"	"$108,478.21"	"$65,054.40"	Not Applicable	"$56,922.60"	"$113,845.20"	"$56,922.60"	"$113,845.20"
SYSTEM PACEMAKER INTICA BIV 404629	C1882	PACE MAKER	"$158,785.00"	Outpatient	"$79,392.50"	Not Applicable	"$86,855.40"	"$105,909.60"	"$63,514.00"	Not Applicable	"$55,574.75"	"$111,149.50"	"$55,574.75"	"$111,149.50"
SPCR SPNL 50X20X12MM PIVOX 12D LAT OLIF25 2112350	C1821	SUPPLY/IMPLANTS	"$158,785.00"	Outpatient	"$79,392.50"	Not Applicable	"$86,855.40"	"$105,909.60"	"$63,514.00"	Not Applicable	"$55,574.75"	"$111,149.50"	"$55,574.75"	"$111,149.50"
PACEMAKER DEVICE  VIGILANT 8XV1	C1882	PACE MAKER	"$157,333.00"	Outpatient	"$78,666.50"	Not Applicable	"$86,061.15"	"$104,941.11"	"$62,933.20"	Not Applicable	"$55,066.55"	"$110,133.10"	"$55,066.55"	"$110,133.10"
NRSTM 2.2INX2.2IN ACTIVA RC IMPL 10.5-V 2-250HZ .4IN 22ML 37612	C1767	SUPPLY/IMPLANTS	"$156,162.00"	Outpatient	"$78,081.00"	Not Applicable	"$85,420.61"	"$104,160.05"	"$62,464.80"	Not Applicable	"$54,656.70"	"$109,313.40"	"$54,656.70"	"$109,313.40"
DFBR CRD AMPLIA MRI CRT-D LV DF-4 IMPL QDPL LTX STRL DTMB1QQ		SUPPLY/IMPLANTS	"$154,886.00"	Outpatient	"$77,443.00"	Not Applicable	"$84,722.64"	"$103,308.96"	"$61,954.40"	Not Applicable	"$54,210.10"	"$108,420.20"	"$54,210.10"	"$108,420.20"
BATTERY KIT  IPG NIPG2000		STERILE SUPPLY	"$152,623.00"	Outpatient	"$76,311.50"	Not Applicable	"$83,484.78"	"$101,799.54"	"$61,049.20"	Not Applicable	"$53,418.05"	"$106,836.10"	"$53,418.05"	"$106,836.10"
SYSTEM ICD COMPIA MRI QUAD US DF4 DTMC1QQ DTMCIQQ	C1882	PACE MAKER	"$151,704.00"	Outpatient	"$75,852.00"	Not Applicable	"$82,982.09"	"$101,186.57"	"$60,681.60"	Not Applicable	"$53,096.40"	"$106,192.80"	"$53,096.40"	"$106,192.80"
DFBR CRD VIVA QD XT BIPHASIC WVFRM DF-1 CNCT ICD 35ML 80GM DTBA1QQ	C1882	PACE MAKER	"$151,020.00"	Outpatient	"$75,510.00"	Not Applicable	"$82,607.94"	"$100,730.34"	"$60,408.00"	Not Applicable	"$52,857.00"	"$105,714.00"	"$52,857.00"	"$105,714.00"
DFBR CRD 40J QD ASR CRT PARYLENE CARDVRT NEXT GNRTN AICD CD3365-40C	C1882	PACE MAKER	"$148,114.00"	Outpatient	"$74,057.00"	Not Applicable	"$81,018.36"	"$98,792.04"	"$59,245.60"	Not Applicable	"$51,839.90"	"$103,679.80"	"$51,839.90"	"$103,679.80"
SYSTEM EMBLEM S-ICD 8B11	C1722	PACE MAKER	"$148,114.00"	Outpatient	"$74,057.00"	Not Applicable	"$81,018.36"	"$98,792.04"	"$59,245.60"	Not Applicable	"$51,839.90"	"$103,679.80"	"$51,839.90"	"$103,679.80"
DFBR CRD THK14MM 40J 41X76MM QD ASR CRT-D 2 CHMBR 38ML 81GM CD3365-40Q	C1882	PACE MAKER	"$148,034.00"	Outpatient	"$74,017.00"	Not Applicable	"$80,974.60"	"$98,738.68"	"$59,213.60"	Not Applicable	"$51,811.90"	"$103,623.80"	"$51,811.90"	"$103,623.80"
SYSTEM GENERATOR SQ-RX PULSE AND ELECTRODE Q-TRAK 8B01	C1820	SUPPLY/IMPLANTS	"$148,034.00"	Outpatient	"$74,017.00"	Not Applicable	"$80,974.60"	"$98,738.68"	"$59,213.60"	Not Applicable	"$51,811.90"	"$103,623.80"	"$51,811.90"	"$103,623.80"
DFBR CRD ILIVIA PROMRI CLS HOME MNTR HI ENRG THOR IMPDN QDPL 431742	C1882	PACE MAKER	"$148,017.00"	Outpatient	"$74,008.50"	Not Applicable	"$80,965.30"	"$98,727.34"	"$59,206.80"	Not Applicable	"$51,805.95"	"$103,611.90"	"$51,805.95"	"$103,611.90"
VIVA S CRT-D PREMUIM SYSTEM INCL DF4 HEADER VIVASCRTDMMPM	C1882	PACE MAKER	"$147,933.00"	Outpatient	"$73,966.50"	Not Applicable	"$80,919.35"	"$98,671.31"	"$59,173.20"	Not Applicable	"$51,776.55"	"$103,553.10"	"$51,776.55"	"$103,553.10"
VIVA S CRT-D PREMUIM SYSTEM INCL DF4 HEADER VIVASCRTDMMPE	C1882	PACE MAKER	"$147,933.00"	Outpatient	"$73,966.50"	Not Applicable	"$80,919.35"	"$98,671.31"	"$59,173.20"	Not Applicable	"$51,776.55"	"$103,553.10"	"$51,776.55"	"$103,553.10"
VIVA S CRT-D ADVANCED SYSTEM INCL DF4 HEADER VIVASCRTDMMAM	C1882	PACE MAKER	"$147,933.00"	Outpatient	"$73,966.50"	Not Applicable	"$80,919.35"	"$98,671.31"	"$59,173.20"	Not Applicable	"$51,776.55"	"$103,553.10"	"$51,776.55"	"$103,553.10"
VIVA S CRT-D ADVANCED SYSTEM INCL DF4 HEADER VIVASCRTDMMAE	C1882	PACE MAKER	"$147,933.00"	Outpatient	"$73,966.50"	Not Applicable	"$80,919.35"	"$98,671.31"	"$59,173.20"	Not Applicable	"$51,776.55"	"$103,553.10"	"$51,776.55"	"$103,553.10"
ACTIVA PC 37612 NKG720375H	C1820	SUPPLY/IMPLANTS	"$146,593.00"	Outpatient	"$73,296.50"	Not Applicable	"$80,186.37"	"$97,777.53"	"$58,637.20"	Not Applicable	"$51,307.55"	"$102,615.10"	"$51,307.55"	"$102,615.10"
SET VNTRC AST 2.5IN IMPELLA STRL LF DISP 5042	C9899	SUPPLY/IMPLANTS	"$145,758.00"	Outpatient	"$72,879.00"	Not Applicable	"$79,729.63"	"$97,220.59"	"$58,303.20"	Not Applicable	"$51,015.30"	"$102,030.60"	"$51,015.30"	"$102,030.60"
DFBR CRD CLARIA MRI QDPL CLARIAMRIQDCRTMMQM	C1882	PACE MAKER	"$145,564.00"	Outpatient	"$72,782.00"	Not Applicable	"$79,623.51"	"$97,091.19"	"$58,225.60"	Not Applicable	"$50,947.40"	"$101,894.80"	"$50,947.40"	"$101,894.80"
SET VNTRC AST IMPELLA RP RT HRT PMP STRL LF DISP 4334		STERILE SUPPLY	"$145,061.00"	Outpatient	"$72,530.50"	Not Applicable	"$79,348.37"	"$96,755.69"	"$58,024.40"	Not Applicable	"$50,771.35"	"$101,542.70"	"$50,771.35"	"$101,542.70"
SET VNTRC AST 17.4X13.8IN IMPELLA CP 9.3IN 10-40C PMP CNTRLR 480003	C9899	SUPPLY/IMPLANTS	"$145,032.00"	Outpatient	"$72,516.00"	Not Applicable	"$79,332.50"	"$96,736.34"	"$58,012.80"	Not Applicable	"$50,761.20"	"$101,522.40"	"$50,761.20"	"$101,522.40"
AMPLIA MRI CRT D SURESCAN SYSTEM DTMB1D4 SYSTEM	C1882	PACE MAKER	"$144,284.00"	Outpatient	"$72,142.00"	Not Applicable	"$78,923.35"	"$96,237.43"	"$57,713.60"	Not Applicable	"$50,499.40"	"$100,998.80"	"$50,499.40"	"$100,998.80"
SYSTEM CLARIA MRI CLARIAMRICRTDMMAM CLARIAMRICRTDMMAM	C1882	PACE MAKER	"$142,575.00"	Outpatient	"$71,287.50"	Not Applicable	"$77,988.53"	"$95,097.53"	"$57,030.00"	Not Applicable	"$49,901.25"	"$99,802.50"	"$49,901.25"	"$99,802.50"
DFBR CRD ILESTO HF-T GSM HM RSYN BIVEN 400451	C1882	PACE MAKER	"$142,277.00"	Outpatient	"$71,138.50"	Not Applicable	"$77,825.52"	"$94,898.76"	"$56,910.80"	Not Applicable	"$49,796.95"	"$99,593.90"	"$49,796.95"	"$99,593.90"
DFBR CRD ITREVIA HF-T CLS HOME MNTR DF-1 BP THOR IMPDN 412425		STERILE SUPPLY	"$142,237.00"	Outpatient	"$71,118.50"	Not Applicable	"$77,803.64"	"$94,872.08"	"$56,894.80"	Not Applicable	"$49,782.95"	"$99,565.90"	"$49,782.95"	"$99,565.90"
DFBR CRD ILESTO HF-T HM RSYN BIVEN 400452	C1882	PACE MAKER	"$142,200.00"	Outpatient	"$71,100.00"	Not Applicable	"$77,783.40"	"$94,847.40"	"$56,880.00"	Not Applicable	"$49,770.00"	"$99,540.00"	"$49,770.00"	"$99,540.00"
GENERATOR VNS ASPIRE SR MODEL106	C1767	SUPPLY/IMPLANTS	"$139,464.00"	Outpatient	"$69,732.00"	Not Applicable	"$76,286.81"	"$93,022.49"	"$55,785.60"	Not Applicable	"$48,812.40"	"$97,624.80"	"$48,812.40"	"$97,624.80"
PACEMAKER VIGILANT X4 IS4 DF 4/2 LEAD AQX4 AND RV 8XV2	C1898	PACE MAKER	"$139,409.00"	Outpatient	"$69,704.50"	Not Applicable	"$76,256.72"	"$92,985.80"	"$55,763.60"	Not Applicable	"$48,793.15"	"$97,586.30"	"$48,793.15"	"$97,586.30"
DFBR CRD THK14MM 40J 40X73MM UNIFY ASR CRT-D ATR VNTRC TI 2 CD3257-40Q	C1882	PACE MAKER	"$138,994.00"	Outpatient	"$69,497.00"	Not Applicable	"$76,029.72"	"$92,709.00"	"$55,597.60"	Not Applicable	"$48,647.90"	"$97,295.80"	"$48,647.90"	"$97,295.80"
LUMAX 740 HF-T HIGH ENERGY SYSTEM WITH TI WITH LANDLINE 390238	C1882	SUPPLY/IMPLANTS	"$137,984.00"	Outpatient	"$68,992.00"	Not Applicable	"$75,477.25"	"$92,035.33"	"$55,193.60"	Not Applicable	"$48,294.40"	"$96,588.80"	"$48,294.40"	"$96,588.80"
STEM FEM 126MM 127D 11 58MM OFST ACLD II V40 PUREFIX TI 40MM 6721-1140	C1776	SUPPLY/IMPLANTS	"$137,589.00"	Outpatient	"$68,794.50"	Not Applicable	"$75,261.18"	"$91,771.86"	"$55,035.60"	Not Applicable	"$48,156.15"	"$96,312.30"	"$48,156.15"	"$96,312.30"
ICD EMBLEM MRI S-ICD SUBCUTANEUS ELECTRODE 9B11	C1896	PACE MAKER	"$136,374.00"	Outpatient	"$68,187.00"	Not Applicable	"$74,596.58"	"$90,961.46"	"$54,549.60"	Not Applicable	"$47,730.90"	"$95,461.80"	"$47,730.90"	"$95,461.80"
DFBR CRD ENERGEN CRT-D IMPL CARDVRT N140		STERILE SUPPLY	"$135,988.00"	Outpatient	"$67,994.00"	Not Applicable	"$74,385.44"	"$90,704.00"	"$54,395.20"	Not Applicable	"$47,595.80"	"$95,191.60"	"$47,595.80"	"$95,191.60"
SYS CRD PCMKR LD DF-4 IS4 IS-1 CNCT QD ASR MP THK14MM 40J 41 CD3369-40Q	C1882	SUPPLY/IMPLANTS	"$133,558.00"	Outpatient	"$66,779.00"	Not Applicable	"$73,056.23"	"$89,083.19"	"$53,423.20"	Not Applicable	"$46,745.30"	"$93,490.60"	"$46,745.30"	"$93,490.60"
DFBR CRD .99CM MN 5.23X7.14CM INOGEN EASYVIEW ACUSHOCK D013		STERILE SUPPLY	"$132,106.00"	Outpatient	"$66,053.00"	Not Applicable	"$72,261.98"	"$88,114.70"	"$52,842.40"	Not Applicable	"$46,237.10"	"$92,474.20"	"$46,237.10"	"$92,474.20"
OMNIA BUNDLE KIT 1080-LW		SUPPLY/IMPLANTS	"$130,707.00"	Outpatient	"$65,353.50"	Not Applicable	"$71,496.73"	"$87,181.57"	"$52,282.80"	Not Applicable	"$45,747.45"	"$91,494.90"	"$45,747.45"	"$91,494.90"
Insert ICD Gen only/w Existing Dual Leads	33230	CARDIAC CATH LAB	"$130,420.00"	Outpatient	"$65,210.00"	"$119,647.64"	"$71,339.74"	"$1,592.00"	"$52,168.00"	"$23,583.00"	"$45,647.00"	"$91,294.00"	"$1,592.00"	"$119,647.64"
Removal Replacement ICD Gen Multi Lead	33264	CARDIAC CATH LAB	"$127,953.00"	Outpatient	"$63,976.50"	"$119,647.64"	"$69,990.29"	"$1,592.00"	"$51,181.20"	"$23,583.00"	"$44,783.55"	"$89,567.10"	"$1,592.00"	"$119,647.64"
Remove and Replace ICD Gen Dual Lead	33263	CARDIAC CATH LAB	"$127,953.00"	Outpatient	"$63,976.50"	"$119,647.64"	"$69,990.29"	"$1,592.00"	"$51,181.20"	"$23,583.00"	"$44,783.55"	"$89,567.10"	"$1,592.00"	"$119,647.64"
Remove Replace ICD Gen Single Lead	33262	CARDIAC CATH LAB	"$127,953.00"	Outpatient	"$63,976.50"	"$119,647.64"	"$69,990.29"	"$1,592.00"	"$51,181.20"	"$23,583.00"	"$44,783.55"	"$89,567.10"	"$1,592.00"	"$119,647.64"
NRSTM 54MMX54MM RESTORESENSOR SURESCAN ADAPTIVESTIM IMPL 45 97714	C1820	SUPPLY/IMPLANTS	"$127,426.00"	Outpatient	"$63,713.00"	Not Applicable	"$69,702.02"	"$84,993.14"	"$50,970.40"	Not Applicable	"$44,599.10"	"$89,198.20"	"$44,599.10"	"$89,198.20"
IMPL CRNL TI PTSPC NS SD420.553	C1713	SUPPLY/IMPLANTS	"$127,035.00"	Outpatient	"$63,517.50"	"$1,365.15"	"$69,488.15"	"$84,732.35"	"$50,814.00"	Not Applicable	"$44,462.25"	"$88,924.50"	"$1,365.15"	"$88,924.50"
DFBR CRD VIVA S CRT-D ICD DF-1 PHYSIOCURVE DSGN SMARTSHOCK DTBB1D1	C1882	PACE MAKER	"$126,398.00"	Outpatient	"$63,199.00"	Not Applicable	"$69,139.71"	"$84,307.47"	"$50,559.20"	Not Applicable	"$44,239.30"	"$88,478.60"	"$44,239.30"	"$88,478.60"
DFBR CRD VIVA S CRT-D PHYSIOCURVE CRDSNC SMARTSHOCK 2 CHMBR DTBB1D4	C1882	PACE MAKER	"$126,398.00"	Outpatient	"$63,199.00"	Not Applicable	"$69,139.71"	"$84,307.47"	"$50,559.20"	Not Applicable	"$44,239.30"	"$88,478.60"	"$44,239.30"	"$88,478.60"
"UNIFY ASSURA NEXT GEN CRT-D DF4 SYS, MERLIN PKG CD3357-40Q SYSCELL"	C2621	PACE MAKER	"$126,109.00"	Outpatient	"$63,054.50"	Not Applicable	"$68,981.62"	"$84,114.70"	"$50,443.60"	Not Applicable	"$44,138.15"	"$88,276.30"	"$44,138.15"	"$88,276.30"
DEFIBRILLATION SYSTEM IMPLANT ICD CD3365-40Q SYSTEM CD3365-40Q SYSTEM	C1882	PACE MAKER	"$126,109.00"	Outpatient	"$63,054.50"	Not Applicable	"$68,981.62"	"$84,114.70"	"$50,443.60"	Not Applicable	"$44,138.15"	"$88,276.30"	"$44,138.15"	"$88,276.30"
ICD QUADRA ASSURA CD3369-40Q SYSCELL	C1882	PACE MAKER	"$126,109.00"	Outpatient	"$63,054.50"	Not Applicable	"$68,981.62"	"$84,114.70"	"$50,443.60"	Not Applicable	"$44,138.15"	"$88,276.30"	"$44,138.15"	"$88,276.30"
MOMENTUM X4 CRT-D IS 1/DR-1/ISR ACUTIY X4 8XM2	C1882	PACE MAKER	"$126,109.00"	Outpatient	"$63,054.50"	Not Applicable	"$68,981.62"	"$84,114.70"	"$50,443.60"	Not Applicable	"$44,138.15"	"$88,276.30"	"$44,138.15"	"$88,276.30"
SYSTEM CARDIAC QUADRA ASSURA MP THK14 MM 40J W41 MM X H75 MM PACEMAKER LEAD DF-4 IS4 IS-1 CONNECTOR	C1882	PACE MAKER	"$126,109.00"	Outpatient	"$63,054.50"	Not Applicable	"$68,981.62"	"$84,114.70"	"$50,443.60"	Not Applicable	"$44,138.15"	"$88,276.30"	"$44,138.15"	"$88,276.30"
DFBR CRD .99CM 5.37X8.18CM VIGILANT MR CONDITIONAL IS 1 DF4 G247	C1882	PACE MAKER	"$125,751.00"	Outpatient	"$62,875.50"	Not Applicable	"$68,785.80"	"$83,875.92"	"$50,300.40"	Not Applicable	"$44,012.85"	"$88,025.70"	"$44,012.85"	"$88,025.70"
KIT BLOOD PUMP TANDEMLUNG L72 CM OD29 FR VENOUS ARTERIAL VEV 5830-2916		STERILE SUPPLY	"$124,898.00"	Outpatient	"$62,449.00"	Not Applicable	"$68,319.21"	"$83,306.97"	"$49,959.20"	Not Applicable	"$43,714.30"	"$87,428.60"	"$43,714.30"	"$87,428.60"
KIT BLOOD PUMP TANDEMLUNG OD31 FR CANNULA OXYGENATER STERILE 5830-3118		STERILE SUPPLY	"$124,898.00"	Outpatient	"$62,449.00"	Not Applicable	"$68,319.21"	"$83,306.97"	"$49,959.20"	Not Applicable	"$43,714.30"	"$87,428.60"	"$43,714.30"	"$87,428.60"
SYS CRD PCMKR LD RF TELEM DF4-LLHH IS-1 CNCT UNIFY ASR 40J CD3357-40Q SYSTEM	C2621	PACE MAKER	"$124,882.00"	Outpatient	"$62,441.00"	Not Applicable	"$68,310.45"	"$83,296.29"	"$49,952.80"	Not Applicable	"$43,708.70"	"$87,417.40"	"$43,708.70"	"$87,417.40"
GENERATOR UNIFY ASSURA ICD UNIFY ASSURA	C1820	SUPPLY/IMPLANTS	"$124,882.00"	Outpatient	"$62,441.00"	Not Applicable	"$68,310.45"	"$83,296.29"	"$49,952.80"	Not Applicable	"$43,708.70"	"$87,417.40"	"$43,708.70"	"$87,417.40"
DFBR CRD 40J UNIFY ASR PARYLENE RF TELEM DF1 IS-1 CNCT CD3357-40C	C1882	PACE MAKER	"$124,813.00"	Outpatient	"$62,406.50"	Not Applicable	"$68,272.71"	"$83,250.27"	"$49,925.20"	Not Applicable	"$43,684.55"	"$87,369.10"	"$43,684.55"	"$87,369.10"
DFBR CRD THK14MM 40J 79X40X14MM UNIFY ASR CRT-D ATR VNTRC TI CD3257-40	C1820	SUPPLY/IMPLANTS	"$124,813.00"	Outpatient	"$62,406.50"	Not Applicable	"$68,272.71"	"$83,250.27"	"$49,925.20"	Not Applicable	"$43,684.55"	"$87,369.10"	"$43,684.55"	"$87,369.10"
SENZA OMNIA IPG KIT NIPG2500	C1822	SUPPLY/IMPLANTS	"$124,608.00"	Outpatient	"$62,304.00"	Not Applicable	"$68,160.58"	"$83,113.54"	"$49,843.20"	Not Applicable	"$43,612.80"	"$87,225.60"	"$43,612.80"	"$87,225.60"
Insertion ICD w/ Exisitng Multi Lead	33231	CARDIAC CATH LAB	"$123,782.00"	Outpatient	"$61,891.00"	"$119,647.64"	"$67,708.75"	"$1,592.00"	"$49,512.80"	"$23,583.00"	"$43,323.70"	"$86,647.40"	"$1,592.00"	"$119,647.64"
DFBR CRD IFORIA DR-T 2 CHMBR 390064	C1721	PACE MAKER	"$121,879.00"	Outpatient	"$60,939.50"	Not Applicable	"$66,667.81"	"$81,293.29"	"$48,751.60"	Not Applicable	"$42,657.65"	"$85,315.30"	"$42,657.65"	"$85,315.30"
DEFIBRILLATOR EVERA XT DR  MMEM EVERAXTDRMMEM	C1721	PACE MAKER	"$121,396.00"	Outpatient	"$60,698.00"	Not Applicable	"$66,403.61"	"$80,971.13"	"$48,558.40"	Not Applicable	"$42,488.60"	"$84,977.20"	"$42,488.60"	"$84,977.20"
IMPL CRNL TI PTSPC NS SD420.453	C1713	SUPPLY/IMPLANTS	"$120,836.00"	Outpatient	"$60,418.00"	"$1,365.15"	"$66,097.29"	"$80,597.61"	"$48,334.40"	Not Applicable	"$42,292.60"	"$84,585.20"	"$1,365.15"	"$84,585.20"
DFBR CRD ITREVIA 7 IMPL RSYN THRP QDPL LF HF-T STRL 401662	C1882	SUPPLY/IMPLANTS	"$120,754.00"	Outpatient	"$60,377.00"	Not Applicable	"$66,052.44"	"$80,542.92"	"$48,301.60"	Not Applicable	"$42,263.90"	"$84,527.80"	"$42,263.90"	"$84,527.80"
DFBR CRD ILIVIA 7 3 CHMBR DF4 CNCT IMPL RSYN THRP HF-T QP 404621	C1882	PACE MAKER	"$120,730.00"	Outpatient	"$60,365.00"	Not Applicable	"$66,039.31"	"$80,526.91"	"$48,292.00"	Not Applicable	"$42,255.50"	"$84,511.00"	"$42,255.50"	"$84,511.00"
DFBR CRD 13MM 51X74MM AMPLIA MRI CRT-D SURESCAN PHYSIOCURVE DTMB1Q1	C1882	SUPPLY/IMPLANTS	"$119,835.00"	Outpatient	"$59,917.50"	Not Applicable	"$65,549.75"	"$79,929.95"	"$47,934.00"	Not Applicable	"$41,942.25"	"$83,884.50"	"$41,942.25"	"$83,884.50"
IMPL CRNL TI PTSPC NS SD420.552	C1713	SUPPLY/IMPLANTS	"$119,589.00"	Outpatient	"$59,794.50"	"$1,365.15"	"$65,415.18"	"$79,765.86"	"$47,835.60"	Not Applicable	"$41,856.15"	"$83,712.30"	"$1,365.15"	"$83,712.30"
GNTR PLS 83.1X69.1MM EBLM S-ICD 12.7MM 59.5CC 130GM LTD NXT A219	C1722	PACE MAKER	"$119,074.00"	Outpatient	"$59,537.00"	Not Applicable	"$65,133.48"	"$79,422.36"	"$47,629.60"	Not Applicable	"$41,675.90"	"$83,351.80"	"$41,675.90"	"$83,351.80"
DFBR CRD 15.7MM 65.5X78.2IN SMRT CHRG SQ-RX INTNL WARN SHOCK 1010	C1820	SUPPLY/IMPLANTS	"$119,008.00"	Outpatient	"$59,504.00"	Not Applicable	"$65,097.38"	"$79,378.34"	"$47,603.20"	Not Applicable	"$41,652.80"	"$83,305.60"	"$41,652.80"	"$83,305.60"
DEFIBRILLATOR CARDIAC AMPLIA MRI 35 CC 80 GM DF-4 CONNECTOR DTMB1D4	C1882	PACE MAKER	"$118,924.00"	Outpatient	"$59,462.00"	Not Applicable	"$65,051.43"	"$79,322.31"	"$47,569.60"	Not Applicable	"$41,623.40"	"$83,246.80"	"$41,623.40"	"$83,246.80"
DEFIBRILLATOR IFORIA DX SYSTEM 404406	C1722	PACE MAKER	"$118,544.00"	Outpatient	"$59,272.00"	Not Applicable	"$64,843.57"	"$79,068.85"	"$47,417.60"	Not Applicable	"$41,490.40"	"$82,980.80"	"$41,490.40"	"$82,980.80"
IFORIA DX SYSTEM W/ LANDLINE HM 404407	C1722	PACE MAKER	"$118,544.00"	Outpatient	"$59,272.00"	Not Applicable	"$64,843.57"	"$79,068.85"	"$47,417.60"	Not Applicable	"$41,490.40"	"$82,980.80"	"$41,490.40"	"$82,980.80"
GENERATOR DEMIPULSE DUO DUAL PIN MODEL 104	C1767	SUPPLY/IMPLANTS	"$118,260.00"	Outpatient	"$59,130.00"	Not Applicable	"$64,688.22"	"$78,879.42"	"$47,304.00"	Not Applicable	"$41,391.00"	"$82,782.00"	"$41,391.00"	"$82,782.00"
(BC3) MODULAR CATHCART FRACTURE HEAD HIP BALL	C1776	SUPPLY/IMPLANTS	"$117,438.00"	Outpatient	"$58,719.00"	Not Applicable	"$64,238.59"	"$78,331.15"	"$46,975.20"	Not Applicable	"$41,103.30"	"$82,206.60"	"$41,103.30"	"$82,206.60"
DFBR CRD .99IN MN 5.37X8.08CM DYNAGEN X4 IS-1 DF-1 IS-4 CNCT G156	C1882	SUPPLY/IMPLANTS	"$117,044.00"	Outpatient	"$58,522.00"	Not Applicable	"$64,023.07"	"$78,068.35"	"$46,817.60"	Not Applicable	"$40,965.40"	"$81,930.80"	"$40,965.40"	"$81,930.80"
DFBR CRD THK12MM 36J 51X69MM ELLIPSE DR VNTRC TI 1 CHMBR CD2311-36	C1721	PACE MAKER	"$116,770.00"	Outpatient	"$58,385.00"	Not Applicable	"$63,873.19"	"$77,885.59"	"$46,708.00"	Not Applicable	"$40,869.50"	"$81,739.00"	"$40,869.50"	"$81,739.00"
DFBR CRD THK.39IN 2.43X2.93IN ENERGEN VR LTD VNTRC 1 CHMBR E141	C1722	PACE MAKER	"$115,238.00"	Outpatient	"$57,619.00"	Not Applicable	"$63,035.19"	"$76,863.75"	"$46,095.20"	Not Applicable	"$40,333.30"	"$80,666.60"	"$40,333.30"	"$80,666.60"
DFBR CRD .99CM 5.37X8.08CM MMNT X4 HEARTLOGIC ENDURALIFE G138	C1882	PACE MAKER	"$114,888.00"	Outpatient	"$57,444.00"	Not Applicable	"$62,843.74"	"$76,630.30"	"$45,955.20"	Not Applicable	"$40,210.80"	"$80,421.60"	"$40,210.80"	"$80,421.60"
GNTR NRSTM VNS DEMIPULSE VAGUS NRV 1 CNCT MODL 103 MODEL 103	C1767	SUPPLY/IMPLANTS	"$114,814.00"	Outpatient	"$57,407.00"	Not Applicable	"$62,803.26"	"$76,580.94"	"$45,925.60"	Not Applicable	"$40,184.90"	"$80,369.80"	"$40,184.90"	"$80,369.80"
DFBR CRD 3D .99CM SPRL 5.37X8.18CM INOGEN ACUSHOCK EASYVIEW G140	C1882	SUPPLY/IMPLANTS	"$114,686.00"	Outpatient	"$57,343.00"	Not Applicable	"$62,733.24"	"$76,495.56"	"$45,874.40"	Not Applicable	"$40,140.10"	"$80,280.20"	"$40,140.10"	"$80,280.20"
DFBR CRD .99CM THN 5.37X8.18CM INOGEN EASYVIEW RT ATR RV LV G146	C1882	SUPPLY/IMPLANTS	"$114,686.00"	Outpatient	"$57,343.00"	Not Applicable	"$62,733.24"	"$76,495.56"	"$45,874.40"	Not Applicable	"$40,140.10"	"$80,280.20"	"$40,140.10"	"$80,280.20"
DFBR CRD ENERGEN CRT-D IMPL CARDVRT MODL N141 N141	C1882	PACE MAKER	"$114,657.00"	Outpatient	"$57,328.50"	Not Applicable	"$62,717.38"	"$76,476.22"	"$45,862.80"	Not Applicable	"$40,129.95"	"$80,259.90"	"$40,129.95"	"$80,259.90"
DFBR CRD VIVA QD XT CRT-D BIPHASIC WVFRM DF-1 CNCT ICD 35ML DTBA1Q1	C1882	PACE MAKER	"$114,609.00"	Outpatient	"$57,304.50"	Not Applicable	"$62,691.12"	"$76,444.20"	"$45,843.60"	Not Applicable	"$40,113.15"	"$80,226.30"	"$40,113.15"	"$80,226.30"
DFBR CRD THK.39IN SM 2.43X3.13IN INCEPTA CRT-D DF-1 IS-1 N164	C1882	PACE MAKER	"$114,576.00"	Outpatient	"$57,288.00"	Not Applicable	"$62,673.07"	"$76,422.19"	"$45,830.40"	Not Applicable	"$40,101.60"	"$80,203.20"	"$40,101.60"	"$80,203.20"
IMPL CRNL TI PTSPC NS SD420.452	C1713	SUPPLY/IMPLANTS	"$113,402.00"	Outpatient	"$56,701.00"	"$1,365.15"	"$62,030.89"	"$75,639.13"	"$45,360.80"	Not Applicable	"$39,690.70"	"$79,381.40"	"$1,365.15"	"$79,381.40"
TANDUM LUNG RAPID DEPLOYEMENT 5830-3631		STERILE SUPPLY	"$113,280.00"	Outpatient	"$56,640.00"	Not Applicable	"$61,964.16"	"$75,557.76"	"$45,312.00"	Not Applicable	"$39,648.00"	"$79,296.00"	"$39,648.00"	"$79,296.00"
KIT BLOOD PUMP PROTEKDUO TANDEMHEART OD29 FR VENO VENOUS CAN 5720-2916		SUPPLY/IMPLANTS	"$113,280.00"	Outpatient	"$56,640.00"	Not Applicable	"$61,964.16"	"$75,557.76"	"$45,312.00"	Not Applicable	"$39,648.00"	"$79,296.00"	"$39,648.00"	"$79,296.00"
KIT BLOOD PUMP PROTEKDUO TANDEMHEART OD31 FR VENO VENOUS CAN 5720-3118		SUPPLY/IMPLANTS	"$113,280.00"	Outpatient	"$56,640.00"	Not Applicable	"$61,964.16"	"$75,557.76"	"$45,312.00"	Not Applicable	"$39,648.00"	"$79,296.00"	"$39,648.00"	"$79,296.00"
DFBR CRD THK12MM 36J 51X70MM ELLIPSE 2 CHMBR DF4 IS-1 CNCT CD2411-36Q	C1721	PACE MAKER	"$113,265.00"	Outpatient	"$56,632.50"	Not Applicable	"$61,955.96"	"$75,547.76"	"$45,306.00"	Not Applicable	"$39,642.75"	"$79,285.50"	"$39,642.75"	"$79,285.50"
SYS CRD PCMKR LD 2 CHMBR DF4 IS-1 CNCT FORTIFY ASR THK14MM CD2357-40Q SYSTEM	C1785	PACE MAKER	"$113,203.00"	Outpatient	"$56,601.50"	Not Applicable	"$61,922.04"	"$75,506.40"	"$45,281.20"	Not Applicable	"$39,621.05"	"$79,242.10"	"$39,621.05"	"$79,242.10"
GRAFT ENDOVASCULAR VALIANT NAVION NITINOL HYDROPHILIC STRAIG VNMC3131C223TU	C1874	SUPPLY/IMPLANTS	"$112,800.00"	Outpatient	"$56,400.00"	Not Applicable	"$61,701.60"	"$75,237.60"	"$45,120.00"	Not Applicable	"$39,480.00"	"$78,960.00"	"$39,480.00"	"$78,960.00"
IMPL CRNL TI PTSPC NS SD420.551	C1713	SUPPLY/IMPLANTS	"$112,696.00"	Outpatient	"$56,348.00"	"$1,365.15"	"$61,644.71"	"$75,168.23"	"$45,078.40"	Not Applicable	"$39,443.60"	"$78,887.20"	"$1,365.15"	"$78,887.20"
DFBR CRD CLARIA MRI BIPHASIC WV 35CC DTMA1QQ	C1882	PACE MAKER	"$112,647.00"	Outpatient	"$56,323.50"	Not Applicable	"$61,617.91"	"$75,135.55"	"$45,058.80"	Not Applicable	"$39,426.45"	"$78,852.90"	"$39,426.45"	"$78,852.90"
IMPL CRNL TI PTSPC NS SD420.550	C1713	SUPPLY/IMPLANTS	"$112,266.00"	Outpatient	"$56,133.00"	"$1,365.15"	"$61,409.50"	"$74,881.42"	"$44,906.40"	Not Applicable	"$39,293.10"	"$78,586.20"	"$1,365.15"	"$78,586.20"
DFBR CRD VIVA XT CRT-D BIPHASIC WVFRM DF-4 CNCT ICD 35ML 80 DTBA1D4	C1882	PACE MAKER	"$112,001.00"	Outpatient	"$56,000.50"	Not Applicable	"$61,264.55"	"$74,704.67"	"$44,800.40"	Not Applicable	"$39,200.35"	"$78,400.70"	"$39,200.35"	"$78,400.70"
DFBR CRD 13MM 51X74MM CLARIA MRI CRT-D SURESCAN PHYSIOCURVE DTMA1Q1	C1882	PACE MAKER	"$112,001.00"	Outpatient	"$56,000.50"	Not Applicable	"$61,264.55"	"$74,704.67"	"$44,800.40"	Not Applicable	"$39,200.35"	"$78,400.70"	"$39,200.35"	"$78,400.70"
DFBR CRD .99CM 5.37X8.08CM MMNT X4 HEARTLOGIC ENDURALIFE G124	C1882	PACE MAKER	"$111,986.00"	Outpatient	"$55,993.00"	Not Applicable	"$61,256.34"	"$74,694.66"	"$44,794.40"	Not Applicable	"$39,195.10"	"$78,390.20"	"$39,195.10"	"$78,390.20"
NRSTM 2.4INX2.2IN ACTIVA SC IMPL 0-10.5V 2-250HZ 0-25.5MA .4 37602	C1767	SUPPLY/IMPLANTS	"$110,775.00"	Outpatient	"$55,387.50"	Not Applicable	"$60,593.93"	"$73,886.93"	"$44,310.00"	Not Applicable	"$38,771.25"	"$77,542.50"	"$38,771.25"	"$77,542.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.553	C1713	SUPPLY/IMPLANTS	"$110,308.00"	Outpatient	"$55,154.00"	"$1,365.15"	"$60,338.48"	"$73,575.44"	"$44,123.20"	Not Applicable	"$38,607.80"	"$77,215.60"	"$1,365.15"	"$77,215.60"
DFBR CRD 40J QD ASR MP PARYLENE RF TELEM DF-1 IS-1 IS4-LLLL CD3369-40C	C1882	SUPPLY/IMPLANTS	"$110,307.00"	Outpatient	"$55,153.50"	Not Applicable	"$60,337.93"	"$73,574.77"	"$44,122.80"	Not Applicable	"$38,607.45"	"$77,214.90"	"$38,607.45"	"$77,214.90"
"KIT, INTELLIS MRI SURGICAL SYSTEM 9771IS"		STERILE SUPPLY	"$110,247.00"	Outpatient	"$55,123.50"	Not Applicable	"$60,305.11"	"$73,534.75"	"$44,098.80"	Not Applicable	"$38,586.45"	"$77,172.90"	"$38,586.45"	"$77,172.90"
EVERA S DR SYSTEM INCL DF4 HEADER EVERASDRMMEM	C1721	PACE MAKER	"$110,225.00"	Outpatient	"$55,112.50"	Not Applicable	"$60,293.08"	"$73,520.08"	"$44,090.00"	Not Applicable	"$38,578.75"	"$77,157.50"	"$38,578.75"	"$77,157.50"
EVERA S DR SYSTEM INCL DF4 HEADER EVERASDRMMEE	C1721	PACE MAKER	"$110,225.00"	Outpatient	"$55,112.50"	Not Applicable	"$60,293.08"	"$73,520.08"	"$44,090.00"	Not Applicable	"$38,578.75"	"$77,157.50"	"$38,578.75"	"$77,157.50"
EVERA S VR SYSTEM INCL DF4 HEADER EVERASVREMEE	C1722	PACE MAKER	"$109,878.00"	Outpatient	"$54,939.00"	Not Applicable	"$60,103.27"	"$73,288.63"	"$43,951.20"	Not Applicable	"$38,457.30"	"$76,914.60"	"$38,457.30"	"$76,914.60"
EVERA S VR SYSTEM INCL DF4 HEADER EVERASVREMEM	C1722	PACE MAKER	"$109,878.00"	Outpatient	"$54,939.00"	Not Applicable	"$60,103.27"	"$73,288.63"	"$43,951.20"	Not Applicable	"$38,457.30"	"$76,914.60"	"$38,457.30"	"$76,914.60"
DFBR CRD 13MM 51X73MM CLARIA MRI CRT-D SURESCAN PHYSIOCURVE DTMA1D4	C1882	PACE MAKER	"$109,651.00"	Outpatient	"$54,825.50"	Not Applicable	"$59,979.10"	"$73,137.22"	"$43,860.40"	Not Applicable	"$38,377.85"	"$76,755.70"	"$38,377.85"	"$76,755.70"
DFBR CRD 13MM 51X71MM SURESCAN CLARIA MRI PHYSIOCURVE DTMA1D1	C1882	PACE MAKER	"$109,651.00"	Outpatient	"$54,825.50"	Not Applicable	"$59,979.10"	"$73,137.22"	"$43,860.40"	Not Applicable	"$38,377.85"	"$76,755.70"	"$38,377.85"	"$76,755.70"
DFBR CRD LUMAX 740 HF-T 3 LD RSYN BIVEN 365608	C1882	SUPPLY/IMPLANTS	"$109,580.00"	Outpatient	"$54,790.00"	Not Applicable	"$59,940.26"	"$73,089.86"	"$43,832.00"	Not Applicable	"$38,353.00"	"$76,706.00"	"$38,353.00"	"$76,706.00"
"TAG CONFORM THORACIC SG AC, 37mmX37mmX20cm 22Fr TGMR373720"	C1874	SUPPLY/IMPLANTS	"$109,225.00"	Outpatient	"$54,612.50"	Not Applicable	"$59,746.08"	"$72,853.08"	"$43,690.00"	Not Applicable	"$38,228.75"	"$76,457.50"	"$38,228.75"	"$76,457.50"
"TAG CONFORM THORACIC SG AC, 37mmX37mmX15cm 22Fr TGMR373715"	C1874	SUPPLY/IMPLANTS	"$109,225.00"	Outpatient	"$54,612.50"	Not Applicable	"$59,746.08"	"$72,853.08"	"$43,690.00"	Not Applicable	"$38,228.75"	"$76,457.50"	"$38,228.75"	"$76,457.50"
DFBR CRD ITREVIA 7 HF-T 393014	C1882	SUPPLY/IMPLANTS	"$109,139.00"	Outpatient	"$54,569.50"	Not Applicable	"$59,699.03"	"$72,795.71"	"$43,655.60"	Not Applicable	"$38,198.65"	"$76,397.30"	"$38,198.65"	"$76,397.30"
DFBR CRD ILESTO HF-T 3 LD RSYN BIVEN 383547	C1882	PACE MAKER	"$109,110.00"	Outpatient	"$54,555.00"	Not Applicable	"$59,683.17"	"$72,776.37"	"$43,644.00"	Not Applicable	"$38,188.50"	"$76,377.00"	"$38,188.50"	"$76,377.00"
Revasc Tp Art Bil Init W St Ath Same	37231	CARDIAC CATH LAB	"$108,830.00"	Outpatient	"$54,415.00"	"$69,531.48"	"$59,530.01"	"$1,592.00"	"$43,532.00"	"$15,995.00"	"$38,090.50"	"$76,181.00"	"$1,592.00"	"$76,181.00"
Revasc F/P Art Bil W St And Ath Same	37227	CARDIAC CATH LAB	"$108,830.00"	Outpatient	"$54,415.00"	"$69,531.48"	"$59,530.01"	"$1,592.00"	"$43,532.00"	"$15,995.00"	"$38,090.50"	"$76,181.00"	"$1,592.00"	"$76,181.00"
DFBR CRD .99CM 5.37X8.08CM DYNAGEN ACUSHOCK EASYVIEW G154	C1882	SUPPLY/IMPLANTS	"$108,682.00"	Outpatient	"$54,341.00"	Not Applicable	"$59,449.05"	"$72,490.89"	"$43,472.80"	Not Applicable	"$38,038.70"	"$76,077.40"	"$38,038.70"	"$76,077.40"
DFBR CRD .99CM 5.37X8.18CM INOGEN EASYVIEW ACUSHOCK G148	C1882	SUPPLY/IMPLANTS	"$108,680.00"	Outpatient	"$54,340.00"	Not Applicable	"$59,447.96"	"$72,489.56"	"$43,472.00"	Not Applicable	"$38,038.00"	"$76,076.00"	"$38,038.00"	"$76,076.00"
KIT IMPL XL CRNL PEEK CSTM 78-10040	C1713	SUPPLY/IMPLANTS	"$108,646.00"	Outpatient	"$54,323.00"	"$1,365.15"	"$59,429.36"	"$72,466.88"	"$43,458.40"	Not Applicable	"$38,026.10"	"$76,052.20"	"$1,365.15"	"$76,052.20"
DEFIBRILLATOR ICC SYSTEM EVERA XT VR EVERAXTVRE MEM	C1722	PACE MAKER	"$108,385.00"	Outpatient	"$54,192.50"	Not Applicable	"$59,286.60"	"$72,292.80"	"$43,354.00"	Not Applicable	"$37,934.75"	"$75,869.50"	"$37,934.75"	"$75,869.50"
DFBR CRD THK14MM 71MMX50MM CRNT DR TI IMPL 30J DF-1 IS-1 39 2107-36	C1721	PACE MAKER	"$108,334.00"	Outpatient	"$54,167.00"	Not Applicable	"$59,258.70"	"$72,258.78"	"$43,333.60"	Not Applicable	"$37,916.90"	"$75,833.80"	"$37,916.90"	"$75,833.80"
NRSTM ACTIVA PC IMPL MULTIPROGRAM 37601	C1767	SUPPLY/IMPLANTS	"$107,803.00"	Outpatient	"$53,901.50"	Not Applicable	"$58,968.24"	"$71,904.60"	"$43,121.20"	Not Applicable	"$37,731.05"	"$75,462.10"	"$37,731.05"	"$75,462.10"
SYSTEM ILESTO DR-T DF4 405576	C1721	PACE MAKER	"$107,428.00"	Outpatient	"$53,714.00"	Not Applicable	"$58,763.12"	"$71,654.48"	"$42,971.20"	Not Applicable	"$37,599.80"	"$75,199.60"	"$37,599.80"	"$75,199.60"
DFBR CRD ILESTO DR-T 2 CHMBR GSM ALACARTE 400448	C1721	PACE MAKER	"$107,397.00"	Outpatient	"$53,698.50"	Not Applicable	"$58,746.16"	"$71,633.80"	"$42,958.80"	Not Applicable	"$37,588.95"	"$75,177.90"	"$37,588.95"	"$75,177.90"
SYSTEM IIESTO 7 DR-T DF4 WITH CELLULAR HM 405575	C1721	PACE MAKER	"$107,397.00"	Outpatient	"$53,698.50"	Not Applicable	"$58,746.16"	"$71,633.80"	"$42,958.80"	Not Applicable	"$37,588.95"	"$75,177.90"	"$37,588.95"	"$75,177.90"
DFBR CRD ITREVIA DR-T CLS HOME MNTR DF-4 2 CHMBR THOR IMPDN 412423	C1721	PACE MAKER	"$107,376.00"	Outpatient	"$53,688.00"	Not Applicable	"$58,734.67"	"$71,619.79"	"$42,950.40"	Not Applicable	"$37,581.60"	"$75,163.20"	"$37,581.60"	"$75,163.20"
LUMAX 540 DRT SYSTEM W/ HMM 540 DR-T SYS	C1721	PACE MAKER	"$107,295.00"	Outpatient	"$53,647.50"	Not Applicable	"$58,690.37"	"$71,565.77"	"$42,918.00"	Not Applicable	"$37,553.25"	"$75,106.50"	"$37,553.25"	"$75,106.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.453	C1713	SUPPLY/IMPLANTS	"$106,707.00"	Outpatient	"$53,353.50"	"$1,365.15"	"$58,368.73"	"$71,173.57"	"$42,682.80"	Not Applicable	"$37,347.45"	"$74,694.90"	"$1,365.15"	"$74,694.90"
IMPL CRNL TI PTSPC NS SD420.451	C1713	SUPPLY/IMPLANTS	"$106,508.00"	Outpatient	"$53,254.00"	"$1,365.15"	"$58,259.88"	"$71,040.84"	"$42,603.20"	Not Applicable	"$37,277.80"	"$74,555.60"	"$1,365.15"	"$74,555.60"
IMPL CRNL TI PTSPC NS SD420.549	C1713	SUPPLY/IMPLANTS	"$106,161.00"	Outpatient	"$53,080.50"	"$1,365.15"	"$58,070.07"	"$70,809.39"	"$42,464.40"	Not Applicable	"$37,156.35"	"$74,312.70"	"$1,365.15"	"$74,312.70"
IMPL CRNL TI PTSPC NS SD420.450	C1713	SUPPLY/IMPLANTS	"$106,068.00"	Outpatient	"$53,034.00"	"$1,365.15"	"$58,019.20"	"$70,747.36"	"$42,427.20"	Not Applicable	"$37,123.80"	"$74,247.60"	"$1,365.15"	"$74,247.60"
GFT STNT 207MM 38MM 24FR VALIANT CAPTIVIA SINUSOIDAL STRG VAMF3838C200TU	C1874	SUPPLY/IMPLANTS	"$105,260.00"	Outpatient	"$52,630.00"	Not Applicable	"$57,577.22"	"$70,208.42"	"$42,104.00"	Not Applicable	"$36,841.00"	"$73,682.00"	"$36,841.00"	"$73,682.00"
GFT STNT 207MM 42MM 25FR VALIANT CAPTIVIA SINUSOIDAL STRG VAMF4242C200TU	C1884	SUPPLY/IMPLANTS	"$105,260.00"	Outpatient	"$52,630.00"	Not Applicable	"$57,577.22"	"$70,208.42"	"$42,104.00"	Not Applicable	"$36,841.00"	"$73,682.00"	"$36,841.00"	"$73,682.00"
GRAFT STENT THORACIC W/CAPTIVIA DEL. SYSTM VAMF3232C200TU	C2625	SUPPLY/IMPLANTS	"$105,200.00"	Outpatient	"$52,600.00"	Not Applicable	"$57,544.40"	"$70,168.40"	"$42,080.00"	Not Applicable	"$36,820.00"	"$73,640.00"	"$36,820.00"	"$73,640.00"
GFT STNT 200MM 34MM 24FR VALIANT STRG SINUSOIDAL EVAS HDRPH VAMF3434C200TU	C1884	SUPPLY/IMPLANTS	"$105,200.00"	Outpatient	"$52,600.00"	Not Applicable	"$57,544.40"	"$70,168.40"	"$42,080.00"	Not Applicable	"$36,820.00"	"$73,640.00"	"$36,820.00"	"$73,640.00"
IMPL CRNL TI PTSPC NS SD420.547	C1713	SUPPLY/IMPLANTS	"$105,098.00"	Outpatient	"$52,549.00"	"$1,365.15"	"$57,488.61"	"$70,100.37"	"$42,039.20"	Not Applicable	"$36,784.30"	"$73,568.60"	"$1,365.15"	"$73,568.60"
GENERATOR PULSE PROCLAIM 5 ELITE IMPLNTBLE 3660	C1767	SUPPLY/IMPLANTS	"$104,896.00"	Outpatient	"$52,448.00"	Not Applicable	"$57,378.11"	"$69,965.63"	"$41,958.40"	Not Applicable	"$36,713.60"	"$73,427.20"	"$36,713.60"	"$73,427.20"
KIT ULTRA SURG 1111-11		STERILE SUPPLY	"$104,551.00"	Outpatient	"$52,275.50"	Not Applicable	"$57,189.40"	"$69,735.52"	"$41,820.40"	Not Applicable	"$36,592.85"	"$73,185.70"	"$36,592.85"	"$73,185.70"
KIT ULTRASURG ULTRASURG		STERILE SUPPLY	"$104,551.00"	Outpatient	"$52,275.50"	Not Applicable	"$57,189.40"	"$69,735.52"	"$41,820.40"	Not Applicable	"$36,592.85"	"$73,185.70"	"$36,592.85"	"$73,185.70"
KIT ULTRA565 ULTRA656		STERILE SUPPLY	"$104,551.00"	Outpatient	"$52,275.50"	Not Applicable	"$57,189.40"	"$69,735.52"	"$41,820.40"	Not Applicable	"$36,592.85"	"$73,185.70"	"$36,592.85"	"$73,185.70"
GRAFT STENT VALIANT CAPTIVIA L182 MM L182 MM OD31 MM RADIOPA VNMC3131C182TU	C2625	SUPPLY/IMPLANTS	"$104,340.00"	Outpatient	"$52,170.00"	Not Applicable	"$57,073.98"	"$69,594.78"	"$41,736.00"	Not Applicable	"$36,519.00"	"$73,038.00"	"$36,519.00"	"$73,038.00"
LUMAX 740 DR-T HIGH ENERGY SYSTEM WITH TI WITH LANDLINE 393809	C1721	PACE MAKER	"$104,184.00"	Outpatient	"$52,092.00"	Not Applicable	"$56,988.65"	"$69,490.73"	"$41,673.60"	Not Applicable	"$36,464.40"	"$72,928.80"	"$36,464.40"	"$72,928.80"
DFBR CRD ILESTO VR-T DX HI ENRG SYS 400031	C1722	PACE MAKER	"$104,087.00"	Outpatient	"$52,043.50"	Not Applicable	"$56,935.59"	"$69,426.03"	"$41,634.80"	Not Applicable	"$36,430.45"	"$72,860.90"	"$36,430.45"	"$72,860.90"
DFBR CRD ILESTO VR-T DX 383594	C1722	PACE MAKER	"$104,059.00"	Outpatient	"$52,029.50"	Not Applicable	"$56,920.27"	"$69,407.35"	"$41,623.60"	Not Applicable	"$36,420.65"	"$72,841.30"	"$36,420.65"	"$72,841.30"
DFBR CRD ITREVIA DX HOME MNTR ATR 2 CHMBR THOR IMPDN DF 1 412424	C1722	PACE MAKER	"$104,059.00"	Outpatient	"$52,029.50"	Not Applicable	"$56,920.27"	"$69,407.35"	"$41,623.60"	Not Applicable	"$36,420.65"	"$72,841.30"	"$36,420.65"	"$72,841.30"
LUMAX 740 VR-T DX HIGH ENERGY SYSTEMS WITH LANDLINE HM 393950	C1722	PACE MAKER	"$103,959.00"	Outpatient	"$51,979.50"	Not Applicable	"$56,865.57"	"$69,340.65"	"$41,583.60"	Not Applicable	"$36,385.65"	"$72,771.30"	"$36,385.65"	"$72,771.30"
LUMAX 740 VR-T DX HIGH ENERGY SYSTEM WITH CELLULAR GSM HM 397192	C1722	PACE MAKER	"$103,959.00"	Outpatient	"$51,979.50"	Not Applicable	"$56,865.57"	"$69,340.65"	"$41,583.60"	Not Applicable	"$36,385.65"	"$72,771.30"	"$36,385.65"	"$72,771.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.552	C1713	SUPPLY/IMPLANTS	"$103,422.00"	Outpatient	"$51,711.00"	"$1,365.15"	"$56,571.83"	"$68,982.47"	"$41,368.80"	Not Applicable	"$36,197.70"	"$72,395.40"	"$1,365.15"	"$72,395.40"
DEFIBRILLATOR CARDIAC IPERIA 7 PROMRI DF-1 IMPLANTABLE RESYNCHRONIZATION THERAPY STERILE LATEX FREE	C1721	PACE MAKER	"$103,296.00"	Outpatient	"$51,648.00"	Not Applicable	"$56,502.91"	"$68,898.43"	"$41,318.40"	Not Applicable	"$36,153.60"	"$72,307.20"	"$36,153.60"	"$72,307.20"
DFBR CRD .99CM 5.37X8.18CM DYNAGEN ACUSHOCK EASYVIEW G150	C1882	SUPPLY/IMPLANTS	"$103,296.00"	Outpatient	"$51,648.00"	Not Applicable	"$56,502.91"	"$68,898.43"	"$41,318.40"	Not Applicable	"$36,153.60"	"$72,307.20"	"$36,153.60"	"$72,307.20"
NRSTM 1.9INX.6IN RESTOREADVANCED IMPL 0-4CM 0-10.5V 3-130HZ 37713	C1820	SUPPLY/IMPLANTS	"$102,973.00"	Outpatient	"$51,486.50"	Not Applicable	"$56,326.23"	"$68,682.99"	"$41,189.20"	Not Applicable	"$36,040.55"	"$72,081.10"	"$36,040.55"	"$72,081.10"
SYSTEM EVERA S MRI DR EVERAMRISDRMMEM	C1882	SUPPLY/IMPLANTS	"$102,775.00"	Outpatient	"$51,387.50"	Not Applicable	"$56,217.93"	"$68,550.93"	"$41,110.00"	Not Applicable	"$35,971.25"	"$71,942.50"	"$35,971.25"	"$71,942.50"
GENERATOR SPECTRA WAVEWRITER PULSE M365SC1060B0	C1822	SUPPLY/IMPLANTS	"$102,401.00"	Outpatient	"$51,200.50"	Not Applicable	"$56,013.35"	"$68,301.47"	"$40,960.40"	Not Applicable	"$35,840.35"	"$71,680.70"	"$35,840.35"	"$71,680.70"
DFBR CRD THK12MM 36J 66X51MM ELLIPSE VR VNTRC TI 2 CHMBR CD1311-36Q	C1722	PACE MAKER	"$102,352.00"	Outpatient	"$51,176.00"	Not Applicable	"$55,986.54"	"$68,268.78"	"$40,940.80"	Not Applicable	"$35,823.20"	"$71,646.40"	"$35,823.20"	"$71,646.40"
KIT NRSTM SENZA IPG STRL LF DISP NIPG1500	C1822	SUPPLY/IMPLANTS	"$101,819.00"	Outpatient	"$50,909.50"	Not Applicable	"$55,694.99"	"$67,913.27"	"$40,727.60"	Not Applicable	"$35,636.65"	"$71,273.30"	"$35,636.65"	"$71,273.30"
VIVA QUAD XT CRT-D SYSTEM DTBA1Q1 VIVAQUADXTCRTDMMQM	C1882	SUPPLY/IMPLANTS	"$101,661.00"	Outpatient	"$50,830.50"	Not Applicable	"$55,608.57"	"$67,807.89"	"$40,664.40"	Not Applicable	"$35,581.35"	"$71,162.70"	"$35,581.35"	"$71,162.70"
KIT BLOOD PUMP PROTEKDUO TANDEMHEART MINI OD31 FR VENO VENOU 5720-3631		SUPPLY/IMPLANTS	"$101,661.00"	Outpatient	"$50,830.50"	Not Applicable	"$55,608.57"	"$67,807.89"	"$40,664.40"	Not Applicable	"$35,581.35"	"$71,162.70"	"$35,581.35"	"$71,162.70"
DFBR CRD THK14MM 40J 40X74MM FORTIFY ASR DR VNTRC TI 2 CHMBR CD2257-40	C1721	PACE MAKER	"$101,649.00"	Outpatient	"$50,824.50"	Not Applicable	"$55,602.00"	"$67,799.88"	"$40,659.60"	Not Applicable	"$35,577.15"	"$71,154.30"	"$35,577.15"	"$71,154.30"
DFBR CRD THK14MM 40J 40X74MM FORTIFY ASR PARYLENE 2 CHMBR DF CD2357-40C	C1721	PACE MAKER	"$101,649.00"	Outpatient	"$50,824.50"	Not Applicable	"$55,602.00"	"$67,799.88"	"$40,659.60"	Not Applicable	"$35,577.15"	"$71,154.30"	"$35,577.15"	"$71,154.30"
DFBR CRD 36J ELLIPSE PARYLENE 2 CHMBR RF TELEM DF1 IS-1 CNCT CD2411-36C	C1882	PACE MAKER	"$101,591.00"	Outpatient	"$50,795.50"	Not Applicable	"$55,570.28"	"$67,761.20"	"$40,636.40"	Not Applicable	"$35,556.85"	"$71,113.70"	"$35,556.85"	"$71,113.70"
DEFIBRILLATOR CARDIAC IMPLTBLE -4 CONNECTOR AT/AF MNGMT UNIF CD3357-40Q CELL	C1882	PACE MAKER	"$101,371.00"	Outpatient	"$50,685.50"	Not Applicable	"$55,449.94"	"$67,614.46"	"$40,548.40"	Not Applicable	"$35,479.85"	"$70,959.70"	"$35,479.85"	"$70,959.70"
QUADRA ASSURA MP CRT-D MERLIN PKG CD3369-40C CELL	C1882	PACE MAKER	"$101,371.00"	Outpatient	"$50,685.50"	Not Applicable	"$55,449.94"	"$67,614.46"	"$40,548.40"	Not Applicable	"$35,479.85"	"$70,959.70"	"$35,479.85"	"$70,959.70"
DFBR CRD IPERIA DX PROMRI HOME MNTR HI ENRG 419364	C1722	PACE MAKER	"$101,309.00"	Outpatient	"$50,654.50"	Not Applicable	"$55,416.02"	"$67,573.10"	"$40,523.60"	Not Applicable	"$35,458.15"	"$70,916.30"	"$35,458.15"	"$70,916.30"
DFBR CRD 13MM 57SQ CM 51X71MM VIVA XT CRT-D SMARTSHOCK VNTRC DTBA1D1	C1882	PACE MAKER	"$101,266.00"	Outpatient	"$50,633.00"	Not Applicable	"$55,392.50"	"$67,544.42"	"$40,506.40"	Not Applicable	"$35,443.10"	"$70,886.20"	"$35,443.10"	"$70,886.20"
DEFIBRILLATOR CARDIAC UNIFY ASSURA 40 J RF TELEMETRY DF4-LLH CD-3357-40Q	C1882	SUPPLY/IMPLANTS	"$101,266.00"	Outpatient	"$50,633.00"	Not Applicable	"$55,392.50"	"$67,544.42"	"$40,506.40"	Not Applicable	"$35,443.10"	"$70,886.20"	"$35,443.10"	"$70,886.20"
GENERATOR PULSE PRECISION SPECTRA M365SC1032B0	C1820	SUPPLY/IMPLANTS	"$100,486.00"	Outpatient	"$50,243.00"	Not Applicable	"$54,965.84"	"$67,024.16"	"$40,194.40"	Not Applicable	"$35,170.10"	"$70,340.20"	"$35,170.10"	"$70,340.20"
GFT VASC AORTOILIAC ART ALGRF CRPRS AI401	C9363	SUPPLY/IMPLANTS	"$100,458.00"	Outpatient	"$50,229.00"	$38.51	"$54,950.53"	"$67,005.49"	"$40,183.20"	Not Applicable	"$35,160.30"	"$70,320.60"	$38.51	"$70,320.60"
GNTR NRSTM PRECISON MNTG CHRG KT MRI STRL LF DISP M365SC1210B0	C1820	SUPPLY/IMPLANTS	"$100,382.00"	Outpatient	"$50,191.00"	Not Applicable	"$54,908.95"	"$66,954.79"	"$40,152.80"	Not Applicable	"$35,133.70"	"$70,267.40"	"$35,133.70"	"$70,267.40"
IMPL CRNL TI PTSPC NS SD420.548	C1713	SUPPLY/IMPLANTS	"$100,126.00"	Outpatient	"$50,063.00"	"$1,365.15"	"$54,768.92"	"$66,784.04"	"$40,050.40"	Not Applicable	"$35,044.10"	"$70,088.20"	"$1,365.15"	"$70,088.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.551	C1713	SUPPLY/IMPLANTS	"$99,983.00"	Outpatient	"$49,991.50"	"$1,365.15"	"$54,690.70"	"$66,688.66"	"$39,993.20"	Not Applicable	"$34,994.05"	"$69,988.10"	"$1,365.15"	"$69,988.10"
IMPL CRNL TI PTSPC NS SD420.449	C1713	SUPPLY/IMPLANTS	"$99,958.00"	Outpatient	"$49,979.00"	"$1,365.15"	"$54,677.03"	"$66,671.99"	"$39,983.20"	Not Applicable	"$34,985.30"	"$69,970.60"	"$1,365.15"	"$69,970.60"
GFT STNT 157MM 28MM 22FR VALIANT CAPTIVIA SINUSOIDAL STRG VAMF2828C150TU	C1884	SUPPLY/IMPLANTS	"$99,861.00"	Outpatient	"$49,930.50"	Not Applicable	"$54,623.97"	"$66,607.29"	"$39,944.40"	Not Applicable	"$34,951.35"	"$69,902.70"	"$34,951.35"	"$69,902.70"
GRAFT STENT VALIANT CAPTIVIA TAPER L150 MM OD34 MM ID30 MM E VAMF3430C150TU		SUPPLY/IMPLANTS	"$99,817.00"	Outpatient	"$49,908.50"	Not Applicable	"$54,599.90"	"$66,577.94"	"$39,926.80"	Not Applicable	"$34,935.95"	"$69,871.90"	"$34,935.95"	"$69,871.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.452	C1713	SUPPLY/IMPLANTS	"$99,815.00"	Outpatient	"$49,907.50"	"$1,365.15"	"$54,598.81"	"$66,576.61"	"$39,926.00"	Not Applicable	"$34,935.25"	"$69,870.50"	"$1,365.15"	"$69,870.50"
GFT STNT 167MM 36MM 24FR VALIANT CAPTIVIA SINUSOIDAL STRG VAMF3636C150TU	C1874	SUPPLY/IMPLANTS	"$99,803.00"	Outpatient	"$49,901.50"	Not Applicable	"$54,592.24"	"$66,568.60"	"$39,921.20"	Not Applicable	"$34,931.05"	"$69,862.10"	"$34,931.05"	"$69,862.10"
GFT STNT VALIANT CAPTIVIA TPR THOR DLV SYS VAMF4642C150TU		SUPPLY/IMPLANTS	"$99,803.00"	Outpatient	"$49,901.50"	Not Applicable	"$54,592.24"	"$66,568.60"	"$39,921.20"	Not Applicable	"$34,931.05"	"$69,862.10"	"$34,931.05"	"$69,862.10"
IMPL CRNL TI PTSPC NS SD420.546	C1713	SUPPLY/IMPLANTS	"$99,719.00"	Outpatient	"$49,859.50"	"$1,365.15"	"$54,546.29"	"$66,512.57"	"$39,887.60"	Not Applicable	"$34,901.65"	"$69,803.30"	"$1,365.15"	"$69,803.30"
DEV TRGT TIB NL ARM CORELOCK TCH PHNX 41000	C1713	SUPPLY/IMPLANTS	"$99,105.00"	Outpatient	"$49,552.50"	"$1,365.15"	"$54,210.44"	"$66,103.04"	"$39,642.00"	Not Applicable	"$34,686.75"	"$69,373.50"	"$1,365.15"	"$69,373.50"
DFBR CRD THK13MM 3.2V 40 J 66X55MM LUMAX 540VR-T AV IMPL 2 362724	C1882	PACE MAKER	"$99,085.00"	Outpatient	"$49,542.50"	Not Applicable	"$54,199.50"	"$66,089.70"	"$39,634.00"	Not Applicable	"$34,679.75"	"$69,359.50"	"$34,679.75"	"$69,359.50"
DFBR CRD LUMAX 740 VR-T HI ENRG GSM HOME MNTR THOR IMPDN 393810	C1722	PACE MAKER	"$99,085.00"	Outpatient	"$49,542.50"	Not Applicable	"$54,199.50"	"$66,089.70"	"$39,634.00"	Not Applicable	"$34,679.75"	"$69,359.50"	"$34,679.75"	"$69,359.50"
DFBR CRD EVERA S DR 2 CHMBR ICD DF-1 SMARTSHOCK TCH DDBC3D1	C1721	PACE MAKER	"$98,924.00"	Outpatient	"$49,462.00"	Not Applicable	"$54,111.43"	"$65,982.31"	"$39,569.60"	Not Applicable	"$34,623.40"	"$69,246.80"	"$34,623.40"	"$69,246.80"
DFBR CRD EVERA S DR PHYSIOCURVE SMARTSHOCK 2 CHMBR DF4 DDBC3D4	C1721	PACE MAKER	"$98,924.00"	Outpatient	"$49,462.00"	Not Applicable	"$54,111.43"	"$65,982.31"	"$39,569.60"	Not Applicable	"$34,623.40"	"$69,246.80"	"$34,623.40"	"$69,246.80"
EVERA MRI XT DR SYSTEM-MMEM EVERAMRIXTDRMMEM	C1721	PACE MAKER	"$98,909.00"	Outpatient	"$49,454.50"	Not Applicable	"$54,103.22"	"$65,972.30"	"$39,563.60"	Not Applicable	"$34,618.15"	"$69,236.30"	"$34,618.15"	"$69,236.30"
IMPL CRNL TI PTSPC NS SD420.447	C1713	SUPPLY/IMPLANTS	"$98,900.00"	Outpatient	"$49,450.00"	"$1,365.15"	"$54,098.30"	"$65,966.30"	"$39,560.00"	Not Applicable	"$34,615.00"	"$69,230.00"	"$1,365.15"	"$69,230.00"
SYSTEM EVERA XT MRI VR EVERAMRIXTVRIEMEM	C1882	SUPPLY/IMPLANTS	"$98,843.00"	Outpatient	"$49,421.50"	Not Applicable	"$54,067.12"	"$65,928.28"	"$39,537.20"	Not Applicable	"$34,595.05"	"$69,190.10"	"$34,595.05"	"$69,190.10"
VISIA AF MRI VR SYSTEM VISIAAFMRIEMEM		STERILE SUPPLY	"$98,843.00"	Outpatient	"$49,421.50"	Not Applicable	"$54,067.12"	"$65,928.28"	"$39,537.20"	Not Applicable	"$34,595.05"	"$69,190.10"	"$34,595.05"	"$69,190.10"
60809-0801-01 - pegloticase 8 mg/mL Soln	J2507	PHARMACY	"$98,789.00"	Outpatient	"$49,394.50"	"$2,849.99"	"$54,037.58"	"$65,892.26"	"$39,515.60"	Not Applicable	"$34,576.15"	"$69,152.30"	"$2,849.99"	"$69,152.30"
STENT GRAFT VAL NAV CS VNMC2525C94TU	C1874	SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
THORACIC STENT GRAFT SYSTEM VALIAN NAVION VNMF2828C97TU	C1874	SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
THORACIC STENT GRAFT SYSTEM VAL NAV CS VNMC2828C90TU VNMC2828C90TU	C1874	SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
DEFIBRILLATOR CARDIAC IMPLANTABLE NEXT GENERATION F/RESYNCHR CD3357-40C CELL	C1882	PACE MAKER	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
21MM WATCHMAN LAA CLOSURE DEVICE M635WU21060		SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
24MM WATCHMAN LAA CLOSURE DEVICE M635WU24060		SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
27MM WATCHMAN LAA CLOSURE DEVICE M635WU27060		SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
30MM WATCHMAN LAA CLOSURE DEVICE M635WU30060		SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
33MM WATCHMAN LAA CLOSURE DEVICE M635WU33060		SUPPLY/IMPLANTS	"$98,757.00"	Outpatient	"$49,378.50"	Not Applicable	"$54,020.08"	"$65,870.92"	"$39,502.80"	Not Applicable	"$34,564.95"	"$69,129.90"	"$34,564.95"	"$69,129.90"
ADVANCED565 ADAVANCED565		STERILE SUPPLY	"$98,744.00"	Outpatient	"$49,372.00"	Not Applicable	"$54,012.97"	"$65,862.25"	"$39,497.60"	Not Applicable	"$34,560.40"	"$69,120.80"	"$34,560.40"	"$69,120.80"
KIT ADVANCEDSURG ADVANCEDSURG		STERILE SUPPLY	"$98,744.00"	Outpatient	"$49,372.00"	Not Applicable	"$54,012.97"	"$65,862.25"	"$39,497.60"	Not Applicable	"$34,560.40"	"$69,120.80"	"$34,560.40"	"$69,120.80"
DFBR CRD ILESTO VR-T 1 CHMBR 383578	C1722	PACE MAKER	"$98,715.00"	Outpatient	"$49,357.50"	Not Applicable	"$53,997.11"	"$65,842.91"	"$39,486.00"	Not Applicable	"$34,550.25"	"$69,100.50"	"$34,550.25"	"$69,100.50"
DFBR CRD ILESTO 7 IMPL 1 CHMBR DF4 LF VR-T STRL 383580	C1722	PACE MAKER	"$98,715.00"	Outpatient	"$49,357.50"	Not Applicable	"$53,997.11"	"$65,842.91"	"$39,486.00"	Not Applicable	"$34,550.25"	"$69,100.50"	"$34,550.25"	"$69,100.50"
SYSTEM ILESTO VR-T DF4 405581	C1722	PACE MAKER	"$98,715.00"	Outpatient	"$49,357.50"	Not Applicable	"$53,997.11"	"$65,842.91"	"$39,486.00"	Not Applicable	"$34,550.25"	"$69,100.50"	"$34,550.25"	"$69,100.50"
DFBR CRD ITREVIA VR-T HOME MNTR DF-4 1 CHMBR THOR IMPDN 412428	C1722	PACE MAKER	"$98,688.00"	Outpatient	"$49,344.00"	Not Applicable	"$53,982.34"	"$65,824.90"	"$39,475.20"	Not Applicable	"$34,540.80"	"$69,081.60"	"$34,540.80"	"$69,081.60"
GFT STNT 100MM 26MM VALIANT EVAS PROX MAIN SECT FREEFLO CLS VAMF2626C100TU	C1884	SUPPLY/IMPLANTS	"$98,668.00"	Outpatient	"$49,334.00"	Not Applicable	"$53,971.40"	"$65,811.56"	"$39,467.20"	Not Applicable	"$34,533.80"	"$69,067.60"	"$34,533.80"	"$69,067.60"
WATCHMAN LAA PROCEDURE DEVICE WMPERPROCDEVICE25		SUPPLY/IMPLANTS	"$98,654.00"	Outpatient	"$49,327.00"	Not Applicable	"$53,963.74"	"$65,802.22"	"$39,461.60"	Not Applicable	"$34,528.90"	"$69,057.80"	"$34,528.90"	"$69,057.80"
CNSL SHVR NS PIEZOELECTRIC SYS 05.001.400.98		STERILE SUPPLY	"$98,653.00"	Outpatient	"$49,326.50"	Not Applicable	"$53,963.19"	"$65,801.55"	"$39,461.20"	Not Applicable	"$34,528.55"	"$69,057.10"	"$34,528.55"	"$69,057.10"
DFBR CRD THK.39IN 2.43X2.69-2.89IN ENERGEN DR LTD ATR VNTRC E142	C1721	PACE MAKER	"$98,623.00"	Outpatient	"$49,311.50"	Not Applicable	"$53,946.78"	"$65,781.54"	"$39,449.20"	Not Applicable	"$34,518.05"	"$69,036.10"	"$34,518.05"	"$69,036.10"
LUMAX 740 VR-T HIGH ENERGY SYSTEM WITH TI WITH LANDLINE 393812	C1722	PACE MAKER	"$98,592.00"	Outpatient	"$49,296.00"	Not Applicable	"$53,929.82"	"$65,760.86"	"$39,436.80"	Not Applicable	"$34,507.20"	"$69,014.40"	"$34,507.20"	"$69,014.40"
DEFIBRILLATOR CARDIAC INOGEN ACUSHOCK EASYVIEW SAFETYCORE 3D G141	C1882	PACE MAKER	"$98,316.00"	Outpatient	"$49,158.00"	Not Applicable	"$53,778.85"	"$65,576.77"	"$39,326.40"	Not Applicable	"$34,410.60"	"$68,821.20"	"$34,410.60"	"$68,821.20"
IMPL CRNL TI PTSPC NS SD420.543	C1713	SUPPLY/IMPLANTS	"$98,031.00"	Outpatient	"$49,015.50"	"$1,365.15"	"$53,622.96"	"$65,386.68"	"$39,212.40"	Not Applicable	"$34,310.85"	"$68,621.70"	"$1,365.15"	"$68,621.70"
MODEL NEUROSTIMULATOR 5.02CML X 6.68CMH RECHARGE-FREE SCS SY 3662	C1820	SUPPLY/IMPLANTS	"$97,031.00"	Outpatient	"$48,515.50"	Not Applicable	"$53,075.96"	"$64,719.68"	"$38,812.40"	Not Applicable	"$33,960.85"	"$67,921.70"	"$33,960.85"	"$67,921.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.550	C1713	SUPPLY/IMPLANTS	"$96,544.00"	Outpatient	"$48,272.00"	"$1,365.15"	"$52,809.57"	"$64,394.85"	"$38,617.60"	Not Applicable	"$33,790.40"	"$67,580.80"	"$1,365.15"	"$67,580.80"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.451	C1713	SUPPLY/IMPLANTS	"$96,380.00"	Outpatient	"$48,190.00"	"$1,365.15"	"$52,719.86"	"$64,285.46"	"$38,552.00"	Not Applicable	"$33,733.00"	"$67,466.00"	"$1,365.15"	"$67,466.00"
COBALT DR MRI CONDITIONAL SAFE DUAL CHAMBER ICD SYSTEM COBALTDRMRIMMEM	C1721	PACE MAKER	"$96,128.00"	Outpatient	"$48,064.00"	Not Applicable	"$52,582.02"	"$64,117.38"	"$38,451.20"	Not Applicable	"$33,644.80"	"$67,289.60"	"$33,644.80"	"$67,289.60"
KIT PRMADVSURG PRMADVSURG		STERILE SUPPLY	"$95,840.00"	Outpatient	"$47,920.00"	Not Applicable	"$52,424.48"	"$63,925.28"	"$38,336.00"	Not Applicable	"$33,544.00"	"$67,088.00"	"$33,544.00"	"$67,088.00"
KIT PRMADV565 PRMADV565		STERILE SUPPLY	"$95,840.00"	Outpatient	"$47,920.00"	Not Applicable	"$52,424.48"	"$63,925.28"	"$38,336.00"	Not Applicable	"$33,544.00"	"$67,088.00"	"$33,544.00"	"$67,088.00"
GFT STNT 150MM 28MM 22FR VALIANT CAPTIVIA SINUSOIDAL STRG VAMC2828C150TU	C1884	SUPPLY/IMPLANTS	"$95,809.00"	Outpatient	"$47,904.50"	Not Applicable	"$52,407.52"	"$63,904.60"	"$38,323.60"	Not Applicable	"$33,533.15"	"$67,066.30"	"$33,533.15"	"$67,066.30"
GFT STNT 155MM 46MM 25FR VALIANT CAPTIVIA SINUSOIDAL STRG VAMC4646C150TU	C1874	SUPPLY/IMPLANTS	"$95,757.00"	Outpatient	"$47,878.50"	Not Applicable	"$52,379.08"	"$63,869.92"	"$38,302.80"	Not Applicable	"$33,514.95"	"$67,029.90"	"$33,514.95"	"$67,029.90"
KIT INTELLIS SENSOR REPLACEMENT 9771IR		NON-STER SUPPLY	"$95,752.00"	Outpatient	"$47,876.00"	Not Applicable	"$52,376.34"	"$63,866.58"	"$38,300.80"	Not Applicable	"$33,513.20"	"$67,026.40"	"$33,513.20"	"$67,026.40"
DFBR CRD THK13MM 57SQ CM 51X66MM EVERA XT SMARTSHOCK DDBB1D1	C1721	PACE MAKER	"$95,491.00"	Outpatient	"$47,745.50"	Not Applicable	"$52,233.58"	"$63,692.50"	"$38,196.40"	Not Applicable	"$33,421.85"	"$66,843.70"	"$33,421.85"	"$66,843.70"
50242-0105-01 - polatuzumab vedotin 140 mg Powd	J9309	PHARMACY	"$79,740.00"	Outpatient	"$39,870.00"	$108.64	"$51,831.00"	"$53,186.58"	"$31,896.00"	Not Applicable	"$27,909.00"	"$55,818.00"	$108.64	"$55,818.00"
GENERATOR NEUROSTIMULATOR PRECISION NOVI SPINAL CORD IMPLANT M365SC11400	C1820	SUPPLY/IMPLANTS	"$94,690.00"	Outpatient	"$47,345.00"	Not Applicable	"$51,795.43"	"$63,158.23"	"$37,876.00"	Not Applicable	"$33,141.50"	"$66,283.00"	"$33,141.50"	"$66,283.00"
IMPL CRNL TI PTSPC NS SD420.545	C1713	SUPPLY/IMPLANTS	"$94,433.00"	Outpatient	"$47,216.50"	"$1,365.15"	"$51,654.85"	"$62,986.81"	"$37,773.20"	Not Applicable	"$33,051.55"	"$66,103.10"	"$1,365.15"	"$66,103.10"
MTRX TISS 20X25CM STRATTICE PRCN DERM FIRM STRL LF DISP 2025002	Q4130	PHARMACY	"$94,381.00"	Outpatient	"$47,190.50"	Not Applicable	"$51,626.41"	"$62,952.13"	"$37,752.40"	Not Applicable	"$33,033.35"	"$66,066.70"	"$33,033.35"	"$66,066.70"
STNT EPTFE FEP NTNL AU 45MM THOR AORTA 20CM CNFRM FLXB TGU454520	C1884	SUPPLY/IMPLANTS	"$94,361.00"	Outpatient	"$47,180.50"	Not Applicable	"$51,615.47"	"$62,938.79"	"$37,744.40"	Not Applicable	"$33,026.35"	"$66,052.70"	"$33,026.35"	"$66,052.70"
STNT EPTFE FEP NTNL AU 31MM THOR AORTA 15CM CNFRM FLXB TGU313115	C1884	SUPPLY/IMPLANTS	"$94,361.00"	Outpatient	"$47,180.50"	Not Applicable	"$51,615.47"	"$62,938.79"	"$37,744.40"	Not Applicable	"$33,026.35"	"$66,052.70"	"$33,026.35"	"$66,052.70"
STNT NTNL FEP EPTFE 34MM THOR AORTA 10CM FLXB RADOPQ GORE TGU343410	C1884	SUPPLY/IMPLANTS	"$94,361.00"	Outpatient	"$47,180.50"	Not Applicable	"$51,615.47"	"$62,938.79"	"$37,744.40"	Not Applicable	"$33,026.35"	"$66,052.70"	"$33,026.35"	"$66,052.70"
STNT NTNL FEP EPTFE 26MM THOR AORTA 10CM FLXB RADOPQ GORE TGU262610	C1884	SUPPLY/IMPLANTS	"$94,361.00"	Outpatient	"$47,180.50"	Not Applicable	"$51,615.47"	"$62,938.79"	"$37,744.40"	Not Applicable	"$33,026.35"	"$66,052.70"	"$33,026.35"	"$66,052.70"
IMPL CRNL TI PTSPC NS SD420.448	C1713	SUPPLY/IMPLANTS	"$93,944.00"	Outpatient	"$46,972.00"	"$1,365.15"	"$51,387.37"	"$62,660.65"	"$37,577.60"	Not Applicable	"$32,880.40"	"$65,760.80"	"$1,365.15"	"$65,760.80"
IMPL CRNL LG CSTM 7850030	C1713	SUPPLY/IMPLANTS	"$93,779.00"	Outpatient	"$46,889.50"	"$1,365.15"	"$51,297.11"	"$62,550.59"	"$37,511.60"	Not Applicable	"$32,822.65"	"$65,645.30"	"$1,365.15"	"$65,645.30"
CRANIAL PEEK CUSTOMIZED COMPLEX MEDIUM 78-10020-1		STERILE SUPPLY	"$93,779.00"	Outpatient	"$46,889.50"	Not Applicable	"$51,297.11"	"$62,550.59"	"$37,511.60"	Not Applicable	"$32,822.65"	"$65,645.30"	"$32,822.65"	"$65,645.30"
CRANIAL CUSTOM IMPLANT 78-10030-1 78-10030-1		SUPPLY/IMPLANTS	"$93,779.00"	Outpatient	"$46,889.50"	Not Applicable	"$51,297.11"	"$62,550.59"	"$37,511.60"	Not Applicable	"$32,822.65"	"$65,645.30"	"$32,822.65"	"$65,645.30"
VISIA AF VR SYSTEM VISIAAFEMEM		STERILE SUPPLY	"$93,617.00"	Outpatient	"$46,808.50"	Not Applicable	"$51,208.50"	"$62,442.54"	"$37,446.80"	Not Applicable	"$32,765.95"	"$65,531.90"	"$32,765.95"	"$65,531.90"
IMPL CRNL TI PTSPC NS SD420.446	C1713	SUPPLY/IMPLANTS	"$93,526.00"	Outpatient	"$46,763.00"	"$1,365.15"	"$51,158.72"	"$62,381.84"	"$37,410.40"	Not Applicable	"$32,734.10"	"$65,468.20"	"$1,365.15"	"$65,468.20"
IMPL CRNL TI PTSPC NS SD420.542	C1713	SUPPLY/IMPLANTS	"$93,421.00"	Outpatient	"$46,710.50"	"$1,365.15"	"$51,101.29"	"$62,311.81"	"$37,368.40"	Not Applicable	"$32,697.35"	"$65,394.70"	"$1,365.15"	"$65,394.70"
PCMKR .75CM 13.7CU CM ESSENTIO PACESAFE RIGHTRATE RYTHMIQ 1 L101	C1785	PACE MAKER	"$93,197.00"	Outpatient	"$46,598.50"	Not Applicable	"$50,978.76"	"$62,162.40"	"$37,278.80"	Not Applicable	"$32,618.95"	"$65,237.90"	"$32,618.95"	"$65,237.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.549	C1713	SUPPLY/IMPLANTS	"$93,104.00"	Outpatient	"$46,552.00"	"$1,365.15"	"$50,927.89"	"$62,100.37"	"$37,241.60"	Not Applicable	"$32,586.40"	"$65,172.80"	"$1,365.15"	"$65,172.80"
GRAFT ENDOVASCULAR RELAYPLUS NITINOL STRAIGHT L200 MM OD34 M 28M334200342490U	C1874	SUPPLY/IMPLANTS	"$92,948.00"	Outpatient	"$46,474.00"	Not Applicable	"$50,842.56"	"$61,996.32"	"$37,179.20"	Not Applicable	"$32,531.80"	"$65,063.60"	"$32,531.80"	"$65,063.60"
GRAFT ENDOVASCULAR 32MM X150MM THORACIC STENT SYSTEM STERILE 28M332155322290U		SUPPLY/IMPLANTS	"$92,948.00"	Outpatient	"$46,474.00"	Not Applicable	"$50,842.56"	"$61,996.32"	"$37,179.20"	Not Applicable	"$32,531.80"	"$65,063.60"	"$32,531.80"	"$65,063.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.450	C1713	SUPPLY/IMPLANTS	"$92,935.00"	Outpatient	"$46,467.50"	"$1,365.15"	"$50,835.45"	"$61,987.65"	"$37,174.00"	Not Applicable	"$32,527.25"	"$65,054.50"	"$1,365.15"	"$65,054.50"
DFBR CRD ANG THK12MM 36J 51X66MM ELLIPSE VR DYNAMICTX CD1411-36Q	C1722	PACE MAKER	"$92,935.00"	Outpatient	"$46,467.50"	Not Applicable	"$50,835.45"	"$61,987.65"	"$37,174.00"	Not Applicable	"$32,527.25"	"$65,054.50"	"$32,527.25"	"$65,054.50"
DFBR CRD THK14MM 40J 40X71MM FORTIFY ASR VR 1 CHMBR DF4 CNCT CD1357-40Q	C1722	PACE MAKER	"$92,935.00"	Outpatient	"$46,467.50"	Not Applicable	"$50,835.45"	"$61,987.65"	"$37,174.00"	Not Applicable	"$32,527.25"	"$65,054.50"	"$32,527.25"	"$65,054.50"
THERASPHERE YTTRIUM 90 YTTRIUM-90	C2616	SUPPLY/IMPLANTS	"$92,891.00"	Outpatient	"$46,445.50"	"$77,955.90"	"$50,811.38"	"$61,958.30"	"$37,156.40"	Not Applicable	"$32,511.85"	"$65,023.70"	"$32,511.85"	"$77,955.90"
DFBR CRD THK14MM 40J NAR 40X71MM FORTIFY ASR VR SECURESENSE CD1257-40Q	C1722	PACE MAKER	"$92,821.00"	Outpatient	"$46,410.50"	Not Applicable	"$50,773.09"	"$61,911.61"	"$37,128.40"	Not Applicable	"$32,487.35"	"$64,974.70"	"$32,487.35"	"$64,974.70"
DEV EMBL 35MM 3.5MM PIPELINE FLX 75% COCR 25% PLTN TUNG PED-350-35	C1874	SUPPLY/IMPLANTS	"$92,803.00"	Outpatient	"$46,401.50"	Not Applicable	"$50,763.24"	"$61,899.60"	"$37,121.20"	Not Applicable	"$32,481.05"	"$64,962.10"	"$32,481.05"	"$64,962.10"
DFBR CRD 13MM 57SQ CM 51X68MM EVERA MRI XT DR SURESCAN DDMB1D4	C1882	SUPPLY/IMPLANTS	"$92,475.00"	Outpatient	"$46,237.50"	Not Applicable	"$50,583.83"	"$61,680.83"	"$36,990.00"	Not Applicable	"$32,366.25"	"$64,732.50"	"$32,366.25"	"$64,732.50"
DFBR CRD EVERA MRI SURESCAN DF-1 PIN PLG XT DR DDMB1D1	C1721	PACE MAKER	"$92,455.00"	Outpatient	"$46,227.50"	Not Applicable	"$50,572.89"	"$61,667.49"	"$36,982.00"	Not Applicable	"$32,359.25"	"$64,718.50"	"$32,359.25"	"$64,718.50"
STNT EPTFE FEP NTNL AU 40MM THOR AORTA 15CM CNFRM FLXB TGU404015	C1884	SUPPLY/IMPLANTS	"$92,209.00"	Outpatient	"$46,104.50"	Not Applicable	"$50,438.32"	"$61,503.40"	"$36,883.60"	Not Applicable	"$32,273.15"	"$64,546.30"	"$32,273.15"	"$64,546.30"
STNT EPTFE FEP NTNL AU 40MM THOR AORTA 10CM CNFRM FLXB TGU404010	C1884	SUPPLY/IMPLANTS	"$92,209.00"	Outpatient	"$46,104.50"	Not Applicable	"$50,438.32"	"$61,503.40"	"$36,883.60"	Not Applicable	"$32,273.15"	"$64,546.30"	"$32,273.15"	"$64,546.30"
DFBR CRD THK15MM 51X64MM PROTECTA XT VR VNTRC 1 CHMBR 1IS-1 D314VRG	C1722	PACE MAKER	"$92,188.00"	Outpatient	"$46,094.00"	Not Applicable	"$50,426.84"	"$61,489.40"	"$36,875.20"	Not Applicable	"$32,265.80"	"$64,531.60"	"$32,265.80"	"$64,531.60"
STNT NTNL FEP EPTFE 28MM THOR AORTA 15CM FLXB RADOPQ GORE TGU282815	C1874	SUPPLY/IMPLANTS	"$92,184.00"	Outpatient	"$46,092.00"	Not Applicable	"$50,424.65"	"$61,486.73"	"$36,873.60"	Not Applicable	"$32,264.40"	"$64,528.80"	"$32,264.40"	"$64,528.80"
STNT EPTFE FEP NTNL AU 37MM THOR AORTA 10CM CNFRM FLXB TGU373710	C1884	SUPPLY/IMPLANTS	"$92,184.00"	Outpatient	"$46,092.00"	Not Applicable	"$50,424.65"	"$61,486.73"	"$36,873.60"	Not Applicable	"$32,264.40"	"$64,528.80"	"$32,264.40"	"$64,528.80"
STNT EPTFE FEP NTNL AU 40MM THOR AORTA 20CM CNFRM FLXB TGU404020	C1884	SUPPLY/IMPLANTS	"$92,184.00"	Outpatient	"$46,092.00"	Not Applicable	"$50,424.65"	"$61,486.73"	"$36,873.60"	Not Applicable	"$32,264.40"	"$64,528.80"	"$32,264.40"	"$64,528.80"
STNT NTNL FEP EPTFE 28MM THOR AORTA 10CM FLXB RADOPQ GORE TGU282810	C1884	SUPPLY/IMPLANTS	"$92,184.00"	Outpatient	"$46,092.00"	Not Applicable	"$50,424.65"	"$61,486.73"	"$36,873.60"	Not Applicable	"$32,264.40"	"$64,528.80"	"$32,264.40"	"$64,528.80"
DFBR CRD EVERA S VR 1 CHMBR ICD DF4 SMARTSHOCK TCH DVBC3D4	C1722	PACE MAKER	"$92,125.00"	Outpatient	"$46,062.50"	Not Applicable	"$50,392.38"	"$61,447.38"	"$36,850.00"	Not Applicable	"$32,243.75"	"$64,487.50"	"$32,243.75"	"$64,487.50"
DFBR CRD EVERA S VR 2 CHMBR ICD DF-1 SMARTSHOCK TCH DVBC3D1	C1721	PACE MAKER	"$92,125.00"	Outpatient	"$46,062.50"	Not Applicable	"$50,392.38"	"$61,447.38"	"$36,850.00"	Not Applicable	"$32,243.75"	"$64,487.50"	"$32,243.75"	"$64,487.50"
Insertion of Single or Dual Chamber ICD Pulse Gene	33240	CARDIAC CATH LAB	"$92,115.00"	Outpatient	"$46,057.50"	"$85,301.79"	"$50,386.91"	"$1,592.00"	"$36,846.00"	"$23,583.00"	"$32,240.25"	"$64,480.50"	"$1,592.00"	"$85,301.79"
DFBR CRD LUMAX 740 DR-T 2 CHMBR CARDVRT LANDLINE HOME MNTR 365606	C1721	PACE MAKER	"$92,089.00"	Outpatient	"$46,044.50"	Not Applicable	"$50,372.68"	"$61,423.36"	"$36,835.60"	Not Applicable	"$32,231.15"	"$64,462.30"	"$32,231.15"	"$64,462.30"
IMPL CRNL TI PTSPC NS SD420.443	C1713	SUPPLY/IMPLANTS	"$91,832.00"	Outpatient	"$45,916.00"	"$1,365.15"	"$50,232.10"	"$61,251.94"	"$36,732.80"	Not Applicable	"$32,141.20"	"$64,282.40"	"$1,365.15"	"$64,282.40"
GFT STNT 112MM 22MM 22FR VALIANT CAPTIVIA SINUSOIDAL STRG VAMF2222C100TU	C1884	SUPPLY/IMPLANTS	"$91,761.00"	Outpatient	"$45,880.50"	Not Applicable	"$50,193.27"	"$61,204.59"	"$36,704.40"	Not Applicable	"$32,116.35"	"$64,232.70"	"$32,116.35"	"$64,232.70"
STENT GRAFT WITH CAPTIVIA THORACIC VAMF4242C100TU	C1784	SUPPLY/IMPLANTS	"$91,721.00"	Outpatient	"$45,860.50"	Not Applicable	"$50,171.39"	"$61,177.91"	"$36,688.40"	Not Applicable	"$32,102.35"	"$64,204.70"	"$32,102.35"	"$64,204.70"
GFT STNT 100MM 30MM 30MM VALIANT STRG EVAS HDRPH SYS VAMF3030C100TU	C1784	SUPPLY/IMPLANTS	"$91,709.00"	Outpatient	"$45,854.50"	Not Applicable	"$50,164.82"	"$61,169.90"	"$36,683.60"	Not Applicable	"$32,098.15"	"$64,196.30"	"$32,098.15"	"$64,196.30"
DFBR CRD ITREVIA 7 DR-T 392412	C1882	PACE MAKER	"$91,701.00"	Outpatient	"$45,850.50"	Not Applicable	"$50,160.45"	"$61,164.57"	"$36,680.40"	Not Applicable	"$32,095.35"	"$64,190.70"	"$32,095.35"	"$64,190.70"
DFBR CRD THK13MM 66X55MM ILESTO VR-T TI 1 LD 2 CHMBR IS-1 383562	C1721	PACE MAKER	"$91,694.00"	Outpatient	"$45,847.00"	Not Applicable	"$50,156.62"	"$61,159.90"	"$36,677.60"	Not Applicable	"$32,092.90"	"$64,185.80"	"$32,092.90"	"$64,185.80"
IMPL CRNL TI PTSPC NS SD420.538	C1713	SUPPLY/IMPLANTS	"$91,110.00"	Outpatient	"$45,555.00"	"$1,365.15"	"$49,837.17"	"$60,770.37"	"$36,444.00"	Not Applicable	"$31,888.50"	"$63,777.00"	"$1,365.15"	"$63,777.00"
DFBR CRD THK14MM 40J 40X71MM FORTIFY VR TI 1 CHMBR DF-4 RF CD1231-40Q	C1898	PACE MAKER	"$91,109.00"	Outpatient	"$45,554.50"	Not Applicable	"$49,836.62"	"$60,769.70"	"$36,443.60"	Not Applicable	"$31,888.15"	"$63,776.30"	"$31,888.15"	"$63,776.30"
DFBR CRD THK.39IN 2.43X2.69-2.89IN ENERGEN VR LTD VNTRC 1 E140	C1722	PACE MAKER	"$91,080.00"	Outpatient	"$45,540.00"	Not Applicable	"$49,820.76"	"$60,750.36"	"$36,432.00"	Not Applicable	"$31,878.00"	"$63,756.00"	"$31,878.00"	"$63,756.00"
IMPL CRNL LG CSTM 54440300		SUPPLY/IMPLANTS	"$90,993.00"	Outpatient	"$45,496.50"	Not Applicable	"$49,773.17"	"$60,692.33"	"$36,397.20"	Not Applicable	"$31,847.55"	"$63,695.10"	"$31,847.55"	"$63,695.10"
FORTIFY ASSURA NEXT GENERATION DR-ICD DF4 SYS MERLIN CD2357-40Q SYSCELL	C1721	PACE MAKER	"$90,384.00"	Outpatient	"$45,192.00"	Not Applicable	"$49,440.05"	"$60,286.13"	"$36,153.60"	Not Applicable	"$31,634.40"	"$63,268.80"	"$31,634.40"	"$63,268.80"
DEFIBRILLATOR CARDIAC INOGEN EASYVIEW ACUSHOCK SAFETYCORE D. 8F62	C1721	PACE MAKER	"$90,299.00"	Outpatient	"$45,149.50"	Not Applicable	"$49,393.55"	"$60,229.43"	"$36,119.60"	Not Applicable	"$31,604.65"	"$63,209.30"	"$31,604.65"	"$63,209.30"
INOGEN EL DR DF4 (1 LD) 8F63	C1721	SUPPLY/IMPLANTS	"$90,299.00"	Outpatient	"$45,149.50"	Not Applicable	"$49,393.55"	"$60,229.43"	"$36,119.60"	Not Applicable	"$31,604.65"	"$63,209.30"	"$31,604.65"	"$63,209.30"
DYNAGEN EL DR DF4 (2 LD) 8D62	C1721	PACE MAKER	"$90,205.00"	Outpatient	"$45,102.50"	Not Applicable	"$49,342.14"	"$60,166.74"	"$36,082.00"	Not Applicable	"$31,571.75"	"$63,143.50"	"$31,571.75"	"$63,143.50"
ICD DYNAGEN EL DR 8D6A	C1721	PACE MAKER	"$90,205.00"	Outpatient	"$45,102.50"	Not Applicable	"$49,342.14"	"$60,166.74"	"$36,082.00"	Not Applicable	"$31,571.75"	"$63,143.50"	"$31,571.75"	"$63,143.50"
ENDURANT II 3-PIECE CASE ENDURANTII3	C1874	SUPPLY/IMPLANTS	"$90,043.00"	Outpatient	"$45,021.50"	Not Applicable	"$49,253.52"	"$60,058.68"	"$36,017.20"	Not Applicable	"$31,515.05"	"$63,030.10"	"$31,515.05"	"$63,030.10"
DFBR CRD .99CM MN 5.23X7.03CM INOGEN EASYVIEW RV RT ATR HDR D012	C1721	PACE MAKER	"$90,032.00"	Outpatient	"$45,016.00"	Not Applicable	"$49,247.50"	"$60,051.34"	"$36,012.80"	Not Applicable	"$31,511.20"	"$63,022.40"	"$31,511.20"	"$63,022.40"
STNT EPTFE FEP NTNL AU 34MM THOR AORTA 20CM CNFRM FLXB TGU343420	C1884	SUPPLY/IMPLANTS	"$90,032.00"	Outpatient	"$45,016.00"	Not Applicable	"$49,247.50"	"$60,051.34"	"$36,012.80"	Not Applicable	"$31,511.20"	"$63,022.40"	"$31,511.20"	"$63,022.40"
DFBR CRD THK12MM 36J ANG 51X68MM ELLIPSE VR DYNAMICTX CD1411-36C	C1820	SUPPLY/IMPLANTS	"$90,032.00"	Outpatient	"$45,016.00"	Not Applicable	"$49,247.50"	"$60,051.34"	"$36,012.80"	Not Applicable	"$31,511.20"	"$63,022.40"	"$31,511.20"	"$63,022.40"
INOGEN MINI DR DF4X4 SITE G ATRIAL 8F2A	C1721	PACE MAKER	"$89,990.00"	Outpatient	"$44,995.00"	Not Applicable	"$49,224.53"	"$60,023.33"	"$35,996.00"	Not Applicable	"$31,496.50"	"$62,993.00"	"$31,496.50"	"$62,993.00"
GFT STNT 103MM 14-32MM 20FR ENDURANT IIS 2 BRCH INFRARENAL ESBF3214C103E	C1884	SUPPLY/IMPLANTS	"$89,990.00"	Outpatient	"$44,995.00"	Not Applicable	"$49,224.53"	"$60,023.33"	"$35,996.00"	Not Applicable	"$31,496.50"	"$62,993.00"	"$31,496.50"	"$62,993.00"
GFT STNT 199MM 16-16MM 16FR ENDURANT II EVAS NTNL PLSTR ETLW1616C199E	C1884	SUPPLY/IMPLANTS	"$89,990.00"	Outpatient	"$44,995.00"	Not Applicable	"$49,224.53"	"$60,023.33"	"$35,996.00"	Not Applicable	"$31,496.50"	"$62,993.00"	"$31,496.50"	"$62,993.00"
STNT EPTFE FEP NTNL AU 45MM THOR AORTA 15CM CNFRM FLXB TGU454515	C1884	SUPPLY/IMPLANTS	"$89,981.00"	Outpatient	"$44,990.50"	Not Applicable	"$49,219.61"	"$60,017.33"	"$35,992.40"	Not Applicable	"$31,493.35"	"$62,986.70"	"$31,493.35"	"$62,986.70"
STNT EPTFE FEP NTNL AU 37MM THOR AORTA 15CM CNFRM FLXB TGU373715	C1884	SUPPLY/IMPLANTS	"$89,981.00"	Outpatient	"$44,990.50"	Not Applicable	"$49,219.61"	"$60,017.33"	"$35,992.40"	Not Applicable	"$31,493.35"	"$62,986.70"	"$31,493.35"	"$62,986.70"
DEVICE NEURO STIM IMPLANTABLE 47.2MMWX57.1MML SMALL 97715	C1767	SUPPLY/IMPLANTS	"$89,949.00"	Outpatient	"$44,974.50"	Not Applicable	"$49,202.10"	"$59,995.98"	"$35,979.60"	Not Applicable	"$31,482.15"	"$62,964.30"	"$31,482.15"	"$62,964.30"
COIL EMBOLIZATION PIPELINE FLEX 4.25MM X 25MM PED-425-25		SUPPLY/IMPLANTS	"$89,891.00"	Outpatient	"$44,945.50"	Not Applicable	"$49,170.38"	"$59,957.30"	"$35,956.40"	Not Applicable	"$31,461.85"	"$62,923.70"	"$31,461.85"	"$62,923.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.547	C1713	SUPPLY/IMPLANTS	"$89,660.00"	Outpatient	"$44,830.00"	"$1,365.15"	"$49,044.02"	"$59,803.22"	"$35,864.00"	Not Applicable	"$31,381.00"	"$62,762.00"	"$1,365.15"	"$62,762.00"
DEVICE EMBOLIZATION PIPELINE FLEX L16 MM OD4 MM NEUROVASCULA PED-400-16		SUPPLY/IMPLANTS	"$89,636.00"	Outpatient	"$44,818.00"	Not Applicable	"$49,030.89"	"$59,787.21"	"$35,854.40"	Not Applicable	"$31,372.60"	"$62,745.20"	"$31,372.60"	"$62,745.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.449	C1713	SUPPLY/IMPLANTS	"$89,502.00"	Outpatient	"$44,751.00"	"$1,365.15"	"$48,957.59"	"$59,697.83"	"$35,800.80"	Not Applicable	"$31,325.70"	"$62,651.40"	"$1,365.15"	"$62,651.40"
DFBR CRD .99CM THN 5.37X7.36CM INOGEN ENDURALIFE EASYVIEW D140	C1722	PACE MAKER	"$89,193.00"	Outpatient	"$44,596.50"	Not Applicable	"$48,788.57"	"$59,491.73"	"$35,677.20"	Not Applicable	"$31,217.55"	"$62,435.10"	"$31,217.55"	"$62,435.10"
GFT SNTH TISS MDPR CSTM MDFC 54440510		SUPPLY/IMPLANTS	"$89,053.00"	Outpatient	"$44,526.50"	Not Applicable	"$48,711.99"	"$59,398.35"	"$35,621.20"	Not Applicable	"$31,168.55"	"$62,337.10"	"$31,168.55"	"$62,337.10"
IMPL CRNL TI PTSPC NS SD420.541	C1713	SUPPLY/IMPLANTS	"$88,944.00"	Outpatient	"$44,472.00"	"$1,365.15"	"$48,652.37"	"$59,325.65"	"$35,577.60"	Not Applicable	"$31,130.40"	"$62,260.80"	"$1,365.15"	"$62,260.80"
"ICD DF4 SYS, MERLIN PKG ELPS NEXT GEN CD1411-36Q SYSCELL"	C1722	PACE MAKER	"$88,499.00"	Outpatient	"$44,249.50"	Not Applicable	"$48,408.95"	"$59,028.83"	"$35,399.60"	Not Applicable	"$30,974.65"	"$61,949.30"	"$30,974.65"	"$61,949.30"
SYSTEM DEFIBRILLATOR 51MM X 66 X 12 CD1411-36Q SYSTEM	C1882	SUPPLY/IMPLANTS	"$88,499.00"	Outpatient	"$44,249.50"	Not Applicable	"$48,408.95"	"$59,028.83"	"$35,399.60"	Not Applicable	"$30,974.65"	"$61,949.30"	"$30,974.65"	"$61,949.30"
NRSTM PRIMEADVANCED SURESCAN IMPL MRI 97702	C1767	SUPPLY/IMPLANTS	"$88,474.00"	Outpatient	"$44,237.00"	Not Applicable	"$48,395.28"	"$59,012.16"	"$35,389.60"	Not Applicable	"$30,965.90"	"$61,931.80"	"$30,965.90"	"$61,931.80"
IMPL CRNL TI PTSPC NS SD420.445	C1713	SUPPLY/IMPLANTS	"$88,229.00"	Outpatient	"$44,114.50"	"$1,365.15"	"$48,261.26"	"$58,848.74"	"$35,291.60"	Not Applicable	"$30,880.15"	"$61,760.30"	"$1,365.15"	"$61,760.30"
STENT ENDOPROSTHESIS GORE TAG EPTFE FEP NITINOL GOLD L20 CM TGU373720	C1874	SUPPLY/IMPLANTS	"$87,836.00"	Outpatient	"$43,918.00"	Not Applicable	"$48,046.29"	"$58,586.61"	"$35,134.40"	Not Applicable	"$30,742.60"	"$61,485.20"	"$30,742.60"	"$61,485.20"
STNT EPTFE FEP NTNL AU 34MM THOR AORTA 15CM CNFRM FLXB TGU343415	C1884	SUPPLY/IMPLANTS	"$87,781.00"	Outpatient	"$43,890.50"	Not Applicable	"$48,016.21"	"$58,549.93"	"$35,112.40"	Not Applicable	"$30,723.35"	"$61,446.70"	"$30,723.35"	"$61,446.70"
STNT NTNL FEP EPTFE 31MM THOR AORTA 10CM FLXB RADOPQ GORE TGU313110	C1876	SUPPLY/IMPLANTS	"$87,781.00"	Outpatient	"$43,890.50"	Not Applicable	"$48,016.21"	"$58,549.93"	"$35,112.40"	Not Applicable	"$30,723.35"	"$61,446.70"	"$30,723.35"	"$61,446.70"
STNT EPTFE FEP NTNL AU 45MM THOR AORTA 10CM CNFRM FLXB TGU454510	C1884	SUPPLY/IMPLANTS	"$87,714.00"	Outpatient	"$43,857.00"	Not Applicable	"$47,979.56"	"$58,505.24"	"$35,085.60"	Not Applicable	"$30,699.90"	"$61,399.80"	"$30,699.90"	"$61,399.80"
VIGILANT EL DR DF4 2ID ICD 8TV1	C1882	PACE MAKER	"$87,592.00"	Outpatient	"$43,796.00"	Not Applicable	"$47,912.82"	"$58,423.86"	"$35,036.80"	Not Applicable	"$30,657.20"	"$61,314.40"	"$30,657.20"	"$61,314.40"
IMPL CRNL TI PTSPC NS SD420.544	C1713	SUPPLY/IMPLANTS	"$87,449.00"	Outpatient	"$43,724.50"	"$1,365.15"	"$47,834.60"	"$58,328.48"	"$34,979.60"	Not Applicable	"$30,607.15"	"$61,214.30"	"$1,365.15"	"$61,214.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.548	C1713	SUPPLY/IMPLANTS	"$87,367.00"	Outpatient	"$43,683.50"	"$1,365.15"	"$47,789.75"	"$58,273.79"	"$34,946.80"	Not Applicable	"$30,578.45"	"$61,156.90"	"$1,365.15"	"$61,156.90"
IMPL CRNL TI PTSPC NS SD420.537	C1713	SUPPLY/IMPLANTS	"$87,340.00"	Outpatient	"$43,670.00"	"$1,365.15"	"$47,774.98"	"$58,255.78"	"$34,936.00"	Not Applicable	"$30,569.00"	"$61,138.00"	"$1,365.15"	"$61,138.00"
VIGILANT EL VR DF4 1 LD 8TV3	C1882	PACE MAKER	"$87,284.00"	Outpatient	"$43,642.00"	Not Applicable	"$47,744.35"	"$58,218.43"	"$34,913.60"	Not Applicable	"$30,549.40"	"$61,098.80"	"$30,549.40"	"$61,098.80"
DEFIBRILLATOR CARDIAC INTICA DX PROMRI CLS HOME MONITORING H 431737	C1882	SUPPLY/IMPLANTS	"$87,272.00"	Outpatient	"$43,636.00"	Not Applicable	"$47,737.78"	"$58,210.42"	"$34,908.80"	Not Applicable	"$30,545.20"	"$61,090.40"	"$30,545.20"	"$61,090.40"
IMPL CRNL TI PTSPC NS SD420.442	C1713	SUPPLY/IMPLANTS	"$87,232.00"	Outpatient	"$43,616.00"	"$1,365.15"	"$47,715.90"	"$58,183.74"	"$34,892.80"	Not Applicable	"$30,531.20"	"$61,062.40"	"$1,365.15"	"$61,062.40"
ICD COBALT DR MRI IS1 DF4 DDPB3D4	C1721	PACE MAKER	"$87,144.00"	Outpatient	"$43,572.00"	Not Applicable	"$47,667.77"	"$58,125.05"	"$34,857.60"	Not Applicable	"$30,500.40"	"$61,000.80"	"$30,500.40"	"$61,000.80"
PACEMAKER CARDIAC COBALT DR 2 CHAMBER DF-1 PIN PLUG RADIOPAQ DDPB3D1	C1721	PACE MAKER	"$87,144.00"	Outpatient	"$43,572.00"	Not Applicable	"$47,667.77"	"$58,125.05"	"$34,857.60"	Not Applicable	"$30,500.40"	"$61,000.80"	"$30,500.40"	"$61,000.80"
DFBR CRD THK.39IN SM 2.43X2.93IN ENERGEN DR LTD ATR VNTRC 2 E143	C1721	PACE MAKER	"$87,102.00"	Outpatient	"$43,551.00"	Not Applicable	"$47,644.79"	"$58,097.03"	"$34,840.80"	Not Applicable	"$30,485.70"	"$60,971.40"	"$30,485.70"	"$60,971.40"
DFBR CRD THK13MM 51X66MM PHYSIOCURVE EVERA XT VR SMARTSHOCK DVBB1D1	C1722	PACE MAKER	"$86,838.00"	Outpatient	"$43,419.00"	Not Applicable	"$47,500.39"	"$57,920.95"	"$34,735.20"	Not Applicable	"$30,393.30"	"$60,786.60"	"$30,393.30"	"$60,786.60"
Insertion Single/Dual Cham Pulse Generator  Leads	33249	CARDIAC CATH LAB	"$86,809.00"	Outpatient	"$43,404.50"	"$69,218.83"	"$47,484.52"	"$1,592.00"	"$34,723.60"	"$23,583.00"	"$30,383.15"	"$60,766.30"	"$1,592.00"	"$69,218.83"
50242-0150-01 - ocrelizumab 300 mg/10 mL Soln	J2350	PHARMACY	"$86,385.00"	Outpatient	"$43,192.50"	$55.58	"$47,252.60"	"$57,618.80"	"$34,554.00"	Not Applicable	"$30,234.75"	"$60,469.50"	$55.58	"$60,469.50"
DFBR CRD LUMAX 740 VR-T 1 CHMBR 393811	C1722	PACE MAKER	"$86,260.00"	Outpatient	"$43,130.00"	Not Applicable	"$47,184.22"	"$57,535.42"	"$34,504.00"	Not Applicable	"$30,191.00"	"$60,382.00"	"$30,191.00"	"$60,382.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.447	C1713	SUPPLY/IMPLANTS	"$86,053.00"	Outpatient	"$43,026.50"	"$1,365.15"	"$47,070.99"	"$57,397.35"	"$34,421.20"	Not Applicable	"$30,118.55"	"$60,237.10"	"$1,365.15"	"$60,237.10"
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC DRG 466 DRG 466SN	C1713	SUPPLY/IMPLANTS	"$85,964.00"	Outpatient	"$42,982.00"	"$1,365.15"	"$47,022.31"	"$57,337.99"	"$34,385.60"	Not Applicable	"$30,087.40"	"$60,174.80"	"$1,365.15"	"$60,174.80"
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC DRG 466 DRG 466ZB	C1713	SUPPLY/IMPLANTS	"$85,964.00"	Outpatient	"$42,982.00"	"$1,365.15"	"$47,022.31"	"$57,337.99"	"$34,385.60"	Not Applicable	"$30,087.40"	"$60,174.80"	"$1,365.15"	"$60,174.80"
REVISION OF HIP OR KNEE REPLACEMENT WITH MCC DRG 466 DRG 466DS	C1713	SUPPLY/IMPLANTS	"$85,964.00"	Outpatient	"$42,982.00"	"$1,365.15"	"$47,022.31"	"$57,337.99"	"$34,385.60"	Not Applicable	"$30,087.40"	"$60,174.80"	"$1,365.15"	"$60,174.80"
DFBR CRD ITREVIA 7 VR-T 393040	C1722	PACE MAKER	"$85,913.00"	Outpatient	"$42,956.50"	Not Applicable	"$46,994.41"	"$57,303.97"	"$34,365.20"	Not Applicable	"$30,069.55"	"$60,139.10"	"$30,069.55"	"$60,139.10"
SPINOUS PROCESS CLAMP ASSEMBLY 35-40MM B24001-135		STERILE SUPPLY	"$85,848.00"	Outpatient	"$42,924.00"	Not Applicable	"$46,958.86"	"$57,260.62"	"$34,339.20"	Not Applicable	"$30,046.80"	"$60,093.60"	"$30,046.80"	"$60,093.60"
DEFIBRILLATOR CARDIAC DYNAGEN ACUSHOCK EASYVIEW SAFETYCORE D G151	C1882	PACE MAKER	"$85,597.00"	Outpatient	"$42,798.50"	Not Applicable	"$46,821.56"	"$57,093.20"	"$34,238.80"	Not Applicable	"$29,958.95"	"$59,917.90"	"$29,958.95"	"$59,917.90"
DFBR CRD EVERA MRI S DR SURESCAN 2 CHMBR ICD DDMC3D4	C1882	SUPPLY/IMPLANTS	"$85,581.00"	Outpatient	"$42,790.50"	Not Applicable	"$46,812.81"	"$57,082.53"	"$34,232.40"	Not Applicable	"$29,953.35"	"$59,906.70"	"$29,953.35"	"$59,906.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.546	C1713	SUPPLY/IMPLANTS	"$85,072.00"	Outpatient	"$42,536.00"	"$1,365.15"	"$46,534.38"	"$56,743.02"	"$34,028.80"	Not Applicable	"$29,775.20"	"$59,550.40"	"$1,365.15"	"$59,550.40"
IMPL CRNL TI PTSPC NS SD420.438	C1713	SUPPLY/IMPLANTS	"$84,938.00"	Outpatient	"$42,469.00"	"$1,365.15"	"$46,461.09"	"$56,653.65"	"$33,975.20"	Not Applicable	"$29,728.30"	"$59,456.60"	"$1,365.15"	"$59,456.60"
GRAFT CAGE LONG BONE STERILE TRUMATCH SD900.501S	C1713	SUPPLY/IMPLANTS	"$84,600.00"	Outpatient	"$42,300.00"	"$1,365.15"	"$46,276.20"	"$56,428.20"	"$33,840.00"	Not Applicable	"$29,610.00"	"$59,220.00"	"$1,365.15"	"$59,220.00"
IMPL CRNL TI PTSPC NS SD420.532	C1713	SUPPLY/IMPLANTS	"$84,483.00"	Outpatient	"$42,241.50"	"$1,365.15"	"$46,212.20"	"$56,350.16"	"$33,793.20"	Not Applicable	"$29,569.05"	"$59,138.10"	"$1,365.15"	"$59,138.10"
DFBR CRD IPERIA 7 PROMRI DF-4 IS-1 CNCT DR-T STRL 392423	C1721	PACE MAKER	"$84,425.00"	Outpatient	"$42,212.50"	Not Applicable	"$46,180.48"	"$56,311.48"	"$33,770.00"	Not Applicable	"$29,548.75"	"$59,097.50"	"$29,548.75"	"$59,097.50"
IMPLANT POULLARD BI FRONTAL 202234-001 PK620796		STERILE SUPPLY	"$84,135.00"	Outpatient	"$42,067.50"	Not Applicable	"$46,021.85"	"$56,118.05"	"$33,654.00"	Not Applicable	"$29,447.25"	"$58,894.50"	"$29,447.25"	"$58,894.50"
DFBR CRD IPERIA 7 VR-T DX IMPL HOME MNTR PROMRI 393032	C1898	PACE MAKER	"$83,892.00"	Outpatient	"$41,946.00"	Not Applicable	"$45,888.92"	"$55,955.96"	"$33,556.80"	Not Applicable	"$29,362.20"	"$58,724.40"	"$29,362.20"	"$58,724.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.448	C1713	SUPPLY/IMPLANTS	"$83,763.00"	Outpatient	"$41,881.50"	"$1,365.15"	"$45,818.36"	"$55,869.92"	"$33,505.20"	Not Applicable	"$29,317.05"	"$58,634.10"	"$1,365.15"	"$58,634.10"
DFBR CRD .99CM 5.37X7.79CM DYNAGEN ENDURALIFE EASYVIEW HF D153	C1721	PACE MAKER	"$83,601.00"	Outpatient	"$41,800.50"	Not Applicable	"$45,729.75"	"$55,761.87"	"$33,440.40"	Not Applicable	"$29,260.35"	"$58,520.70"	"$29,260.35"	"$58,520.70"
IMPL CRNL TI PTSPC NS SD420.536	C1713	SUPPLY/IMPLANTS	"$83,574.00"	Outpatient	"$41,787.00"	"$1,365.15"	"$45,714.98"	"$55,743.86"	"$33,429.60"	Not Applicable	"$29,250.90"	"$58,501.80"	"$1,365.15"	"$58,501.80"
IPG AND CHARGER KIT SC-1010C		STERILE SUPPLY	"$83,234.00"	Outpatient	"$41,617.00"	Not Applicable	"$45,529.00"	"$55,517.08"	"$33,293.60"	Not Applicable	"$29,131.90"	"$58,263.80"	"$29,131.90"	"$58,263.80"
IMPL CRNL TI CSTM PTSPC NS SD420.540	C1713	SUPPLY/IMPLANTS	"$82,829.00"	Outpatient	"$41,414.50"	"$1,365.15"	"$45,307.46"	"$55,246.94"	"$33,131.60"	Not Applicable	"$28,990.15"	"$57,980.30"	"$1,365.15"	"$57,980.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.543	C1713	SUPPLY/IMPLANTS	"$82,779.00"	Outpatient	"$41,389.50"	"$1,365.15"	"$45,280.11"	"$55,213.59"	"$33,111.60"	Not Applicable	"$28,972.65"	"$57,945.30"	"$1,365.15"	"$57,945.30"
IMPL CRNL TI PTSPC NS SD420.441	C1713	SUPPLY/IMPLANTS	"$82,751.00"	Outpatient	"$41,375.50"	"$1,365.15"	"$45,264.80"	"$55,194.92"	"$33,100.40"	Not Applicable	"$28,962.85"	"$57,925.70"	"$1,365.15"	"$57,925.70"
DFBR CRD 66X51X13MM VISIA AF MRI SURESCAN DVFB1D1	C1722	PACE MAKER	"$82,364.00"	Outpatient	"$41,182.00"	Not Applicable	"$45,053.11"	"$54,936.79"	"$32,945.60"	Not Applicable	"$28,827.40"	"$57,654.80"	"$28,827.40"	"$57,654.80"
CLAMP BRIDGEPOINT SPINOUS PROCESS DS24001-145	C1713	SUPPLY/IMPLANTS	"$81,737.00"	Outpatient	"$40,868.50"	"$1,365.15"	"$44,710.14"	"$54,518.58"	"$32,694.80"	Not Applicable	"$28,607.95"	"$57,215.90"	"$1,365.15"	"$57,215.90"
SPINOUS ACCESS CLAMP ASSEMBLY 40-45MM B24001-140	C1713	SUPPLY/IMPLANTS	"$81,737.00"	Outpatient	"$40,868.50"	"$1,365.15"	"$44,710.14"	"$54,518.58"	"$32,694.80"	Not Applicable	"$28,607.95"	"$57,215.90"	"$1,365.15"	"$57,215.90"
SPINOUS PROCESS CLAMP ASSEMBLY 40-50MM DS24001-140D	C1713	SUPPLY/IMPLANTS	"$81,684.00"	Outpatient	"$40,842.00"	"$1,365.15"	"$44,681.15"	"$54,483.23"	"$32,673.60"	Not Applicable	"$28,589.40"	"$57,178.80"	"$1,365.15"	"$57,178.80"
SPINOUS PROCESS CLAMP ASSEMBLY 35-40MM DS24001-135D	C1713	SUPPLY/IMPLANTS	"$81,684.00"	Outpatient	"$40,842.00"	"$1,365.15"	"$44,681.15"	"$54,483.23"	"$32,673.60"	Not Applicable	"$28,589.40"	"$57,178.80"	"$1,365.15"	"$57,178.80"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.446	C1713	SUPPLY/IMPLANTS	"$81,465.00"	Outpatient	"$40,732.50"	"$1,365.15"	"$44,561.36"	"$54,337.16"	"$32,586.00"	Not Applicable	"$28,512.75"	"$57,025.50"	"$1,365.15"	"$57,025.50"
IMPL CRNL TI PTSPC NS SD420.531	C1713	SUPPLY/IMPLANTS	"$81,417.00"	Outpatient	"$40,708.50"	"$1,365.15"	"$44,535.10"	"$54,305.14"	"$32,566.80"	Not Applicable	"$28,495.95"	"$56,991.90"	"$1,365.15"	"$56,991.90"
"Y-90 Isotope, Per Source"	C2616	SUPPLY/IMPLANTS	"$81,343.00"	Outpatient	"$40,671.50"	"$77,955.90"	"$44,494.62"	"$54,255.78"	"$32,537.20"	Not Applicable	"$28,470.05"	"$56,940.10"	"$28,470.05"	"$77,955.90"
GRAFT ENDOVASCULAR RELAYPLUS NITINOL STRAIGHT L90 MM OD22 MM 28M322090222290U	C1874	SUPPLY/IMPLANTS	"$81,329.00"	Outpatient	"$40,664.50"	Not Applicable	"$44,486.96"	"$54,246.44"	"$32,531.60"	Not Applicable	"$28,465.15"	"$56,930.30"	"$28,465.15"	"$56,930.30"
GRAFT THORACIC STENT 26X100 RELAY 28M326095262290U	C1874	SUPPLY/IMPLANTS	"$81,329.00"	Outpatient	"$40,664.50"	Not Applicable	"$44,486.96"	"$54,246.44"	"$32,531.60"	Not Applicable	"$28,465.15"	"$56,930.30"	"$28,465.15"	"$56,930.30"
RELAY THORACIC STENT-GRAFT 30 X 30 X 155 28-M330155302290U	C1874	SUPPLY/IMPLANTS	"$81,329.00"	Outpatient	"$40,664.50"	Not Applicable	"$44,486.96"	"$54,246.44"	"$32,531.60"	Not Applicable	"$28,465.15"	"$56,930.30"	"$28,465.15"	"$56,930.30"
RELAY THORACIC STENT-GRAFT 32 X 32 X 95 28-M332095322290U	C1874	SUPPLY/IMPLANTS	"$81,329.00"	Outpatient	"$40,664.50"	Not Applicable	"$44,486.96"	"$54,246.44"	"$32,531.60"	Not Applicable	"$28,465.15"	"$56,930.30"	"$28,465.15"	"$56,930.30"
STENT GRAFT ENDOVASCULAR 34MM DIA VESSEL STRAIGHT 28-M334100342390U	C1874	SUPPLY/IMPLANTS	"$81,329.00"	Outpatient	"$40,664.50"	Not Applicable	"$44,486.96"	"$54,246.44"	"$32,531.60"	Not Applicable	"$28,465.15"	"$56,930.30"	"$28,465.15"	"$56,930.30"
IMPL CRNL TI PTSPC NS SD420.444	C1713	SUPPLY/IMPLANTS	"$81,260.00"	Outpatient	"$40,630.00"	"$1,365.15"	"$44,449.22"	"$54,200.42"	"$32,504.00"	Not Applicable	"$28,441.00"	"$56,882.00"	"$1,365.15"	"$56,882.00"
"FORTIFY ASSURA NEXT GENERATION VR-ICD DF4 SYS, MERLINPKG CD1357-40Q SYSCELL"	C1722	PACE MAKER	"$81,244.00"	Outpatient	"$40,622.00"	Not Applicable	"$44,440.47"	"$54,189.75"	"$32,497.60"	Not Applicable	"$28,435.40"	"$56,870.80"	"$28,435.40"	"$56,870.80"
SYSTEM CARDIAC FORTIFY ASSURA VR THK14 MM 40 J W40 MM X H71 MM 35 CC 75 GM PACEMAKER LEAD 1 CHAMBER	C1786	PACE MAKER	"$81,234.00"	Outpatient	"$40,617.00"	Not Applicable	"$44,435.00"	"$54,183.08"	"$32,493.60"	Not Applicable	"$28,431.90"	"$56,863.80"	"$28,431.90"	"$56,863.80"
IMPL CRNL TI PTSPC NS SD420.437	C1713	SUPPLY/IMPLANTS	"$81,152.00"	Outpatient	"$40,576.00"	"$1,365.15"	"$44,390.14"	"$54,128.38"	"$32,460.80"	Not Applicable	"$28,403.20"	"$56,806.40"	"$1,365.15"	"$56,806.40"
DFBR CRD VISIA AF MRI DF-4VR CNCT 33CC 77GM DVFB1D4	C1722	PACE MAKER	"$81,011.00"	Outpatient	"$40,505.50"	Not Applicable	"$44,313.02"	"$54,034.34"	"$32,404.40"	Not Applicable	"$28,353.85"	"$56,707.70"	"$28,353.85"	"$56,707.70"
DFBR CRD 13MM 57SQ CM 51X64MM EVERA MRI XT DR SURESCAN DVMB1D4	C1882	SUPPLY/IMPLANTS	"$81,011.00"	Outpatient	"$40,505.50"	Not Applicable	"$44,313.02"	"$54,034.34"	"$32,404.40"	Not Applicable	"$28,353.85"	"$56,707.70"	"$28,353.85"	"$56,707.70"
DEFIBRILLATOR CARDIAC IPERIA 7 PROMRI DF-1/IS-1 CONNECTOR STERILE DR-T 392409	C1721	PACE MAKER	"$80,960.00"	Outpatient	"$40,480.00"	Not Applicable	"$44,285.12"	"$54,000.32"	"$32,384.00"	Not Applicable	"$28,336.00"	"$56,672.00"	"$28,336.00"	"$56,672.00"
DFBR CRD .99CM 5.37X7.68CM DYNAGEN ENDURALIFE EASYVIEW HF D152	C1721	PACE MAKER	"$80,949.00"	Outpatient	"$40,474.50"	Not Applicable	"$44,279.10"	"$53,992.98"	"$32,379.60"	Not Applicable	"$28,332.15"	"$56,664.30"	"$28,332.15"	"$56,664.30"
IMPLANT CRANIAL PEEK MEDIUM CUSTOMIZE PRIORITY NONSTERILE 78-50020	C1713	SUPPLY/IMPLANTS	"$80,869.00"	Outpatient	"$40,434.50"	"$1,365.15"	"$44,235.34"	"$53,939.62"	"$32,347.60"	Not Applicable	"$28,304.15"	"$56,608.30"	"$1,365.15"	"$56,608.30"
DFBR CRD .99CM SM THN 5.23X7CM DYNAGEN MN EASYVIEW HDR CLR D022	C1721	PACE MAKER	"$80,815.00"	Outpatient	"$40,407.50"	Not Applicable	"$44,205.81"	"$53,903.61"	"$32,326.00"	Not Applicable	"$28,285.25"	"$56,570.50"	"$28,285.25"	"$56,570.50"
ENDURANT II 2 PIECE CASE ENDURANTII2		STERILE SUPPLY	"$80,748.00"	Outpatient	"$40,374.00"	Not Applicable	"$44,169.16"	"$53,858.92"	"$32,299.20"	Not Applicable	"$28,261.80"	"$56,523.60"	"$28,261.80"	"$56,523.60"
GFT STNT 145MM 36-16MM 20FR ENDURANT II 2 BRCH EVAS NTNL ETBF3616C145E	C1884	SUPPLY/IMPLANTS	"$80,700.00"	Outpatient	"$40,350.00"	Not Applicable	"$44,142.90"	"$53,826.90"	"$32,280.00"	Not Applicable	"$28,245.00"	"$56,490.00"	"$28,245.00"	"$56,490.00"
DEVICE EMBOLIZATION PIPELINE FLEX L16 MM OD4.5 MM NEUROVASCU PED-450-16		SUPPLY/IMPLANTS	"$80,673.00"	Outpatient	"$40,336.50"	Not Applicable	"$44,128.13"	"$53,808.89"	"$32,269.20"	Not Applicable	"$28,235.55"	"$56,471.10"	"$28,235.55"	"$56,471.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.545	C1713	SUPPLY/IMPLANTS	"$80,483.00"	Outpatient	"$40,241.50"	"$1,365.15"	"$44,024.20"	"$53,682.16"	"$32,193.20"	Not Applicable	"$28,169.05"	"$56,338.10"	"$1,365.15"	"$56,338.10"
OBLIQUE FLAT TRUSS 30 X 12 MM 0 DEGREE 6 MM HEIGHT OSTS-MD0006-30	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 30 X 12 MM 0 DEGREE 8 MM HEIGHT OSTS-MD0008-30	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 30 X 12 MM 0 DEGREE 10 MM HEIGHT OSTS-MD0010-30	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 30 X 12 MM 0 DEGREE 12 MM HEIGHT OSTS-MD0012-30	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 30 X 12 MM 0 DEGREE 14 MM HEIGHT OSTS-MD0014-30	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 34 X 12 MM 0 DEGREE 6 MM HEIGHT OSTS-MD0006-34	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 34 X 12 MM 0 DEGREE 8 MM HEIGHT OSTS-MD0008-34	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 34 X 12 MM 0 DEGREE 10 MM HEIGHT OSTS-MD0010-34	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 34 X 12 MM 0 DEGREE 12 MM HEIGHT OSTS-MD0012-34	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
OBLIQUE FLAT TRUSS 34 X 12 MM 0 DEGREE 14 MM HEIGHT OSTS-MD0014-34	C1821	SUPPLY/IMPLANTS	"$79,844.00"	Outpatient	"$39,922.00"	Not Applicable	"$43,674.67"	"$53,255.95"	"$31,937.60"	Not Applicable	"$27,945.40"	"$55,890.80"	"$27,945.40"	"$55,890.80"
75987-0130-15 - teprotumumab trbw 500 mg Powd	C9399	PHARMACY	"$79,209.00"	Outpatient	"$39,604.50"	Not Applicable	"$43,327.32"	"$52,832.40"	"$31,683.60"	Not Applicable	"$27,723.15"	"$55,446.30"	"$27,723.15"	"$55,446.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.443	C1713	SUPPLY/IMPLANTS	"$79,175.00"	Outpatient	"$39,587.50"	"$1,365.15"	"$43,308.73"	"$52,809.73"	"$31,670.00"	Not Applicable	"$27,711.25"	"$55,422.50"	"$1,365.15"	"$55,422.50"
IMPL CRNL TI PTSPC NS SD420.539	C1713	SUPPLY/IMPLANTS	"$78,736.00"	Outpatient	"$39,368.00"	"$1,365.15"	"$43,068.59"	"$52,516.91"	"$31,494.40"	Not Applicable	"$27,557.60"	"$55,115.20"	"$1,365.15"	"$55,115.20"
VIGILANT EL DR DF4 D233	C1721	PACE MAKER	"$78,610.00"	Outpatient	"$39,305.00"	Not Applicable	"$42,999.67"	"$52,432.87"	"$31,444.00"	Not Applicable	"$27,513.50"	"$55,027.00"	"$27,513.50"	"$55,027.00"
CARDIOVERTER DEFIBRILLATOR DUAL CHAMBER ILIVIA DR-T DF1 404622	C1721	PACE MAKER	"$78,602.00"	Outpatient	"$39,301.00"	Not Applicable	"$42,995.29"	"$52,427.53"	"$31,440.80"	Not Applicable	"$27,510.70"	"$55,021.40"	"$27,510.70"	"$55,021.40"
DEFIBRILLATOR CARDIAC IMPLANTABLE 5.37CMW X 7.68CMH X 0.99CM D142	C1721	PACE MAKER	"$78,602.00"	Outpatient	"$39,301.00"	Not Applicable	"$42,995.29"	"$52,427.53"	"$31,440.80"	Not Applicable	"$27,510.70"	"$55,021.40"	"$27,510.70"	"$55,021.40"
DFBR CRD .99CM MN 5.23X6.71CM INOGEN EASYVIEW ACUSHOCK D010	C1722	PACE MAKER	"$78,413.00"	Outpatient	"$39,206.50"	Not Applicable	"$42,891.91"	"$52,301.47"	"$31,365.20"	Not Applicable	"$27,444.55"	"$54,889.10"	"$27,444.55"	"$54,889.10"
IMPL CRNL TI PTSPC NS SD420.530	C1713	SUPPLY/IMPLANTS	"$78,378.00"	Outpatient	"$39,189.00"	"$1,365.15"	"$42,872.77"	"$52,278.13"	"$31,351.20"	Not Applicable	"$27,432.30"	"$54,864.60"	"$1,365.15"	"$54,864.60"
IMPL CRNL TI PTSPC NS SD420.535	C1713	SUPPLY/IMPLANTS	"$78,352.00"	Outpatient	"$39,176.00"	"$1,365.15"	"$42,858.54"	"$52,260.78"	"$31,340.80"	Not Applicable	"$27,423.20"	"$54,846.40"	"$1,365.15"	"$54,846.40"
COIL EMBOLIZATION 3.75MM DIA 14MML 75% COBALT CHROMIUM 25% P PED-375-14		SUPPLY/IMPLANTS	"$78,323.00"	Outpatient	"$39,161.50"	Not Applicable	"$42,842.68"	"$52,241.44"	"$31,329.20"	Not Applicable	"$27,413.05"	"$54,826.10"	"$27,413.05"	"$54,826.10"
COIL EMBOLIZATION 3.5MM DIA 16MML 75% COBALT CHROMIUM 25% PL PED-350-16		SUPPLY/IMPLANTS	"$78,323.00"	Outpatient	"$39,161.50"	Not Applicable	"$42,842.68"	"$52,241.44"	"$31,329.20"	Not Applicable	"$27,413.05"	"$54,826.10"	"$27,413.05"	"$54,826.10"
PIPELINE FLEX EMBOL. DEVICE 4.5MM X 14MM PED-450-14		SUPPLY/IMPLANTS	"$78,323.00"	Outpatient	"$39,161.50"	Not Applicable	"$42,842.68"	"$52,241.44"	"$31,329.20"	Not Applicable	"$27,413.05"	"$54,826.10"	"$27,413.05"	"$54,826.10"
PIPELINE FLEX EMBOL DEVICE 3.25 MM X 14 MM PED-325-14		SUPPLY/IMPLANTS	"$78,323.00"	Outpatient	"$39,161.50"	Not Applicable	"$42,842.68"	"$52,241.44"	"$31,329.20"	Not Applicable	"$27,413.05"	"$54,826.10"	"$27,413.05"	"$54,826.10"
IMPL CRNL TI PTSPC NS SD420.432	C1713	SUPPLY/IMPLANTS	"$78,311.00"	Outpatient	"$39,155.50"	"$1,365.15"	"$42,836.12"	"$52,233.44"	"$31,324.40"	Not Applicable	"$27,408.85"	"$54,817.70"	"$1,365.15"	"$54,817.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.542	C1713	SUPPLY/IMPLANTS	"$78,189.00"	Outpatient	"$39,094.50"	"$1,365.15"	"$42,769.38"	"$52,152.06"	"$31,275.60"	Not Applicable	"$27,366.15"	"$54,732.30"	"$1,365.15"	"$54,732.30"
IMPL CRNL TI PTSPC NS SD420.525	C1713	SUPPLY/IMPLANTS	"$78,158.00"	Outpatient	"$39,079.00"	"$1,365.15"	"$42,752.43"	"$52,131.39"	"$31,263.20"	Not Applicable	"$27,355.30"	"$54,710.60"	"$1,365.15"	"$54,710.60"
AV Fistula Thromboectomy Lysis and PTA Stent	36906	CARDIAC CATH LAB	"$77,477.00"	Outpatient	"$38,738.50"	"$31,335.18"	"$42,379.92"	"$51,677.16"	"$30,990.80"	"$15,995.00"	"$27,116.95"	"$54,233.90"	"$15,995.00"	"$54,233.90"
GFT STNT 90MM 25MM 20MM AFX2 2 BRCH MAIN BD ILC LMB 30MM AAA BEA25-90/I20-30	C1874	SUPPLY/IMPLANTS	"$77,406.00"	Outpatient	"$38,703.00"	Not Applicable	"$42,341.08"	"$51,629.80"	"$30,962.40"	Not Applicable	"$27,092.10"	"$54,184.20"	"$27,092.10"	"$54,184.20"
IMPL CRNL TI PTSPC NS SD420.436	C1713	SUPPLY/IMPLANTS	"$77,397.00"	Outpatient	"$38,698.50"	"$1,365.15"	"$42,336.16"	"$51,623.80"	"$30,958.80"	Not Applicable	"$27,088.95"	"$54,177.90"	"$1,365.15"	"$54,177.90"
GFT STNT 80MM 25MM 16MM AFX2 2 BRCH MAIN BD ILC LMB 40MM AAA BEA25-80/I16-40	C1884	SUPPLY/IMPLANTS	"$77,391.00"	Outpatient	"$38,695.50"	Not Applicable	"$42,332.88"	"$51,619.80"	"$30,956.40"	Not Applicable	"$27,086.85"	"$54,173.70"	"$27,086.85"	"$54,173.70"
GFT STNT 90MM 28MM 16MM AFX2 2 BRCH MAIN BD ILC LMB 30MM AAA BEA28-90/I16-30	C1884	SUPPLY/IMPLANTS	"$77,231.00"	Outpatient	"$38,615.50"	Not Applicable	"$42,245.36"	"$51,513.08"	"$30,892.40"	Not Applicable	"$27,030.85"	"$54,061.70"	"$27,030.85"	"$54,061.70"
MICRA AV PACEMAKER MC1AVR1	C1785	PACE MAKER	"$76,972.00"	Outpatient	"$38,486.00"	Not Applicable	"$42,103.68"	"$51,340.32"	"$30,788.80"	Not Applicable	"$26,940.20"	"$53,880.40"	"$26,940.20"	"$53,880.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.445	C1713	SUPPLY/IMPLANTS	"$76,881.00"	Outpatient	"$38,440.50"	"$1,365.15"	"$42,053.91"	"$51,279.63"	"$30,752.40"	Not Applicable	"$26,908.35"	"$53,816.70"	"$1,365.15"	"$53,816.70"
IMPL CRNL TI PTSPC NS SD420.440	C1713	SUPPLY/IMPLANTS	"$76,636.00"	Outpatient	"$38,318.00"	"$1,365.15"	"$41,919.89"	"$51,116.21"	"$30,654.40"	Not Applicable	"$26,822.60"	"$53,645.20"	"$1,365.15"	"$53,645.20"
DEFIBRILLATOR CARDIAC FORTIFY ASSURA THK14 MM 40 J W40 MM X H71 MM 35 CC 75 GM 2 CHAMBER DF4 IS-1 CO	C1721	PACE MAKER	"$76,278.00"	Outpatient	"$38,139.00"	Not Applicable	"$41,724.07"	"$50,877.43"	"$30,511.20"	Not Applicable	"$26,697.30"	"$53,394.60"	"$26,697.30"	"$53,394.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.538	C1713	SUPPLY/IMPLANTS	"$75,899.00"	Outpatient	"$37,949.50"	"$1,365.15"	"$41,516.75"	"$50,624.63"	"$30,359.60"	Not Applicable	"$26,564.65"	"$53,129.30"	"$1,365.15"	"$53,129.30"
IMPL CRNL TI PTSPC NS SD420.524	C1713	SUPPLY/IMPLANTS	"$75,812.00"	Outpatient	"$37,906.00"	"$1,365.15"	"$41,469.16"	"$50,566.60"	"$30,324.80"	Not Applicable	"$26,534.20"	"$53,068.40"	"$1,365.15"	"$53,068.40"
DFBR CRD VISIA AF DF-4 CNCT VR DVAB1D4		STERILE SUPPLY	"$75,786.00"	Outpatient	"$37,893.00"	Not Applicable	"$41,454.94"	"$50,549.26"	"$30,314.40"	Not Applicable	"$26,525.10"	"$53,050.20"	"$26,525.10"	"$53,050.20"
DFBR CRD VISIA AF CX CNCT 33CC 77GM DVAB1D1		STERILE SUPPLY	"$75,786.00"	Outpatient	"$37,893.00"	Not Applicable	"$41,454.94"	"$50,549.26"	"$30,314.40"	Not Applicable	"$26,525.10"	"$53,050.20"	"$26,525.10"	"$53,050.20"
CAGE SPNL 32MM 18MM VLIFT TI LMBR INTRBD FS NS LF 48291832		SUPPLY/IMPLANTS	"$75,268.00"	Outpatient	"$37,634.00"	Not Applicable	"$41,171.60"	"$50,203.76"	"$30,107.20"	Not Applicable	"$26,343.80"	"$52,687.60"	"$26,343.80"	"$52,687.60"
IMPL CRNL TI PTSPC NS SD420.431	C1713	SUPPLY/IMPLANTS	"$75,229.00"	Outpatient	"$37,614.50"	"$1,365.15"	"$41,150.26"	"$50,177.74"	"$30,091.60"	Not Applicable	"$26,330.15"	"$52,660.30"	"$1,365.15"	"$52,660.30"
DEFIBRILLATOR CARDIAC DYNAGEN EASYVIEW ACUSHOCK SAFETYCORE D.99 CM MINI W5.23 CM X H7.14 CM 28.5 CC	C1722	PACE MAKER	"$75,209.00"	Outpatient	"$37,604.50"	Not Applicable	"$41,139.32"	"$50,164.40"	"$30,083.60"	Not Applicable	"$26,323.15"	"$52,646.30"	"$26,323.15"	"$52,646.30"
IMPL CRNL TI PTSPC NS SD420.534	C1713	SUPPLY/IMPLANTS	"$75,009.00"	Outpatient	"$37,504.50"	"$1,365.15"	"$41,029.92"	"$50,031.00"	"$30,003.60"	Not Applicable	"$26,253.15"	"$52,506.30"	"$1,365.15"	"$52,506.30"
GNTR NRSTM EON 16 CHNL RCHRG IMPL PLS 3701 ANS CHRG SYS 3716	C1820	SUPPLY/IMPLANTS	"$74,900.00"	Outpatient	"$37,450.00"	Not Applicable	"$40,970.30"	"$49,958.30"	"$29,960.00"	Not Applicable	"$26,215.00"	"$52,430.00"	"$26,215.00"	"$52,430.00"
PSI SD800.442 PEEK IMPLANT SD800.442	C1713	SUPPLY/IMPLANTS	"$74,586.00"	Outpatient	"$37,293.00"	"$1,365.15"	"$40,798.54"	"$49,748.86"	"$29,834.40"	Not Applicable	"$26,105.10"	"$52,210.20"	"$1,365.15"	"$52,210.20"
PLT PEEK-OPTM PTSPC BN NS SD800.544	C1713	SUPPLY/IMPLANTS	"$74,515.00"	Outpatient	"$37,257.50"	"$1,365.15"	"$40,759.71"	"$49,701.51"	"$29,806.00"	Not Applicable	"$26,080.25"	"$52,160.50"	"$1,365.15"	"$52,160.50"
IMPL CRNL TI PTSPC NS SD420.529	C1713	SUPPLY/IMPLANTS	"$74,107.00"	Outpatient	"$37,053.50"	"$1,365.15"	"$40,536.53"	"$49,429.37"	"$29,642.80"	Not Applicable	"$25,937.45"	"$51,874.90"	"$1,365.15"	"$51,874.90"
47335-0177-95 - tildrakizumab 100 mg/mL Soln	J3245	PHARMACY	"$73,973.00"	Outpatient	"$36,986.50"	$138.93	"$40,463.23"	"$49,339.99"	"$29,589.20"	Not Applicable	"$25,890.55"	"$51,781.10"	$138.93	"$51,781.10"
ILIVIA VR-T DF1 PROMRI WITH CLS WITH TI WITH HOME MONITORING 404625	C1722	PACE MAKER	"$73,748.00"	Outpatient	"$36,874.00"	Not Applicable	"$40,340.16"	"$49,189.92"	"$29,499.20"	Not Applicable	"$25,811.80"	"$51,623.60"	"$25,811.80"	"$51,623.60"
COMPONENT FEMORAL LPS COCR 2XS KNEE LEFT TAPER FEMALE ANTIRO 1987-13-111	C1776	SUPPLY/IMPLANTS	"$73,726.00"	Outpatient	"$36,863.00"	Not Applicable	"$40,328.12"	"$49,175.24"	"$29,490.40"	Not Applicable	"$25,804.10"	"$51,608.20"	"$25,804.10"	"$51,608.20"
LEAD ICD INTICA 7 VR-T DX 404633	C1722	PACE MAKER	"$73,661.00"	Outpatient	"$36,830.50"	Not Applicable	"$40,292.57"	"$49,131.89"	"$29,464.40"	Not Applicable	"$25,781.35"	"$51,562.70"	"$25,781.35"	"$51,562.70"
DFBR CRD .99CM SM THN 5.23X6.71CM DYNAGEN MN EASYVIEW HDR D020	C1721	PACE MAKER	"$73,661.00"	Outpatient	"$36,830.50"	Not Applicable	"$40,292.57"	"$49,131.89"	"$29,464.40"	Not Applicable	"$25,781.35"	"$51,562.70"	"$25,781.35"	"$51,562.70"
IMPL CRNL TI PTSPC NS SD420.523	C1713	SUPPLY/IMPLANTS	"$73,528.00"	Outpatient	"$36,764.00"	"$1,365.15"	"$40,219.82"	"$49,043.18"	"$29,411.20"	Not Applicable	"$25,734.80"	"$51,469.60"	"$1,365.15"	"$51,469.60"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.541	C1713	SUPPLY/IMPLANTS	"$73,140.00"	Outpatient	"$36,570.00"	"$1,365.15"	"$40,007.58"	"$48,784.38"	"$29,256.00"	Not Applicable	"$25,599.00"	"$51,198.00"	"$1,365.15"	"$51,198.00"
00024-5824-11 - cabazitaxel 60 mg/1.5 mL Soln	J9043	PHARMACY	"$61,355.00"	Outpatient	"$30,677.50"	$185.49	"$39,880.75"	"$40,923.79"	"$24,542.00"	Not Applicable	"$21,474.25"	"$42,948.50"	$185.49	"$42,948.50"
"TRIFLANGED ACETABULAR COMPONENT, RT SZ 25 LINER POROUS COAT PM0002854"	C1776	SUPPLY/IMPLANTS	"$72,818.00"	Outpatient	"$36,409.00"	Not Applicable	"$39,831.45"	"$48,569.61"	"$29,127.20"	Not Applicable	"$25,486.30"	"$50,972.60"	"$25,486.30"	"$50,972.60"
PEEK CRANIAL IMPLANT PK622972	C1713	SUPPLY/IMPLANTS	"$72,615.00"	Outpatient	"$36,307.50"	"$1,365.15"	"$39,720.41"	"$48,434.21"	"$29,046.00"	Not Applicable	"$25,415.25"	"$50,830.50"	"$1,365.15"	"$50,830.50"
DFBR CRD .99CM MN 5.23X7.14CM INOGEN EASYVIEW ACUSHOCK D011	C1722	PACE MAKER	"$72,587.00"	Outpatient	"$36,293.50"	Not Applicable	"$39,705.09"	"$48,415.53"	"$29,034.80"	Not Applicable	"$25,405.45"	"$50,810.90"	"$25,405.45"	"$50,810.90"
Revasc Tp Art Uni Init W St Ath Same	37231	CARDIAC CATH LAB	"$72,554.00"	Outpatient	"$36,277.00"	"$69,531.48"	"$39,687.04"	"$1,592.00"	"$29,021.60"	"$15,995.00"	"$25,393.90"	"$50,787.80"	"$1,592.00"	"$69,531.48"
Revasc F/P Art Uni W St And Ath Same	37227	CARDIAC CATH LAB	"$72,554.00"	Outpatient	"$36,277.00"	"$69,531.48"	"$39,687.04"	"$1,592.00"	"$29,021.60"	"$15,995.00"	"$25,393.90"	"$50,787.80"	"$1,592.00"	"$69,531.48"
IMPL CRNL TI PTSPC NS SD420.439	C1713	SUPPLY/IMPLANTS	"$72,546.00"	Outpatient	"$36,273.00"	"$1,365.15"	"$39,682.66"	"$48,388.18"	"$29,018.40"	Not Applicable	"$25,391.10"	"$50,782.20"	"$1,365.15"	"$50,782.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.438	C1713	SUPPLY/IMPLANTS	"$72,297.00"	Outpatient	"$36,148.50"	"$1,365.15"	"$39,546.46"	"$48,222.10"	"$28,918.80"	Not Applicable	"$25,303.95"	"$50,607.90"	"$1,365.15"	"$50,607.90"
IMPL CRNL TI PTSPC NS SD420.517	C1713	SUPPLY/IMPLANTS	"$72,215.00"	Outpatient	"$36,107.50"	"$1,365.15"	"$39,501.61"	"$48,167.41"	"$28,886.00"	Not Applicable	"$25,275.25"	"$50,550.50"	"$1,365.15"	"$50,550.50"
IMPL CRNL TI PTSPC NS SD420.430	C1713	SUPPLY/IMPLANTS	"$72,210.00"	Outpatient	"$36,105.00"	"$1,365.15"	"$39,498.87"	"$48,164.07"	"$28,884.00"	Not Applicable	"$25,273.50"	"$50,547.00"	"$1,365.15"	"$50,547.00"
IMPL CRNL TI PTSPC NS SD420.435	C1713	SUPPLY/IMPLANTS	"$72,160.00"	Outpatient	"$36,080.00"	"$1,365.15"	"$39,471.52"	"$48,130.72"	"$28,864.00"	Not Applicable	"$25,256.00"	"$50,512.00"	"$1,365.15"	"$50,512.00"
IMPL CRNL TI PTSPC NS SD420.425	C1713	SUPPLY/IMPLANTS	"$71,965.00"	Outpatient	"$35,982.50"	"$1,365.15"	"$39,364.86"	"$48,000.66"	"$28,786.00"	Not Applicable	"$25,187.75"	"$50,375.50"	"$1,365.15"	"$50,375.50"
IMPL CRNL TI PTSPC NS SD420.533	C1713	SUPPLY/IMPLANTS	"$71,796.00"	Outpatient	"$35,898.00"	"$1,365.15"	"$39,272.41"	"$47,887.93"	"$28,718.40"	Not Applicable	"$25,128.60"	"$50,257.20"	"$1,365.15"	"$50,257.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.537	C1713	SUPPLY/IMPLANTS	"$71,764.00"	Outpatient	"$35,882.00"	"$1,365.15"	"$39,254.91"	"$47,866.59"	"$28,705.60"	Not Applicable	"$25,117.40"	"$50,234.80"	"$1,365.15"	"$50,234.80"
DEFIBRILLATOR CARDIAC VIGILANT HEARTLOGIC IMAGEREADY D.99 CM D232	C1722	PACE MAKER	"$71,535.00"	Outpatient	"$35,767.50"	Not Applicable	"$39,129.65"	"$47,713.85"	"$28,614.00"	Not Applicable	"$25,037.25"	"$50,074.50"	"$25,037.25"	"$50,074.50"
IMPL CRNL TI PTSPC NS SD420.528	C1713	SUPPLY/IMPLANTS	"$71,412.00"	Outpatient	"$35,706.00"	"$1,365.15"	"$39,062.36"	"$47,631.80"	"$28,564.80"	Not Applicable	"$24,994.20"	"$49,988.40"	"$1,365.15"	"$49,988.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.444	C1713	SUPPLY/IMPLANTS	"$70,912.00"	Outpatient	"$35,456.00"	"$1,365.15"	"$38,788.86"	"$47,298.30"	"$28,364.80"	Not Applicable	"$24,819.20"	"$49,638.40"	"$1,365.15"	"$49,638.40"
MTRX TISS 25X15CM STRATTICE PRCN DERM RECON STRL 1525002	Q4130	PHARMACY	"$70,790.00"	Outpatient	"$35,395.00"	Not Applicable	"$38,722.13"	"$47,216.93"	"$28,316.00"	Not Applicable	"$24,776.50"	"$49,553.00"	"$24,776.50"	"$49,553.00"
IMPL CRNL TI PTSPC NS SD420.516	C1713	SUPPLY/IMPLANTS	"$70,580.00"	Outpatient	"$35,290.00"	"$1,365.15"	"$38,607.26"	"$47,076.86"	"$28,232.00"	Not Applicable	"$24,703.00"	"$49,406.00"	"$1,365.15"	"$49,406.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.540	C1713	SUPPLY/IMPLANTS	"$70,389.00"	Outpatient	"$35,194.50"	"$1,365.15"	"$38,502.78"	"$46,949.46"	"$28,155.60"	Not Applicable	"$24,636.15"	"$49,272.30"	"$1,365.15"	"$49,272.30"
IMPL CRNL TI PTSPC NS SD420.522	C1713	SUPPLY/IMPLANTS	"$70,140.00"	Outpatient	"$35,070.00"	"$1,365.15"	"$38,366.58"	"$46,783.38"	"$28,056.00"	Not Applicable	"$24,549.00"	"$49,098.00"	"$1,365.15"	"$49,098.00"
PLT ELB LCK CMPLT SET BN 231218100		SUPPLY/IMPLANTS	"$70,059.00"	Outpatient	"$35,029.50"	Not Applicable	"$38,322.27"	"$46,729.35"	"$28,023.60"	Not Applicable	"$24,520.65"	"$49,041.30"	"$24,520.65"	"$49,041.30"
DEFIBRILLATOR CARDIAC FORTIFY ASSURA VR PARYLENE THK14 MM 40 CD1357-40C CELL	C1722	PACE MAKER	"$69,711.00"	Outpatient	"$34,855.50"	Not Applicable	"$38,131.92"	"$46,497.24"	"$27,884.40"	Not Applicable	"$24,398.85"	"$48,797.70"	"$24,398.85"	"$48,797.70"
STENT GRAFT 24 X 96MM X 80 X 12MM SG-HBB-24-96-80-12-A		SUPPLY/IMPLANTS	"$69,702.00"	Outpatient	"$34,851.00"	Not Applicable	"$38,126.99"	"$46,491.23"	"$27,880.80"	Not Applicable	"$24,395.70"	"$48,791.40"	"$24,395.70"	"$48,791.40"
DFBR CRD THK14MM 40J 40X73MM FORTIFY ASR VR PARYLENE 1 CHMBR CD1357-40C	C1722	PACE MAKER	"$69,682.00"	Outpatient	"$34,841.00"	Not Applicable	"$38,116.05"	"$46,477.89"	"$27,872.80"	Not Applicable	"$24,388.70"	"$48,777.40"	"$24,388.70"	"$48,777.40"
DFBR CRD CD1357-40Q CELL CD1357-40Q CELL	C1722	PACE MAKER	"$69,638.00"	Outpatient	"$34,819.00"	Not Applicable	"$38,091.99"	"$46,448.55"	"$27,855.20"	Not Applicable	"$24,373.30"	"$48,746.60"	"$24,373.30"	"$48,746.60"
MESH IMPLANT POROUS POLYETHYLENE AND TITANIUM PK621881	C1771	SUPPLY/IMPLANTS	"$69,638.00"	Outpatient	"$34,819.00"	Not Applicable	"$38,091.99"	"$46,448.55"	"$27,855.20"	Not Applicable	"$24,373.30"	"$48,746.60"	"$24,373.30"	"$48,746.60"
IMPL CRNL TI PTSPC NS SD420.424	C1713	SUPPLY/IMPLANTS	"$69,619.00"	Outpatient	"$34,809.50"	"$1,365.15"	"$38,081.59"	"$46,435.87"	"$27,847.60"	Not Applicable	"$24,366.65"	"$48,733.30"	"$1,365.15"	"$48,733.30"
IMPL CRNL PEEK PTSPC NS SD800.441	C1713	SUPPLY/IMPLANTS	"$69,537.00"	Outpatient	"$34,768.50"	"$1,365.15"	"$38,036.74"	"$46,381.18"	"$27,814.80"	Not Applicable	"$24,337.95"	"$48,675.90"	"$1,365.15"	"$48,675.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.532	C1713	SUPPLY/IMPLANTS	"$69,010.00"	Outpatient	"$34,505.00"	"$1,365.15"	"$37,748.47"	"$46,029.67"	"$27,604.00"	Not Applicable	"$24,153.50"	"$48,307.00"	"$1,365.15"	"$48,307.00"
PSI SD800.536 PEEK IMPLANT SD800.536	C1713	SUPPLY/IMPLANTS	"$69,010.00"	Outpatient	"$34,505.00"	"$1,365.15"	"$37,748.47"	"$46,029.67"	"$27,604.00"	Not Applicable	"$24,153.50"	"$48,307.00"	"$1,365.15"	"$48,307.00"
IMPL CRNL TI PTSPC NS SD420.515	C1713	SUPPLY/IMPLANTS	"$68,959.00"	Outpatient	"$34,479.50"	"$1,365.15"	"$37,720.57"	"$45,995.65"	"$27,583.60"	Not Applicable	"$24,135.65"	"$48,271.30"	"$1,365.15"	"$48,271.30"
IMPL CRNL TI PTSPC NS SD420.527	C1713	SUPPLY/IMPLANTS	"$68,880.00"	Outpatient	"$34,440.00"	"$1,365.15"	"$37,677.36"	"$45,942.96"	"$27,552.00"	Not Applicable	"$24,108.00"	"$48,216.00"	"$1,365.15"	"$48,216.00"
PLT CRNL TI BN NS SD420.434	C1713	SUPPLY/IMPLANTS	"$68,817.00"	Outpatient	"$34,408.50"	"$1,365.15"	"$37,642.90"	"$45,900.94"	"$27,526.80"	Not Applicable	"$24,085.95"	"$48,171.90"	"$1,365.15"	"$48,171.90"
PLT 120X120MM CRNMXF TI MESH PREFRM BN 9200645	C1713	SUPPLY/IMPLANTS	"$68,811.00"	Outpatient	"$34,405.50"	"$1,365.15"	"$37,639.62"	"$45,896.94"	"$27,524.40"	Not Applicable	"$24,083.85"	"$48,167.70"	"$1,365.15"	"$48,167.70"
CAGE SPINAL OBELISC TITANIUM UNIVERSAL H32-47 MM OD20 MM THO CS 2920-32	C1821	SUPPLY/IMPLANTS	"$68,752.00"	Outpatient	"$34,376.00"	Not Applicable	"$37,607.34"	"$45,857.58"	"$27,500.80"	Not Applicable	"$24,063.20"	"$48,126.40"	"$24,063.20"	"$48,126.40"
"OBELISC CENTER PIECE 20mm, HEIGHT 32-47mm CS2920-32"	C1821	SUPPLY/IMPLANTS	"$68,752.00"	Outpatient	"$34,376.00"	Not Applicable	"$37,607.34"	"$45,857.58"	"$27,500.80"	Not Applicable	"$24,063.20"	"$48,126.40"	"$24,063.20"	"$48,126.40"
SPACER LUMBER 12MM 7 DEG LORDOTIC 25200-112-S	C1821	SUPPLY/IMPLANTS	"$68,541.00"	Outpatient	"$34,270.50"	Not Applicable	"$37,491.93"	"$45,716.85"	"$27,416.40"	Not Applicable	"$23,989.35"	"$47,978.70"	"$23,989.35"	"$47,978.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.437	C1713	SUPPLY/IMPLANTS	"$68,157.00"	Outpatient	"$34,078.50"	"$1,365.15"	"$37,281.88"	"$45,460.72"	"$27,262.80"	Not Applicable	"$23,854.95"	"$47,709.90"	"$1,365.15"	"$47,709.90"
IMPL CRNL TI PTSPC NS SD420.521	C1713	SUPPLY/IMPLANTS	"$68,126.00"	Outpatient	"$34,063.00"	"$1,365.15"	"$37,264.92"	"$45,440.04"	"$27,250.40"	Not Applicable	"$23,844.10"	"$47,688.20"	"$1,365.15"	"$47,688.20"
IMPL CRNL TI PTSPC NS SD420.429	C1713	SUPPLY/IMPLANTS	"$67,914.00"	Outpatient	"$33,957.00"	"$1,365.15"	"$37,148.96"	"$45,298.64"	"$27,165.60"	Not Applicable	"$23,769.90"	"$47,539.80"	"$1,365.15"	"$47,539.80"
BILATERAL OR MULTIPLE MAJOR JOINT WITH MCC DRG 461 DRG 461SN	C1713	SUPPLY/IMPLANTS	"$67,376.00"	Outpatient	"$33,688.00"	"$1,365.15"	"$36,854.67"	"$44,939.79"	"$26,950.40"	Not Applicable	"$23,581.60"	"$47,163.20"	"$1,365.15"	"$47,163.20"
BILATERAL OR MULTIPLE MAJOR JOINT WITH MCC DRG 461 DRG 461ZB	C1713	SUPPLY/IMPLANTS	"$67,376.00"	Outpatient	"$33,688.00"	"$1,365.15"	"$36,854.67"	"$44,939.79"	"$26,950.40"	Not Applicable	"$23,581.60"	"$47,163.20"	"$1,365.15"	"$47,163.20"
BILATERAL OR MULTIPLE MAJOR JOINT WITH MCC DRG 461 DRG 461DS	C1713	SUPPLY/IMPLANTS	"$67,376.00"	Outpatient	"$33,688.00"	"$1,365.15"	"$36,854.67"	"$44,939.79"	"$26,950.40"	Not Applicable	"$23,581.60"	"$47,163.20"	"$1,365.15"	"$47,163.20"
IMPL CRNL TI PTSPC NS SD420.423	C1713	SUPPLY/IMPLANTS	"$67,324.00"	Outpatient	"$33,662.00"	"$1,365.15"	"$36,826.23"	"$44,905.11"	"$26,929.60"	Not Applicable	"$23,563.40"	"$47,126.80"	"$1,365.15"	"$47,126.80"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.531	C1713	SUPPLY/IMPLANTS	"$67,288.00"	Outpatient	"$33,644.00"	"$1,365.15"	"$36,806.54"	"$44,881.10"	"$26,915.20"	Not Applicable	"$23,550.80"	"$47,101.60"	"$1,365.15"	"$47,101.60"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.539	C1713	SUPPLY/IMPLANTS	"$67,288.00"	Outpatient	"$33,644.00"	"$1,365.15"	"$36,806.54"	"$44,881.10"	"$26,915.20"	Not Applicable	"$23,550.80"	"$47,101.60"	"$1,365.15"	"$47,101.60"
GFT STNT 110MM 25MM 20MM AFX 2 BRCH MAIN BD ILC LMB STRATA BA25-110/I20-30	C1874	SUPPLY/IMPLANTS	"$67,264.00"	Outpatient	"$33,632.00"	Not Applicable	"$36,793.41"	"$44,865.09"	"$26,905.60"	Not Applicable	"$23,542.40"	"$47,084.80"	"$23,542.40"	"$47,084.80"
GFT STNT 80MM 25-13MM 17FR AFX ACTIVESEAL STRATA BFUR EVAS BA25-80/I13-40	C1874	SUPPLY/IMPLANTS	"$67,264.00"	Outpatient	"$33,632.00"	Not Applicable	"$36,793.41"	"$44,865.09"	"$26,905.60"	Not Applicable	"$23,542.40"	"$47,084.80"	"$23,542.40"	"$47,084.80"
GRAFT AFX MAIN BODY 25 X 80CM BA25-80/I16-55	C1874	SUPPLY/IMPLANTS	"$67,264.00"	Outpatient	"$33,632.00"	Not Applicable	"$36,793.41"	"$44,865.09"	"$26,905.60"	Not Applicable	"$23,542.40"	"$47,084.80"	"$23,542.40"	"$47,084.80"
GFT STNT 100MM 28MM 20MM AFX 40MM AAA EVAS STRL BA28-100/I20-40	C1884	SUPPLY/IMPLANTS	"$67,264.00"	Outpatient	"$33,632.00"	Not Applicable	"$36,793.41"	"$44,865.09"	"$26,905.60"	Not Applicable	"$23,542.40"	"$47,084.80"	"$23,542.40"	"$47,084.80"
GFT STNT 120MM 25MM 16MM AFX 2 BRCH MAIN BD ILC LMB STRATA BA25-120/I16-40	C1874	SUPPLY/IMPLANTS	"$67,227.00"	Outpatient	"$33,613.50"	Not Applicable	"$36,773.17"	"$44,840.41"	"$26,890.80"	Not Applicable	"$23,529.45"	"$47,058.90"	"$23,529.45"	"$47,058.90"
GFT STNT 90MM 25-16MM 17FR AFX ACTIVESEAL STRATA 2 BRCH EVAS BA25-90/I16-30	C1874	SUPPLY/IMPLANTS	"$67,227.00"	Outpatient	"$33,613.50"	Not Applicable	"$36,773.17"	"$44,840.41"	"$26,890.80"	Not Applicable	"$23,529.45"	"$47,058.90"	"$23,529.45"	"$47,058.90"
GFT STNT 60MM 22-13MM 17FR AFX ACTIVESEAL STRATA BFUR EVAS BA22-60/I13-40	C1874	SUPPLY/IMPLANTS	"$67,227.00"	Outpatient	"$33,613.50"	Not Applicable	"$36,773.17"	"$44,840.41"	"$26,890.80"	Not Applicable	"$23,529.45"	"$47,058.90"	"$23,529.45"	"$47,058.90"
GFT STNT 110MM 25MM 16MM AFX 30MM AAA EVAS STRL BA25-110/I16-30	C1874	SUPPLY/IMPLANTS	"$67,227.00"	Outpatient	"$33,613.50"	Not Applicable	"$36,773.17"	"$44,840.41"	"$26,890.80"	Not Applicable	"$23,529.45"	"$47,058.90"	"$23,529.45"	"$47,058.90"
GFT STNT 100MM 25-16MM 17FR AFX ACTIVESEAL STRATA BFUR EVAS BA25-100/I16-40	C1874	SUPPLY/IMPLANTS	"$67,227.00"	Outpatient	"$33,613.50"	Not Applicable	"$36,773.17"	"$44,840.41"	"$26,890.80"	Not Applicable	"$23,529.45"	"$47,058.90"	"$23,529.45"	"$47,058.90"
MAIN BODY BA25-90/120-30	C1713	SUPPLY/IMPLANTS	"$67,227.00"	Outpatient	"$33,613.50"	"$1,365.15"	"$36,773.17"	"$44,840.41"	"$26,890.80"	Not Applicable	"$23,529.45"	"$47,058.90"	"$1,365.15"	"$47,058.90"
GFT STNT 80MM 28-16MM 17FR AFX ACTIVESEAL STRATA BFUR EVAS BA28-80/I16-40	C1874	SUPPLY/IMPLANTS	"$67,179.00"	Outpatient	"$33,589.50"	Not Applicable	"$36,746.91"	"$44,808.39"	"$26,871.60"	Not Applicable	"$23,512.65"	"$47,025.30"	"$23,512.65"	"$47,025.30"
GFT STNT 80MM 28MM 20MM AFX 40MM AAA EVAS STRL BA28-80/I20-40	C1874	SUPPLY/IMPLANTS	"$67,179.00"	Outpatient	"$33,589.50"	Not Applicable	"$36,746.91"	"$44,808.39"	"$26,871.60"	Not Applicable	"$23,512.65"	"$47,025.30"	"$23,512.65"	"$47,025.30"
GFT STNT 100MM 28-16MM 17FR AFX ACTIVESEAL STRATA BFUR EVAS BA28-100/I16-40	C1874	SUPPLY/IMPLANTS	"$67,179.00"	Outpatient	"$33,589.50"	Not Applicable	"$36,746.91"	"$44,808.39"	"$26,871.60"	Not Applicable	"$23,512.65"	"$47,025.30"	"$23,512.65"	"$47,025.30"
GFT STNT 80MM 25-16MM 17FR AFX ACTIVESEAL STRATA 2 BRCH EVAS BA25-80/I16-40	C1874	SUPPLY/IMPLANTS	"$67,179.00"	Outpatient	"$33,589.50"	Not Applicable	"$36,746.91"	"$44,808.39"	"$26,871.60"	Not Applicable	"$23,512.65"	"$47,025.30"	"$23,512.65"	"$47,025.30"
IMPL CRNL TI PTSPC NS SD420.509	C1713	SUPPLY/IMPLANTS	"$66,839.00"	Outpatient	"$33,419.50"	"$1,365.15"	"$36,560.93"	"$44,581.61"	"$26,735.60"	Not Applicable	"$23,393.65"	"$46,787.30"	"$1,365.15"	"$46,787.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.440	C1713	SUPPLY/IMPLANTS	"$66,776.00"	Outpatient	"$33,388.00"	"$1,365.15"	"$36,526.47"	"$44,539.59"	"$26,710.40"	Not Applicable	"$23,371.60"	"$46,743.20"	"$1,365.15"	"$46,743.20"
IMPL CRNL TI PTSPC NS SD420.526	C1713	SUPPLY/IMPLANTS	"$66,532.00"	Outpatient	"$33,266.00"	"$1,365.15"	"$36,393.00"	"$44,376.84"	"$26,612.80"	Not Applicable	"$23,286.20"	"$46,572.40"	"$1,365.15"	"$46,572.40"
IMPL CRNL TI PTSPC NS SD420.514	C1713	SUPPLY/IMPLANTS	"$66,477.00"	Outpatient	"$33,238.50"	"$1,365.15"	"$36,362.92"	"$44,340.16"	"$26,590.80"	Not Applicable	"$23,266.95"	"$46,533.90"	"$1,365.15"	"$46,533.90"
PACEMAKER PERCEPTA QUAD CRT P SYSTEM -MMQM PERCEPTAMR IQDMMQM	C2621	PACE MAKER	"$66,255.00"	Outpatient	"$33,127.50"	Not Applicable	"$36,241.49"	"$44,192.09"	"$26,502.00"	Not Applicable	"$23,189.25"	"$46,378.50"	"$23,189.25"	"$46,378.50"
IMPL CRNL TI PTSPC NS SD420.520	C1713	SUPPLY/IMPLANTS	"$66,201.00"	Outpatient	"$33,100.50"	"$1,365.15"	"$36,211.95"	"$44,156.07"	"$26,480.40"	Not Applicable	"$23,170.35"	"$46,340.70"	"$1,365.15"	"$46,340.70"
GFT STNT 80MM 23MM 14FR 12FR TRIVASCULAR OV PRM OV IX AOR BD TV-AB2380-J	C1874	SUPPLY/IMPLANTS	"$66,179.00"	Outpatient	"$33,089.50"	Not Applicable	"$36,199.91"	"$44,141.39"	"$26,471.60"	Not Applicable	"$23,162.65"	"$46,325.30"	"$23,162.65"	"$46,325.30"
GFT STNT 80MM 26MM 14FR 12FR TRIVASCULAR OV PRM OV IX AOR BD TV-AB2680-J	C1884	SUPPLY/IMPLANTS	"$66,179.00"	Outpatient	"$33,089.50"	Not Applicable	"$36,199.91"	"$44,141.39"	"$26,471.60"	Not Applicable	"$23,162.65"	"$46,325.30"	"$23,162.65"	"$46,325.30"
IMPL CRNL TI PTSPC NS SD420.417	C1713	SUPPLY/IMPLANTS	"$66,021.00"	Outpatient	"$33,010.50"	"$1,365.15"	"$36,113.49"	"$44,036.01"	"$26,408.40"	Not Applicable	"$23,107.35"	"$46,214.70"	"$1,365.15"	"$46,214.70"
IMPL CRNL TI PTSPC NS SD420.508	C1713	SUPPLY/IMPLANTS	"$65,833.00"	Outpatient	"$32,916.50"	"$1,365.15"	"$36,010.65"	"$43,910.61"	"$26,333.20"	Not Applicable	"$23,041.55"	"$46,083.10"	"$1,365.15"	"$46,083.10"
IMPL CRNL TI PTSPC NS SD420.433	C1713	SUPPLY/IMPLANTS	"$65,603.00"	Outpatient	"$32,801.50"	"$1,365.15"	"$35,884.84"	"$43,757.20"	"$26,241.20"	Not Applicable	"$22,961.05"	"$45,922.10"	"$1,365.15"	"$45,922.10"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.535	C1713	SUPPLY/IMPLANTS	"$65,570.00"	Outpatient	"$32,785.00"	"$1,365.15"	"$35,866.79"	"$43,735.19"	"$26,228.00"	Not Applicable	"$22,949.50"	"$45,899.00"	"$1,365.15"	"$45,899.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.432	C1713	SUPPLY/IMPLANTS	"$65,397.00"	Outpatient	"$32,698.50"	"$1,365.15"	"$35,772.16"	"$43,619.80"	"$26,158.80"	Not Applicable	"$22,888.95"	"$45,777.90"	"$1,365.15"	"$45,777.90"
PSI SD800.436 PEEK IMPLANT SD800.436	C1713	SUPPLY/IMPLANTS	"$65,397.00"	Outpatient	"$32,698.50"	"$1,365.15"	"$35,772.16"	"$43,619.80"	"$26,158.80"	Not Applicable	"$22,888.95"	"$45,777.90"	"$1,365.15"	"$45,777.90"
MOD IMPL RECON SCR SLD NTR NL ANTGRD SM FEM 249009116	C1713	SUPPLY/IMPLANTS	"$65,342.00"	Outpatient	"$32,671.00"	"$1,365.15"	"$35,742.07"	"$43,583.11"	"$26,136.80"	Not Applicable	"$22,869.70"	"$45,739.40"	"$1,365.15"	"$45,739.40"
CURVED FLAT TRUSS 26 X 9 MM 0 DEGREE 6 MM HEIGHT TSTS-SM0006-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 26 X 9 MM 0 DEGREE 8 MM HEIGHT TSTS-SM0008-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 26 X 9 MM 0 DEGREE 10 MM HEIGHT TSTS-SM0010-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 26 X 9 MM 0 DEGREE 12 MM HEIGHT TSTS-SM0012-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 26 X 9 MM 0 DEGREE 14 MM HEIGHT TSTS-SM0014-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 6 MM HEIGHT TSTS-SM0606-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 8 MM HEIGHT TSTS-SM0608-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 10 MM HEIGHT TSTS-SM0610-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 12 MM HEIGHT TSTS-SM0612-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 14 MM HEIGHT TSTS-SM0614-26	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 32 X 9 MM 0 DEGREE 6 MM HEIGHT TSTS-SM0006-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 32 X 9 MM 0 DEGREE 8 MM HEIGHT TSTS-SM0008-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 32 X 9 MM 0 DEGREE 10 MM HEIGHT TSTS-SM0010-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 32 X 9 MM 0 DEGREE 12 MM HEIGHT TSTS-SM0012-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED FLAT TRUSS 32 X 9 MM 0 DEGREE 14 MM HEIGHT TSTS-SM0014-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 32 X 9 MM 6 DEGREE 6 MM HEIGHT TSTS-SM0606-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 32 X 9 MM 6 DEGREE 8 MM HEIGHT TSTS-SM0608-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 32 X 9 MM 6 DEGREE 10 MM HEIGHT TSTS-SM0610-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 32 X 9 MM 6 DEGREE 12 MM HEIGHT TSTS-SM0612-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
CURVED LORDOTIC TRUSS 32 X 9 MM 6 DEGREE 14 MM HEIGHT TSTS-SM0614-32	C1713	SUPPLY/IMPLANTS	"$65,326.00"	Outpatient	"$32,663.00"	"$1,365.15"	"$35,733.32"	"$43,572.44"	"$26,130.40"	Not Applicable	"$22,864.10"	"$45,728.20"	"$1,365.15"	"$45,728.20"
PUMP IT 20ML SNCHR II RSRV FLTR MESH PCH PRGM TI THK.78IN 8637-20	C1772	SUPPLY/IMPLANTS	"$65,301.00"	Outpatient	"$32,650.50"	Not Applicable	"$35,719.65"	"$43,555.77"	"$26,120.40"	Not Applicable	"$22,855.35"	"$45,710.70"	"$22,855.35"	"$45,710.70"
DRSG BIO INTGR 10X8IN BVN CLGN GAG POLYSILOXANE BL MX MESH MWM8101	C9363	SUPPLY/IMPLANTS	"$65,241.00"	Outpatient	"$32,620.50"	$38.51	"$35,686.83"	"$43,515.75"	"$26,096.40"	Not Applicable	"$22,834.35"	"$45,668.70"	$38.51	"$45,668.70"
IMPL CRNL TI PTSPC NS SD420.428	C1713	SUPPLY/IMPLANTS	"$65,214.00"	Outpatient	"$32,607.00"	"$1,365.15"	"$35,672.06"	"$43,497.74"	"$26,085.60"	Not Applicable	"$22,824.90"	"$45,649.80"	"$1,365.15"	"$45,649.80"
IMPL CRNL TI PTSPC NS SD420.513	C1713	SUPPLY/IMPLANTS	"$65,052.00"	Outpatient	"$32,526.00"	"$1,365.15"	"$35,583.44"	"$43,389.68"	"$26,020.80"	Not Applicable	"$22,768.20"	"$45,536.40"	"$1,365.15"	"$45,536.40"
IMPL CRNL TI PTSPC NS SD420.507	C1713	SUPPLY/IMPLANTS	"$64,851.00"	Outpatient	"$32,425.50"	"$1,365.15"	"$35,473.50"	"$43,255.62"	"$25,940.40"	Not Applicable	"$22,697.85"	"$45,395.70"	"$1,365.15"	"$45,395.70"
DEV TRGT ARM RTRGD C FEM NL SYS 14-442020	C1713	SUPPLY/IMPLANTS	"$64,694.00"	Outpatient	"$32,347.00"	"$1,365.15"	"$35,387.62"	"$43,150.90"	"$25,877.60"	Not Applicable	"$22,642.90"	"$45,285.80"	"$1,365.15"	"$45,285.80"
CAGE CORPECTOMY 10 X 12 X 14 NOVEL CP CP64713-110	C1821	SUPPLY/IMPLANTS	"$64,408.00"	Outpatient	"$32,204.00"	Not Applicable	"$35,231.18"	"$42,960.14"	"$25,763.20"	Not Applicable	"$22,542.80"	"$45,085.60"	"$22,542.80"	"$45,085.60"
IMPL CRNL TI PTSPC NS SD420.416	C1713	SUPPLY/IMPLANTS	"$64,375.00"	Outpatient	"$32,187.50"	"$1,365.15"	"$35,213.13"	"$42,938.13"	"$25,750.00"	Not Applicable	"$22,531.25"	"$45,062.50"	"$1,365.15"	"$45,062.50"
IMPL CRNL TI PTSPC NS SD420.519	C1713	SUPPLY/IMPLANTS	"$64,357.00"	Outpatient	"$32,178.50"	"$1,365.15"	"$35,203.28"	"$42,926.12"	"$25,742.80"	Not Applicable	"$22,524.95"	"$45,049.90"	"$1,365.15"	"$45,049.90"
IMPL CRNL TI PTSPC NS SD420.422	C1713	SUPPLY/IMPLANTS	"$63,937.00"	Outpatient	"$31,968.50"	"$1,365.15"	"$34,973.54"	"$42,645.98"	"$25,574.80"	Not Applicable	"$22,377.95"	"$44,755.90"	"$1,365.15"	"$44,755.90"
GRAFT STENT AFX2 2 BRANCH L110 MM L30 MM OD28 MM ODSEC20 MM BEA28-110/I20-30	C1874	SUPPLY/IMPLANTS	"$63,902.00"	Outpatient	"$31,951.00"	Not Applicable	"$34,954.39"	"$42,622.63"	"$25,560.80"	Not Applicable	"$22,365.70"	"$44,731.40"	"$22,365.70"	"$44,731.40"
GFT EVAS 14CM 23MM 12MM 19-21MM 10-11MM GORE XCLDR C3 RLT231214	C1874	SUPPLY/IMPLANTS	"$63,876.00"	Outpatient	"$31,938.00"	Not Applicable	"$34,940.17"	"$42,605.29"	"$25,550.40"	Not Applicable	"$22,356.60"	"$44,713.20"	"$22,356.60"	"$44,713.20"
GFT EVAS 18CM 26MM 12MM 22-23MM 10-11MM GORE XCLDR C3 RLT261218	C1884	SUPPLY/IMPLANTS	"$63,876.00"	Outpatient	"$31,938.00"	Not Applicable	"$34,940.17"	"$42,605.29"	"$25,550.40"	Not Applicable	"$22,356.60"	"$44,713.20"	"$22,356.60"	"$44,713.20"
GFT STNT 90MM 28-16MM 17FR AFX ACTIVESEAL STRATA 2 BRCH EVAS BA28-90/I16-30	C1884	SUPPLY/IMPLANTS	"$63,876.00"	Outpatient	"$31,938.00"	Not Applicable	"$34,940.17"	"$42,605.29"	"$25,550.40"	Not Applicable	"$22,356.60"	"$44,713.20"	"$22,356.60"	"$44,713.20"
STENT ENDOLOGIX GRAFT SYSTEM BEA25-100/116-40	C1874	SUPPLY/IMPLANTS	"$63,863.00"	Outpatient	"$31,931.50"	Not Applicable	"$34,933.06"	"$42,596.62"	"$25,545.20"	Not Applicable	"$22,352.05"	"$44,704.10"	"$22,352.05"	"$44,704.10"
GFT STNT 90MM 25MM 16MM AFX2 2 BRCH MAIN BD ILC LMB 30MM AAA BEA25-90/I16-30	C1884	SUPPLY/IMPLANTS	"$63,863.00"	Outpatient	"$31,931.50"	Not Applicable	"$34,933.06"	"$42,596.62"	"$25,545.20"	Not Applicable	"$22,352.05"	"$44,704.10"	"$22,352.05"	"$44,704.10"
GFT STNT 100MM 25MM 16MM AFX2 2 BRCH MAIN BD ILC LMB 40MM BEA25-100/I16-40	C1884	SUPPLY/IMPLANTS	"$63,863.00"	Outpatient	"$31,931.50"	Not Applicable	"$34,933.06"	"$42,596.62"	"$25,545.20"	Not Applicable	"$22,352.05"	"$44,704.10"	"$22,352.05"	"$44,704.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.530	C1713	SUPPLY/IMPLANTS	"$63,840.00"	Outpatient	"$31,920.00"	"$1,365.15"	"$34,920.48"	"$42,581.28"	"$25,536.00"	Not Applicable	"$22,344.00"	"$44,688.00"	"$1,365.15"	"$44,688.00"
GRAFT STENT AFX2 2 BRANCH L80 MM L40 MM OD25 MM ODSEC13 MM MAIN BODY ILIAC LIMB STERILE LATEX FREE A	C1874	SUPPLY/IMPLANTS	"$63,835.00"	Outpatient	"$31,917.50"	Not Applicable	"$34,917.75"	"$42,577.95"	"$25,534.00"	Not Applicable	"$22,342.25"	"$44,684.50"	"$22,342.25"	"$44,684.50"
GRAFT STENT AFX2 2 BRANCH L70 MM L30 MM OD25 MM ODSEC16 MM M BEA25-70/I16-30	C1874	SUPPLY/IMPLANTS	"$63,835.00"	Outpatient	"$31,917.50"	Not Applicable	"$34,917.75"	"$42,577.95"	"$25,534.00"	Not Applicable	"$22,342.25"	"$44,684.50"	"$22,342.25"	"$44,684.50"
IMPLANT LEFT FRONTAL SPHENOID PARIETAL TEMPORAL PK621116	C1713	SUPPLY/IMPLANTS	"$63,835.00"	Outpatient	"$31,917.50"	"$1,365.15"	"$34,917.75"	"$42,577.95"	"$25,534.00"	Not Applicable	"$22,342.25"	"$44,684.50"	"$1,365.15"	"$44,684.50"
IMPLANT PARIETAL TEMPORAL COLOMB RT PK621642		SUPPLY/IMPLANTS	"$63,835.00"	Outpatient	"$31,917.50"	Not Applicable	"$34,917.75"	"$42,577.95"	"$25,534.00"	Not Applicable	"$22,342.25"	"$44,684.50"	"$22,342.25"	"$44,684.50"
STENT GRAFT SYSTEM BEA28-120/116-40	C1874	SUPPLY/IMPLANTS	"$63,827.00"	Outpatient	"$31,913.50"	Not Applicable	"$34,913.37"	"$42,572.61"	"$25,530.80"	Not Applicable	"$22,339.45"	"$44,678.90"	"$22,339.45"	"$44,678.90"
GFT STNT 40MM 22MM 13MM AFX2 2 BRCH MAIN BD ILC LMB 40MM AAA BEA22-40/I13-40	C1884	SUPPLY/IMPLANTS	"$63,827.00"	Outpatient	"$31,913.50"	Not Applicable	"$34,913.37"	"$42,572.61"	"$25,530.80"	Not Applicable	"$22,339.45"	"$44,678.90"	"$22,339.45"	"$44,678.90"
GFT STNT 80MM 28MM 20MM AFX2 2 BRCH MAIN BD ILC LMB 40MM AAA BEA28-80/I20-40	C1884	SUPPLY/IMPLANTS	"$63,827.00"	Outpatient	"$31,913.50"	Not Applicable	"$34,913.37"	"$42,572.61"	"$25,530.80"	Not Applicable	"$22,339.45"	"$44,678.90"	"$22,339.45"	"$44,678.90"
GFT STNT 80MM 25MM 16MM AFX2 2 BRCH MAIN BD ILC LMB 55MM AAA BEA25-80/I16-55		STERILE SUPPLY	"$63,827.00"	Outpatient	"$31,913.50"	Not Applicable	"$34,913.37"	"$42,572.61"	"$25,530.80"	Not Applicable	"$22,339.45"	"$44,678.90"	"$22,339.45"	"$44,678.90"
GFT EVAS 17CM 31MM 14.5MM XCLDR C3 TRNKIPSL LG GRTX NTNL FEP RLT311417	C1884	SUPPLY/IMPLANTS	"$63,749.00"	Outpatient	"$31,874.50"	Not Applicable	"$34,870.70"	"$42,520.58"	"$25,499.60"	Not Applicable	"$22,312.15"	"$44,624.30"	"$22,312.15"	"$44,624.30"
IMPL CRNL TI PTSPC NS SD420.512	C1713	SUPPLY/IMPLANTS	"$63,722.00"	Outpatient	"$31,861.00"	"$1,365.15"	"$34,855.93"	"$42,502.57"	"$25,488.80"	Not Applicable	"$22,302.70"	"$44,605.40"	"$1,365.15"	"$44,605.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.431	C1713	SUPPLY/IMPLANTS	"$63,681.00"	Outpatient	"$31,840.50"	"$1,365.15"	"$34,833.51"	"$42,475.23"	"$25,472.40"	Not Applicable	"$22,288.35"	"$44,576.70"	"$1,365.15"	"$44,576.70"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.439	C1713	SUPPLY/IMPLANTS	"$63,681.00"	Outpatient	"$31,840.50"	"$1,365.15"	"$34,833.51"	"$42,475.23"	"$25,472.40"	Not Applicable	"$22,288.35"	"$44,576.70"	"$1,365.15"	"$44,576.70"
IMPL CRNL TI PTSPC NS SD420.506	C1713	SUPPLY/IMPLANTS	"$63,222.00"	Outpatient	"$31,611.00"	"$1,365.15"	"$34,582.43"	"$42,169.07"	"$25,288.80"	Not Applicable	"$22,127.70"	"$44,255.40"	"$1,365.15"	"$44,255.40"
00074-3473-03 - leuprolide 45 mg/6 months PWDI	J9217	PHARMACY	"$53,085.00"	Outpatient	"$26,542.50"	$258.91	"$34,505.25"	"$35,407.70"	"$21,234.00"	Not Applicable	"$18,579.75"	"$37,159.50"	$258.91	"$37,159.50"
Revasc Tp Art Bil Init W St Same Vsl	37230	CARDIAC CATH LAB	"$62,841.00"	Outpatient	"$31,420.50"	"$40,148.14"	"$34,374.03"	"$1,592.00"	"$25,136.40"	"$8,681.00"	"$21,994.35"	"$43,988.70"	"$1,592.00"	"$43,988.70"
Revasc Tp Art Bil Init Vsl W Ath Same	37229	CARDIAC CATH LAB	"$62,841.00"	Outpatient	"$31,420.50"	"$40,148.14"	"$34,374.03"	"$1,592.00"	"$25,136.40"	"$8,681.00"	"$21,994.35"	"$43,988.70"	"$1,592.00"	"$43,988.70"
Femoral Poplitial Revasc W/Stent Bilateral	37226	CARDIAC CATH LAB	"$62,841.00"	Outpatient	"$31,420.50"	"$40,148.14"	"$34,374.03"	"$1,592.00"	"$25,136.40"	"$8,681.00"	"$21,994.35"	"$43,988.70"	"$1,592.00"	"$43,988.70"
Revasc Fem/Pop Art Bil W Ath Same Vsl	37225	CARDIAC CATH LAB	"$62,841.00"	Outpatient	"$31,420.50"	"$40,148.14"	"$34,374.03"	"$1,592.00"	"$25,136.40"	"$8,681.00"	"$21,994.35"	"$43,988.70"	"$1,592.00"	"$43,988.70"
IMPL CRNL TI PTSPC NS SD420.415	C1713	SUPPLY/IMPLANTS	"$62,757.00"	Outpatient	"$31,378.50"	"$1,365.15"	"$34,328.08"	"$41,858.92"	"$25,102.80"	Not Applicable	"$21,964.95"	"$43,929.90"	"$1,365.15"	"$43,929.90"
IMPL CRNL TI PTSPC NS SD420.518	C1713	SUPPLY/IMPLANTS	"$62,732.00"	Outpatient	"$31,366.00"	"$1,365.15"	"$34,314.40"	"$41,842.24"	"$25,092.80"	Not Applicable	"$21,956.20"	"$43,912.40"	"$1,365.15"	"$43,912.40"
IMPL CRNL TI PTSPC NS LF SD420.427	C1713	SUPPLY/IMPLANTS	"$62,686.00"	Outpatient	"$31,343.00"	"$1,365.15"	"$34,289.24"	"$41,811.56"	"$25,074.40"	Not Applicable	"$21,940.10"	"$43,880.20"	"$1,365.15"	"$43,880.20"
IMPL CRNL TI PTSPC NS SD420.511	C1713	SUPPLY/IMPLANTS	"$62,464.00"	Outpatient	"$31,232.00"	"$1,365.15"	"$34,167.81"	"$41,663.49"	"$24,985.60"	Not Applicable	"$21,862.40"	"$43,724.80"	"$1,365.15"	"$43,724.80"
GFT EVAS 14CM 23MM 14.5MM 19-21MM 12-13.5MM GORE XCLDR C3 RLT231414	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 14CM 35MM 14.5MM 30-32MM 12-13.5MM GORE XCLDR C3 RLT351414	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 14CM 26MM 14.5MM GORE XCLDR C3 TRNKIPSL LG AAA ACPT RLT261414	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 12CM 26MM 14.5MM 22-23MM 12-13.5MM GORE XCLDR C3 RLT261412	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 16CM 28.5MM 14.5MM 24-26MM 12-13.5MM GORE XCLDR C3 RLT281416	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 16CM 35MM 14.5MM XCLDR C3 TRNKIPSL LG GRTX NTNL FEP RLT351416	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 16CM 26MM 12MM 22-23MM 10-11MM GORE XCLDR C3 RLT261216	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 16CM 26MM 14.5MM GORE XCLDR C3 TRNKIPSL LG AAA ACPT RLT261416	C1884	SUPPLY/IMPLANTS	"$62,442.00"	Outpatient	"$31,221.00"	Not Applicable	"$34,155.77"	"$41,648.81"	"$24,976.80"	Not Applicable	"$21,854.70"	"$43,709.40"	"$21,854.70"	"$43,709.40"
GFT EVAS 10CM 14.5MM GORE XCLDR ILC BRCH CMPNT AAA CEB231410A	C1884	SUPPLY/IMPLANTS	"$62,424.00"	Outpatient	"$31,212.00"	Not Applicable	"$34,145.93"	"$41,636.81"	"$24,969.60"	Not Applicable	"$21,848.40"	"$43,696.80"	"$21,848.40"	"$43,696.80"
SYS DLV HBRD TRANSCATHETER PCNG 1 CHMBR BTRY MICRA SURESCAN MC1VR01		PACE MAKER	"$62,376.00"	Outpatient	"$31,188.00"	Not Applicable	"$34,119.67"	"$41,604.79"	"$24,950.40"	Not Applicable	"$21,831.60"	"$43,663.20"	"$21,831.60"	"$43,663.20"
IMPL CRNL TI PTSPC NS SD420.505	C1713	SUPPLY/IMPLANTS	"$62,362.00"	Outpatient	"$31,181.00"	"$1,365.15"	"$34,112.01"	"$41,595.45"	"$24,944.80"	Not Applicable	"$21,826.70"	"$43,653.40"	"$1,365.15"	"$43,653.40"
GFT EVAS 12CM 28.5MM 14.5MM 24-26MM 12-13.5MM GORE XCLDR C3 RLT281412	C1874	SUPPLY/IMPLANTS	"$62,194.00"	Outpatient	"$31,097.00"	Not Applicable	"$34,020.12"	"$41,483.40"	"$24,877.60"	Not Applicable	"$21,767.90"	"$43,535.80"	"$21,767.90"	"$43,535.80"
GRAFT ENDOVASCULAR GORE EXCLUDER C3 NITINOL EPTFE L14 CM OD2 RLT261214	C1874	SUPPLY/IMPLANTS	"$62,194.00"	Outpatient	"$31,097.00"	Not Applicable	"$34,020.12"	"$41,483.40"	"$24,877.60"	Not Applicable	"$21,767.90"	"$43,535.80"	"$21,767.90"	"$43,535.80"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.533	C1713	SUPPLY/IMPLANTS	"$62,168.00"	Outpatient	"$31,084.00"	"$1,365.15"	"$34,005.90"	"$41,466.06"	"$24,867.20"	Not Applicable	"$21,758.80"	"$43,517.60"	"$1,365.15"	"$43,517.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.534	C1713	SUPPLY/IMPLANTS	"$62,127.00"	Outpatient	"$31,063.50"	"$1,365.15"	"$33,983.47"	"$41,438.71"	"$24,850.80"	Not Applicable	"$21,744.45"	"$43,488.90"	"$1,365.15"	"$43,488.90"
PLT CRNL PEEK PTSPC BN SD800.525	C1713	SUPPLY/IMPLANTS	"$62,127.00"	Outpatient	"$31,063.50"	"$1,365.15"	"$33,983.47"	"$41,438.71"	"$24,850.80"	Not Applicable	"$21,744.45"	"$43,488.90"	"$1,365.15"	"$43,488.90"
INTERSTIM MICRO SURESCAN MRI RECHARGEABLE NEUROSTIMULATOR 97810	C1787	SUPPLY/IMPLANTS	"$62,113.00"	Outpatient	"$31,056.50"	Not Applicable	"$33,975.81"	"$41,429.37"	"$24,845.20"	Not Applicable	"$21,739.55"	"$43,479.10"	"$21,739.55"	"$43,479.10"
IMPL CRNL PEEK CSTM PTSPC NS SD800.435	C1713	SUPPLY/IMPLANTS	"$61,964.00"	Outpatient	"$30,982.00"	"$1,365.15"	"$33,894.31"	"$41,329.99"	"$24,785.60"	Not Applicable	"$21,687.40"	"$43,374.80"	"$1,365.15"	"$43,374.80"
IMPL CRNL TI PTSPC NS SD420.421	C1713	SUPPLY/IMPLANTS	"$61,924.00"	Outpatient	"$30,962.00"	"$1,365.15"	"$33,872.43"	"$41,303.31"	"$24,769.60"	Not Applicable	"$21,673.40"	"$43,346.80"	"$1,365.15"	"$43,346.80"
PEEK CRANIAL IMPLANT CUSTOM XL 78-10010-1	C1713	SUPPLY/IMPLANTS	"$61,712.00"	Outpatient	"$30,856.00"	"$1,365.15"	"$33,756.46"	"$41,161.90"	"$24,684.80"	Not Applicable	"$21,599.20"	"$43,198.40"	"$1,365.15"	"$43,198.40"
NRSTM RESTOREULTRA SURESCAN IMPL MRI TCH LNG LST 97712	C1820	SUPPLY/IMPLANTS	"$61,582.00"	Outpatient	"$30,791.00"	Not Applicable	"$33,685.35"	"$41,075.19"	"$24,632.80"	Not Applicable	"$21,553.70"	"$43,107.40"	"$21,553.70"	"$43,107.40"
IMPL CRNL TI PTSPC NS SD420.504	C1713	SUPPLY/IMPLANTS	"$61,530.00"	Outpatient	"$30,765.00"	"$1,365.15"	"$33,656.91"	"$41,040.51"	"$24,612.00"	Not Applicable	"$21,535.50"	"$43,071.00"	"$1,365.15"	"$43,071.00"
57894-0060-03 - ustekinumab 45 mg/0.5 mL Soln	J3357	PHARMACY	"$61,355.00"	Outpatient	"$30,677.50"	$204.35	"$33,561.19"	"$40,923.79"	"$24,542.00"	Not Applicable	"$21,474.25"	"$42,948.50"	$204.35	"$42,948.50"
IMPL CRNL TI PTSPC NS SD420.510	C1713	SUPPLY/IMPLANTS	"$61,076.00"	Outpatient	"$30,538.00"	"$1,365.15"	"$33,408.57"	"$40,737.69"	"$24,430.40"	Not Applicable	"$21,376.60"	"$42,753.20"	"$1,365.15"	"$42,753.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.529	C1713	SUPPLY/IMPLANTS	"$60,994.00"	Outpatient	"$30,497.00"	"$1,365.15"	"$33,363.72"	"$40,683.00"	"$24,397.60"	Not Applicable	"$21,347.90"	"$42,695.80"	"$1,365.15"	"$42,695.80"
GFT EVAS 16CM 28.5MM 12MM 24-26MM 10-11MM GORE XCLDR C3 RLT281216	C1884	SUPPLY/IMPLANTS	"$60,989.00"	Outpatient	"$30,494.50"	Not Applicable	"$33,360.98"	"$40,679.66"	"$24,395.60"	Not Applicable	"$21,346.15"	"$42,692.30"	"$21,346.15"	"$42,692.30"
GFT EVAS 14CM 28.5MM 14.5MM 24-26MM 12-13.5MM GORE XCLDR C3 RLT281414	C1884	SUPPLY/IMPLANTS	"$60,972.00"	Outpatient	"$30,486.00"	Not Applicable	"$33,351.68"	"$40,668.32"	"$24,388.80"	Not Applicable	"$21,340.20"	"$42,680.40"	"$21,340.20"	"$42,680.40"
REVERSE SHOULDER CONTRACT PRICE RVSR		SUPPLY/IMPLANTS	"$60,961.00"	Outpatient	"$30,480.50"	Not Applicable	"$33,345.67"	"$40,660.99"	"$24,384.40"	Not Applicable	"$21,336.35"	"$42,672.70"	"$21,336.35"	"$42,672.70"
GFT EVAS 18CM 23MM 14.5MM XCLDR C3 TRNKIPSL LG GRTX NTNL FEP RMT231418	C1874	SUPPLY/IMPLANTS	"$60,956.00"	Outpatient	"$30,478.00"	Not Applicable	"$33,342.93"	"$40,657.65"	"$24,382.40"	Not Applicable	"$21,334.60"	"$42,669.20"	"$21,334.60"	"$42,669.20"
CAP AEQ RVS FX--ALL INCLUSIVE CAP10102	C1713	SUPPLY/IMPLANTS	"$60,956.00"	Outpatient	"$30,478.00"	"$1,365.15"	"$33,342.93"	"$40,657.65"	"$24,382.40"	Not Applicable	"$21,334.60"	"$42,669.20"	"$1,365.15"	"$42,669.20"
Zevalin	A9543	Therapeutic radiopharmaceuticals	"$60,855.00"	Outpatient	"$30,427.50"	"$59,134.66"	"$33,287.69"	"$40,590.29"	"$24,342.00"	Not Applicable	"$21,299.25"	"$42,598.50"	"$21,299.25"	"$59,134.66"
IMPL CRNL TI PTSPC NS SD420.503	C1713	SUPPLY/IMPLANTS	"$60,781.00"	Outpatient	"$30,390.50"	"$1,365.15"	"$33,247.21"	"$40,540.93"	"$24,312.40"	Not Applicable	"$21,273.35"	"$42,546.70"	"$1,365.15"	"$42,546.70"
SYS CRD APD A ALRT LTD NXT INTUA PCMKR CRTP V273		STERILE SUPPLY	"$60,681.00"	Outpatient	"$30,340.50"	Not Applicable	"$33,192.51"	"$40,474.23"	"$24,272.40"	Not Applicable	"$21,238.35"	"$42,476.70"	"$21,238.35"	"$42,476.70"
IMPL CRNL TI PTSPC NS SD420.409	C1713	SUPPLY/IMPLANTS	"$60,642.00"	Outpatient	"$30,321.00"	"$1,365.15"	"$33,171.17"	"$40,448.21"	"$24,256.80"	Not Applicable	"$21,224.70"	"$42,449.40"	"$1,365.15"	"$42,449.40"
CASE STRL CMPLT ALPS FT 829960000		STERILE SUPPLY	"$60,588.00"	Outpatient	"$30,294.00"	Not Applicable	"$33,141.64"	"$40,412.20"	"$24,235.20"	Not Applicable	"$21,205.80"	"$42,411.60"	"$21,205.80"	"$42,411.60"
 MICRA TRANSCATHETER PACING SYSTEM MICRATCPSYSTEM	C1786	PACE MAKER	"$60,568.00"	Outpatient	"$30,284.00"	Not Applicable	"$33,130.70"	"$40,398.86"	"$24,227.20"	Not Applicable	"$21,198.80"	"$42,397.60"	"$21,198.80"	"$42,397.60"
NRSTM 2INX1.7IN INTSTM II IMPL THK.3IN 10-14HZ 0-4V 14ML 22 3058	C1767	SUPPLY/IMPLANTS	"$60,517.00"	Outpatient	"$30,258.50"	Not Applicable	"$33,102.80"	"$40,364.84"	"$24,206.80"	Not Applicable	"$21,180.95"	"$42,361.90"	"$21,180.95"	"$42,361.90"
"PEEK SYNFIX, 12, LG-FOOTPRINT, 15MM 08.805.013S"	C1821	SUPPLY/IMPLANTS	"$60,346.00"	Outpatient	"$30,173.00"	Not Applicable	"$33,009.26"	"$40,250.78"	"$24,138.40"	Not Applicable	"$21,121.10"	"$42,242.20"	"$21,121.10"	"$42,242.20"
IMPL CRNL TI PTSPC NS SD420.426	C1713	SUPPLY/IMPLANTS	"$60,334.00"	Outpatient	"$30,167.00"	"$1,365.15"	"$33,002.70"	"$40,242.78"	"$24,133.60"	Not Applicable	"$21,116.90"	"$42,233.80"	"$1,365.15"	"$42,233.80"
IMPL CRNL TI PTSPC NS SD420.414	C1713	SUPPLY/IMPLANTS	"$60,293.00"	Outpatient	"$30,146.50"	"$1,365.15"	"$32,980.27"	"$40,215.43"	"$24,117.20"	Not Applicable	"$21,102.55"	"$42,205.10"	"$1,365.15"	"$42,205.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.430	C1713	SUPPLY/IMPLANTS	"$60,237.00"	Outpatient	"$30,118.50"	"$1,365.15"	"$32,949.64"	"$40,178.08"	"$24,094.80"	Not Applicable	"$21,082.95"	"$42,165.90"	"$1,365.15"	"$42,165.90"
DEV TRGT JIG ARM PHNX ANKL ARTHDS NL SYS 14-440050	C1713	SUPPLY/IMPLANTS	"$60,216.00"	Outpatient	"$30,108.00"	"$1,365.15"	"$32,938.15"	"$40,164.07"	"$24,086.40"	Not Applicable	"$21,075.60"	"$42,151.20"	"$1,365.15"	"$42,151.20"
IMPL CRNL TI PTSPC NS SD420.420	C1713	SUPPLY/IMPLANTS	"$60,002.00"	Outpatient	"$30,001.00"	"$1,365.15"	"$32,821.09"	"$40,021.33"	"$24,000.80"	Not Applicable	"$21,000.70"	"$42,001.40"	"$1,365.15"	"$42,001.40"
IMPL CRNL TI PTSPC NS SD420.502	C1713	SUPPLY/IMPLANTS	"$59,930.00"	Outpatient	"$29,965.00"	"$1,365.15"	"$32,781.71"	"$39,973.31"	"$23,972.00"	Not Applicable	"$20,975.50"	"$41,951.00"	"$1,365.15"	"$41,951.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.524	C1713	SUPPLY/IMPLANTS	"$59,843.00"	Outpatient	"$29,921.50"	"$1,365.15"	"$32,734.12"	"$39,915.28"	"$23,937.20"	Not Applicable	"$20,945.05"	"$41,890.10"	"$1,365.15"	"$41,890.10"
CAGE SPNL 50X22X10MM CLYDESDALE 0D PEEK-OPTM RADOPQ INTRBD X0909088	C1821	SUPPLY/IMPLANTS	"$59,644.00"	Outpatient	"$29,822.00"	Not Applicable	"$32,625.27"	"$39,782.55"	"$23,857.60"	Not Applicable	"$20,875.40"	"$41,750.80"	"$20,875.40"	"$41,750.80"
IMPL CRNL TI PTSPC NS SD420.408	C1713	SUPPLY/IMPLANTS	"$59,633.00"	Outpatient	"$29,816.50"	"$1,365.15"	"$32,619.25"	"$39,775.21"	"$23,853.20"	Not Applicable	"$20,871.55"	"$41,743.10"	"$1,365.15"	"$41,743.10"
PLT CRNL FSFLP BN NS SD800.434		SUPPLY/IMPLANTS	"$59,576.00"	Outpatient	"$29,788.00"	Not Applicable	"$32,588.07"	"$39,737.19"	"$23,830.40"	Not Applicable	"$20,851.60"	"$41,703.20"	"$20,851.60"	"$41,703.20"
PUMP IT 40ML SNCHR II PRGM RADOPQ ID BCTR RTN FLTR SIL SPT 8637-40	C1772	SUPPLY/IMPLANTS	"$59,523.00"	Outpatient	"$29,761.50"	Not Applicable	"$32,559.08"	"$39,701.84"	"$23,809.20"	Not Applicable	"$20,833.05"	"$41,666.10"	"$20,833.05"	"$41,666.10"
GRAFT ENDOVASCULAR GORE EXCLUDER C3 NITINOL EPTFE L18 CM OD2 RLT261418		SUPPLY/IMPLANTS	"$59,516.00"	Outpatient	"$29,758.00"	Not Applicable	"$32,555.25"	"$39,697.17"	"$23,806.40"	Not Applicable	"$20,830.60"	"$41,661.20"	"$20,830.60"	"$41,661.20"
SCREW 6.5 X 45MM 4840006545	C1713	SUPPLY/IMPLANTS	"$59,509.00"	Outpatient	"$29,754.50"	"$1,365.15"	"$32,551.42"	"$39,692.50"	"$23,803.60"	Not Applicable	"$20,828.15"	"$41,656.30"	"$1,365.15"	"$41,656.30"
SCREW 3.5 X 14MM 35035-15	C1713	SUPPLY/IMPLANTS	"$59,491.00"	Outpatient	"$29,745.50"	"$1,365.15"	"$32,541.58"	"$39,680.50"	"$23,796.40"	Not Applicable	"$20,821.85"	"$41,643.70"	"$1,365.15"	"$41,643.70"
GFT EVAS 15CM 31MM 14.5MM XCLDR C3 TRNKIPSL LG GRTX NTNL FEP RLT311415	C1884	SUPPLY/IMPLANTS	"$59,491.00"	Outpatient	"$29,745.50"	Not Applicable	"$32,541.58"	"$39,680.50"	"$23,796.40"	Not Applicable	"$20,821.85"	"$41,643.70"	"$20,821.85"	"$41,643.70"
GFT EVAS 18CM 28.5MM 14.5MM 24-26MM 12-13.5MM GORE XCLDR C3 RLT281418	C1884	SUPPLY/IMPLANTS	"$59,491.00"	Outpatient	"$29,745.50"	Not Applicable	"$32,541.58"	"$39,680.50"	"$23,796.40"	Not Applicable	"$20,821.85"	"$41,643.70"	"$20,821.85"	"$41,643.70"
GFT EVAS 16CM 23MM 14.5MM 19-21MM 12-13.5MM GORE XCLDR C3 RLT231416	C1884	SUPPLY/IMPLANTS	"$59,491.00"	Outpatient	"$29,745.50"	Not Applicable	"$32,541.58"	"$39,680.50"	"$23,796.40"	Not Applicable	"$20,821.85"	"$41,643.70"	"$20,821.85"	"$41,643.70"
ENDOPROSTHESIS EXCLUDER C3 31MMX14.5MMX15CM RTL311415	C1884	SUPPLY/IMPLANTS	"$59,480.00"	Outpatient	"$29,740.00"	Not Applicable	"$32,535.56"	"$39,673.16"	"$23,792.00"	Not Applicable	"$20,818.00"	"$41,636.00"	"$20,818.00"	"$41,636.00"
GFT EVAS 18CM 35MM 14.5MM 30-32MM 12-13.5MM GORE XCLDR C3 RLT351418	C1884	SUPPLY/IMPLANTS	"$59,480.00"	Outpatient	"$29,740.00"	Not Applicable	"$32,535.56"	"$39,673.16"	"$23,792.00"	Not Applicable	"$20,818.00"	"$41,636.00"	"$20,818.00"	"$41,636.00"
 ENDOPROSTHESIS AAA GORE EXCLUDER RLT231218	C1874	SUPPLY/IMPLANTS	"$59,453.00"	Outpatient	"$29,726.50"	Not Applicable	"$32,520.79"	"$39,655.15"	"$23,781.20"	Not Applicable	"$20,808.55"	"$41,617.10"	"$20,808.55"	"$41,617.10"
GRAFT ENDOVASCULAR GORE EXCLUDER 23MM X 4CM X 12MM RLT231216		SUPPLY/IMPLANTS	"$59,453.00"	Outpatient	"$29,726.50"	Not Applicable	"$32,520.79"	"$39,655.15"	"$23,781.20"	Not Applicable	"$20,808.55"	"$41,617.10"	"$20,808.55"	"$41,617.10"
GFT EVAS 14CM 26MM 14.5MM GORE XCLDR C3 TRNKIPSL LG AAA ACPT RMT261414	C1874	SUPPLY/IMPLANTS	"$59,436.00"	Outpatient	"$29,718.00"	Not Applicable	"$32,511.49"	"$39,643.81"	"$23,774.40"	Not Applicable	"$20,802.60"	"$41,605.20"	"$20,802.60"	"$41,605.20"
GFT EVAS 16CM 23MM 12MM XCLDR C3 TRNKIPSL LG GRTX NTNL FEP RMT231216	C1874	SUPPLY/IMPLANTS	"$59,436.00"	Outpatient	"$29,718.00"	Not Applicable	"$32,511.49"	"$39,643.81"	"$23,774.40"	Not Applicable	"$20,802.60"	"$41,605.20"	"$20,802.60"	"$41,605.20"
IMPL CRNL TI PTSPC NS SD420.501	C1713	SUPPLY/IMPLANTS	"$59,312.00"	Outpatient	"$29,656.00"	"$1,365.15"	"$32,443.66"	"$39,561.10"	"$23,724.80"	Not Applicable	"$20,759.20"	"$41,518.40"	"$1,365.15"	"$41,518.40"
MESH 12X10IN RECT POLY-4-HB PHASIX MFL SCFLD FULL RSRB SRG 1190500	C1781	SUPPLY/IMPLANTS	"$58,957.00"	Outpatient	"$29,478.50"	Not Applicable	"$32,249.48"	"$39,324.32"	"$23,582.80"	Not Applicable	"$20,634.95"	"$41,269.90"	"$20,634.95"	"$41,269.90"
VLV AOR 22+ MM CARDIOGRAFT ALGRF CRPRS ADLT HVAL	C1762	SUPPLY/IMPLANTS	"$58,910.00"	Outpatient	"$29,455.00"	Not Applicable	"$32,223.77"	"$39,292.97"	"$23,564.00"	Not Applicable	"$20,618.50"	"$41,237.00"	"$20,618.50"	"$41,237.00"
IMPL CRNL TI PTSPC NS SD420.413	C1713	SUPPLY/IMPLANTS	"$58,867.00"	Outpatient	"$29,433.50"	"$1,365.15"	"$32,200.25"	"$39,264.29"	"$23,546.80"	Not Applicable	"$20,603.45"	"$41,206.90"	"$1,365.15"	"$41,206.90"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE ES8916	C1813	SUPPLY/IMPLANTS	"$58,714.00"	Outpatient	"$29,357.00"	Not Applicable	"$32,116.56"	"$39,162.24"	"$23,485.60"	Not Applicable	"$20,549.90"	"$41,099.80"	"$20,549.90"	"$41,099.80"
IMPL CRNL TI PTSPC NS SD420.407	C1713	SUPPLY/IMPLANTS	"$58,657.00"	Outpatient	"$29,328.50"	"$1,365.15"	"$32,085.38"	"$39,124.22"	"$23,462.80"	Not Applicable	"$20,529.95"	"$41,059.90"	"$1,365.15"	"$41,059.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.425	C1713	SUPPLY/IMPLANTS	"$58,517.00"	Outpatient	"$29,258.50"	"$1,365.15"	"$32,008.80"	"$39,030.84"	"$23,406.80"	Not Applicable	"$20,480.95"	"$40,961.90"	"$1,365.15"	"$40,961.90"
GFT EVAS 14CM 28.5MM 14.5MM XCLDR LOPRFL TRNKIPSL LG GRTX RMT281414	C1874	SUPPLY/IMPLANTS	"$58,274.00"	Outpatient	"$29,137.00"	Not Applicable	"$31,875.88"	"$38,868.76"	"$23,309.60"	Not Applicable	"$20,395.90"	"$40,791.80"	"$20,395.90"	"$40,791.80"
GFT EVAS 12CM 23MM 14.5MM 19-21MM 12-13.5MM GORE XCLDR C3 RLT231412	C1874	SUPPLY/IMPLANTS	"$58,274.00"	Outpatient	"$29,137.00"	Not Applicable	"$31,875.88"	"$38,868.76"	"$23,309.60"	Not Applicable	"$20,395.90"	"$40,791.80"	"$20,395.90"	"$40,791.80"
GFT EVAS 12CM 26MM 14.5MM XCLDR C3 TRNKIPSL LG GRTX NTNL FEP RMT261412	C1874	SUPPLY/IMPLANTS	"$58,274.00"	Outpatient	"$29,137.00"	Not Applicable	"$31,875.88"	"$38,868.76"	"$23,309.60"	Not Applicable	"$20,395.90"	"$40,791.80"	"$20,395.90"	"$40,791.80"
TUBE ORTH 28.3CM 4.32MM 3.35MM INTRACONE PP RMR IM NL NS 142800700	C1713	SUPPLY/IMPLANTS	"$58,220.00"	Outpatient	"$29,110.00"	"$1,365.15"	"$31,846.34"	"$38,832.74"	"$23,288.00"	Not Applicable	"$20,377.00"	"$40,754.00"	"$1,365.15"	"$40,754.00"
IMPL CRNL TI PTSPC NS SD420.419	C1713	SUPPLY/IMPLANTS	"$58,168.00"	Outpatient	"$29,084.00"	"$1,365.15"	"$31,817.90"	"$38,798.06"	"$23,267.20"	Not Applicable	"$20,358.80"	"$40,717.60"	"$1,365.15"	"$40,717.60"
50242-0917-01 - atezolizumab 1200 mg/20 mL Soln	J9022	PHARMACY	"$48,876.00"	Outpatient	"$24,438.00"	$77.07	"$31,769.40"	"$32,600.29"	"$19,550.40"	Not Applicable	"$17,106.60"	"$34,213.20"	$77.07	"$34,213.20"
OCLR CV 18/18MM 8FR PFO 2 DISK SLF EXPANDABLE DLV SYS AMPLZR 9-PFO-018	C1817	SUPPLY/IMPLANTS	"$58,029.00"	Outpatient	"$29,014.50"	Not Applicable	"$31,741.86"	"$38,705.34"	"$23,211.60"	Not Applicable	"$20,310.15"	"$40,620.30"	"$20,310.15"	"$40,620.30"
OCLR CV 25MM 18MM FORAMEN OVALE 2 DISC DEV AMPLZR 45D CRV 9-PFO-025	C1817	SUPPLY/IMPLANTS	"$58,029.00"	Outpatient	"$29,014.50"	Not Applicable	"$31,741.86"	"$38,705.34"	"$23,211.60"	Not Applicable	"$20,310.15"	"$40,620.30"	"$20,310.15"	"$40,620.30"
OCLR CV 35MM 25MM FORAMEN OVALE 2 DISC DEV AMPLZR 45D CRV 9-PFO-035	C1817	SUPPLY/IMPLANTS	"$58,029.00"	Outpatient	"$29,014.50"	Not Applicable	"$31,741.86"	"$38,705.34"	"$23,211.60"	Not Applicable	"$20,310.15"	"$40,620.30"	"$20,310.15"	"$40,620.30"
PACEMAKER EVIA HF-T SYS W/ GSM HM 395420	C2621	PACE MAKER	"$58,013.00"	Outpatient	"$29,006.50"	Not Applicable	"$31,733.11"	"$38,694.67"	"$23,205.20"	Not Applicable	"$20,304.55"	"$40,609.10"	"$20,304.55"	"$40,609.10"
GRAFT ENDOVASCULAR GORE EXCLUDER C3 NITINOL EPTFE L18 CM OD2 RLT281218		SUPPLY/IMPLANTS	"$57,722.00"	Outpatient	"$28,861.00"	Not Applicable	"$31,573.93"	"$38,500.57"	"$23,088.80"	Not Applicable	"$20,202.70"	"$40,405.40"	"$20,202.70"	"$40,405.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.523	C1713	SUPPLY/IMPLANTS	"$57,545.00"	Outpatient	"$28,772.50"	"$1,365.15"	"$31,477.12"	"$38,382.52"	"$23,018.00"	Not Applicable	"$20,140.75"	"$40,281.50"	"$1,365.15"	"$40,281.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.528	C1713	SUPPLY/IMPLANTS	"$57,545.00"	Outpatient	"$28,772.50"	"$1,365.15"	"$31,477.12"	"$38,382.52"	"$23,018.00"	Not Applicable	"$20,140.75"	"$40,281.50"	"$1,365.15"	"$40,281.50"
IMPL CRNL TI PTSPC NS SD420.412	C1713	SUPPLY/IMPLANTS	"$57,538.00"	Outpatient	"$28,769.00"	"$1,365.15"	"$31,473.29"	"$38,377.85"	"$23,015.20"	Not Applicable	"$20,138.30"	"$40,276.60"	"$1,365.15"	"$40,276.60"
61755-0008-01 - cemiplimab 350 mg/7 mL Soln	J9119	PHARMACY	"$48,376.00"	Outpatient	"$24,188.00"	$30.16	"$31,444.40"	"$32,266.79"	"$19,350.40"	Not Applicable	"$16,931.60"	"$33,863.20"	$30.16	"$33,863.20"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.429	C1713	SUPPLY/IMPLANTS	"$57,386.00"	Outpatient	"$28,693.00"	"$1,365.15"	"$31,390.14"	"$38,276.46"	"$22,954.40"	Not Applicable	"$20,085.10"	"$40,170.20"	"$1,365.15"	"$40,170.20"
IMPL CRNL TI PTSPC NS SD420.406	C1713	SUPPLY/IMPLANTS	"$57,033.00"	Outpatient	"$28,516.50"	"$1,365.15"	"$31,197.05"	"$38,041.01"	"$22,813.20"	Not Applicable	"$19,961.55"	"$39,923.10"	"$1,365.15"	"$39,923.10"
PSI SD420.418 TITANIUM IMPLANT SD420.418	C1713	SUPPLY/IMPLANTS	"$56,547.00"	Outpatient	"$28,273.50"	"$1,365.15"	"$30,931.21"	"$37,716.85"	"$22,618.80"	Not Applicable	"$19,791.45"	"$39,582.90"	"$1,365.15"	"$39,582.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.522	C1713	SUPPLY/IMPLANTS	"$56,395.00"	Outpatient	"$28,197.50"	"$1,365.15"	"$30,848.07"	"$37,615.47"	"$22,558.00"	Not Applicable	"$19,738.25"	"$39,476.50"	"$1,365.15"	"$39,476.50"
AV Fistula Thromboectomy Lysis and PTA	36905	CARDIAC CATH LAB	"$56,304.00"	Outpatient	"$28,152.00"	"$20,673.20"	"$30,798.29"	"$37,554.77"	"$22,521.60"	"$8,681.00"	"$19,706.40"	"$39,412.80"	"$8,681.00"	"$39,412.80"
IMPL CRNL TI PTSPC NS SD420.411	C1713	SUPPLY/IMPLANTS	"$56,270.00"	Outpatient	"$28,135.00"	"$1,365.15"	"$30,779.69"	"$37,532.09"	"$22,508.00"	Not Applicable	"$19,694.50"	"$39,389.00"	"$1,365.15"	"$39,389.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.424	C1713	SUPPLY/IMPLANTS	"$56,231.00"	Outpatient	"$28,115.50"	"$1,365.15"	"$30,758.36"	"$37,506.08"	"$22,492.40"	Not Applicable	"$19,680.85"	"$39,361.70"	"$1,365.15"	"$39,361.70"
IMPL CRNL TI PTSPC NS SD420.405	C1713	SUPPLY/IMPLANTS	"$56,169.00"	Outpatient	"$28,084.50"	"$1,365.15"	"$30,724.44"	"$37,464.72"	"$22,467.60"	Not Applicable	"$19,659.15"	"$39,318.30"	"$1,365.15"	"$39,318.30"
RETRIEVER PACKTREVO XP 4 X 30 18 CAT 6 U 3PK4302200		STERILE SUPPLY	"$56,087.00"	Outpatient	"$28,043.50"	Not Applicable	"$30,679.59"	"$37,410.03"	"$22,434.80"	Not Applicable	"$19,630.45"	"$39,260.90"	"$19,630.45"	"$39,260.90"
REVISION OF HIP OR KNEE REPLACEMENT WITH CC DRG 467 DRG 467SN	C1713	SUPPLY/IMPLANTS	"$55,817.00"	Outpatient	"$27,908.50"	"$1,365.15"	"$30,531.90"	"$37,229.94"	"$22,326.80"	Not Applicable	"$19,535.95"	"$39,071.90"	"$1,365.15"	"$39,071.90"
REVISION OF HIP OR KNEE REPLACEMENT WITH CC DRG 467 DRG 467ZB	C1713	SUPPLY/IMPLANTS	"$55,817.00"	Outpatient	"$27,908.50"	"$1,365.15"	"$30,531.90"	"$37,229.94"	"$22,326.80"	Not Applicable	"$19,535.95"	"$39,071.90"	"$1,365.15"	"$39,071.90"
REVISION OF HIP OR KNEE REPLACEMENT WITH CC DRG 467 DRG 467DS	C1713	SUPPLY/IMPLANTS	"$55,817.00"	Outpatient	"$27,908.50"	"$1,365.15"	"$30,531.90"	"$37,229.94"	"$22,326.80"	Not Applicable	"$19,535.95"	"$39,071.90"	"$1,365.15"	"$39,071.90"
NRSTM 2.4INX2.2IN ACTIVA SC IMPL 0-10.5V 2-250HZ 0-25.5MA .4 37603	C1767	SUPPLY/IMPLANTS	"$55,737.00"	Outpatient	"$27,868.50"	Not Applicable	"$30,488.14"	"$37,176.58"	"$22,294.80"	Not Applicable	"$19,507.95"	"$39,015.90"	"$19,507.95"	"$39,015.90"
69794-0304-01 - burosumab 30 mg/mL Soln	J0584	PHARMACY	"$55,579.00"	Outpatient	"$27,789.50"	$348.84	"$30,401.71"	"$37,071.19"	"$22,231.60"	Not Applicable	"$19,452.65"	"$38,905.30"	$348.84	"$38,905.30"
IMPL CRNL TI PTSPC NS SD420.404	C1713	SUPPLY/IMPLANTS	"$55,331.00"	Outpatient	"$27,665.50"	"$1,365.15"	"$30,266.06"	"$36,905.78"	"$22,132.40"	Not Applicable	"$19,365.85"	"$38,731.70"	"$1,365.15"	"$38,731.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.517	C1713	SUPPLY/IMPLANTS	"$55,245.00"	Outpatient	"$27,622.50"	"$1,365.15"	"$30,219.02"	"$36,848.42"	"$22,098.00"	Not Applicable	"$19,335.75"	"$38,671.50"	"$1,365.15"	"$38,671.50"
PLT CRNL BN NS SD800.527	C1713	SUPPLY/IMPLANTS	"$55,245.00"	Outpatient	"$27,622.50"	"$1,365.15"	"$30,219.02"	"$36,848.42"	"$22,098.00"	Not Applicable	"$19,335.75"	"$38,671.50"	"$1,365.15"	"$38,671.50"
PSI SD800.570 PEEK IMPLANT SD800.570	C1713	SUPPLY/IMPLANTS	"$55,245.00"	Outpatient	"$27,622.50"	"$1,365.15"	"$30,219.02"	"$36,848.42"	"$22,098.00"	Not Applicable	"$19,335.75"	"$38,671.50"	"$1,365.15"	"$38,671.50"
DISC INTVRTB 15X6MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3556	C1713	SUPPLY/IMPLANTS	"$55,181.00"	Outpatient	"$27,590.50"	"$1,365.15"	"$30,184.01"	"$36,805.73"	"$22,072.40"	Not Applicable	"$19,313.35"	"$38,626.70"	"$1,365.15"	"$38,626.70"
DISC INTVRTB 17X6MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3576	C1713	SUPPLY/IMPLANTS	"$55,181.00"	Outpatient	"$27,590.50"	"$1,365.15"	"$30,184.01"	"$36,805.73"	"$22,072.40"	Not Applicable	"$19,313.35"	"$38,626.70"	"$1,365.15"	"$38,626.70"
DISC INTVRTB 15X5MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3555	C1713	SUPPLY/IMPLANTS	"$55,181.00"	Outpatient	"$27,590.50"	"$1,365.15"	"$30,184.01"	"$36,805.73"	"$22,072.40"	Not Applicable	"$19,313.35"	"$38,626.70"	"$1,365.15"	"$38,626.70"
PUMP SCT MAX PENUMBRA SYS ASP PMX110		STERILE SUPPLY	"$55,181.00"	Outpatient	"$27,590.50"	Not Applicable	"$30,184.01"	"$36,805.73"	"$22,072.40"	Not Applicable	"$19,313.35"	"$38,626.70"	"$19,313.35"	"$38,626.70"
DISC PROSTHESIS MOBI-C 15 X 15 X 7MM MB3557	C1713	SUPPLY/IMPLANTS	"$55,166.00"	Outpatient	"$27,583.00"	"$1,365.15"	"$30,175.80"	"$36,795.72"	"$22,066.40"	Not Applicable	"$19,308.10"	"$38,616.20"	"$1,365.15"	"$38,616.20"
DISC INTVRTB 17X5MM MOBI-C 13MM SPNE CRV COCRMO TI UHMWPE HA MB 3375		SUPPLY/IMPLANTS	"$55,151.00"	Outpatient	"$27,575.50"	Not Applicable	"$30,167.60"	"$36,785.72"	"$22,060.40"	Not Applicable	"$19,302.85"	"$38,605.70"	"$19,302.85"	"$38,605.70"
DISC INTVRTB 15X5MM MOBI-C 13MM SPNE CRV COCRMO TI UHMWPE HA MB 3355		SUPPLY/IMPLANTS	"$55,151.00"	Outpatient	"$27,575.50"	Not Applicable	"$30,167.60"	"$36,785.72"	"$22,060.40"	Not Applicable	"$19,302.85"	"$38,605.70"	"$19,302.85"	"$38,605.70"
IMPLANT PITRE LEFT POSTERIOR PARIETAL OCCIPITAL PK620626	C1876	SUPPLY/IMPLANTS	"$55,123.00"	Outpatient	"$27,561.50"	Not Applicable	"$30,152.28"	"$36,767.04"	"$22,049.20"	Not Applicable	"$19,293.05"	"$38,586.10"	"$19,293.05"	"$38,586.10"
OCCLUDER CARDIOVASCULAR AMPLATZER NITINOL POLYESTER 45 D CUR 9-ASD-MF-018	C1817	SUPPLY/IMPLANTS	"$55,083.00"	Outpatient	"$27,541.50"	Not Applicable	"$30,130.40"	"$36,740.36"	"$22,033.20"	Not Applicable	"$19,279.05"	"$38,558.10"	"$19,279.05"	"$38,558.10"
IMPL CRNL TI PTSPC NS SD420.410	C1713	SUPPLY/IMPLANTS	"$54,883.00"	Outpatient	"$27,441.50"	"$1,365.15"	"$30,021.00"	"$36,606.96"	"$21,953.20"	Not Applicable	"$19,209.05"	"$38,418.10"	"$1,365.15"	"$38,418.10"
59572-0775-01 - luspatercept 75 mg Powd	C9399	PHARMACY	"$54,880.00"	Outpatient	"$27,440.00"	Not Applicable	"$30,019.36"	"$36,604.96"	"$21,952.00"	Not Applicable	"$19,208.00"	"$38,416.00"	"$19,208.00"	"$38,416.00"
HNDL GD NTR NL ANTGRD TLL FEM TRGT IM NL 249000105		STERILE SUPPLY	"$54,739.00"	Outpatient	"$27,369.50"	Not Applicable	"$29,942.23"	"$36,510.91"	"$21,895.60"	Not Applicable	"$19,158.65"	"$38,317.30"	"$19,158.65"	"$38,317.30"
LEAD PCNG 86CM 4.7FR LH QRTT QDPL IS-4 LLLL CNCT 16 CRV 1457Q/86	C1895	SUPPLY/IMPLANTS	"$54,719.00"	Outpatient	"$27,359.50"	Not Applicable	"$29,931.29"	"$36,497.57"	"$21,887.60"	Not Applicable	"$19,151.65"	"$38,303.30"	"$19,151.65"	"$38,303.30"
IMPL CRNL TI PTSPC NS SD420.403	C1713	SUPPLY/IMPLANTS	"$54,586.00"	Outpatient	"$27,293.00"	"$1,365.15"	"$29,858.54"	"$36,408.86"	"$21,834.40"	Not Applicable	"$19,105.10"	"$38,210.20"	"$1,365.15"	"$38,210.20"
PLT 200X200X.6MM RECT CRNFCL TI CNTR MESH RGD BN NS TEAL 1.3 421.009	C1713	SUPPLY/IMPLANTS	"$54,324.00"	Outpatient	"$27,162.00"	"$1,365.15"	"$29,715.23"	"$36,234.11"	"$21,729.60"	Not Applicable	"$19,013.40"	"$38,026.80"	"$1,365.15"	"$38,026.80"
CAGE SPNL 31MM 22MM T2 ALTD CENTERPIECE THOR LMBR ANT TI 9392231	C1821	SUPPLY/IMPLANTS	"$54,280.00"	Outpatient	"$27,140.00"	Not Applicable	"$29,691.16"	"$36,204.76"	"$21,712.00"	Not Applicable	"$18,998.00"	"$37,996.00"	"$18,998.00"	"$37,996.00"
51144-0050-01 - brentuximab vedotin 50 mg Powd	J9042	PHARMACY	"$45,676.00"	Outpatient	"$22,838.00"	$168.90	"$29,689.40"	"$30,465.89"	"$18,270.40"	Not Applicable	"$15,986.60"	"$31,973.20"	$168.90	"$31,973.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.516	C1713	SUPPLY/IMPLANTS	"$54,105.00"	Outpatient	"$27,052.50"	"$1,365.15"	"$29,595.44"	"$36,088.04"	"$21,642.00"	Not Applicable	"$18,936.75"	"$37,873.50"	"$1,365.15"	"$37,873.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.521	C1713	SUPPLY/IMPLANTS	"$54,105.00"	Outpatient	"$27,052.50"	"$1,365.15"	"$29,595.44"	"$36,088.04"	"$21,642.00"	Not Applicable	"$18,936.75"	"$37,873.50"	"$1,365.15"	"$37,873.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.569	C1713	SUPPLY/IMPLANTS	"$54,105.00"	Outpatient	"$27,052.50"	"$1,365.15"	"$29,595.44"	"$36,088.04"	"$21,642.00"	Not Applicable	"$18,936.75"	"$37,873.50"	"$1,365.15"	"$37,873.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.423	C1713	SUPPLY/IMPLANTS	"$53,936.00"	Outpatient	"$26,968.00"	"$1,365.15"	"$29,502.99"	"$35,975.31"	"$21,574.40"	Not Applicable	"$18,877.60"	"$37,755.20"	"$1,365.15"	"$37,755.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.428	C1713	SUPPLY/IMPLANTS	"$53,936.00"	Outpatient	"$26,968.00"	"$1,365.15"	"$29,502.99"	"$35,975.31"	"$21,574.40"	Not Applicable	"$18,877.60"	"$37,755.20"	"$1,365.15"	"$37,755.20"
GFT STNT 166MM 23-13MM 18FR ENDURANT II 2 BRCH EVAS NTNL ETBF2313C166E	C1874	SUPPLY/IMPLANTS	"$53,869.00"	Outpatient	"$26,934.50"	Not Applicable	"$29,466.34"	"$35,930.62"	"$21,547.60"	Not Applicable	"$18,854.15"	"$37,708.30"	"$18,854.15"	"$37,708.30"
GFT STNT 166MM 36-16MM 20FR ENDURANT II 2 BRCH EVAS NTNL ETBF3616C166E	C1874	SUPPLY/IMPLANTS	"$53,869.00"	Outpatient	"$26,934.50"	Not Applicable	"$29,466.34"	"$35,930.62"	"$21,547.60"	Not Applicable	"$18,854.15"	"$37,708.30"	"$18,854.15"	"$37,708.30"
GFT STNT 166MM 28-16MM 18FR ENDURANT II 2 BRCH EVAS NTNL ETBF2816C166E	C1884	SUPPLY/IMPLANTS	"$53,869.00"	Outpatient	"$26,934.50"	Not Applicable	"$29,466.34"	"$35,930.62"	"$21,547.60"	Not Applicable	"$18,854.15"	"$37,708.30"	"$18,854.15"	"$37,708.30"
GFT STNT 166MM 36-20MM 20FR ENDURANT II 2 BRCH EVAS NTNL ETBF3620C166E	C1876	SUPPLY/IMPLANTS	"$53,869.00"	Outpatient	"$26,934.50"	Not Applicable	"$29,466.34"	"$35,930.62"	"$21,547.60"	Not Applicable	"$18,854.15"	"$37,708.30"	"$18,854.15"	"$37,708.30"
GFT STNT 102MM 14-36MM 20FR 26-28MM ENDURANT II 2 BRCH NTNL ETUF3614C102E	C1876	SUPPLY/IMPLANTS	"$53,869.00"	Outpatient	"$26,934.50"	Not Applicable	"$29,466.34"	"$35,930.62"	"$21,547.60"	Not Applicable	"$18,854.15"	"$37,708.30"	"$18,854.15"	"$37,708.30"
GFT STNT 145MM 25-16MM 18FR ENDURANT II 2 BRCH EVAS NTNL ETBF2516C145E	C1876	SUPPLY/IMPLANTS	"$53,869.00"	Outpatient	"$26,934.50"	Not Applicable	"$29,466.34"	"$35,930.62"	"$21,547.60"	Not Applicable	"$18,854.15"	"$37,708.30"	"$18,854.15"	"$37,708.30"
GFT STNT 124MM 28-13MM 18FR ENDURANT EVAS PROX DIST SYS BFUR ETBF2813C124E	C1874	SUPPLY/IMPLANTS	"$53,849.00"	Outpatient	"$26,924.50"	Not Applicable	"$29,455.40"	"$35,917.28"	"$21,539.60"	Not Applicable	"$18,847.15"	"$37,694.30"	"$18,847.15"	"$37,694.30"
STENT GRAFT SYSTEM AROTO UNI ILIAC ETUF3214C102E	C1784	SUPPLY/IMPLANTS	"$53,834.00"	Outpatient	"$26,917.00"	Not Applicable	"$29,447.20"	"$35,907.28"	"$21,533.60"	Not Applicable	"$18,841.90"	"$37,683.80"	"$18,841.90"	"$37,683.80"
IMPL CRNL TI PTSPC NS SD420.402	C1713	SUPPLY/IMPLANTS	"$53,731.00"	Outpatient	"$26,865.50"	"$1,365.15"	"$29,390.86"	"$35,838.58"	"$21,492.40"	Not Applicable	"$18,805.85"	"$37,611.70"	"$1,365.15"	"$37,611.70"
IMPL CRNL TI PTSPC NS SD420.401	C1713	SUPPLY/IMPLANTS	"$53,108.00"	Outpatient	"$26,554.00"	"$1,365.15"	"$29,050.08"	"$35,423.04"	"$21,243.20"	Not Applicable	"$18,587.80"	"$37,175.60"	"$1,365.15"	"$37,175.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.515	C1713	SUPPLY/IMPLANTS	"$52,961.00"	Outpatient	"$26,480.50"	"$1,365.15"	"$28,969.67"	"$35,324.99"	"$21,184.40"	Not Applicable	"$18,536.35"	"$37,072.70"	"$1,365.15"	"$37,072.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.526	C1713	SUPPLY/IMPLANTS	"$52,961.00"	Outpatient	"$26,480.50"	"$1,365.15"	"$28,969.67"	"$35,324.99"	"$21,184.40"	Not Applicable	"$18,536.35"	"$37,072.70"	"$1,365.15"	"$37,072.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.568	C1713	SUPPLY/IMPLANTS	"$52,961.00"	Outpatient	"$26,480.50"	"$1,365.15"	"$28,969.67"	"$35,324.99"	"$21,184.40"	Not Applicable	"$18,536.35"	"$37,072.70"	"$1,365.15"	"$37,072.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.422	C1713	SUPPLY/IMPLANTS	"$52,782.00"	Outpatient	"$26,391.00"	"$1,365.15"	"$28,871.75"	"$35,205.59"	"$21,112.80"	Not Applicable	"$18,473.70"	"$36,947.40"	"$1,365.15"	"$36,947.40"
GRAFT STENT ENDURANT II L102 MM OD25-14 MM ODSEC18 FR ENDOVA ETUF2514C102E	C2625	SUPPLY/IMPLANTS	"$52,321.00"	Outpatient	"$26,160.50"	Not Applicable	"$28,619.59"	"$34,898.11"	"$20,928.40"	Not Applicable	"$18,312.35"	"$36,624.70"	"$18,312.35"	"$36,624.70"
GFT STNT 103MM 14-28MM 18FR ENDURANT IIS INFRARENAL NTNL PL ESBF2814C103E	C1884	SUPPLY/IMPLANTS	"$52,321.00"	Outpatient	"$26,160.50"	Not Applicable	"$28,619.59"	"$34,898.11"	"$20,928.40"	Not Applicable	"$18,312.35"	"$36,624.70"	"$18,312.35"	"$36,624.70"
GFT STNT 102MM 28-14MM 18FR ENDURANT II EVAS PLSTR NTNL AUI ETUF2814C102E	C1874	SUPPLY/IMPLANTS	"$52,252.00"	Outpatient	"$26,126.00"	Not Applicable	"$28,581.84"	"$34,852.08"	"$20,900.80"	Not Applicable	"$18,288.20"	"$36,576.40"	"$18,288.20"	"$36,576.40"
GFT STNT 102MM 23-14MM 18FR ENDURANT II EVAS PLSTR NTNL AUI ETUF2314C102E	C1874	SUPPLY/IMPLANTS	"$52,252.00"	Outpatient	"$26,126.00"	Not Applicable	"$28,581.84"	"$34,852.08"	"$20,900.80"	Not Applicable	"$18,288.20"	"$36,576.40"	"$18,288.20"	"$36,576.40"
GFT STNT 166MM 32-16MM 20FR ENDURANT II 2 BRCH EVAS NTNL ETBF3216C166E	C1874	SUPPLY/IMPLANTS	"$52,252.00"	Outpatient	"$26,126.00"	Not Applicable	"$28,581.84"	"$34,852.08"	"$20,900.80"	Not Applicable	"$18,288.20"	"$36,576.40"	"$18,288.20"	"$36,576.40"
GFT STNT 145MM 32-16MM 20FR ENDURANT II 2 BRCH EVAS NTNL ETBF3216C145E	C2625	SUPPLY/IMPLANTS	"$52,252.00"	Outpatient	"$26,126.00"	Not Applicable	"$28,581.84"	"$34,852.08"	"$20,900.80"	Not Applicable	"$18,288.20"	"$36,576.40"	"$18,288.20"	"$36,576.40"
PCMKR THK6MM ALR QD RF INVISILINK IS4-LLLL IS-1 59X56MM CRD PM3242	C2621	PACE MAKER	"$52,247.00"	Outpatient	"$26,123.50"	Not Applicable	"$28,579.11"	"$34,848.75"	"$20,898.80"	Not Applicable	"$18,286.45"	"$36,572.90"	"$18,286.45"	"$36,572.90"
"ASPIRATION GUIDE CATHETER 20FR, 95CM 21-101"		STERILE SUPPLY	"$52,229.00"	Outpatient	"$26,114.50"	Not Applicable	"$28,569.26"	"$34,836.74"	"$20,891.60"	Not Applicable	"$18,280.15"	"$36,560.30"	"$18,280.15"	"$36,560.30"
FLOWTRIEVER PPP (USED FOR PE) FT-PPP		STERILE SUPPLY	"$52,229.00"	Outpatient	"$26,114.50"	Not Applicable	"$28,569.26"	"$34,836.74"	"$20,891.60"	Not Applicable	"$18,280.15"	"$36,560.30"	"$18,280.15"	"$36,560.30"
CRANIOPLASTY SKULL FLAP PK619980		SUPPLY/IMPLANTS	"$52,223.00"	Outpatient	"$26,111.50"	Not Applicable	"$28,565.98"	"$34,832.74"	"$20,889.20"	Not Applicable	"$18,278.05"	"$36,556.10"	"$18,278.05"	"$36,556.10"
STEM FEM 170MM 16MM SNG POR HIP STD OFST 71306616	C1776	SUPPLY/IMPLANTS	"$51,972.00"	Outpatient	"$25,986.00"	Not Applicable	"$28,428.68"	"$34,665.32"	"$20,788.80"	Not Applicable	"$18,190.20"	"$36,380.40"	"$18,190.20"	"$36,380.40"
STEM FEM 155MM 13MM SNG TI POR HIP STD OFST 71306613	C1776	SUPPLY/IMPLANTS	"$51,972.00"	Outpatient	"$25,986.00"	Not Applicable	"$28,428.68"	"$34,665.32"	"$20,788.80"	Not Applicable	"$18,190.20"	"$36,380.40"	"$18,190.20"	"$36,380.40"
PCMKR 11MM PERCEPTA QD MRI SURESCAN MR CONDITIONAL RADOPQ W4TR01	C2621	PACE MAKER	"$51,933.00"	Outpatient	"$25,966.50"	Not Applicable	"$28,407.35"	"$34,639.31"	"$20,773.20"	Not Applicable	"$18,176.55"	"$36,353.10"	"$18,176.55"	"$36,353.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.520	C1713	SUPPLY/IMPLANTS	"$51,805.00"	Outpatient	"$25,902.50"	"$1,365.15"	"$28,337.34"	"$34,553.94"	"$20,722.00"	Not Applicable	"$18,131.75"	"$36,263.50"	"$1,365.15"	"$36,263.50"
PACEMAKER VALITUDE X4 IS-1/IS4 8V4H	C2621	PACE MAKER	"$51,700.00"	Outpatient	"$25,850.00"	Not Applicable	"$28,279.90"	"$34,483.90"	"$20,680.00"	Not Applicable	"$18,095.00"	"$36,190.00"	"$18,095.00"	"$36,190.00"
"CRT-P SYSTEM, VALITUDE X4/ACUITY X4 W/RV OR ATRL LEAD U120"	C1722	PACE MAKER	"$51,700.00"	Outpatient	"$25,850.00"	Not Applicable	"$28,279.90"	"$34,483.90"	"$20,680.00"	Not Applicable	"$18,095.00"	"$36,190.00"	"$18,095.00"	"$36,190.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.417	C1713	SUPPLY/IMPLANTS	"$51,636.00"	Outpatient	"$25,818.00"	"$1,365.15"	"$28,244.89"	"$34,441.21"	"$20,654.40"	Not Applicable	"$18,072.60"	"$36,145.20"	"$1,365.15"	"$36,145.20"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.427	C1713	SUPPLY/IMPLANTS	"$51,636.00"	Outpatient	"$25,818.00"	"$1,365.15"	"$28,244.89"	"$34,441.21"	"$20,654.40"	Not Applicable	"$18,072.60"	"$36,145.20"	"$1,365.15"	"$36,145.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.470	C1713	SUPPLY/IMPLANTS	"$51,636.00"	Outpatient	"$25,818.00"	"$1,365.15"	"$28,244.89"	"$34,441.21"	"$20,654.40"	Not Applicable	"$18,072.60"	"$36,145.20"	"$1,365.15"	"$36,145.20"
STM BN OSTGN MTI SIL 40UA SPNE 2 LD IMPL MESH CTHD 10-1348M		STERILE SUPPLY	"$51,493.00"	Outpatient	"$25,746.50"	Not Applicable	"$28,166.67"	"$34,345.83"	"$20,597.20"	Not Applicable	"$18,022.55"	"$36,045.10"	"$18,022.55"	"$36,045.10"
NAIL IM 740MM 10MM T2 TI RT STRL ARTHDS 1829-2074S	C1713	SUPPLY/IMPLANTS	"$51,462.00"	Outpatient	"$25,731.00"	"$1,365.15"	"$28,149.71"	"$34,325.15"	"$20,584.80"	Not Applicable	"$18,011.70"	"$36,023.40"	"$1,365.15"	"$36,023.40"
ASMB ORTH IJS BSPLT IJS-ELB-BPA	C1776	SUPPLY/IMPLANTS	"$51,029.00"	Outpatient	"$25,514.50"	Not Applicable	"$27,912.86"	"$34,036.34"	"$20,411.60"	Not Applicable	"$17,860.15"	"$35,720.30"	"$17,860.15"	"$35,720.30"
(BC10) MAJOR JOINT AND LIMB REATTACHMENT WITH MCC/CC SHOULDE UPCHRG	C1776	SUPPLY/IMPLANTS	"$50,867.00"	Outpatient	"$25,433.50"	Not Applicable	"$27,824.25"	"$33,928.29"	"$20,346.80"	Not Applicable	"$17,803.45"	"$35,606.90"	"$17,803.45"	"$35,606.90"
STRAIGHT FLAT TRUSS 22 X 9 MM 0 DEGREE 6 MM HEIGHT PSTS-SM0006-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 22 X 9 MM 0 DEGREE 8 MM HEIGHT PSTS-SM0008-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 22 X 9 MM 0 DEGREE 10 MM HEIGHT PSTS-SM0010-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 22 X 9 MM 0 DEGREE 12 MM HEIGHT PSTS-SM0012-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 22 X 9 MM 0 DEGREE 14 MM HEIGHT PSTS-SM0014-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 22 X 9 MM 6 DEGREE 6 MM HEIGHT PSTS-SM0606-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 22 X 9 MM 6 DEGREE 8 MM HEIGHT PSTS-SM0608-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 22 X 9 MM 6 DEGREE 10 MM HEIGHT PSTS-SM0610-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 22 X 9 MM 6 DEGREE 12 MM HEIGHT PSTS-SM0612-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 22 X 9 MM 6 DEGREE 14 MM HEIGHT PSTS-SM0614-22	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 26 X 9 MM 0 DEGREE 6 MM HEIGHT PSTS-SM0006-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 26 X 9 MM 0 DEGREE 8 MM HEIGHT PSTS-SM0008-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 26 X 9 MM 0 DEGREE 10 MM HEIGHT PSTS-SM0010-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 26 X 9 MM 0 DEGREE 12 MM HEIGHT PSTS-SM0012-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT FLAT TRUSS 26 X 9 MM 0 DEGREE 14 MM HEIGHT PSTS-SM0014-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 6 MM HEIGHT PSTS-SM0606-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 8 MM HEIGHT PSTS-SM0608-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 10 MM HEIGHT PSTS-SM0610-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 12 MM HEIGHT PSTS-SM0612-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
STRAIGHT LORDOTIC TRUSS 26 X 9 MM 6 DEGREE 14 MM HEIGHT PSTS-SM0614-26	C1821	SUPPLY/IMPLANTS	"$50,810.00"	Outpatient	"$25,405.00"	Not Applicable	"$27,793.07"	"$33,890.27"	"$20,324.00"	Not Applicable	"$17,783.50"	"$35,567.00"	"$17,783.50"	"$35,567.00"
SCREW COMP SHRT ST/COMP RVS GLN XL/AB 98-B009-001-23	C1713	SUPPLY/IMPLANTS	"$50,778.00"	Outpatient	"$25,389.00"	"$1,365.15"	"$27,775.57"	"$33,868.93"	"$20,311.20"	Not Applicable	"$17,772.30"	"$35,544.60"	"$1,365.15"	"$35,544.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.514	C1713	SUPPLY/IMPLANTS	"$50,662.00"	Outpatient	"$25,331.00"	"$1,365.15"	"$27,712.11"	"$33,791.55"	"$20,264.80"	Not Applicable	"$17,731.70"	"$35,463.40"	"$1,365.15"	"$35,463.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.567	C1713	SUPPLY/IMPLANTS	"$50,662.00"	Outpatient	"$25,331.00"	"$1,365.15"	"$27,712.11"	"$33,791.55"	"$20,264.80"	Not Applicable	"$17,731.70"	"$35,463.40"	"$1,365.15"	"$35,463.40"
Tx Atrial Fib Pulmonary Vein Isolation	93656	CARDIAC CATH LAB	"$50,556.00"	Outpatient	"$25,278.00"	"$44,890.73"	"$27,654.13"	"$33,720.85"	"$20,222.40"	"$12,306.00"	"$17,694.60"	"$35,389.20"	"$12,306.00"	"$44,890.73"
HNDPC ESURG 13CM 11GA MYRIAD TISS AUTOMATE RESCT LTWT NN-8007		STERILE SUPPLY	"$50,507.00"	Outpatient	"$25,253.50"	Not Applicable	"$27,627.33"	"$33,688.17"	"$20,202.80"	Not Applicable	"$17,677.45"	"$35,354.90"	"$17,677.45"	"$35,354.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.416	C1713	SUPPLY/IMPLANTS	"$50,492.00"	Outpatient	"$25,246.00"	"$1,365.15"	"$27,619.12"	"$33,678.16"	"$20,196.80"	Not Applicable	"$17,672.20"	"$35,344.40"	"$1,365.15"	"$35,344.40"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.421	C1713	SUPPLY/IMPLANTS	"$50,492.00"	Outpatient	"$25,246.00"	"$1,365.15"	"$27,619.12"	"$33,678.16"	"$20,196.80"	Not Applicable	"$17,672.20"	"$35,344.40"	"$1,365.15"	"$35,344.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.469	C1713	SUPPLY/IMPLANTS	"$50,492.00"	Outpatient	"$25,246.00"	"$1,365.15"	"$27,619.12"	"$33,678.16"	"$20,196.80"	Not Applicable	"$17,672.20"	"$35,344.40"	"$1,365.15"	"$35,344.40"
PCMKR THK6MM CONSULTA CRT-P 2 CHMBR RR UNPLR BP 57X59MM CRD C4TR01		PACE MAKER	"$50,491.00"	Outpatient	"$25,245.50"	Not Applicable	"$27,618.58"	"$33,677.50"	"$20,196.40"	Not Applicable	"$17,671.85"	"$35,343.70"	"$17,671.85"	"$35,343.70"
HNDL GD NTR NL ANTGRD STD FEM TRGT IM NL 249000100		STERILE SUPPLY	"$50,414.00"	Outpatient	"$25,207.00"	Not Applicable	"$27,576.46"	"$33,626.14"	"$20,165.60"	Not Applicable	"$17,644.90"	"$35,289.80"	"$17,644.90"	"$35,289.80"
PLT 2.5MM LG 2 ANG MXL RECON MATRIXMANDIBLE BN PSPC SD449.514A	C1713	SUPPLY/IMPLANTS	"$50,135.00"	Outpatient	"$25,067.50"	"$1,365.15"	"$27,423.85"	"$33,440.05"	"$20,054.00"	Not Applicable	"$17,547.25"	"$35,094.50"	"$1,365.15"	"$35,094.50"
Enterra II Neurostimulator 37800	C1883	PACE MAKER	"$50,055.00"	Outpatient	"$25,027.50"	Not Applicable	"$27,380.09"	"$33,386.69"	"$20,022.00"	Not Applicable	"$17,519.25"	"$35,038.50"	"$17,519.25"	"$35,038.50"
Ablation Ventricular Tachycardia	93654	CARDIAC CATH LAB	"$49,948.00"	Outpatient	"$24,974.00"	"$44,890.73"	"$27,321.56"	"$33,315.32"	"$19,979.20"	"$12,306.00"	"$17,481.80"	"$34,963.60"	"$12,306.00"	"$44,890.73"
Ablate Supraventricular Tachycardia	93653	CARDIAC CATH LAB	"$49,948.00"	Outpatient	"$24,974.00"	"$44,890.73"	"$27,321.56"	"$33,315.32"	"$19,979.20"	"$12,306.00"	"$17,481.80"	"$34,963.60"	"$12,306.00"	"$44,890.73"
CMPNT FEM 5 KN RT POST STAB GNS2 LEGION SPC OXNM 71421205	C1776	SUPPLY/IMPLANTS	"$49,814.00"	Outpatient	"$24,907.00"	Not Applicable	"$27,248.26"	"$33,225.94"	"$19,925.60"	Not Applicable	"$17,434.90"	"$34,869.80"	"$17,434.90"	"$34,869.80"
CMPNT FEM 4 KN LT POST STAB GNS2 LEGION SPC OXNM 71421214	C1776	SUPPLY/IMPLANTS	"$49,814.00"	Outpatient	"$24,907.00"	Not Applicable	"$27,248.26"	"$33,225.94"	"$19,925.60"	Not Applicable	"$17,434.90"	"$34,869.80"	"$17,434.90"	"$34,869.80"
CMPNT FEM 6 KN RT POST STAB GNS2 LEGION SPC OXNM 71421206	C1776	SUPPLY/IMPLANTS	"$49,786.00"	Outpatient	"$24,893.00"	Not Applicable	"$27,232.94"	"$33,207.26"	"$19,914.40"	Not Applicable	"$17,425.10"	"$34,850.20"	"$17,425.10"	"$34,850.20"
DRSG BIO INTGR 10X4IN BVN CLGN GAG POLYSILOXANE BL MX MESH MWM4101	C9363	SUPPLY/IMPLANTS	"$49,751.00"	Outpatient	"$24,875.50"	$38.51	"$27,213.80"	"$33,183.92"	"$19,900.40"	Not Applicable	"$17,412.85"	"$34,825.70"	$38.51	"$34,825.70"
PCMKR ETRINSA 8 IMPL RSYN THRP CRD HF-T 394919	C1786	PACE MAKER	"$49,632.00"	Outpatient	"$24,816.00"	Not Applicable	"$27,148.70"	"$33,104.54"	"$19,852.80"	Not Applicable	"$17,371.20"	"$34,742.40"	"$17,371.20"	"$34,742.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.513	C1713	SUPPLY/IMPLANTS	"$49,521.00"	Outpatient	"$24,760.50"	"$1,365.15"	"$27,087.99"	"$33,030.51"	"$19,808.40"	Not Applicable	"$17,332.35"	"$34,664.70"	"$1,365.15"	"$34,664.70"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.519	C1713	SUPPLY/IMPLANTS	"$49,521.00"	Outpatient	"$24,760.50"	"$1,365.15"	"$27,087.99"	"$33,030.51"	"$19,808.40"	Not Applicable	"$17,332.35"	"$34,664.70"	"$1,365.15"	"$34,664.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.566	C1713	SUPPLY/IMPLANTS	"$49,521.00"	Outpatient	"$24,760.50"	"$1,365.15"	"$27,087.99"	"$33,030.51"	"$19,808.40"	Not Applicable	"$17,332.35"	"$34,664.70"	"$1,365.15"	"$34,664.70"
"QUADRA ALLURE MP RF CRT-P MRI SYSTEM, MERLIN PKG PM3562 SYSCELL"	C2621	PACE MAKER	"$49,379.00"	Outpatient	"$24,689.50"	Not Applicable	"$27,010.31"	"$32,935.79"	"$19,751.60"	Not Applicable	"$17,282.65"	"$34,565.30"	"$17,282.65"	"$34,565.30"
PCMKR THK6MM QD ALR MP RF IS4-LLLL IS-1 CNCT 59X56MM CRD 15 PM3262	C2621	PACE MAKER	"$49,359.00"	Outpatient	"$24,679.50"	Not Applicable	"$26,999.37"	"$32,922.45"	"$19,743.60"	Not Applicable	"$17,275.65"	"$34,551.30"	"$17,275.65"	"$34,551.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.415	C1713	SUPPLY/IMPLANTS	"$49,353.00"	Outpatient	"$24,676.50"	"$1,365.15"	"$26,996.09"	"$32,918.45"	"$19,741.20"	Not Applicable	"$17,273.55"	"$34,547.10"	"$1,365.15"	"$34,547.10"
IMPL CRNL PEEK NS LF SD800.426	C1713	SUPPLY/IMPLANTS	"$49,353.00"	Outpatient	"$24,676.50"	"$1,365.15"	"$26,996.09"	"$32,918.45"	"$19,741.20"	Not Applicable	"$17,273.55"	"$34,547.10"	"$1,365.15"	"$34,547.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.468	C1713	SUPPLY/IMPLANTS	"$49,353.00"	Outpatient	"$24,676.50"	"$1,365.15"	"$26,996.09"	"$32,918.45"	"$19,741.20"	Not Applicable	"$17,273.55"	"$34,547.10"	"$1,365.15"	"$34,547.10"
SYS CRD PCMKR LD IS4-LLLL IS-1 CNCT QD ALR MP RF THK6MM 59 PM3262 SYSTEM	C2621	PACE MAKER	"$49,349.00"	Outpatient	"$24,674.50"	Not Applicable	"$26,993.90"	"$32,915.78"	"$19,739.60"	Not Applicable	"$17,272.15"	"$34,544.30"	"$17,272.15"	"$34,544.30"
GRAFT BONE CARTIFORM DISC OD20 MM ALLOGRAFT ABS-1101-20	C1713	SUPPLY/IMPLANTS	"$49,327.00"	Outpatient	"$24,663.50"	"$1,365.15"	"$26,981.87"	"$32,901.11"	"$19,730.80"	Not Applicable	"$17,264.45"	"$34,528.90"	"$1,365.15"	"$34,528.90"
PACEMAKER CARDIAC IMPLANTABLE 59MMW X 56MML X 6MMH 27GM IS-1 CONNECTOR ALLURE QUADRA MP RF MRI-CONDI	C2621	PACE MAKER	"$49,327.00"	Outpatient	"$24,663.50"	Not Applicable	"$26,981.87"	"$32,901.11"	"$19,730.80"	Not Applicable	"$17,264.45"	"$34,528.90"	"$17,264.45"	"$34,528.90"
CRANIOPLASTY IMPLANT PK619483 PK619483		SUPPLY/IMPLANTS	"$49,321.00"	Outpatient	"$24,660.50"	Not Applicable	"$26,978.59"	"$32,897.11"	"$19,728.40"	Not Applicable	"$17,262.35"	"$34,524.70"	"$17,262.35"	"$34,524.70"
GFT SFT TIS 6X4CM LNYRD AMNIO TISS ALGRF CLGN MTRX AGT-5460	C9363	SUPPLY/IMPLANTS	"$49,317.00"	Outpatient	"$24,658.50"	$38.51	"$26,976.40"	"$32,894.44"	"$19,726.80"	Not Applicable	"$17,260.95"	"$34,521.90"	$38.51	"$34,521.90"
TISSUE LANYARD WRAP 4X6 CM AWT-5460	C9363	SUPPLY/IMPLANTS	"$49,317.00"	Outpatient	"$24,658.50"	$38.51	"$26,976.40"	"$32,894.44"	"$19,726.80"	Not Applicable	"$17,260.95"	"$34,521.90"	$38.51	"$34,521.90"
PCMKR PLS CRD EVIA HF T 377 208	C2621	PACE MAKER	"$49,313.00"	Outpatient	"$24,656.50"	Not Applicable	"$26,974.21"	"$32,891.77"	"$19,725.20"	Not Applicable	"$17,259.55"	"$34,519.10"	"$17,259.55"	"$34,519.10"
ALIF ENZA 15MM X 8DEG 26X 32MM EZAT-2632-0815	C1821	SUPPLY/IMPLANTS	"$49,212.00"	Outpatient	"$24,606.00"	Not Applicable	"$26,918.96"	"$32,824.40"	"$19,684.80"	Not Applicable	"$17,224.20"	"$34,448.40"	"$17,224.20"	"$34,448.40"
SPACER ENZA A 11MM X 23 X 26MM X 15 DEGREE EZAT-2326-1511	C1821	SUPPLY/IMPLANTS	"$49,212.00"	Outpatient	"$24,606.00"	Not Applicable	"$26,918.96"	"$32,824.40"	"$19,684.80"	Not Applicable	"$17,224.20"	"$34,448.40"	"$17,224.20"	"$34,448.40"
SPACER ENZA A 11MM X 26 X 32MM X 15 DEGREE EZAT-2632-1511	C1821	SUPPLY/IMPLANTS	"$49,212.00"	Outpatient	"$24,606.00"	Not Applicable	"$26,918.96"	"$32,824.40"	"$19,684.80"	Not Applicable	"$17,224.20"	"$34,448.40"	"$17,224.20"	"$34,448.40"
SPACER ENZA A-8 DEG 23X26MM 11 EZAT-2326-0811	C1821	SUPPLY/IMPLANTS	"$49,212.00"	Outpatient	"$24,606.00"	Not Applicable	"$26,918.96"	"$32,824.40"	"$19,684.80"	Not Applicable	"$17,224.20"	"$34,448.40"	"$17,224.20"	"$34,448.40"
Open/Percutaneous Placement Stent 1st	37236	CARDIAC CATH LAB	"$49,123.00"	Outpatient	"$24,561.50"	"$45,623.37"	"$26,870.28"	"$1,592.00"	"$19,649.20"	"$8,681.00"	"$17,193.05"	"$34,386.10"	"$1,592.00"	"$45,623.37"
VALVE AORTIC INSPIRIS RESILIA BOVINE PERICARDIUM SILICON RUB 11500A19		SUPPLY/IMPLANTS	"$49,059.00"	Outpatient	"$24,529.50"	Not Applicable	"$26,835.27"	"$32,722.35"	"$19,623.60"	Not Applicable	"$17,170.65"	"$34,341.30"	"$17,170.65"	"$34,341.30"
VALVE AORTIC INSPIRIS RESILIA 11500A		SUPPLY/IMPLANTS	"$49,008.00"	Outpatient	"$24,504.00"	Not Applicable	"$26,807.38"	"$32,688.34"	"$19,603.20"	Not Applicable	"$17,152.80"	"$34,305.60"	"$17,152.80"	"$34,305.60"
FIXATOR FRAME EZ LG EF10000L		NON-STER SUPPLY	"$48,984.00"	Outpatient	"$24,492.00"	Not Applicable	"$26,794.25"	"$32,672.33"	"$19,593.60"	Not Applicable	"$17,144.40"	"$34,288.80"	"$17,144.40"	"$34,288.80"
MTRX TISS 19.3X9.6CM ALDRM SLCT DUO THK.4-1.6MM MED CNTR CM1518PBP	Q4116	SUPPLY/IMPLANTS	"$48,665.00"	Outpatient	"$24,332.50"	$34.22	"$26,619.76"	"$32,459.56"	"$19,466.00"	Not Applicable	"$17,032.75"	"$34,065.50"	$34.22	"$34,065.50"
SMALL ANT FEM TARG GDE 512WD 249000810	C1713	SUPPLY/IMPLANTS	"$48,653.00"	Outpatient	"$24,326.50"	"$1,365.15"	"$26,613.19"	"$32,451.55"	"$19,461.20"	Not Applicable	"$17,028.55"	"$34,057.10"	"$1,365.15"	"$34,057.10"
JIG PSTN BLK FEM RT PERC DIST SS CF PEEK MIS PERIART LCK PLT 236009015	C1713	SUPPLY/IMPLANTS	"$48,632.00"	Outpatient	"$24,316.00"	"$1,365.15"	"$26,601.70"	"$32,437.54"	"$19,452.80"	Not Applicable	"$17,021.20"	"$34,042.40"	"$1,365.15"	"$34,042.40"
JIG PSTN BLK FEM LT PERC DIST SS CF PEEK MIS PERIART LCK PLT 236009016	C1713	SUPPLY/IMPLANTS	"$48,632.00"	Outpatient	"$24,316.00"	"$1,365.15"	"$26,601.70"	"$32,437.54"	"$19,452.80"	Not Applicable	"$17,021.20"	"$34,042.40"	"$1,365.15"	"$34,042.40"
PCMKR THK6MM SYNCRA 2 CHMBR RR UNPLR IS 1 57X59MM CRD 15ML C2TR01	C2621	PACE MAKER	"$48,532.00"	Outpatient	"$24,266.00"	Not Applicable	"$26,547.00"	"$32,370.84"	"$19,412.80"	Not Applicable	"$16,986.20"	"$33,972.40"	"$16,986.20"	"$33,972.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.509	C1713	SUPPLY/IMPLANTS	"$48,367.00"	Outpatient	"$24,183.50"	"$1,365.15"	"$26,456.75"	"$32,260.79"	"$19,346.80"	Not Applicable	"$16,928.45"	"$33,856.90"	"$1,365.15"	"$33,856.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.512	C1713	SUPPLY/IMPLANTS	"$48,367.00"	Outpatient	"$24,183.50"	"$1,365.15"	"$26,456.75"	"$32,260.79"	"$19,346.80"	Not Applicable	"$16,928.45"	"$33,856.90"	"$1,365.15"	"$33,856.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.562	C1713	SUPPLY/IMPLANTS	"$48,367.00"	Outpatient	"$24,183.50"	"$1,365.15"	"$26,456.75"	"$32,260.79"	"$19,346.80"	Not Applicable	"$16,928.45"	"$33,856.90"	"$1,365.15"	"$33,856.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.565	C1713	SUPPLY/IMPLANTS	"$48,367.00"	Outpatient	"$24,183.50"	"$1,365.15"	"$26,456.75"	"$32,260.79"	"$19,346.80"	Not Applicable	"$16,928.45"	"$33,856.90"	"$1,365.15"	"$33,856.90"
PLT 2.8MM ANG LT MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.517A	C1713	SUPPLY/IMPLANTS	"$48,255.00"	Outpatient	"$24,127.50"	"$1,365.15"	"$26,395.49"	"$32,186.09"	"$19,302.00"	Not Applicable	"$16,889.25"	"$33,778.50"	"$1,365.15"	"$33,778.50"
PLT 2.8MM ANG RT MXL TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.518A	C1713	SUPPLY/IMPLANTS	"$48,255.00"	Outpatient	"$24,127.50"	"$1,365.15"	"$26,395.49"	"$32,186.09"	"$19,302.00"	Not Applicable	"$16,889.25"	"$33,778.50"	"$1,365.15"	"$33,778.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.420	C1713	SUPPLY/IMPLANTS	"$48,193.00"	Outpatient	"$24,096.50"	"$1,365.15"	"$26,361.57"	"$32,144.73"	"$19,277.20"	Not Applicable	"$16,867.55"	"$33,735.10"	"$1,365.15"	"$33,735.10"
PLT 2.5MM MED 2 ANG MXL RECON MATRIXMANDIBLE BN PSPC SD449.513A	C1713	SUPPLY/IMPLANTS	"$48,173.00"	Outpatient	"$24,086.50"	"$1,365.15"	"$26,350.63"	"$32,131.39"	"$19,269.20"	Not Applicable	"$16,860.55"	"$33,721.10"	"$1,365.15"	"$33,721.10"
GFT SFT TIS 80+ CM 3MM ANGIOGRAFT SV CRPRS CV>80	C1768	SUPPLY/IMPLANTS	"$47,987.00"	Outpatient	"$23,993.50"	Not Applicable	"$26,248.89"	"$32,007.33"	"$19,194.80"	Not Applicable	"$16,795.45"	"$33,590.90"	"$16,795.45"	"$33,590.90"
PACEMAKER CARDIAC EDORA PROMRI TITANIUM SILICONE RUBBER EPOX 407145	C1786	PACE MAKER	"$47,926.00"	Outpatient	"$23,963.00"	Not Applicable	"$26,215.52"	"$31,966.64"	"$19,170.40"	Not Applicable	"$16,774.10"	"$33,548.20"	"$16,774.10"	"$33,548.20"
REUNION REVERSE SHOULDER RRS	C1713	SUPPLY/IMPLANTS	"$47,897.00"	Outpatient	"$23,948.50"	"$1,365.15"	"$26,199.66"	"$31,947.30"	"$19,158.80"	Not Applicable	"$16,763.95"	"$33,527.90"	"$1,365.15"	"$33,527.90"
COMP SHRT ST/COMP RVS GLN E1 98B00901602	C1776	SUPPLY/IMPLANTS	"$47,877.00"	Outpatient	"$23,938.50"	Not Applicable	"$26,188.72"	"$31,933.96"	"$19,150.80"	Not Applicable	"$16,756.95"	"$33,513.90"	"$16,756.95"	"$33,513.90"
SIDUS ANCHOR RGX GLD HUM HD 98-0009-000-06	C1776	SUPPLY/IMPLANTS	"$47,877.00"	Outpatient	"$23,938.50"	Not Applicable	"$26,188.72"	"$31,933.96"	"$19,150.80"	Not Applicable	"$16,756.95"	"$33,513.90"	"$16,756.95"	"$33,513.90"
COMP SHRT STiCOMP RVS 98B00901302	C1776	SUPPLY/IMPLANTS	"$47,871.00"	Outpatient	"$23,935.50"	Not Applicable	"$26,185.44"	"$31,929.96"	"$19,148.40"	Not Applicable	"$16,754.85"	"$33,509.70"	"$16,754.85"	"$33,509.70"
FRAC ST/COMP RVS GLN/XLPE 98-B009-020-03	C1776	SUPPLY/IMPLANTS	"$47,871.00"	Outpatient	"$23,935.50"	Not Applicable	"$26,185.44"	"$31,929.96"	"$19,148.40"	Not Applicable	"$16,754.85"	"$33,509.70"	"$16,754.85"	"$33,509.70"
SHOULDER REV. ARTHOSPLASTY INCLUDES ANY POROUS OR NON POROUS 98-B009-013-02		NON-STER SUPPLY	"$47,871.00"	Outpatient	"$23,935.50"	Not Applicable	"$26,185.44"	"$31,929.96"	"$19,148.40"	Not Applicable	"$16,754.85"	"$33,509.70"	"$16,754.85"	"$33,509.70"
STENT INTRACRANIAL WINGSPAN GATEWAY 9 X 3.5MM WS035009	C1874	SUPPLY/IMPLANTS	"$47,832.00"	Outpatient	"$23,916.00"	Not Applicable	"$26,164.10"	"$31,903.94"	"$19,132.80"	Not Applicable	"$16,741.20"	"$33,482.40"	"$16,741.20"	"$33,482.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.508	C1713	SUPPLY/IMPLANTS	"$47,672.00"	Outpatient	"$23,836.00"	"$1,365.15"	"$26,076.58"	"$31,797.22"	"$19,068.80"	Not Applicable	"$16,685.20"	"$33,370.40"	"$1,365.15"	"$33,370.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.518	C1713	SUPPLY/IMPLANTS	"$47,672.00"	Outpatient	"$23,836.00"	"$1,365.15"	"$26,076.58"	"$31,797.22"	"$19,068.80"	Not Applicable	"$16,685.20"	"$33,370.40"	"$1,365.15"	"$33,370.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.561	C1713	SUPPLY/IMPLANTS	"$47,672.00"	Outpatient	"$23,836.00"	"$1,365.15"	"$26,076.58"	"$31,797.22"	"$19,068.80"	Not Applicable	"$16,685.20"	"$33,370.40"	"$1,365.15"	"$33,370.40"
Open/Perc Place Intravascular Stent 1st Vein	37238	CARDIAC CATH LAB	"$47,606.00"	Outpatient	"$23,803.00"	"$45,623.37"	"$26,040.48"	"$1,592.00"	"$19,042.40"	"$8,681.00"	"$16,662.10"	"$33,324.20"	"$1,592.00"	"$45,623.37"
Open/Percutaneous Placement Stent Same	37238	CARDIAC CATH LAB	"$47,606.00"	Outpatient	"$23,803.00"	"$45,623.37"	"$26,040.48"	"$1,592.00"	"$19,042.40"	"$8,681.00"	"$16,662.10"	"$33,324.20"	"$1,592.00"	"$45,623.37"
"Open/Perc Place Intravascular Stent 1st Artery, except leg"	37236	CARDIAC CATH LAB	"$47,606.00"	Outpatient	"$23,803.00"	"$45,623.37"	"$26,040.48"	"$1,592.00"	"$19,042.40"	"$8,681.00"	"$16,662.10"	"$33,324.20"	"$1,592.00"	"$45,623.37"
"50242-0109-01 - hyaluronidase-rituximab 26,800 units-1600 mg/13.4 mL Soln"	J9311	PHARMACY	"$39,956.00"	Outpatient	"$19,978.00"	$46.67	"$25,971.40"	"$26,650.65"	"$15,982.40"	Not Applicable	"$13,984.60"	"$27,969.20"	$46.67	"$27,969.20"
CASE INST CMPLT NS SM FRAG ANTM LCK PLT SYS 8299-51-000		STERILE SUPPLY	"$47,471.00"	Outpatient	"$23,735.50"	Not Applicable	"$25,966.64"	"$31,663.16"	"$18,988.40"	Not Applicable	"$16,614.85"	"$33,229.70"	"$16,614.85"	"$33,229.70"
"PTCA/Drug-eluting stent, single vessel"	C9600	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$38,837.07"	"$25,960.18"	"$8,056.00"	"$17,481.60"	"$8,681.00"	"$15,296.40"	"$30,592.80"	"$8,056.00"	"$38,837.07"
Place Drug Eluting Stent Perc Single	C9600	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$38,837.07"	"$25,960.18"	"$8,056.00"	"$17,481.60"	"$8,681.00"	"$15,296.40"	"$30,592.80"	"$8,056.00"	"$38,837.07"
Intracoronary Stent Placement 1st Vessel	92928	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$30,568.87"	"$25,960.18"	"$8,056.00"	"$17,481.60"	"$7,310.00"	"$15,296.40"	"$30,592.80"	"$7,310.00"	"$30,592.80"
PLT 2MM 2 ANG LG MXL RECON MATRIXMANDIBLE BN PTSPC PLT CNTR SD449.507A	C1713	SUPPLY/IMPLANTS	"$47,422.00"	Outpatient	"$23,711.00"	"$1,365.15"	"$25,939.83"	"$31,630.47"	"$18,968.80"	Not Applicable	"$16,597.70"	"$33,195.40"	"$1,365.15"	"$33,195.40"
PLT 2.5MM 2 ANG LG RECON MATRIXMANDIBLE BN SD449.514	C1713	SUPPLY/IMPLANTS	"$47,412.00"	Outpatient	"$23,706.00"	"$1,365.15"	"$25,934.36"	"$31,623.80"	"$18,964.80"	Not Applicable	"$16,594.20"	"$33,188.40"	"$1,365.15"	"$33,188.40"
00003-2327-11 - ipilimumab 5 mg/mL Soln	J9228	PHARMACY	"$39,878.00"	Outpatient	"$19,939.00"	$149.88	"$25,920.70"	"$26,598.63"	"$15,951.20"	Not Applicable	"$13,957.30"	"$27,914.60"	$149.88	"$27,914.60"
Insert Bivent Lead New System	33225	CARDIAC CATH LAB	"$47,309.00"	Outpatient	"$23,654.50"	"$30,812.59"	"$25,878.02"	"$1,592.00"	"$18,923.60"	"$12,306.00"	"$16,558.15"	"$33,116.30"	"$1,592.00"	"$33,116.30"
Insert Bivent Lead Existing System	33224	CARDIAC CATH LAB	"$47,309.00"	Outpatient	"$23,654.50"	"$30,812.59"	"$25,878.02"	"$1,592.00"	"$18,923.60"	"$12,306.00"	"$16,558.15"	"$33,116.30"	"$1,592.00"	"$33,116.30"
GD TRGT SM NTR NL CEPHALOMEDULLARY NL 249000308		STERILE SUPPLY	"$47,160.00"	Outpatient	"$23,580.00"	Not Applicable	"$25,796.52"	"$31,455.72"	"$18,864.00"	Not Applicable	"$16,506.00"	"$33,012.00"	"$16,506.00"	"$33,012.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.414	C1713	SUPPLY/IMPLANTS	"$47,055.00"	Outpatient	"$23,527.50"	"$1,365.15"	"$25,739.09"	"$31,385.69"	"$18,822.00"	Not Applicable	"$16,469.25"	"$32,938.50"	"$1,365.15"	"$32,938.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.467	C1713	SUPPLY/IMPLANTS	"$47,055.00"	Outpatient	"$23,527.50"	"$1,365.15"	"$25,739.09"	"$31,385.69"	"$18,822.00"	Not Applicable	"$16,469.25"	"$32,938.50"	"$1,365.15"	"$32,938.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.507	C1713	SUPPLY/IMPLANTS	"$46,988.00"	Outpatient	"$23,494.00"	"$1,365.15"	"$25,702.44"	"$31,341.00"	"$18,795.20"	Not Applicable	"$16,445.80"	"$32,891.60"	"$1,365.15"	"$32,891.60"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.511	C1713	SUPPLY/IMPLANTS	"$46,988.00"	Outpatient	"$23,494.00"	"$1,365.15"	"$25,702.44"	"$31,341.00"	"$18,795.20"	Not Applicable	"$16,445.80"	"$32,891.60"	"$1,365.15"	"$32,891.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.560	C1713	SUPPLY/IMPLANTS	"$46,988.00"	Outpatient	"$23,494.00"	"$1,365.15"	"$25,702.44"	"$31,341.00"	"$18,795.20"	Not Applicable	"$16,445.80"	"$32,891.60"	"$1,365.15"	"$32,891.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.564	C1713	SUPPLY/IMPLANTS	"$46,988.00"	Outpatient	"$23,494.00"	"$1,365.15"	"$25,702.44"	"$31,341.00"	"$18,795.20"	Not Applicable	"$16,445.80"	"$32,891.60"	"$1,365.15"	"$32,891.60"
MAJOR JOINT REPLACEMENT OR REATTACHMENT WITH MCC HIPS KNEES DRG 469SN	C1776	SUPPLY/IMPLANTS	"$46,959.00"	Outpatient	"$23,479.50"	Not Applicable	"$25,686.57"	"$31,321.65"	"$18,783.60"	Not Applicable	"$16,435.65"	"$32,871.30"	"$16,435.65"	"$32,871.30"
MAJOR JOINT REPLACEMENT OR REATTACHMENT WITH MCC HIPS KNEES DRG 469ZB	C1776	SUPPLY/IMPLANTS	"$46,959.00"	Outpatient	"$23,479.50"	Not Applicable	"$25,686.57"	"$31,321.65"	"$18,783.60"	Not Applicable	"$16,435.65"	"$32,871.30"	"$16,435.65"	"$32,871.30"
MAJOR JOINT REPLACEMENT OR REATTACHMENT WITH MCC HIPS KNEES DRG 469DS	C1776	SUPPLY/IMPLANTS	"$46,959.00"	Outpatient	"$23,479.50"	Not Applicable	"$25,686.57"	"$31,321.65"	"$18,783.60"	Not Applicable	"$16,435.65"	"$32,871.30"	"$16,435.65"	"$32,871.30"
LEAD NEUROSTIMULATOR VNS THERAPY PERENNIAFLEX OD2 MM STERILE 304-20	C1778	SUPPLY/IMPLANTS	"$46,870.00"	Outpatient	"$23,435.00"	Not Applicable	"$25,637.89"	"$31,262.29"	"$18,748.00"	Not Applicable	"$16,404.50"	"$32,809.00"	"$16,404.50"	"$32,809.00"
50242-0085-27 - alteplase 100 mg Inj (per 1mg)	J2997	PHARMACY	"$46,783.00"	Outpatient	"$23,391.50"	$96.47	"$25,590.30"	"$31,204.26"	"$18,713.20"	Not Applicable	"$16,374.05"	"$32,748.10"	$96.47	"$32,748.10"
JIG PSTN TIB RT PROX LAT 30% C REINF PEEK SS 3.5 MM SCR MIS 236009305	C1713	SUPPLY/IMPLANTS	"$46,644.00"	Outpatient	"$23,322.00"	"$1,365.15"	"$25,514.27"	"$31,111.55"	"$18,657.60"	Not Applicable	"$16,325.40"	"$32,650.80"	"$1,365.15"	"$32,650.80"
JIG PSTN TIB LT PROX LAT 30% C REINF PEEK SS 3.5 MM SCR MIS 236009306	C1713	SUPPLY/IMPLANTS	"$46,644.00"	Outpatient	"$23,322.00"	"$1,365.15"	"$25,514.27"	"$31,111.55"	"$18,657.60"	Not Applicable	"$16,325.40"	"$32,650.80"	"$1,365.15"	"$32,650.80"
15054-1120-03 - lanreotide 120 mg/0.5 mL Soln	J1930	PHARMACY	"$46,547.00"	Outpatient	"$23,273.50"	$72.44	"$25,461.21"	"$31,046.85"	"$18,618.80"	Not Applicable	"$16,291.45"	"$32,582.90"	$72.44	"$32,582.90"
15054-1120-04 - lanreotide 120 mg/0.5 mL Soln	J1930	PHARMACY	"$46,547.00"	Outpatient	"$23,273.50"	$72.44	"$25,461.21"	"$31,046.85"	"$18,618.80"	Not Applicable	"$16,291.45"	"$32,582.90"	$72.44	"$32,582.90"
SYS CRD PCMKR LD IS-1 CNCT ALR RF THK6MM 59X55MM 14CC 24GM PM3222 SYSTEM	C2621	PACE MAKER	"$46,443.00"	Outpatient	"$23,221.50"	Not Applicable	"$25,404.32"	"$30,977.48"	"$18,577.20"	Not Applicable	"$16,255.05"	"$32,510.10"	"$16,255.05"	"$32,510.10"
BILATERAL OR MULTIPLE MAJOR JOINT WITHOUT MCC DRG 462 DRG 462SN	C1713	SUPPLY/IMPLANTS	"$46,343.00"	Outpatient	"$23,171.50"	"$1,365.15"	"$25,349.62"	"$30,910.78"	"$18,537.20"	Not Applicable	"$16,220.05"	"$32,440.10"	"$1,365.15"	"$32,440.10"
BILATERAL OR MULTIPLE MAJOR JOINT WITHOUT MCC DRG 462 DRG 462ZB	C1713	SUPPLY/IMPLANTS	"$46,343.00"	Outpatient	"$23,171.50"	"$1,365.15"	"$25,349.62"	"$30,910.78"	"$18,537.20"	Not Applicable	"$16,220.05"	"$32,440.10"	"$1,365.15"	"$32,440.10"
BILATERAL OR MULTIPLE MAJOR JOINT WITHOUT MCC DRG 462 DRG 462DS	C1713	SUPPLY/IMPLANTS	"$46,343.00"	Outpatient	"$23,171.50"	"$1,365.15"	"$25,349.62"	"$30,910.78"	"$18,537.20"	Not Applicable	"$16,220.05"	"$32,440.10"	"$1,365.15"	"$32,440.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.506	C1713	SUPPLY/IMPLANTS	"$46,292.00"	Outpatient	"$23,146.00"	"$1,365.15"	"$25,321.72"	"$30,876.76"	"$18,516.80"	Not Applicable	"$16,202.20"	"$32,404.40"	"$1,365.15"	"$32,404.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.559	C1713	SUPPLY/IMPLANTS	"$46,292.00"	Outpatient	"$23,146.00"	"$1,365.15"	"$25,321.72"	"$30,876.76"	"$18,516.80"	Not Applicable	"$16,202.20"	"$32,404.40"	"$1,365.15"	"$32,404.40"
PLT 2.5MM SM 2 ANG MXL RECON MATRIXMANDIBLE BN PSPC SD449.512A	C1713	SUPPLY/IMPLANTS	"$46,278.00"	Outpatient	"$23,139.00"	"$1,365.15"	"$25,314.07"	"$30,867.43"	"$18,511.20"	Not Applicable	"$16,197.30"	"$32,394.60"	"$1,365.15"	"$32,394.60"
SPCR SPNL 50X18X10MM ALEUTIAN 8D LRDTC PEEK NS LF 3203-21050SL	C1821	SUPPLY/IMPLANTS	"$46,211.00"	Outpatient	"$23,105.50"	Not Applicable	"$25,277.42"	"$30,822.74"	"$18,484.40"	Not Applicable	"$16,173.85"	"$32,347.70"	"$16,173.85"	"$32,347.70"
SPCR SPNL 50X18X12MM ALEUTIAN 8D LRDTC PEEK NS LF 3203-21250SL	C1821	SUPPLY/IMPLANTS	"$46,211.00"	Outpatient	"$23,105.50"	Not Applicable	"$25,277.42"	"$30,822.74"	"$18,484.40"	Not Applicable	"$16,173.85"	"$32,347.70"	"$16,173.85"	"$32,347.70"
SPCR SPNL 50X18X14MM ALEUTIAN 8D LRDTC PEEK NS LF 3203-21450SL	C1821	SUPPLY/IMPLANTS	"$46,211.00"	Outpatient	"$23,105.50"	Not Applicable	"$25,277.42"	"$30,822.74"	"$18,484.40"	Not Applicable	"$16,173.85"	"$32,347.70"	"$16,173.85"	"$32,347.70"
SPCR SPNL 45X18X14MM ALEUTIAN 8D LRDTC PEEK NS LF 3203-21445SL	C1821	SUPPLY/IMPLANTS	"$46,178.00"	Outpatient	"$23,089.00"	Not Applicable	"$25,259.37"	"$30,800.73"	"$18,471.20"	Not Applicable	"$16,162.30"	"$32,324.60"	"$16,162.30"	"$32,324.60"
SPCR SPNL 22X10X10-15MM CLBR 4D LRDTC NS LF 194.222	C1821	SUPPLY/IMPLANTS	"$46,152.00"	Outpatient	"$23,076.00"	Not Applicable	"$25,245.14"	"$30,783.38"	"$18,460.80"	Not Applicable	"$16,153.20"	"$32,306.40"	"$16,153.20"	"$32,306.40"
SPCR SPNL 26X10X8MM CLBR 4D LRDTC NS LF 194.126	C1821	SUPPLY/IMPLANTS	"$46,152.00"	Outpatient	"$23,076.00"	Not Applicable	"$25,245.14"	"$30,783.38"	"$18,460.80"	Not Applicable	"$16,153.20"	"$32,306.40"	"$16,153.20"	"$32,306.40"
SPCR SPNL 22X10X7MM CLBR 10- D NS LF 194.272	C1821	SUPPLY/IMPLANTS	"$46,152.00"	Outpatient	"$23,076.00"	Not Applicable	"$25,245.14"	"$30,783.38"	"$18,460.80"	Not Applicable	"$16,153.20"	"$32,306.40"	"$16,153.20"	"$32,306.40"
SPCR SPNL 22X10X7MM CLBR NS LF 194.51	C1821	SUPPLY/IMPLANTS	"$46,152.00"	Outpatient	"$23,076.00"	Not Applicable	"$25,245.14"	"$30,783.38"	"$18,460.80"	Not Applicable	"$16,153.20"	"$32,306.40"	"$16,153.20"	"$32,306.40"
SPCR SPNL 26X10X7MM CLBR NS LF 194.511		STERILE SUPPLY	"$46,152.00"	Outpatient	"$23,076.00"	Not Applicable	"$25,245.14"	"$30,783.38"	"$18,460.80"	Not Applicable	"$16,153.20"	"$32,306.40"	"$16,153.20"	"$32,306.40"
SPCR SPNL 22X10X7MM RISE NS 193.101	C1821	SUPPLY/IMPLANTS	"$46,121.00"	Outpatient	"$23,060.50"	Not Applicable	"$25,228.19"	"$30,762.71"	"$18,448.40"	Not Applicable	"$16,142.35"	"$32,284.70"	"$16,142.35"	"$32,284.70"
SPCR SPNL 26X10X7MM RISE NS 193.102	C1821	SUPPLY/IMPLANTS	"$46,121.00"	Outpatient	"$23,060.50"	Not Applicable	"$25,228.19"	"$30,762.71"	"$18,448.40"	Not Applicable	"$16,142.35"	"$32,284.70"	"$16,142.35"	"$32,284.70"
SPCR SPNL 22X10X8MM CLBR 4D LRDTC NS LF 194.122	C1821	SUPPLY/IMPLANTS	"$46,121.00"	Outpatient	"$23,060.50"	Not Applicable	"$25,228.19"	"$30,762.71"	"$18,448.40"	Not Applicable	"$16,142.35"	"$32,284.70"	"$16,142.35"	"$32,284.70"
SMALL ANTE FEM TARG GDE HANDLE 249000800	C1713	SUPPLY/IMPLANTS	"$45,916.00"	Outpatient	"$22,958.00"	"$1,365.15"	"$25,116.05"	"$30,625.97"	"$18,366.40"	Not Applicable	"$16,070.60"	"$32,141.20"	"$1,365.15"	"$32,141.20"
PACEMAKER CARDIAC VIVA CRT-P L12 MM X H6 MM 2 CHAMBER DIGITA C6TR01	C1785	PACE MAKER	"$45,915.00"	Outpatient	"$22,957.50"	Not Applicable	"$25,115.51"	"$30,625.31"	"$18,366.00"	Not Applicable	"$16,070.25"	"$32,140.50"	"$16,070.25"	"$32,140.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.413	C1713	SUPPLY/IMPLANTS	"$45,909.00"	Outpatient	"$22,954.50"	"$1,365.15"	"$25,112.22"	"$30,621.30"	"$18,363.60"	Not Applicable	"$16,068.15"	"$32,136.30"	"$1,365.15"	"$32,136.30"
IMPL CRNL PEEK-OPTM CSTM PTSPC NS SD800.419	C1713	SUPPLY/IMPLANTS	"$45,909.00"	Outpatient	"$22,954.50"	"$1,365.15"	"$25,112.22"	"$30,621.30"	"$18,363.60"	Not Applicable	"$16,068.15"	"$32,136.30"	"$1,365.15"	"$32,136.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.466	C1713	SUPPLY/IMPLANTS	"$45,909.00"	Outpatient	"$22,954.50"	"$1,365.15"	"$25,112.22"	"$30,621.30"	"$18,363.60"	Not Applicable	"$16,068.15"	"$32,136.30"	"$1,365.15"	"$32,136.30"
VALVE PERICARDIAL  23MM 3000 3000	C1763	SUPPLY/IMPLANTS	"$45,707.00"	Outpatient	"$22,853.50"	Not Applicable	"$25,001.73"	"$30,486.57"	"$18,282.80"	Not Applicable	"$15,997.45"	"$31,994.90"	"$15,997.45"	"$31,994.90"
OSSEOTI RECON WDG CASE KITTED TRAY 597019	C1713	SUPPLY/IMPLANTS	"$45,670.00"	Outpatient	"$22,835.00"	"$1,365.15"	"$24,981.49"	"$30,461.89"	"$18,268.00"	Not Applicable	"$15,984.50"	"$31,969.00"	"$1,365.15"	"$31,969.00"
SET SCR MDN SM INTLK CMPLT IM NL SYS 225300037	C1713	SUPPLY/IMPLANTS	"$45,648.00"	Outpatient	"$22,824.00"	"$1,365.15"	"$24,969.46"	"$30,447.22"	"$18,259.20"	Not Applicable	"$15,976.80"	"$31,953.60"	"$1,365.15"	"$31,953.60"
SET SCR MDN MED INTLK CMPLT IM NL SYS 225300042	C1713	SUPPLY/IMPLANTS	"$45,648.00"	Outpatient	"$22,824.00"	"$1,365.15"	"$24,969.46"	"$30,447.22"	"$18,259.20"	Not Applicable	"$15,976.80"	"$31,953.60"	"$1,365.15"	"$31,953.60"
PLT 2MM 2 ANG MED MXL RECON MATRIXMANDIBLE BN PTSPC PLT CNTR SD449.506A	C1713	SUPPLY/IMPLANTS	"$45,639.00"	Outpatient	"$22,819.50"	"$1,365.15"	"$24,964.53"	"$30,441.21"	"$18,255.60"	Not Applicable	"$15,973.65"	"$31,947.30"	"$1,365.15"	"$31,947.30"
GFT BN ZYG SD800.563	C1713	SUPPLY/IMPLANTS	"$45,613.00"	Outpatient	"$22,806.50"	"$1,365.15"	"$24,950.31"	"$30,423.87"	"$18,245.20"	Not Applicable	"$15,964.55"	"$31,929.10"	"$1,365.15"	"$31,929.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.505	C1713	SUPPLY/IMPLANTS	"$45,613.00"	Outpatient	"$22,806.50"	"$1,365.15"	"$24,950.31"	"$30,423.87"	"$18,245.20"	Not Applicable	"$15,964.55"	"$31,929.10"	"$1,365.15"	"$31,929.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.558	C1713	SUPPLY/IMPLANTS	"$45,613.00"	Outpatient	"$22,806.50"	"$1,365.15"	"$24,950.31"	"$30,423.87"	"$18,245.20"	Not Applicable	"$15,964.55"	"$31,929.10"	"$1,365.15"	"$31,929.10"
IMPL MALAR SPC ZYG NS SD800.510	C1713	SUPPLY/IMPLANTS	"$45,613.00"	Outpatient	"$22,806.50"	"$1,365.15"	"$24,950.31"	"$30,423.87"	"$18,245.20"	Not Applicable	"$15,964.55"	"$31,929.10"	"$1,365.15"	"$31,929.10"
SPCR SPNL 55X20X15MM TRANSCONTINENTAL MPEEK 6D LRDTC LAT 375.485	C1821	SUPPLY/IMPLANTS	"$45,572.00"	Outpatient	"$22,786.00"	Not Applicable	"$24,927.88"	"$30,396.52"	"$18,228.80"	Not Applicable	"$15,950.20"	"$31,900.40"	"$15,950.20"	"$31,900.40"
STEM FEM 164MM 133D 22 HI OFST TPR TPRLK PPS HIP TY 1 PRFT 51-104220	C1776	SUPPLY/IMPLANTS	"$45,554.00"	Outpatient	"$22,777.00"	Not Applicable	"$24,918.04"	"$30,384.52"	"$18,221.60"	Not Applicable	"$15,943.90"	"$31,887.80"	"$15,943.90"	"$31,887.80"
STEM FEM 128MM 133D 4 STD OFST TPR TPRLK PPS HIP TY 1 PRFT 51-100040	C1776	SUPPLY/IMPLANTS	"$45,523.00"	Outpatient	"$22,761.50"	Not Applicable	"$24,901.08"	"$30,363.84"	"$18,209.20"	Not Applicable	"$15,933.05"	"$31,866.10"	"$15,933.05"	"$31,866.10"
STEM FEM 167MM 133D 24 HI OFST TPR TPRLK PPS HIP TY 1 PRFT 51-104240	C1776	SUPPLY/IMPLANTS	"$45,523.00"	Outpatient	"$22,761.50"	Not Applicable	"$24,901.08"	"$30,363.84"	"$18,209.20"	Not Applicable	"$15,933.05"	"$31,866.10"	"$15,933.05"	"$31,866.10"
PLT 2.8MM ANG LT MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.517	C1713	SUPPLY/IMPLANTS	"$45,495.00"	Outpatient	"$22,747.50"	"$1,365.15"	"$24,885.77"	"$30,345.17"	"$18,198.00"	Not Applicable	"$15,923.25"	"$31,846.50"	"$1,365.15"	"$31,846.50"
PLT 2.8MM ANG RT MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.518	C1713	SUPPLY/IMPLANTS	"$45,495.00"	Outpatient	"$22,747.50"	"$1,365.15"	"$24,885.77"	"$30,345.17"	"$18,198.00"	Not Applicable	"$15,923.25"	"$31,846.50"	"$1,365.15"	"$31,846.50"
PLT 2.5MM MED RT MNDB TI 2 ANG RECON MATRIXMANDIBLE BN NS SD449.513	C1713	SUPPLY/IMPLANTS	"$45,404.00"	Outpatient	"$22,702.00"	"$1,365.15"	"$24,835.99"	"$30,284.47"	"$18,161.60"	Not Applicable	"$15,891.40"	"$31,782.80"	"$1,365.15"	"$31,782.80"
CAGE SPNL 27X11X8-12MM ACCULIF 8D OBLQ TI XPD TLIF STRL LF 400008	C1821	SUPPLY/IMPLANTS	"$45,306.00"	Outpatient	"$22,653.00"	Not Applicable	"$24,782.38"	"$30,219.10"	"$18,122.40"	Not Applicable	"$15,857.10"	"$31,714.20"	"$15,857.10"	"$31,714.20"
PCMKR .75CM ACLD LTD NXT PACESAFE EASYVIEW 2 CHMBR IS1 CNCT L301	C1785	PACE MAKER	"$45,295.00"	Outpatient	"$22,647.50"	Not Applicable	"$24,776.37"	"$30,211.77"	"$18,118.00"	Not Applicable	"$15,853.25"	"$31,706.50"	"$15,853.25"	"$31,706.50"
CAGE SPNL 16-25MM 12MM SM VBR ADD 0D THOR LMBR TI CNT XPD CS 2250-12-16	C1821	SUPPLY/IMPLANTS	"$45,284.00"	Outpatient	"$22,642.00"	Not Applicable	"$24,770.35"	"$30,204.43"	"$18,113.60"	Not Applicable	"$15,849.40"	"$31,698.80"	"$15,849.40"	"$31,698.80"
CAGE SPNL 50X18X10MM CRNT XLF PEEK-OPTM 1ST LAT APRCH NS LF 7861050	C1821	SUPPLY/IMPLANTS	"$45,230.00"	Outpatient	"$22,615.00"	Not Applicable	"$24,740.81"	"$30,168.41"	"$18,092.00"	Not Applicable	"$15,830.50"	"$31,661.00"	"$15,830.50"	"$31,661.00"
CMPNT FEM 8 KN RT POST STAB GNS2 LEGION SPC OXNM 71421208	C1776	SUPPLY/IMPLANTS	"$45,178.00"	Outpatient	"$22,589.00"	Not Applicable	"$24,712.37"	"$30,133.73"	"$18,071.20"	Not Applicable	"$15,812.30"	"$31,624.60"	"$15,812.30"	"$31,624.60"
CASE INST CMPLT PROX TIB ANTM LCK PLT SYS 8299-58-100	C1713	SUPPLY/IMPLANTS	"$45,178.00"	Outpatient	"$22,589.00"	"$1,365.15"	"$24,712.37"	"$30,133.73"	"$18,071.20"	Not Applicable	"$15,812.30"	"$31,624.60"	"$1,365.15"	"$31,624.60"
CASE STRL CMPLT LWR XTRMT 8299-53-000	C1713	SUPPLY/IMPLANTS	"$45,020.00"	Outpatient	"$22,510.00"	"$1,365.15"	"$24,625.94"	"$30,028.34"	"$18,008.00"	Not Applicable	"$15,757.00"	"$31,514.00"	"$1,365.15"	"$31,514.00"
STEM HUM 130MM 9MM RVRS FX AQLS SHLDR GRN DWD902	C1776	SUPPLY/IMPLANTS	"$44,959.00"	Outpatient	"$22,479.50"	Not Applicable	"$24,592.57"	"$29,987.65"	"$17,983.60"	Not Applicable	"$15,735.65"	"$31,471.30"	"$15,735.65"	"$31,471.30"
STEM HUM 130MM 7MM RVRS FX AQLS SHLDR YLW DWD901	C1776	SUPPLY/IMPLANTS	"$44,959.00"	Outpatient	"$22,479.50"	Not Applicable	"$24,592.57"	"$29,987.65"	"$17,983.60"	Not Applicable	"$15,735.65"	"$31,471.30"	"$15,735.65"	"$31,471.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.504	C1713	SUPPLY/IMPLANTS	"$44,912.00"	Outpatient	"$22,456.00"	"$1,365.15"	"$24,566.86"	"$29,956.30"	"$17,964.80"	Not Applicable	"$15,719.20"	"$31,438.40"	"$1,365.15"	"$31,438.40"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.557	C1713	SUPPLY/IMPLANTS	"$44,912.00"	Outpatient	"$22,456.00"	"$1,365.15"	"$24,566.86"	"$29,956.30"	"$17,964.80"	Not Applicable	"$15,719.20"	"$31,438.40"	"$1,365.15"	"$31,438.40"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE HYDROPHILIC 0 D CYLINDER  20CM  INFRAPUB	C1813	SUPPLY/IMPLANTS	"$44,830.00"	Outpatient	"$22,415.00"	Not Applicable	"$24,522.01"	"$29,901.61"	"$17,932.00"	Not Applicable	"$15,690.50"	"$31,381.00"	"$15,690.50"	"$31,381.00"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE HYDROPHILIC 0 D CYLINDER L18 CM INFRAPUB	C1813	SUPPLY/IMPLANTS	"$44,830.00"	Outpatient	"$22,415.00"	Not Applicable	"$24,522.01"	"$29,901.61"	"$17,932.00"	Not Applicable	"$15,690.50"	"$31,381.00"	"$15,690.50"	"$31,381.00"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE HYDROPHILIC 0 D CYLINDER L22 CM INFRAPUB	C1813	SUPPLY/IMPLANTS	"$44,830.00"	Outpatient	"$22,415.00"	Not Applicable	"$24,522.01"	"$29,901.61"	"$17,932.00"	Not Applicable	"$15,690.50"	"$31,381.00"	"$15,690.50"	"$31,381.00"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE HYDROPHILIC 0 D CYLINDER L16 CM INFRAPUB	C1813	SUPPLY/IMPLANTS	"$44,830.00"	Outpatient	"$22,415.00"	Not Applicable	"$24,522.01"	"$29,901.61"	"$17,932.00"	Not Applicable	"$15,690.50"	"$31,381.00"	"$15,690.50"	"$31,381.00"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE ES8920	C1813	SUPPLY/IMPLANTS	"$44,830.00"	Outpatient	"$22,415.00"	Not Applicable	"$24,522.01"	"$29,901.61"	"$17,932.00"	Not Applicable	"$15,690.50"	"$31,381.00"	"$15,690.50"	"$31,381.00"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE ES8922	C1813	SUPPLY/IMPLANTS	"$44,830.00"	Outpatient	"$22,415.00"	Not Applicable	"$24,522.01"	"$29,901.61"	"$17,932.00"	Not Applicable	"$15,690.50"	"$31,381.00"	"$15,690.50"	"$31,381.00"
PROSTHESIS PENILE TITAN COLOPLAST LOCK-OUT BIOFLEX SILICONE ES8918	C1813	SUPPLY/IMPLANTS	"$44,830.00"	Outpatient	"$22,415.00"	Not Applicable	"$24,522.01"	"$29,901.61"	"$17,932.00"	Not Applicable	"$15,690.50"	"$31,381.00"	"$15,690.50"	"$31,381.00"
STIMULATOR SPINAL FUSION SPF-PLUS 60/W 10-1398EW		STERILE SUPPLY	"$44,766.00"	Outpatient	"$22,383.00"	Not Applicable	"$24,487.00"	"$29,858.92"	"$17,906.40"	Not Applicable	"$15,668.10"	"$31,336.20"	"$15,668.10"	"$31,336.20"
STM BN SPF 60UA SPNE MN WV CTHD 10-1398W		STERILE SUPPLY	"$44,766.00"	Outpatient	"$22,383.00"	Not Applicable	"$24,487.00"	"$29,858.92"	"$17,906.40"	Not Applicable	"$15,668.10"	"$31,336.20"	"$15,668.10"	"$31,336.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.409	C1713	SUPPLY/IMPLANTS	"$44,760.00"	Outpatient	"$22,380.00"	"$1,365.15"	"$24,483.72"	"$29,854.92"	"$17,904.00"	Not Applicable	"$15,666.00"	"$31,332.00"	"$1,365.15"	"$31,332.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.412	C1713	SUPPLY/IMPLANTS	"$44,760.00"	Outpatient	"$22,380.00"	"$1,365.15"	"$24,483.72"	"$29,854.92"	"$17,904.00"	Not Applicable	"$15,666.00"	"$31,332.00"	"$1,365.15"	"$31,332.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.462	C1713	SUPPLY/IMPLANTS	"$44,760.00"	Outpatient	"$22,380.00"	"$1,365.15"	"$24,483.72"	"$29,854.92"	"$17,904.00"	Not Applicable	"$15,666.00"	"$31,332.00"	"$1,365.15"	"$31,332.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.465	C1713	SUPPLY/IMPLANTS	"$44,760.00"	Outpatient	"$22,380.00"	"$1,365.15"	"$24,483.72"	"$29,854.92"	"$17,904.00"	Not Applicable	"$15,666.00"	"$31,332.00"	"$1,365.15"	"$31,332.00"
INS TIB STD+ 10MM KN GVF PE ROT PLAT LCS CMPT STRL LF 129405510	C1776	SUPPLY/IMPLANTS	"$44,754.00"	Outpatient	"$22,377.00"	Not Applicable	"$24,480.44"	"$29,850.92"	"$17,901.60"	Not Applicable	"$15,663.90"	"$31,327.80"	"$15,663.90"	"$31,327.80"
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT MCC/CC DRG 468 DRG 468SN	C1713	SUPPLY/IMPLANTS	"$44,754.00"	Outpatient	"$22,377.00"	"$1,365.15"	"$24,480.44"	"$29,850.92"	"$17,901.60"	Not Applicable	"$15,663.90"	"$31,327.80"	"$1,365.15"	"$31,327.80"
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT MCC/CC DRG 468 DRG 468ZB	C1713	SUPPLY/IMPLANTS	"$44,754.00"	Outpatient	"$22,377.00"	"$1,365.15"	"$24,480.44"	"$29,850.92"	"$17,901.60"	Not Applicable	"$15,663.90"	"$31,327.80"	"$1,365.15"	"$31,327.80"
REVISION OF HIP OR KNEE REPLACEMENT WITHOUT MCC/CC DRG 468 DRG 468DS	C1713	SUPPLY/IMPLANTS	"$44,754.00"	Outpatient	"$22,377.00"	"$1,365.15"	"$24,480.44"	"$29,850.92"	"$17,901.60"	Not Applicable	"$15,663.90"	"$31,327.80"	"$1,365.15"	"$31,327.80"
MESH FRONTOTEMPORAL LT MATRIXNEURO 151X125X.6MM TI CNTR 04.503.155S	C1713	SUPPLY/IMPLANTS	"$44,739.00"	Outpatient	"$22,369.50"	"$1,365.15"	"$24,472.23"	"$29,840.91"	"$17,895.60"	Not Applicable	"$15,658.65"	"$31,317.30"	"$1,365.15"	"$31,317.30"
MESH FRONTOTEMPORAL RT MATRIXNEURO 151X125X.6MM TI CNTR 04.503.156S	C1713	SUPPLY/IMPLANTS	"$44,739.00"	Outpatient	"$22,369.50"	"$1,365.15"	"$24,472.23"	"$29,840.91"	"$17,895.60"	Not Applicable	"$15,658.65"	"$31,317.30"	"$1,365.15"	"$31,317.30"
FIL BN VOID CERAMENT HA CA SLF CANC 18ML PREFL VLV BCMPT 800-4002	C9359	SUPPLY/IMPLANTS	"$44,714.00"	Outpatient	"$22,357.00"	$130.50	"$24,458.56"	"$29,824.24"	"$17,885.60"	Not Applicable	"$15,649.90"	"$31,299.80"	$130.50	"$31,299.80"
GFT SFT TIS 71-80CM 3MM ANGIOGRAFT SV CRPRS CV71-80	C1768	SUPPLY/IMPLANTS	"$44,701.00"	Outpatient	"$22,350.50"	Not Applicable	"$24,451.45"	"$29,815.57"	"$17,880.40"	Not Applicable	"$15,645.35"	"$31,290.70"	"$15,645.35"	"$31,290.70"
PLT 2MM 2 ANG LG RECON MATRIXMANDIBLE BN SD449.507	C1713	SUPPLY/IMPLANTS	"$44,656.00"	Outpatient	"$22,328.00"	"$1,365.15"	"$24,426.83"	"$29,785.55"	"$17,862.40"	Not Applicable	"$15,629.60"	"$31,259.20"	"$1,365.15"	"$31,259.20"
GFT EVAS 13CM 31MM 14.5MM XCLDR C3 TRNKIPSL LG GRTX NTNL FEP RLT311413		STERILE SUPPLY	"$44,485.00"	Outpatient	"$22,242.50"	Not Applicable	"$24,333.30"	"$29,671.50"	"$17,794.00"	Not Applicable	"$15,569.75"	"$31,139.50"	"$15,569.75"	"$31,139.50"
PACEMAKER INGENIO DR 2 LD 8N22	C1785	PACE MAKER	"$44,423.00"	Outpatient	"$22,211.50"	Not Applicable	"$24,299.38"	"$29,630.14"	"$17,769.20"	Not Applicable	"$15,548.05"	"$31,096.10"	"$15,548.05"	"$31,096.10"
DEV THRMB 180CM 4MM SOLITARE SCFLD RADOPQ 40MM ACPT .021IN SFR3-4-40-10	C1757	SUPPLY/IMPLANTS	"$44,289.00"	Outpatient	"$22,144.50"	Not Applicable	"$24,226.08"	"$29,540.76"	"$17,715.60"	Not Applicable	"$15,501.15"	"$31,002.30"	"$15,501.15"	"$31,002.30"
DEV THRMB 42CM 6MM SOLITAIRE 2 30MM MIC REVSC 180CM ACPT SFR2-6-30	C1757	SUPPLY/IMPLANTS	"$44,289.00"	Outpatient	"$22,144.50"	Not Applicable	"$24,226.08"	"$29,540.76"	"$17,715.60"	Not Applicable	"$15,501.15"	"$31,002.30"	"$15,501.15"	"$31,002.30"
DEV THRMB 30MM 3MM CPTR LP 23MM LOPRFL RADOPQ 178CM 10/14 300016	C1757	SUPPLY/IMPLANTS	"$44,289.00"	Outpatient	"$22,144.50"	Not Applicable	"$24,226.08"	"$29,540.76"	"$17,715.60"	Not Applicable	"$15,501.15"	"$31,002.30"	"$15,501.15"	"$31,002.30"
KIT SRG CSTM BNDL VSPCUST		STERILE SUPPLY	"$44,276.00"	Outpatient	"$22,138.00"	Not Applicable	"$24,218.97"	"$29,532.09"	"$17,710.40"	Not Applicable	"$15,496.60"	"$30,993.20"	"$15,496.60"	"$30,993.20"
DEV THRMB 180CM 6MM SOLITARE SCFLD RADOPQ 20MM ACPT .027IN SFR3-6-20-10		SUPPLY/IMPLANTS	"$44,269.00"	Outpatient	"$22,134.50"	Not Applicable	"$24,215.14"	"$29,527.42"	"$17,707.60"	Not Applicable	"$15,494.15"	"$30,988.30"	"$15,494.15"	"$30,988.30"
STENT DEVICE SOLITAIRE 2 SFR2-6-40-10	C2625	SUPPLY/IMPLANTS	"$44,244.00"	Outpatient	"$22,122.00"	Not Applicable	"$24,201.47"	"$29,510.75"	"$17,697.60"	Not Applicable	"$15,485.40"	"$30,970.80"	"$15,485.40"	"$30,970.80"
DEV THRMB 180CM 6MM SOLITARE SCFLD RADIOQPAQUE 40MM ACPT SFR3-6-40-10	C1757	SUPPLY/IMPLANTS	"$44,244.00"	Outpatient	"$22,122.00"	Not Applicable	"$24,201.47"	"$29,510.75"	"$17,697.60"	Not Applicable	"$15,485.40"	"$30,970.80"	"$15,485.40"	"$30,970.80"
STENT SOLITAURE PLATINUM SFR3-6-40-10	C1757	SUPPLY/IMPLANTS	"$44,244.00"	Outpatient	"$22,122.00"	Not Applicable	"$24,201.47"	"$29,510.75"	"$17,697.60"	Not Applicable	"$15,485.40"	"$30,970.80"	"$15,485.40"	"$30,970.80"
DEV THRMB 180CM 4MM SOLITARE SCFLD RADOPQ 20MM ACPT .021IN SFR3-4-20-10		SUPPLY/IMPLANTS	"$44,244.00"	Outpatient	"$22,122.00"	Not Applicable	"$24,201.47"	"$29,510.75"	"$17,697.60"	Not Applicable	"$15,485.40"	"$30,970.80"	"$15,485.40"	"$30,970.80"
STEM FEM 102MM 127D 3 TPR ACLD 30MM HIP MDLR STRL 6721-0330	C1776	SUPPLY/IMPLANTS	"$44,185.00"	Outpatient	"$22,092.50"	Not Applicable	"$24,169.20"	"$29,471.40"	"$17,674.00"	Not Applicable	"$15,464.75"	"$30,929.50"	"$15,464.75"	"$30,929.50"
STEM FEM 5 ANATO HIP RT ANTEVERTED 4845-7-105	C1776	SUPPLY/IMPLANTS	"$44,185.00"	Outpatient	"$22,092.50"	Not Applicable	"$24,169.20"	"$29,471.40"	"$17,674.00"	Not Applicable	"$15,464.75"	"$30,929.50"	"$15,464.75"	"$30,929.50"
STEM FEM 155MM 9.7MM 132D 11 47.9MM OFST SCRFT ADV PUREFIX 1601-11132	C1776	SUPPLY/IMPLANTS	"$44,185.00"	Outpatient	"$22,092.50"	Not Applicable	"$24,169.20"	"$29,471.40"	"$17,674.00"	Not Applicable	"$15,464.75"	"$30,929.50"	"$15,464.75"	"$30,929.50"
STEM FEM 148MM 9.7MM 127D 10 48.1MM OFST SCRFT ADV PUREFIX 1601-10127	C1776	SUPPLY/IMPLANTS	"$44,185.00"	Outpatient	"$22,092.50"	Not Applicable	"$24,169.20"	"$29,471.40"	"$17,674.00"	Not Applicable	"$15,464.75"	"$30,929.50"	"$15,464.75"	"$30,929.50"
STEM FEM 142MM 8.9MM 127D 9 46.9MM OFST SCRFT ADV PUREFIX TI 1601-09127	C1776	SUPPLY/IMPLANTS	"$44,185.00"	Outpatient	"$22,092.50"	Not Applicable	"$24,169.20"	"$29,471.40"	"$17,674.00"	Not Applicable	"$15,464.75"	"$30,929.50"	"$15,464.75"	"$30,929.50"
STEM FEM 205MM 16MM 10 RSTR TI HA HIP 6013-1016	C1776	SUPPLY/IMPLANTS	"$44,185.00"	Outpatient	"$22,092.50"	Not Applicable	"$24,169.20"	"$29,471.40"	"$17,674.00"	Not Applicable	"$15,464.75"	"$30,929.50"	"$15,464.75"	"$30,929.50"
STEM FEM 132D 8 SCRFT HIP PRFT ADV 1601-08132	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 132D 9 SCRFT HIP PRFT ADV 1601-09132	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 136MM 8.1MM 127D 8 42.4MM OFST SCRFT ADV PUREFIX TI 1601-08127	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 132D 6 SCRFT HIP PRFT ADV 1601-06132	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 148MM 9.7MM 132D 10 43.8MM SCRFT PUREFIX TI PLSM 1601-10132	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 6 ANATO HIP RT ANTEVERT 4845-7-106	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 4 ANATO HIP RT ANTEVERT 4845-7-104	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 6 NTRL HIP RT 4845-7-116	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 5 ANATO HIP LT ANTEVERTED 4845-7-205	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 6 ANATO HIP LT ANTEVERT 4845-7-206	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM FEM 4 ANATO HIP LT ANTEVERT 4845-7-204	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
STEM HIP 130' NECK ANGLE SZ #7/36MM/120MM/LT 4845-7-207	C1776	SUPPLY/IMPLANTS	"$44,161.00"	Outpatient	"$22,080.50"	Not Applicable	"$24,156.07"	"$29,455.39"	"$17,664.40"	Not Applicable	"$15,456.35"	"$30,912.70"	"$15,456.35"	"$30,912.70"
 NF ATLAS STENT 3.0X21MM NO TIP SZAS3021	C1876	SUPPLY/IMPLANTS	"$44,150.00"	Outpatient	"$22,075.00"	Not Applicable	"$24,150.05"	"$29,448.05"	"$17,660.00"	Not Applicable	"$15,452.50"	"$30,905.00"	"$15,452.50"	"$30,905.00"
STENT INTRCRAN 30MM 24MM NRFRM ATLS SZAS3024	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT INTRACRANIAL NEUROFORM ATLAS L30 MM OD4.5 MM ODSEC5 MM M003SZAS45300	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT INTRACRANIAL NEUROFORM ATLAS L24 MM OD3 MM ODSEC3.5 MM M003SZAS30240	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT INTRACRANIAL NEUROFORM ATLAS L15 MM OD3 MM ODSEC3.5 MM M003SZAS30150	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT INTRACRANIAL NEUROFORM ATLAS L15 MM OD3 MM ODSEC3.5 MM SZAS3015	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT INTRACRANIAL NEUROFORM ATLAS L21 MM OD4.5 MM ODSEC5 MM M003SZAS45210	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT SYSTEM NEUROFORM ATLAS 3.0X15MM M03UZAS30150	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT SYSTEM NEUROFORM ATLAS 3.0X21MM M003UZAS30210	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT SYSTEM NEUROFORM ATLAS 3.0X24MM M003UZAS30240	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT NEUROFORM ATLAS 4.0X21MM M003UZAS40210	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
STENT NEUROFORM ATLAS 4.0X24MM M003SZAS40240	C1876	SUPPLY/IMPLANTS	"$44,104.00"	Outpatient	"$22,052.00"	Not Applicable	"$24,124.89"	"$29,417.37"	"$17,641.60"	Not Applicable	"$15,436.40"	"$30,872.80"	"$15,436.40"	"$30,872.80"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.408	C1713	SUPPLY/IMPLANTS	"$44,069.00"	Outpatient	"$22,034.50"	"$1,365.15"	"$24,105.74"	"$29,394.02"	"$17,627.60"	Not Applicable	"$15,424.15"	"$30,848.30"	"$1,365.15"	"$30,848.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.418	C1713	SUPPLY/IMPLANTS	"$44,069.00"	Outpatient	"$22,034.50"	"$1,365.15"	"$24,105.74"	"$29,394.02"	"$17,627.60"	Not Applicable	"$15,424.15"	"$30,848.30"	"$1,365.15"	"$30,848.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.461	C1713	SUPPLY/IMPLANTS	"$44,069.00"	Outpatient	"$22,034.50"	"$1,365.15"	"$24,105.74"	"$29,394.02"	"$17,627.60"	Not Applicable	"$15,424.15"	"$30,848.30"	"$1,365.15"	"$30,848.30"
MOD IMPL INTLK SCR SLD NTR NL ANTGRD SM FEM 249009115	C1713	SUPPLY/IMPLANTS	"$44,021.00"	Outpatient	"$22,010.50"	"$1,365.15"	"$24,079.49"	"$29,362.01"	"$17,608.40"	Not Applicable	"$15,407.35"	"$30,814.70"	"$1,365.15"	"$30,814.70"
CMPNT FEM 2 KN LT TL STAB TRTHLN COCR 5512-F-201	C1776	SUPPLY/IMPLANTS	"$43,981.00"	Outpatient	"$21,990.50"	Not Applicable	"$24,057.61"	"$29,335.33"	"$17,592.40"	Not Applicable	"$15,393.35"	"$30,786.70"	"$15,393.35"	"$30,786.70"
MESH MATRIXNEURO 200X200X.6MM TI CNTR CRNL RGD STRL PNK 04.503.122S	C1713	SUPPLY/IMPLANTS	"$43,968.00"	Outpatient	"$21,984.00"	"$1,365.15"	"$24,050.50"	"$29,326.66"	"$17,587.20"	Not Applicable	"$15,388.80"	"$30,777.60"	"$1,365.15"	"$30,777.60"
PLT 200X200X.4MM CRNMXF TI RGD MESH CNTR MATRIXNEURO BN STRL 04.503.085S	C1713	SUPPLY/IMPLANTS	"$43,968.00"	Outpatient	"$21,984.00"	"$1,365.15"	"$24,050.50"	"$29,326.66"	"$17,587.20"	Not Applicable	"$15,388.80"	"$30,777.60"	"$1,365.15"	"$30,777.60"
CASE INST LCK LG FRAG SYS NS 8299-52-000		SUPPLY/IMPLANTS	"$43,919.00"	Outpatient	"$21,959.50"	Not Applicable	"$24,023.69"	"$29,293.97"	"$17,567.60"	Not Applicable	"$15,371.65"	"$30,743.30"	"$15,371.65"	"$30,743.30"
PLT 2MM 2 ANG SM MXL RECON MATRIXMANDIBLE BN PTSPC PLT CNTR SD449.505A	C1713	SUPPLY/IMPLANTS	"$43,854.00"	Outpatient	"$21,927.00"	"$1,365.15"	"$23,988.14"	"$29,250.62"	"$17,541.60"	Not Applicable	"$15,348.90"	"$30,697.80"	"$1,365.15"	"$30,697.80"
CAGE SPNL 35X16X10MM CRNT XL THOR PEEK NS LF 6991035	C1821	SUPPLY/IMPLANTS	"$43,800.00"	Outpatient	"$21,900.00"	Not Applicable	"$23,958.60"	"$29,214.60"	"$17,520.00"	Not Applicable	"$15,330.00"	"$30,660.00"	"$15,330.00"	"$30,660.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.503	C1713	SUPPLY/IMPLANTS	"$43,779.00"	Outpatient	"$21,889.50"	"$1,365.15"	"$23,947.11"	"$29,200.59"	"$17,511.60"	Not Applicable	"$15,322.65"	"$30,645.30"	"$1,365.15"	"$30,645.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.556	C1713	SUPPLY/IMPLANTS	"$43,779.00"	Outpatient	"$21,889.50"	"$1,365.15"	"$23,947.11"	"$29,200.59"	"$17,511.60"	Not Applicable	"$15,322.65"	"$30,645.30"	"$1,365.15"	"$30,645.30"
OCCLUDER CARDIOVASCULAR GORE EPTFE OD30 MM SEPTAL SOFT WIRE GSX0030A	C1817	SUPPLY/IMPLANTS	"$43,721.00"	Outpatient	"$21,860.50"	Not Applicable	"$23,915.39"	"$29,161.91"	"$17,488.40"	Not Applicable	"$15,302.35"	"$30,604.70"	"$15,302.35"	"$30,604.70"
PTCA Coronary Drug Eluting Single Vessel	C9607	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$38,837.07"	"$23,906.09"	"$8,056.00"	"$17,481.60"	"$8,681.00"	"$15,296.40"	"$30,592.80"	"$8,056.00"	"$38,837.07"
PTCA DES Bypass Graft Single	C9604	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$38,837.07"	"$23,906.09"	"$8,056.00"	"$17,481.60"	"$8,681.00"	"$15,296.40"	"$30,592.80"	"$8,056.00"	"$38,837.07"
PTCA Drug Eluting Artherectomy Single	C9602	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$38,837.07"	"$23,906.09"	"$8,056.00"	"$17,481.60"	"$8,681.00"	"$15,296.40"	"$30,592.80"	"$8,056.00"	"$38,837.07"
Stent Transluminal Revasc AMI Single	C9606	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$38,837.07"	"$23,906.09"	"$8,056.00"	"$17,481.60"	"$1,563.00"	"$15,296.40"	"$30,592.80"	"$1,563.00"	"$38,837.07"
Place Drug Eluting Stent Each Add'l Branch	C9601	CARDIAC CATH LAB	"$43,704.00"	Outpatient	"$21,852.00"	"$38,837.07"	"$23,906.09"	"$8,056.00"	"$17,481.60"	$819.00	"$15,296.40"	"$30,592.80"	$819.00	"$38,837.07"
70121-1389-07 - dexmedetomidine 400 MCG / 100 ML Soln	J3490	PHARMACY	"$43,592.00"	Outpatient	"$21,796.00"	Not Applicable	"$23,844.82"	"$29,075.86"	"$17,436.80"	Not Applicable	"$15,257.20"	"$30,514.40"	"$15,257.20"	"$30,514.40"
PLT 2.5MM 2 ANG MNDB TI BN NS PTSPC SD480.101	C1713	SUPPLY/IMPLANTS	"$43,573.00"	Outpatient	"$21,786.50"	"$1,365.15"	"$23,834.43"	"$29,063.19"	"$17,429.20"	Not Applicable	"$15,250.55"	"$30,501.10"	"$1,365.15"	"$30,501.10"
CAGE SPINAL ENZA-A TITANIUM 15 D D26 MM BICONVEX W32 MM X H1 EZAT-2632-1513	C1821	SUPPLY/IMPLANTS	"$43,569.00"	Outpatient	"$21,784.50"	Not Applicable	"$23,832.24"	"$29,060.52"	"$17,427.60"	Not Applicable	"$15,249.15"	"$30,498.30"	"$15,249.15"	"$30,498.30"
CAGE SPINAL ENZA-A TITANIUM 15 D D26 MM BICONVEX W32 MM X H1 EZAT-2632-1515	C1821	SUPPLY/IMPLANTS	"$43,569.00"	Outpatient	"$21,784.50"	Not Applicable	"$23,832.24"	"$29,060.52"	"$17,427.60"	Not Applicable	"$15,249.15"	"$30,498.30"	"$15,249.15"	"$30,498.30"
CAGE SPINAL ENZA-A TITANIUM 8 D D23 MM BICONVEX W26 MM X H15 EZAT-2326-0815	C1821	SUPPLY/IMPLANTS	"$43,569.00"	Outpatient	"$21,784.50"	Not Applicable	"$23,832.24"	"$29,060.52"	"$17,427.60"	Not Applicable	"$15,249.15"	"$30,498.30"	"$15,249.15"	"$30,498.30"
CAGE SPINAL ENZA TITANIUM 8 D D23 MM BICONVEX W26 MM X H9 MM EZAT-2326-0809	C1821	SUPPLY/IMPLANTS	"$43,569.00"	Outpatient	"$21,784.50"	Not Applicable	"$23,832.24"	"$29,060.52"	"$17,427.60"	Not Applicable	"$15,249.15"	"$30,498.30"	"$15,249.15"	"$30,498.30"
CAGE SPINAL ENZA TITANIUM 15 D D30 MM BICONVEX W38 MM X H15 EZAT-3038-1515	C1821	SUPPLY/IMPLANTS	"$43,569.00"	Outpatient	"$21,784.50"	Not Applicable	"$23,832.24"	"$29,060.52"	"$17,427.60"	Not Applicable	"$15,249.15"	"$30,498.30"	"$15,249.15"	"$30,498.30"
CAGE ALIF SOLUS ZERO PROFILE 14MM X 12 DEGREE 25200-314-S	C1821	SUPPLY/IMPLANTS	"$43,563.00"	Outpatient	"$21,781.50"	Not Applicable	"$23,828.96"	"$29,056.52"	"$17,425.20"	Not Applicable	"$15,247.05"	"$30,494.10"	"$15,247.05"	"$30,494.10"
CAGE SOLAS ALIF 16MM X 7 DEGREES 25200-116-S	C1821	SUPPLY/IMPLANTS	"$43,563.00"	Outpatient	"$21,781.50"	Not Applicable	"$23,828.96"	"$29,056.52"	"$17,425.20"	Not Applicable	"$15,247.05"	"$30,494.10"	"$15,247.05"	"$30,494.10"
SPACER LUMBER 12MM 12 DEGREE LORDOTIC 25200-312-S	C1821	SUPPLY/IMPLANTS	"$43,563.00"	Outpatient	"$21,781.50"	Not Applicable	"$23,828.96"	"$29,056.52"	"$17,425.20"	Not Applicable	"$15,247.05"	"$30,494.10"	"$15,247.05"	"$30,494.10"
INGEVITY MRI ATRIAL LEAD 40CM 7740-40	C1898	SUPPLY/IMPLANTS	"$43,553.00"	Outpatient	"$21,776.50"	Not Applicable	"$23,823.49"	"$29,049.85"	"$17,421.20"	Not Applicable	"$15,243.55"	"$30,487.10"	"$15,243.55"	"$30,487.10"
LEAD VENTRICULAR MODEL 0292 ENDOTAK RELIANCE SG SN-36138	C1777	SUPPLY/IMPLANTS	"$43,553.00"	Outpatient	"$21,776.50"	Not Applicable	"$23,823.49"	"$29,049.85"	"$17,421.20"	Not Applicable	"$15,243.55"	"$30,487.10"	"$15,243.55"	"$30,487.10"
GFT STNT 103MM 14-36MM 20FR ENDURANT IIS 2 BRCH INFRARENAL ESBF3614C103E	C1874	SUPPLY/IMPLANTS	"$43,543.00"	Outpatient	"$21,771.50"	Not Applicable	"$23,818.02"	"$29,043.18"	"$17,417.20"	Not Applicable	"$15,240.05"	"$30,480.10"	"$15,240.05"	"$30,480.10"
GFT VASC 80-100CM RESTOREFLOW SV ALGRF SV106	C1768	SUPPLY/IMPLANTS	"$43,543.00"	Outpatient	"$21,771.50"	Not Applicable	"$23,818.02"	"$29,043.18"	"$17,417.20"	Not Applicable	"$15,240.05"	"$30,480.10"	"$15,240.05"	"$30,480.10"
CAGE SPINAL ENZA TITANIUM 15 D D23 MM BICONVEX W26 MM X H13 EZAT-2326-1513	C1821	SUPPLY/IMPLANTS	"$43,524.00"	Outpatient	"$21,762.00"	Not Applicable	"$23,807.63"	"$29,030.51"	"$17,409.60"	Not Applicable	"$15,233.40"	"$30,466.80"	"$15,233.40"	"$30,466.80"
CAGE SPINAL ENZA-A TITANIUM 8 D D23 MM BICONVEX W26 MM X H13 EZAT-2326-0813	C1821	SUPPLY/IMPLANTS	"$43,524.00"	Outpatient	"$21,762.00"	Not Applicable	"$23,807.63"	"$29,030.51"	"$17,409.60"	Not Applicable	"$15,233.40"	"$30,466.80"	"$15,233.40"	"$30,466.80"
CAGE SPINAL ENZA-A TITANIUM 8 D D26 MM BICONVEX W32 MM X H13 EZAT-2632-0813	C1821	SUPPLY/IMPLANTS	"$43,524.00"	Outpatient	"$21,762.00"	Not Applicable	"$23,807.63"	"$29,030.51"	"$17,409.60"	Not Applicable	"$15,233.40"	"$30,466.80"	"$15,233.40"	"$30,466.80"
SPACER ENZA A -8 DEG 26X32MM 11 EZAT-2632-0811	C1821	SUPPLY/IMPLANTS	"$43,524.00"	Outpatient	"$21,762.00"	Not Applicable	"$23,807.63"	"$29,030.51"	"$17,409.60"	Not Applicable	"$15,233.40"	"$30,466.80"	"$15,233.40"	"$30,466.80"
PLT 2.5MM SM RT MNDB TI 2 ANG RECON MATRIXMANDIBLE BN NS SD449.512	C1713	SUPPLY/IMPLANTS	"$43,502.00"	Outpatient	"$21,751.00"	"$1,365.15"	"$23,795.59"	"$29,015.83"	"$17,400.80"	Not Applicable	"$15,225.70"	"$30,451.40"	"$1,365.15"	"$30,451.40"
Atherectomy each Additional Vessel	92925	CARDIAC CATH LAB	"$40,044.00"	Outpatient	"$20,022.00"	"$38,376.82"	"$23,786.14"	"$8,056.00"	"$16,017.60"	"$8,681.00"	"$14,015.40"	"$28,030.80"	"$8,056.00"	"$38,376.82"
Artherectomy Single Vessel	92924	CARDIAC CATH LAB	"$40,044.00"	Outpatient	"$20,022.00"	"$38,376.82"	"$23,786.14"	"$8,056.00"	"$16,017.60"	"$8,681.00"	"$14,015.40"	"$28,030.80"	"$8,056.00"	"$38,376.82"
MAJOR JOINT AND LIMB REATTACHMENT WITH  AND WITHOUT MCC/CC S DRG 483SN	C1776	SUPPLY/IMPLANTS	"$43,456.00"	Outpatient	"$21,728.00"	Not Applicable	"$23,770.43"	"$28,985.15"	"$17,382.40"	Not Applicable	"$15,209.60"	"$30,419.20"	"$15,209.60"	"$30,419.20"
MAJOR JOINT AND LIMB REATTACHMENT WITH MCC/CC SHOULDERS DRG DRG 483ZB	C1776	SUPPLY/IMPLANTS	"$43,456.00"	Outpatient	"$21,728.00"	Not Applicable	"$23,770.43"	"$28,985.15"	"$17,382.40"	Not Applicable	"$15,209.60"	"$30,419.20"	"$15,209.60"	"$30,419.20"
MAJOR JOINT AND LIMB REATTACHMENT WITH MCC/CC SHOULDERS DRG DRG 483DS	C1776	SUPPLY/IMPLANTS	"$43,456.00"	Outpatient	"$21,728.00"	Not Applicable	"$23,770.43"	"$28,985.15"	"$17,382.40"	Not Applicable	"$15,209.60"	"$30,419.20"	"$15,209.60"	"$30,419.20"
DRG 483 MAJOR JOINT SHOULDER DRG 483	C1713	SUPPLY/IMPLANTS	"$43,448.00"	Outpatient	"$21,724.00"	"$1,365.15"	"$23,766.06"	"$28,979.82"	"$17,379.20"	Not Applicable	"$15,206.80"	"$30,413.60"	"$1,365.15"	"$30,413.60"
SET SCR SM OPTN FRM PLT 480003514	C1713	SUPPLY/IMPLANTS	"$43,426.00"	Outpatient	"$21,713.00"	"$1,365.15"	"$23,754.02"	"$28,965.14"	"$17,370.40"	Not Applicable	"$15,199.10"	"$30,398.20"	"$1,365.15"	"$30,398.20"
DEV THRMB 31MM 4MM SOLITAIRE 2 20MM MIC REVSC 180CM ACPT SFR2-4-20	C1757	SUPPLY/IMPLANTS	"$43,419.00"	Outpatient	"$21,709.50"	Not Applicable	"$23,750.19"	"$28,960.47"	"$17,367.60"	Not Applicable	"$15,196.65"	"$30,393.30"	"$15,196.65"	"$30,393.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.407	C1713	SUPPLY/IMPLANTS	"$43,379.00"	Outpatient	"$21,689.50"	"$1,365.15"	"$23,728.31"	"$28,933.79"	"$17,351.60"	Not Applicable	"$15,182.65"	"$30,365.30"	"$1,365.15"	"$30,365.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.411	C1713	SUPPLY/IMPLANTS	"$43,379.00"	Outpatient	"$21,689.50"	"$1,365.15"	"$23,728.31"	"$28,933.79"	"$17,351.60"	Not Applicable	"$15,182.65"	"$30,365.30"	"$1,365.15"	"$30,365.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.460	C1713	SUPPLY/IMPLANTS	"$43,379.00"	Outpatient	"$21,689.50"	"$1,365.15"	"$23,728.31"	"$28,933.79"	"$17,351.60"	Not Applicable	"$15,182.65"	"$30,365.30"	"$1,365.15"	"$30,365.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.464	C1713	SUPPLY/IMPLANTS	"$43,379.00"	Outpatient	"$21,689.50"	"$1,365.15"	"$23,728.31"	"$28,933.79"	"$17,351.60"	Not Applicable	"$15,182.65"	"$30,365.30"	"$1,365.15"	"$30,365.30"
RTRV 25MM 6MM ESCP TREVO XP PROVUE 90186		STERILE SUPPLY	"$43,310.00"	Outpatient	"$21,655.00"	Not Applicable	"$23,690.57"	"$28,887.77"	"$17,324.00"	Not Applicable	"$15,158.50"	"$30,317.00"	"$15,158.50"	"$30,317.00"
RTRV 20MM 3MM ESCP TREVO XP PROVUE 90183		STERILE SUPPLY	"$43,310.00"	Outpatient	"$21,655.00"	Not Applicable	"$23,690.57"	"$28,887.77"	"$17,324.00"	Not Applicable	"$15,158.50"	"$30,317.00"	"$15,158.50"	"$30,317.00"
RTRV 30MM 4MM ESCP STRL DISP LF TREVO XP PROVUE 90185		STERILE SUPPLY	"$43,310.00"	Outpatient	"$21,655.00"	Not Applicable	"$23,690.57"	"$28,887.77"	"$17,324.00"	Not Applicable	"$15,158.50"	"$30,317.00"	"$15,158.50"	"$30,317.00"
CAGE LONG TPLIF 12 X 28 X 9 DP3012	C1821	SUPPLY/IMPLANTS	"$43,104.00"	Outpatient	"$21,552.00"	Not Applicable	"$23,577.89"	"$28,750.37"	"$17,241.60"	Not Applicable	"$15,086.40"	"$30,172.80"	"$15,086.40"	"$30,172.80"
CAGE LONG TPLIF 14 X 28 X 9 DP6014	C1821	SUPPLY/IMPLANTS	"$43,104.00"	Outpatient	"$21,552.00"	Not Applicable	"$23,577.89"	"$28,750.37"	"$17,241.60"	Not Applicable	"$15,086.40"	"$30,172.80"	"$15,086.40"	"$30,172.80"
"CAGE TPLIF, 9 X 25 X 11 AP1108-0409"	C1821	SUPPLY/IMPLANTS	"$43,104.00"	Outpatient	"$21,552.00"	Not Applicable	"$23,577.89"	"$28,750.37"	"$17,241.60"	Not Applicable	"$15,086.40"	"$30,172.80"	"$15,086.40"	"$30,172.80"
CAGE TPLIF 11 X 25 X 11-0 AP1108-0011	C1821	SUPPLY/IMPLANTS	"$43,104.00"	Outpatient	"$21,552.00"	Not Applicable	"$23,577.89"	"$28,750.37"	"$17,241.60"	Not Applicable	"$15,086.40"	"$30,172.80"	"$15,086.40"	"$30,172.80"
CAGE TPLIF 11 X 28 X 9-0 DP3011	C1821	SUPPLY/IMPLANTS	"$43,104.00"	Outpatient	"$21,552.00"	Not Applicable	"$23,577.89"	"$28,750.37"	"$17,241.60"	Not Applicable	"$15,086.40"	"$30,172.80"	"$15,086.40"	"$30,172.80"
CAGE TPLIF 9 X 25 X 9-0 DP2009	C1821	SUPPLY/IMPLANTS	"$43,104.00"	Outpatient	"$21,552.00"	Not Applicable	"$23,577.89"	"$28,750.37"	"$17,241.60"	Not Applicable	"$15,086.40"	"$30,172.80"	"$15,086.40"	"$30,172.80"
SPACER LUMBAR TPLIF 12 X 25 X 11-4 AP1108-0012	C1821	SUPPLY/IMPLANTS	"$43,076.00"	Outpatient	"$21,538.00"	Not Applicable	"$23,562.57"	"$28,731.69"	"$17,230.40"	Not Applicable	"$15,076.60"	"$30,153.20"	"$15,076.60"	"$30,153.20"
SPACER LUMBAR TPLIF 11 X 25 X 11 -4 AP1108-0411	C1821	SUPPLY/IMPLANTS	"$43,076.00"	Outpatient	"$21,538.00"	Not Applicable	"$23,562.57"	"$28,731.69"	"$17,230.40"	Not Applicable	"$15,076.60"	"$30,153.20"	"$15,076.60"	"$30,153.20"
SPACER LUMBAR TPLIF 13 X 25 X 11-4 AP1108-0413	C1821	SUPPLY/IMPLANTS	"$43,076.00"	Outpatient	"$21,538.00"	Not Applicable	"$23,562.57"	"$28,731.69"	"$17,230.40"	Not Applicable	"$15,076.60"	"$30,153.20"	"$15,076.60"	"$30,153.20"
SPACER LUMBAR TPLIF 12 X 25 X 11-4 AP1108-0412	C1821	SUPPLY/IMPLANTS	"$43,076.00"	Outpatient	"$21,538.00"	Not Applicable	"$23,562.57"	"$28,731.69"	"$17,230.40"	Not Applicable	"$15,076.60"	"$30,153.20"	"$15,076.60"	"$30,153.20"
SPACER LUMBR TPLIF 10 X 25 X 11 X 4 AP1108-0010	C1821	SUPPLY/IMPLANTS	"$43,076.00"	Outpatient	"$21,538.00"	Not Applicable	"$23,562.57"	"$28,731.69"	"$17,230.40"	Not Applicable	"$15,076.60"	"$30,153.20"	"$15,076.60"	"$30,153.20"
CAGE SPNL 55X22X10MM CRNT XL W LRDTC PEEK-OPTM NS LF 6921055	C1821	SUPPLY/IMPLANTS	"$43,042.00"	Outpatient	"$21,521.00"	Not Applicable	"$23,543.97"	"$28,709.01"	"$17,216.80"	Not Applicable	"$15,064.70"	"$30,129.40"	"$15,064.70"	"$30,129.40"
"COROENT XL WIDE LORDOTIC, 10 X 22 X 55MM 6821055"	C1821	SUPPLY/IMPLANTS	"$43,042.00"	Outpatient	"$21,521.00"	Not Applicable	"$23,543.97"	"$28,709.01"	"$17,216.80"	Not Applicable	"$15,064.70"	"$30,129.40"	"$15,064.70"	"$30,129.40"
CAGE SPNL 55X22X12MM CRNT XL W NS LF 6912255	C1821	SUPPLY/IMPLANTS	"$43,010.00"	Outpatient	"$21,505.00"	Not Applicable	"$23,526.47"	"$28,687.67"	"$17,204.00"	Not Applicable	"$15,053.50"	"$30,107.00"	"$15,053.50"	"$30,107.00"
CAGE SPNL 45X22X8MM CRNT XL W NS LF 6908245	C1821	SUPPLY/IMPLANTS	"$43,010.00"	Outpatient	"$21,505.00"	Not Applicable	"$23,526.47"	"$28,687.67"	"$17,204.00"	Not Applicable	"$15,053.50"	"$30,107.00"	"$15,053.50"	"$30,107.00"
CAGE SPNL 50X22X8MM CRNT XL W LRDTC PEEK-OPTM NS LF 6920850	C1821	SUPPLY/IMPLANTS	"$43,010.00"	Outpatient	"$21,505.00"	Not Applicable	"$23,526.47"	"$28,687.67"	"$17,204.00"	Not Applicable	"$15,053.50"	"$30,107.00"	"$15,053.50"	"$30,107.00"
CAGE SPNL 50X22X10MM CRNT XL W LRDTC PEEK-OPTM NS LF 6921050	C1821	SUPPLY/IMPLANTS	"$43,010.00"	Outpatient	"$21,505.00"	Not Applicable	"$23,526.47"	"$28,687.67"	"$17,204.00"	Not Applicable	"$15,053.50"	"$30,107.00"	"$15,053.50"	"$30,107.00"
CAGE SPNL 50X22X12MM CRNT XL W NS LF 6912250	C1821	SUPPLY/IMPLANTS	"$43,010.00"	Outpatient	"$21,505.00"	Not Applicable	"$23,526.47"	"$28,687.67"	"$17,204.00"	Not Applicable	"$15,053.50"	"$30,107.00"	"$15,053.50"	"$30,107.00"
CAGE SPINAL AERO PEEK-OPTIMA TITANIUM ALUMINUM VANADIUM 8 D 48943412	C1821	SUPPLY/IMPLANTS	"$42,989.00"	Outpatient	"$21,494.50"	Not Applicable	"$23,514.98"	"$28,673.66"	"$17,195.60"	Not Applicable	"$15,046.15"	"$30,092.30"	"$15,046.15"	"$30,092.30"
MODL ANTM CLR XL SD900.216	C1713	SUPPLY/IMPLANTS	"$42,924.00"	Outpatient	"$21,462.00"	"$1,365.15"	"$23,479.43"	"$28,630.31"	"$17,169.60"	Not Applicable	"$15,023.40"	"$30,046.80"	"$1,365.15"	"$30,046.80"
STENT NEUROFORM ATLAS 4.5X21MM M003UZAS45210	C1876	SUPPLY/IMPLANTS	"$42,864.00"	Outpatient	"$21,432.00"	Not Applicable	"$23,446.61"	"$28,590.29"	"$17,145.60"	Not Applicable	"$15,002.40"	"$30,004.80"	"$15,002.40"	"$30,004.80"
PLT 2MM 2 ANG MED RECON MATRIXMANDIBLE BN PTSPC PLT CNTR SD449.506	C1713	SUPPLY/IMPLANTS	"$42,842.00"	Outpatient	"$21,421.00"	"$1,365.15"	"$23,434.57"	"$28,575.61"	"$17,136.80"	Not Applicable	"$14,994.70"	"$29,989.40"	"$1,365.15"	"$29,989.40"
GD TRGT STD NTR NL CEPHALOMEDULLARY NL 249000300		STERILE SUPPLY	"$42,758.00"	Outpatient	"$21,379.00"	Not Applicable	"$23,388.63"	"$28,519.59"	"$17,103.20"	Not Applicable	"$14,965.30"	"$29,930.60"	"$14,965.30"	"$29,930.60"
TNSNR SRG A FSHR WRE 8180-50-000		STERILE SUPPLY	"$42,738.00"	Outpatient	"$21,369.00"	Not Applicable	"$23,377.69"	"$28,506.25"	"$17,095.20"	Not Applicable	"$14,958.30"	"$29,916.60"	"$14,958.30"	"$29,916.60"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.406	C1713	SUPPLY/IMPLANTS	"$42,689.00"	Outpatient	"$21,344.50"	"$1,365.15"	"$23,350.88"	"$28,473.56"	"$17,075.60"	Not Applicable	"$14,941.15"	"$29,882.30"	"$1,365.15"	"$29,882.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.459	C1713	SUPPLY/IMPLANTS	"$42,689.00"	Outpatient	"$21,344.50"	"$1,365.15"	"$23,350.88"	"$28,473.56"	"$17,075.60"	Not Applicable	"$14,941.15"	"$29,882.30"	"$1,365.15"	"$29,882.30"
PACEMAKER ADVANTIO DR (2 LD) 8A22	C1785	PACE MAKER	"$42,681.00"	Outpatient	"$21,340.50"	Not Applicable	"$23,346.51"	"$28,468.23"	"$17,072.40"	Not Applicable	"$14,938.35"	"$29,876.70"	"$14,938.35"	"$29,876.70"
STEM FEM 127MM 13MM STRG GMRS HIP PROX CMNT BD SECT 64853113	C1776	SUPPLY/IMPLANTS	"$42,661.00"	Outpatient	"$21,330.50"	Not Applicable	"$23,335.57"	"$28,454.89"	"$17,064.40"	Not Applicable	"$14,931.35"	"$29,862.70"	"$14,931.35"	"$29,862.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.502	C1713	SUPPLY/IMPLANTS	"$42,627.00"	Outpatient	"$21,313.50"	"$1,365.15"	"$23,316.97"	"$28,432.21"	"$17,050.80"	Not Applicable	"$14,919.45"	"$29,838.90"	"$1,365.15"	"$29,838.90"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.555	C1713	SUPPLY/IMPLANTS	"$42,618.00"	Outpatient	"$21,309.00"	"$1,365.15"	"$23,312.05"	"$28,426.21"	"$17,047.20"	Not Applicable	"$14,916.30"	"$29,832.60"	"$1,365.15"	"$29,832.60"
71225-0126-06 - dexmedetomidine 400 MCG / 100 ML Soln	J3490	PHARMACY	"$42,528.00"	Outpatient	"$21,264.00"	Not Applicable	"$23,262.82"	"$28,366.18"	"$17,011.20"	Not Applicable	"$14,884.80"	"$29,769.60"	"$14,884.80"	"$29,769.60"
DES Coronary Revasc Chronic Total Occlusion Each Addl	C9608	CARDIAC CATH LAB	"$42,431.00"	Outpatient	"$21,215.50"	"$38,837.07"	"$23,209.76"	"$8,056.00"	"$16,972.40"	$819.00	"$14,850.85"	"$29,701.70"	$819.00	"$38,837.07"
DES Coronary Revasc CABG Each Addl	C9605	CARDIAC CATH LAB	"$42,431.00"	Outpatient	"$21,215.50"	"$38,837.07"	"$23,209.76"	"$8,056.00"	"$16,972.40"	$819.00	"$14,850.85"	"$29,701.70"	$819.00	"$38,837.07"
DES PTCA Atherectomy Each Addl	C9603	CARDIAC CATH LAB	"$42,431.00"	Outpatient	"$21,215.50"	"$38,837.07"	"$23,209.76"	"$8,056.00"	"$16,972.40"	$819.00	"$14,850.85"	"$29,701.70"	$819.00	"$38,837.07"
GFT VASC 70-79CM RESTOREFLOW SV ALGRF SV105	C1768	SUPPLY/IMPLANTS	"$42,358.00"	Outpatient	"$21,179.00"	Not Applicable	"$23,169.83"	"$28,252.79"	"$16,943.20"	Not Applicable	"$14,825.30"	"$29,650.60"	"$14,825.30"	"$29,650.60"
STENT WINGSPAN SYSTEM 2.5 X 15 M003WS0250150		SUPPLY/IMPLANTS	"$42,335.00"	Outpatient	"$21,167.50"	Not Applicable	"$23,157.25"	"$28,237.45"	"$16,934.00"	Not Applicable	"$14,817.25"	"$29,634.50"	"$14,817.25"	"$29,634.50"
CAGE ALIF ENZA A TITANIUM 8 LORDOTIC 30MMX38MM 13MM TAV ASSE EZAT-3038-0813	C1821	SUPPLY/IMPLANTS	"$42,300.00"	Outpatient	"$21,150.00"	Not Applicable	"$23,138.10"	"$28,214.10"	"$16,920.00"	Not Applicable	"$14,805.00"	"$29,610.00"	"$14,805.00"	"$29,610.00"
PLT 200X200X.6MM CRNFCL TI CNTR MESH RGD NEURO LOPRFL BN 421.535S	C1713	SUPPLY/IMPLANTS	"$42,214.00"	Outpatient	"$21,107.00"	"$1,365.15"	"$23,091.06"	"$28,156.74"	"$16,885.60"	Not Applicable	"$14,774.90"	"$29,549.80"	"$1,365.15"	"$29,549.80"
CRT-P SYSTEM ALLURE MERLINPKG PM3222 SYSCELL	C2621	PACE MAKER	"$42,117.00"	Outpatient	"$21,058.50"	Not Applicable	"$23,038.00"	"$28,092.04"	"$16,846.80"	Not Applicable	"$14,740.95"	"$29,481.90"	"$14,740.95"	"$29,481.90"
CAGE LORDOTIC LUMBAR SPACER 14 X 45 X 18 DRS6114	C1821	SUPPLY/IMPLANTS	"$42,089.00"	Outpatient	"$21,044.50"	Not Applicable	"$23,022.68"	"$28,073.36"	"$16,835.60"	Not Applicable	"$14,731.15"	"$29,462.30"	"$14,731.15"	"$29,462.30"
STNT INTRCRAN 45MM 21MM NRFRM ATLS SZAS4521		SUPPLY/IMPLANTS	"$42,069.00"	Outpatient	"$21,034.50"	Not Applicable	"$23,011.74"	"$28,060.02"	"$16,827.60"	Not Applicable	"$14,724.15"	"$29,448.30"	"$14,724.15"	"$29,448.30"
CAGE LATERAL 12 X 50 X 18 X 0 DRS7112	C1713	SUPPLY/IMPLANTS	"$42,061.00"	Outpatient	"$21,030.50"	"$1,365.15"	"$23,007.37"	"$28,054.69"	"$16,824.40"	Not Applicable	"$14,721.35"	"$29,442.70"	"$1,365.15"	"$29,442.70"
CAGE LATERAL 14 X 50 X 18 X 0 DRS7114	C1713	SUPPLY/IMPLANTS	"$42,061.00"	Outpatient	"$21,030.50"	"$1,365.15"	"$23,007.37"	"$28,054.69"	"$16,824.40"	Not Applicable	"$14,721.35"	"$29,442.70"	"$1,365.15"	"$29,442.70"
CAGE LORDOTIC LATERAL LUMBAR 10 X 18 X 50MM DRS7110	C1821	SUPPLY/IMPLANTS	"$42,061.00"	Outpatient	"$21,030.50"	Not Applicable	"$23,007.37"	"$28,054.69"	"$16,824.40"	Not Applicable	"$14,721.35"	"$29,442.70"	"$14,721.35"	"$29,442.70"
CAGE LATERAL LORDOTIC 18 X 45 X 12MM DRS6112	C1821	SUPPLY/IMPLANTS	"$42,061.00"	Outpatient	"$21,030.50"	Not Applicable	"$23,007.37"	"$28,054.69"	"$16,824.40"	Not Applicable	"$14,721.35"	"$29,442.70"	"$14,721.35"	"$29,442.70"
CAGE LORDOTIC LATERAL 16 X 18 X 50MM DRS7116	C1821	SUPPLY/IMPLANTS	"$42,061.00"	Outpatient	"$21,030.50"	Not Applicable	"$23,007.37"	"$28,054.69"	"$16,824.40"	Not Applicable	"$14,721.35"	"$29,442.70"	"$14,721.35"	"$29,442.70"
GRAFT LATERAL LUMBAR 12 X 18 X 50MM DRS7012	C1821	SUPPLY/IMPLANTS	"$42,061.00"	Outpatient	"$21,030.50"	Not Applicable	"$23,007.37"	"$28,054.69"	"$16,824.40"	Not Applicable	"$14,721.35"	"$29,442.70"	"$14,721.35"	"$29,442.70"
00074-3683-03 - leuprolide acetate 30 mg kit	J9217	PHARMACY	"$35,389.00"	Outpatient	"$17,694.50"	$258.91	"$23,002.85"	"$23,604.46"	"$14,155.60"	Not Applicable	"$12,386.15"	"$24,772.30"	$258.91	"$24,772.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.405	C1713	SUPPLY/IMPLANTS	"$42,010.00"	Outpatient	"$21,005.00"	"$1,365.15"	"$22,979.47"	"$28,020.67"	"$16,804.00"	Not Applicable	"$14,703.50"	"$29,407.00"	"$1,365.15"	"$29,407.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.458	C1713	SUPPLY/IMPLANTS	"$42,010.00"	Outpatient	"$21,005.00"	"$1,365.15"	"$22,979.47"	"$28,020.67"	"$16,804.00"	Not Applicable	"$14,703.50"	"$29,407.00"	"$1,365.15"	"$29,407.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.463	C1713	SUPPLY/IMPLANTS	"$42,010.00"	Outpatient	"$21,005.00"	"$1,365.15"	"$22,979.47"	"$28,020.67"	"$16,804.00"	Not Applicable	"$14,703.50"	"$29,407.00"	"$1,365.15"	"$29,407.00"
PLT CRNL PEEK BN NS SD800.410	C1713	SUPPLY/IMPLANTS	"$42,010.00"	Outpatient	"$21,005.00"	"$1,365.15"	"$22,979.47"	"$28,020.67"	"$16,804.00"	Not Applicable	"$14,703.50"	"$29,407.00"	"$1,365.15"	"$29,407.00"
50242-0070-01 - obinutuzumab 25 mg/mL Soln	J9301	PHARMACY	"$35,348.00"	Outpatient	"$17,674.00"	$66.43	"$22,976.20"	"$23,577.12"	"$14,139.20"	Not Applicable	"$12,371.80"	"$24,743.60"	$66.43	"$24,743.60"
PLT 302MM HUM LT DIST SS 14 HL LMT CNTCT PRECONTOUR LCP CMBN 02.104.034S	C1713	SUPPLY/IMPLANTS	"$41,970.00"	Outpatient	"$20,985.00"	"$1,365.15"	"$22,957.59"	"$27,993.99"	"$16,788.00"	Not Applicable	"$14,689.50"	"$29,379.00"	"$1,365.15"	"$29,379.00"
SPCR SPNL 50X20X12MM PIVOX 18D LAT OLIF25 2113350	C1821	SUPPLY/IMPLANTS	"$41,970.00"	Outpatient	"$20,985.00"	Not Applicable	"$22,957.59"	"$27,993.99"	"$16,788.00"	Not Applicable	"$14,689.50"	"$29,379.00"	"$14,689.50"	"$29,379.00"
68727-0712-01 - lurbinectedin 4 mg Powd	J9999	PHARMACY	"$35,262.00"	Outpatient	"$17,631.00"	Not Applicable	"$22,920.30"	"$23,519.75"	"$14,104.80"	Not Applicable	"$12,341.70"	"$24,683.40"	"$12,341.70"	"$24,683.40"
Revas Tp Art Uni Ea Addl Vsl W Ath Sm	37233	CARDIAC CATH LAB	"$41,894.00"	Outpatient	"$20,947.00"	"$40,148.14"	"$22,916.02"	"$1,592.00"	"$16,757.60"	"$8,681.00"	"$14,662.90"	"$29,325.80"	"$1,592.00"	"$40,148.14"
Revasc Tp Art Uni Init W St Same Vsl	37230	CARDIAC CATH LAB	"$41,894.00"	Outpatient	"$20,947.00"	"$40,148.14"	"$22,916.02"	"$1,592.00"	"$16,757.60"	"$8,681.00"	"$14,662.90"	"$29,325.80"	"$1,592.00"	"$40,148.14"
Revasc Tp Art Uni Init Vsl W Ath Same	37229	CARDIAC CATH LAB	"$41,894.00"	Outpatient	"$20,947.00"	"$40,148.14"	"$22,916.02"	"$1,592.00"	"$16,757.60"	"$8,681.00"	"$14,662.90"	"$29,325.80"	"$1,592.00"	"$40,148.14"
Femoral Poplitial Revasc W/Stent	37226	CARDIAC CATH LAB	"$41,894.00"	Outpatient	"$20,947.00"	"$40,148.14"	"$22,916.02"	"$1,592.00"	"$16,757.60"	"$8,681.00"	"$14,662.90"	"$29,325.80"	"$1,592.00"	"$40,148.14"
Revasc Fem/Pop Art Uni W Ath Same Vsl	37225	CARDIAC CATH LAB	"$41,894.00"	Outpatient	"$20,947.00"	"$40,148.14"	"$22,916.02"	"$1,592.00"	"$16,757.60"	"$8,681.00"	"$14,662.90"	"$29,325.80"	"$1,592.00"	"$40,148.14"
PACEMAKER EDORA 8 HF-T 407138	C2621	PACE MAKER	"$41,827.00"	Outpatient	"$20,913.50"	Not Applicable	"$22,879.37"	"$27,898.61"	"$16,730.80"	Not Applicable	"$14,639.45"	"$29,278.90"	"$14,639.45"	"$29,278.90"
DISC INTVRTB 15X7MM MOBI-C 13MM SPNE CRV COCRMO TI UHMWPE HA MB 3357	C1713	SUPPLY/IMPLANTS	"$41,823.00"	Outpatient	"$20,911.50"	"$1,365.15"	"$22,877.18"	"$27,895.94"	"$16,729.20"	Not Applicable	"$14,638.05"	"$29,276.10"	"$1,365.15"	"$29,276.10"
DISC INTVRTB 17X7MM MOBI-C 13MM SPNE CRV COCRMO TI UHMWPE HA MB 3377	C1713	SUPPLY/IMPLANTS	"$41,823.00"	Outpatient	"$20,911.50"	"$1,365.15"	"$22,877.18"	"$27,895.94"	"$16,729.20"	Not Applicable	"$14,638.05"	"$29,276.10"	"$1,365.15"	"$29,276.10"
SPCR SPNL 22X10X9MM CLBR 4D LRDTC NS LF 194.422	C1821	SUPPLY/IMPLANTS	"$41,823.00"	Outpatient	"$20,911.50"	Not Applicable	"$22,877.18"	"$27,895.94"	"$16,729.20"	Not Applicable	"$14,638.05"	"$29,276.10"	"$14,638.05"	"$29,276.10"
DISC INTVRTB 17X6MM MOBI-C 13MM SPNE CRV COCRMO TI UHMWPE HA MB 3376	C1713	SUPPLY/IMPLANTS	"$41,809.00"	Outpatient	"$20,904.50"	"$1,365.15"	"$22,869.52"	"$27,886.60"	"$16,723.60"	Not Applicable	"$14,633.15"	"$29,266.30"	"$1,365.15"	"$29,266.30"
SPCR SPNL 26X10X9MM CLBR 4D LRDTC NS LF 194.426	C1821	SUPPLY/IMPLANTS	"$41,809.00"	Outpatient	"$20,904.50"	Not Applicable	"$22,869.52"	"$27,886.60"	"$16,723.60"	Not Applicable	"$14,633.15"	"$29,266.30"	"$14,633.15"	"$29,266.30"
SPCR SPNL 22X10X9-13MM CLBR 12D LRDTC NS LF 194.61	C1821	SUPPLY/IMPLANTS	"$41,809.00"	Outpatient	"$20,904.50"	Not Applicable	"$22,869.52"	"$27,886.60"	"$16,723.60"	Not Applicable	"$14,633.15"	"$29,266.30"	"$14,633.15"	"$29,266.30"
SPCR SPNL 26X10X9-13MM CLBR 12D LRDTC NS LF 194.611	C1821	SUPPLY/IMPLANTS	"$41,809.00"	Outpatient	"$20,904.50"	Not Applicable	"$22,869.52"	"$27,886.60"	"$16,723.60"	Not Applicable	"$14,633.15"	"$29,266.30"	"$14,633.15"	"$29,266.30"
SPCR SPNL 26X10X12MM CLBR 4D LRDTC NS LF 194.326	C1821	SUPPLY/IMPLANTS	"$41,809.00"	Outpatient	"$20,904.50"	Not Applicable	"$22,869.52"	"$27,886.60"	"$16,723.60"	Not Applicable	"$14,633.15"	"$29,266.30"	"$14,633.15"	"$29,266.30"
DISC INTVRTB 15X6MM MOBI-C 13MM SPNE CRV COCRMO TI UHMWPE HA MB 3356		STERILE SUPPLY	"$41,809.00"	Outpatient	"$20,904.50"	Not Applicable	"$22,869.52"	"$27,886.60"	"$16,723.60"	Not Applicable	"$14,633.15"	"$29,266.30"	"$14,633.15"	"$29,266.30"
PCMKR 7.5MM MOD ELLIPSE INGENIO RYTHMIQ 2 CHMBR IS-1 CNCT RR K173		STERILE SUPPLY	"$41,809.00"	Outpatient	"$20,904.50"	Not Applicable	"$22,869.52"	"$27,886.60"	"$16,723.60"	Not Applicable	"$14,633.15"	"$29,266.30"	"$14,633.15"	"$29,266.30"
VALVE PERICARDIAL TISSUE 29MM 7300TFX	C9354	SUPPLY/IMPLANTS	"$41,800.00"	Outpatient	"$20,900.00"	$20.52	"$22,864.60"	"$27,880.60"	"$16,720.00"	Not Applicable	"$14,630.00"	"$29,260.00"	$20.52	"$29,260.00"
SLING URETHRAL ADVANCE XP MALE KIT INTERNET EXPLORER 720163-01	C1771	SUPPLY/IMPLANTS	"$41,798.00"	Outpatient	"$20,899.00"	Not Applicable	"$22,863.51"	"$27,879.27"	"$16,719.20"	Not Applicable	"$14,629.30"	"$29,258.60"	"$14,629.30"	"$29,258.60"
VLV AOR 21MM CRP-ED PRIMNT MG EASE THERMAFIX BPRTH STNT BS 3300TFX21MM	C9354	SUPPLY/IMPLANTS	"$41,769.00"	Outpatient	"$20,884.50"	$20.52	"$22,847.64"	"$27,859.92"	"$16,707.60"	Not Applicable	"$14,619.15"	"$29,238.30"	$20.52	"$29,238.30"
GFT STNT 70MM 36MM 20FR ENDURANT II EVAS AAA SYS C DSGN BFUR ETTF3636C70E	C1876	SUPPLY/IMPLANTS	"$41,718.00"	Outpatient	"$20,859.00"	Not Applicable	"$22,819.75"	"$27,825.91"	"$16,687.20"	Not Applicable	"$14,601.30"	"$29,202.60"	"$14,601.30"	"$29,202.60"
PLT 2.5MM ANG LT MNDB 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.510A	C1713	SUPPLY/IMPLANTS	"$41,667.00"	Outpatient	"$20,833.50"	"$1,365.15"	"$22,791.85"	"$27,791.89"	"$16,666.80"	Not Applicable	"$14,583.45"	"$29,166.90"	"$1,365.15"	"$29,166.90"
PLT 2.5MM ANG RT 7X23 HL RECON MATRIXMANDIBLE BN NS PSPC SD449.511A	C1713	SUPPLY/IMPLANTS	"$41,667.00"	Outpatient	"$20,833.50"	"$1,365.15"	"$22,791.85"	"$27,791.89"	"$16,666.80"	Not Applicable	"$14,583.45"	"$29,166.90"	"$1,365.15"	"$29,166.90"
00003-3734-13 - nivolumab 10 mg/mL Soln	J9299	PHARMACY	"$34,982.00"	Outpatient	"$17,491.00"	$27.39	"$22,738.30"	"$23,332.99"	"$13,992.80"	Not Applicable	"$12,243.70"	"$24,487.40"	$27.39	"$24,487.40"
PROSA WITH PROGAV 2.0 AND PAEDIATRIC BURRHOLE RESERVOIR 14MM FX997T		SUPPLY/IMPLANTS	"$41,559.00"	Outpatient	"$20,779.50"	Not Applicable	"$22,732.77"	"$27,719.85"	"$16,623.60"	Not Applicable	"$14,545.65"	"$29,091.30"	"$14,545.65"	"$29,091.30"
"50242-0108-01 - hyaluronidase-rituximab 23,400 units-1400 mg/11.7 mL Soln"	J9311	PHARMACY	"$34,962.00"	Outpatient	"$17,481.00"	$46.67	"$22,725.30"	"$23,319.65"	"$13,984.80"	Not Applicable	"$12,236.70"	"$24,473.40"	$46.67	"$24,473.40"
PROS PENL GNSS 16-25CM 11MM STRL LF 91-9511SC	C2622	SUPPLY/IMPLANTS	"$41,513.00"	Outpatient	"$20,756.50"	Not Applicable	"$22,707.61"	"$27,689.17"	"$16,605.20"	Not Applicable	"$14,529.55"	"$29,059.10"	"$14,529.55"	"$29,059.10"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.554	C1713	SUPPLY/IMPLANTS	"$41,479.00"	Outpatient	"$20,739.50"	"$1,365.15"	"$22,689.01"	"$27,666.49"	"$16,591.60"	Not Applicable	"$14,517.65"	"$29,035.30"	"$1,365.15"	"$29,035.30"
PSI SD800.501 PEEK IMPLANT SD800.501	C1713	SUPPLY/IMPLANTS	"$41,479.00"	Outpatient	"$20,739.50"	"$1,365.15"	"$22,689.01"	"$27,666.49"	"$16,591.60"	Not Applicable	"$14,517.65"	"$29,035.30"	"$1,365.15"	"$29,035.30"
TRAY TIBIAL MBT 4+ MM L74.9 MM X W49.3 MM X H15 MM KNEE CEME 1294-35-415	C1776	SUPPLY/IMPLANTS	"$41,472.00"	Outpatient	"$20,736.00"	Not Applicable	"$22,685.18"	"$27,661.82"	"$16,588.80"	Not Applicable	"$14,515.20"	"$29,030.40"	"$14,515.20"	"$29,030.40"
CMPNT FEM SM 65MM DIST RT GMRS 64952020		STERILE SUPPLY	"$41,404.00"	Outpatient	"$20,702.00"	Not Applicable	"$22,647.99"	"$27,616.47"	"$16,561.60"	Not Applicable	"$14,491.40"	"$28,982.80"	"$14,491.40"	"$28,982.80"
CMPNT FEM STD 65MM KN RT GMRS COCR 64952040	C1776	SUPPLY/IMPLANTS	"$41,395.00"	Outpatient	"$20,697.50"	Not Applicable	"$22,643.07"	"$27,610.47"	"$16,558.00"	Not Applicable	"$14,488.25"	"$28,976.50"	"$14,488.25"	"$28,976.50"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.404	C1713	SUPPLY/IMPLANTS	"$41,309.00"	Outpatient	"$20,654.50"	"$1,365.15"	"$22,596.02"	"$27,553.10"	"$16,523.60"	Not Applicable	"$14,458.15"	"$28,916.30"	"$1,365.15"	"$28,916.30"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.457	C1713	SUPPLY/IMPLANTS	"$41,309.00"	Outpatient	"$20,654.50"	"$1,365.15"	"$22,596.02"	"$27,553.10"	"$16,523.60"	Not Applicable	"$14,458.15"	"$28,916.30"	"$1,365.15"	"$28,916.30"
SPCR SPNL 50X18X8MM AVS ARIA 8D LRDTC PEEK-OPTM INTVRTB BD 48751208	C1821	SUPPLY/IMPLANTS	"$41,134.00"	Outpatient	"$20,567.00"	Not Applicable	"$22,500.30"	"$27,436.38"	"$16,453.60"	Not Applicable	"$14,396.90"	"$28,793.80"	"$14,396.90"	"$28,793.80"
SPCR SPNL 45X18X8MM AVS ARIA 0D PEEK-OPTM INTVRTB BD FSN NS 48750108	C1821	SUPPLY/IMPLANTS	"$41,134.00"	Outpatient	"$20,567.00"	Not Applicable	"$22,500.30"	"$27,436.38"	"$16,453.60"	Not Applicable	"$14,396.90"	"$28,793.80"	"$14,396.90"	"$28,793.80"
MESH CRNMXF MATRIXNEURO 200X200X.6MM TI CRNL RGD CNTR PNK 04.503.122	C1713	SUPPLY/IMPLANTS	"$41,096.00"	Outpatient	"$20,548.00"	"$1,365.15"	"$22,479.51"	"$27,411.03"	"$16,438.40"	Not Applicable	"$14,383.60"	"$28,767.20"	"$1,365.15"	"$28,767.20"
PLT CRNMXF TI CNTR MESH RGD MATRIXNEURO BN NS 04.503.085	C1713	SUPPLY/IMPLANTS	"$41,096.00"	Outpatient	"$20,548.00"	"$1,365.15"	"$22,479.51"	"$27,411.03"	"$16,438.40"	Not Applicable	"$14,383.60"	"$28,767.20"	"$1,365.15"	"$28,767.20"
PLT 2MM 2 ANG SM RECON MATRIXMANDIBLE BN PTSPC PLT CNTR SD449.505	C1713	SUPPLY/IMPLANTS	"$41,034.00"	Outpatient	"$20,517.00"	"$1,365.15"	"$22,445.60"	"$27,369.68"	"$16,413.60"	Not Applicable	"$14,361.90"	"$28,723.80"	"$1,365.15"	"$28,723.80"
GFT STNT 70MM 28MM 18FR ENDURANT II EVAS PLSTR NTNL AOR XTN ETTF2828C70E	C1784	SUPPLY/IMPLANTS	"$40,909.00"	Outpatient	"$20,454.50"	Not Applicable	"$22,377.22"	"$27,286.30"	"$16,363.60"	Not Applicable	"$14,318.15"	"$28,636.30"	"$14,318.15"	"$28,636.30"
Remove Replace Pacer Gen Multi Lead System	33229	CARDIAC CATH LAB	"$40,877.00"	Outpatient	"$20,438.50"	"$36,197.64"	"$22,359.72"	"$1,592.00"	"$16,350.80"	"$8,681.00"	"$14,306.95"	"$28,613.90"	"$1,592.00"	"$36,197.64"
Removal Replacement PM Generator  Dual Lead	33228	CARDIAC CATH LAB	"$40,877.00"	Outpatient	"$20,438.50"	"$36,197.64"	"$22,359.72"	"$1,592.00"	"$16,350.80"	"$8,681.00"	"$14,306.95"	"$28,613.90"	"$1,592.00"	"$36,197.64"
SPACER SPINAL FORTIFY D20 MM W20 MM X H31 MM NONSTERILE LATE 151.152	C1821	SUPPLY/IMPLANTS	"$40,863.00"	Outpatient	"$20,431.50"	Not Applicable	"$22,352.06"	"$27,255.62"	"$16,345.20"	Not Applicable	"$14,302.05"	"$28,604.10"	"$14,302.05"	"$28,604.10"
VLV AOR 15MM 19MM 24MM TRIFECTA LINX AC STNT TISS LFLT UNQ TF-19A		SUPPLY/IMPLANTS	"$40,783.00"	Outpatient	"$20,391.50"	Not Applicable	"$22,308.30"	"$27,202.26"	"$16,313.20"	Not Applicable	"$14,274.05"	"$28,548.10"	"$14,274.05"	"$28,548.10"
VLV AOR 18MM 25MM TRIFECTA BPRTH STNT CUF HLDR PRICRD TI TF-25A		SUPPLY/IMPLANTS	"$40,783.00"	Outpatient	"$20,391.50"	Not Applicable	"$22,308.30"	"$27,202.26"	"$16,313.20"	Not Applicable	"$14,274.05"	"$28,548.10"	"$14,274.05"	"$28,548.10"
VLV AOR 17MM 23MM TRIFECTA BPRTH STNT CUF HLDR PRICRD TI TF-23A		SUPPLY/IMPLANTS	"$40,783.00"	Outpatient	"$20,391.50"	Not Applicable	"$22,308.30"	"$27,202.26"	"$16,313.20"	Not Applicable	"$14,274.05"	"$28,548.10"	"$14,274.05"	"$28,548.10"
VLV AOR 16MM 26MM 21MM TRIFECTA DRBLE PROTRUSION FTG RST TI TF-21A		SUPPLY/IMPLANTS	"$40,783.00"	Outpatient	"$20,391.50"	Not Applicable	"$22,308.30"	"$27,202.26"	"$16,313.20"	Not Applicable	"$14,274.05"	"$28,548.10"	"$14,274.05"	"$28,548.10"
VLV AOR 19MM 27MM TRIFECTA BPRTH STNT CUF HLDR PRICRD TI TF-27A		SUPPLY/IMPLANTS	"$40,783.00"	Outpatient	"$20,391.50"	Not Applicable	"$22,308.30"	"$27,202.26"	"$16,313.20"	Not Applicable	"$14,274.05"	"$28,548.10"	"$14,274.05"	"$28,548.10"
Insert/Replace Pacer Gen Dual Atri /Vent	33213	CARDIAC CATH LAB	"$40,700.00"	Outpatient	"$20,350.00"	"$20,382.87"	"$22,262.90"	"$1,771.00"	"$16,280.00"	"$8,681.00"	"$14,245.00"	"$28,490.00"	"$1,771.00"	"$28,490.00"
EV FEMPOP ARTL REVSC TCAT PLMT IV ST GRF & CLSR	0505T	CARDIAC CATH LAB	"$40,673.00"	Outpatient	"$20,336.50"	"$20,496.43"	"$22,248.13"	"$27,128.89"	"$16,269.20"	"$8,681.00"	"$14,235.55"	"$28,471.10"	"$8,681.00"	"$28,471.10"
CATHETER WAVELINQ 4F ENDOAVF SYSTEM WQ4300		SUPPLY/IMPLANTS	"$40,665.00"	Outpatient	"$20,332.50"	Not Applicable	"$22,243.76"	"$27,123.56"	"$16,266.00"	Not Applicable	"$14,232.75"	"$28,465.50"	"$14,232.75"	"$28,465.50"
EPLT SPNL 12X6MM SCR-C 6D 11MM SPHRCL CYL CRV TI COCRMO MLT 714.166S	C1713	SUPPLY/IMPLANTS	"$40,659.00"	Outpatient	"$20,329.50"	"$1,365.15"	"$22,240.47"	"$27,119.55"	"$16,263.60"	Not Applicable	"$14,230.65"	"$28,461.30"	"$1,365.15"	"$28,461.30"
50242-0918-01 - atezolizumab 840 mg/14 mL Soln	J9022	PHARMACY	"$34,213.00"	Outpatient	"$17,106.50"	$77.07	"$22,238.45"	"$22,820.07"	"$13,685.20"	Not Applicable	"$11,974.55"	"$23,949.10"	$77.07	"$23,949.10"
OCLR CV 20MM SPT SFT WRE FRM FLRSCP IMG GORE EPTFE GSX0020A		STERILE SUPPLY	"$40,631.00"	Outpatient	"$20,315.50"	Not Applicable	"$22,225.16"	"$27,100.88"	"$16,252.40"	Not Applicable	"$14,220.85"	"$28,441.70"	"$14,220.85"	"$28,441.70"
OCLR CV 25MM SPT SFT WRE FRM FLRSCP IMG GORE EPTFE GSX0025A		STERILE SUPPLY	"$40,631.00"	Outpatient	"$20,315.50"	Not Applicable	"$22,225.16"	"$27,100.88"	"$16,252.40"	Not Applicable	"$14,220.85"	"$28,441.70"	"$14,220.85"	"$28,441.70"
PACEMAKER CARDIAC ALLURE RF THK6 MM W59 MM X H55 MM 14 CC 24 PM3222	C2621	PACE MAKER	"$40,623.00"	Outpatient	"$20,311.50"	Not Applicable	"$22,220.78"	"$27,095.54"	"$16,249.20"	Not Applicable	"$14,218.05"	"$28,436.10"	"$14,218.05"	"$28,436.10"
VG NS FEM/CEM/TIB/ARC/PAT 98-B002-005-37	C1713	SUPPLY/IMPLANTS	"$40,618.00"	Outpatient	"$20,309.00"	"$1,365.15"	"$22,218.05"	"$27,092.21"	"$16,247.20"	Not Applicable	"$14,216.30"	"$28,432.60"	"$1,365.15"	"$28,432.60"
STENT NEUROFORM 3 EZ 3.0 X 20MM N3EZ30200	C1876	SUPPLY/IMPLANTS	"$40,588.00"	Outpatient	"$20,294.00"	Not Applicable	"$22,201.64"	"$27,072.20"	"$16,235.20"	Not Applicable	"$14,205.80"	"$28,411.60"	"$14,205.80"	"$28,411.60"
PLT 2MM 2 ANG MNDB TI PTSPC BN SD480.111	C1713	SUPPLY/IMPLANTS	"$40,493.00"	Outpatient	"$20,246.50"	"$1,365.15"	"$22,149.67"	"$27,008.83"	"$16,197.20"	Not Applicable	"$14,172.55"	"$28,345.10"	"$1,365.15"	"$28,345.10"
STENT WINGSPAN 4.5 X 15.0MM WS0450150	C1876	SUPPLY/IMPLANTS	"$40,443.00"	Outpatient	"$20,221.50"	Not Applicable	"$22,122.32"	"$26,975.48"	"$16,177.20"	Not Applicable	"$14,155.05"	"$28,310.10"	"$14,155.05"	"$28,310.10"
STENT WINGSPAN 4.5 X 20.0MM M003WS0450200	C1876	SUPPLY/IMPLANTS	"$40,443.00"	Outpatient	"$20,221.50"	Not Applicable	"$22,122.32"	"$26,975.48"	"$16,177.20"	Not Applicable	"$14,155.05"	"$28,310.10"	"$14,155.05"	"$28,310.10"
STNT INTRCRAN 4MM 3.5FR 15MM SLF XPD OTW BLN CATH VSL WL WS0400150	C1876	SUPPLY/IMPLANTS	"$40,443.00"	Outpatient	"$20,221.50"	Not Applicable	"$22,122.32"	"$26,975.48"	"$16,177.20"	Not Applicable	"$14,155.05"	"$28,310.10"	"$14,155.05"	"$28,310.10"
STNT INTRCRAN 4MM 3.5FR 20MM SLF XPD OTW BLN CATH VSL WL M003WS0400200	C1876	SUPPLY/IMPLANTS	"$40,443.00"	Outpatient	"$20,221.50"	Not Applicable	"$22,122.32"	"$26,975.48"	"$16,177.20"	Not Applicable	"$14,155.05"	"$28,310.10"	"$14,155.05"	"$28,310.10"
STENT WINGSPAN SYSTEM 3.0 X 15.0MM M003WS0300150		SUPPLY/IMPLANTS	"$40,443.00"	Outpatient	"$20,221.50"	Not Applicable	"$22,122.32"	"$26,975.48"	"$16,177.20"	Not Applicable	"$14,155.05"	"$28,310.10"	"$14,155.05"	"$28,310.10"
STNT INTRCRAN 2.5MM 3.5FR 20MM SLF XPD OTW BLN CATH VSL WL M003WS0250200		SUPPLY/IMPLANTS	"$40,443.00"	Outpatient	"$20,221.50"	Not Applicable	"$22,122.32"	"$26,975.48"	"$16,177.20"	Not Applicable	"$14,155.05"	"$28,310.10"	"$14,155.05"	"$28,310.10"
STNT INTRCRAN 3.5MM 3.5FR 20MM SLF XPD OTW BLN CATH VSL WL M003WS0350200		SUPPLY/IMPLANTS	"$40,443.00"	Outpatient	"$20,221.50"	Not Applicable	"$22,122.32"	"$26,975.48"	"$16,177.20"	Not Applicable	"$14,155.05"	"$28,310.10"	"$14,155.05"	"$28,310.10"
"Perc AMI Stent, Atherect, PTCA, ASP, Thrombectomy"	92941	CARDIAC CATH LAB	"$37,219.00"	Outpatient	"$18,609.50"	"$30,568.87"	"$22,108.09"	"$8,056.00"	"$14,887.60"	"$7,310.00"	"$13,026.65"	"$26,053.30"	"$7,310.00"	"$30,568.87"
STENT GRAFT ETTF2323C70E ENDUR II AOEXT ETTF2323C70E	C1874	SUPPLY/IMPLANTS	"$40,385.00"	Outpatient	"$20,192.50"	Not Applicable	"$22,090.60"	"$26,936.80"	"$16,154.00"	Not Applicable	"$14,134.75"	"$28,269.50"	"$14,134.75"	"$28,269.50"
DSTRCT RT MNDB MTVCTR ASMB SRG TI NS 487.966	C1713	SUPPLY/IMPLANTS	"$40,323.00"	Outpatient	"$20,161.50"	"$1,365.15"	"$22,056.68"	"$26,895.44"	"$16,129.20"	Not Applicable	"$14,113.05"	"$28,226.10"	"$1,365.15"	"$28,226.10"
DSTRCT MNDB LT MTVCTR ASMB SRG TI NS 487.967	C1713	SUPPLY/IMPLANTS	"$40,323.00"	Outpatient	"$20,161.50"	"$1,365.15"	"$22,056.68"	"$26,895.44"	"$16,129.20"	Not Applicable	"$14,113.05"	"$28,226.10"	"$1,365.15"	"$28,226.10"
ANTE FEM TARG GDE 512 WD 249000110	C1713	SUPPLY/IMPLANTS	"$40,289.00"	Outpatient	"$20,144.50"	"$1,365.15"	"$22,038.08"	"$26,872.76"	"$16,115.60"	Not Applicable	"$14,101.15"	"$28,202.30"	"$1,365.15"	"$28,202.30"
MALLEABLE PENILE PROSTHESIS 13MM X 18X27CM 91-9513SC	C2622	SUPPLY/IMPLANTS	"$40,181.00"	Outpatient	"$20,090.50"	Not Applicable	"$21,979.01"	"$26,800.73"	"$16,072.40"	Not Applicable	"$14,063.35"	"$28,126.70"	"$14,063.35"	"$28,126.70"
MALLEABLE PENILE PROSTHESIS 9.5MM X 14 X 23CM 91-9509SC		STERILE SUPPLY	"$40,181.00"	Outpatient	"$20,090.50"	Not Applicable	"$21,979.01"	"$26,800.73"	"$16,072.40"	Not Applicable	"$14,063.35"	"$28,126.70"	"$14,063.35"	"$28,126.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.403	C1713	SUPPLY/IMPLANTS	"$40,170.00"	Outpatient	"$20,085.00"	"$1,365.15"	"$21,972.99"	"$26,793.39"	"$16,068.00"	Not Applicable	"$14,059.50"	"$28,119.00"	"$1,365.15"	"$28,119.00"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.456	C1713	SUPPLY/IMPLANTS	"$40,170.00"	Outpatient	"$20,085.00"	"$1,365.15"	"$21,972.99"	"$26,793.39"	"$16,068.00"	Not Applicable	"$14,059.50"	"$28,119.00"	"$1,365.15"	"$28,119.00"
STNT INTRCRAN 4MM 30MM NRFRM EZ MCDLVR SYS N3EZ4030		SUPPLY/IMPLANTS	"$40,060.00"	Outpatient	"$20,030.00"	Not Applicable	"$21,912.82"	"$26,720.02"	"$16,024.00"	Not Applicable	"$14,021.00"	"$28,042.00"	"$14,021.00"	"$28,042.00"
STNT INTRCRAN 4MM 20MM NRFRM EZ MCDLVR SYS N3EZ4020		SUPPLY/IMPLANTS	"$40,037.00"	Outpatient	"$20,018.50"	Not Applicable	"$21,900.24"	"$26,704.68"	"$16,014.80"	Not Applicable	"$14,012.95"	"$28,025.90"	"$14,012.95"	"$28,025.90"
STENT VASCULAR SOLITAIRE 10 MM SPACE 4-1 L31 MM L20 MM OD6 M SFR4-6-20-10	C1876	SUPPLY/IMPLANTS	"$39,976.00"	Outpatient	"$19,988.00"	Not Applicable	"$21,866.87"	"$26,663.99"	"$15,990.40"	Not Applicable	"$13,991.60"	"$27,983.20"	"$13,991.60"	"$27,983.20"
STNT HEP NTNL EPTFE 8MM 25CM FLXB SLF XPD RADOPQ VBHN EPRSTH VBJR082502A	C1874	SUPPLY/IMPLANTS	"$39,961.00"	Outpatient	"$19,980.50"	Not Applicable	"$21,858.67"	"$26,653.99"	"$15,984.40"	Not Applicable	"$13,986.35"	"$27,972.70"	"$13,986.35"	"$27,972.70"
CAGE SPNL 30X9.5-12MM ROI-A VERTEBRIDGE 6D LRDTC 27MM MEDIAN IR2524P	C1821	SUPPLY/IMPLANTS	"$39,909.00"	Outpatient	"$19,954.50"	Not Applicable	"$21,830.22"	"$26,619.30"	"$15,963.60"	Not Applicable	"$13,968.15"	"$27,936.30"	"$13,968.15"	"$27,936.30"
HNDPC ESCP SLGRP3 DLV SYS 705-37020		STERILE SUPPLY	"$39,905.00"	Outpatient	"$19,952.50"	Not Applicable	"$21,828.04"	"$26,616.64"	"$15,962.00"	Not Applicable	"$13,966.75"	"$27,933.50"	"$13,966.75"	"$27,933.50"
JIG PSTN 125D INS FXTR ASMB 2112-01-207	C1713	SUPPLY/IMPLANTS	"$39,892.00"	Outpatient	"$19,946.00"	"$1,365.15"	"$21,820.92"	"$26,607.96"	"$15,956.80"	Not Applicable	"$13,962.20"	"$27,924.40"	"$1,365.15"	"$27,924.40"
JIG PSTN 130D INS FXTR ASMB 2112-01-208	C1713	SUPPLY/IMPLANTS	"$39,892.00"	Outpatient	"$19,946.00"	"$1,365.15"	"$21,820.92"	"$26,607.96"	"$15,956.80"	Not Applicable	"$13,962.20"	"$27,924.40"	"$1,365.15"	"$27,924.40"
PCMKR .75CM VALITUDE X4 IS-1 CNCT 4.45X6.17CM CRD 17.6ML 33 U128	C2621	PACE MAKER	"$39,777.00"	Outpatient	"$19,888.50"	Not Applicable	"$21,758.02"	"$26,531.26"	"$15,910.80"	Not Applicable	"$13,921.95"	"$27,843.90"	"$13,921.95"	"$27,843.90"
PCMKR 3D .75CM 16.2CU CM SPRL VALITUDE PACESAFE RIGHTRATE U125	C2621	PACE MAKER	"$39,777.00"	Outpatient	"$19,888.50"	Not Applicable	"$21,758.02"	"$26,531.26"	"$15,910.80"	Not Applicable	"$13,921.95"	"$27,843.90"	"$13,921.95"	"$27,843.90"
PCMKR THK7.5MM MOD ELLIPSE INVIVE SMRT DELAY 2 CHMBR IS-1 V172	C2621	PACE MAKER	"$39,768.00"	Outpatient	"$19,884.00"	Not Applicable	"$21,753.10"	"$26,525.26"	"$15,907.20"	Not Applicable	"$13,918.80"	"$27,837.60"	"$13,918.80"	"$27,837.60"
GENERATOR CRT-P INTUA V272/73	C1820	SUPPLY/IMPLANTS	"$39,768.00"	Outpatient	"$19,884.00"	Not Applicable	"$21,753.10"	"$26,525.26"	"$15,907.20"	Not Applicable	"$13,918.80"	"$27,837.60"	"$13,918.80"	"$27,837.60"
CAGE SPNL 50X22X10MM CLYDESDALE 6D PEEK RADOPQ LMBR INTRBD 2926050	C9362	SUPPLY/IMPLANTS	"$39,764.00"	Outpatient	"$19,882.00"	$110.85	"$21,750.91"	"$26,522.59"	"$15,905.60"	Not Applicable	"$13,917.40"	"$27,834.80"	$110.85	"$27,834.80"
CAGE SPNL 26X8-10MM ROI-A VERTEBRIDGE 6D LRDTC 23MM MEDIAN IR 2422 P	C1821	SUPPLY/IMPLANTS	"$39,761.00"	Outpatient	"$19,880.50"	Not Applicable	"$21,749.27"	"$26,520.59"	"$15,904.40"	Not Applicable	"$13,916.35"	"$27,832.70"	"$13,916.35"	"$27,832.70"
CAGE SPNL 30X7.5-12MM ROI-A VERTEBRIDGE 10D LRDTC 27MM IR 2532 P	C1821	SUPPLY/IMPLANTS	"$39,761.00"	Outpatient	"$19,880.50"	Not Applicable	"$21,749.27"	"$26,520.59"	"$15,904.40"	Not Applicable	"$13,916.35"	"$27,832.70"	"$13,916.35"	"$27,832.70"
CAGE SPNL 30X11.5-14MM ROI-A VERTEBRIDGE 6D LRDTC 27MM IR 2526 P	C1821	SUPPLY/IMPLANTS	"$39,761.00"	Outpatient	"$19,880.50"	Not Applicable	"$21,749.27"	"$26,520.59"	"$15,904.40"	Not Applicable	"$13,916.35"	"$27,832.70"	"$13,916.35"	"$27,832.70"
IMPLANT MEDIAN ROI-A 10MM 23MM X 26MM/ 10 DEG IR2431P	C1821	SUPPLY/IMPLANTS	"$39,748.00"	Outpatient	"$19,874.00"	Not Applicable	"$21,742.16"	"$26,511.92"	"$15,899.20"	Not Applicable	"$13,911.80"	"$27,823.60"	"$13,911.80"	"$27,823.60"
PCMKR THK7.5MM MOD ELLIPSE INVIVE SMRT DELAY 2 CHMBR IS-1 V173	C2621	PACE MAKER	"$39,740.00"	Outpatient	"$19,870.00"	Not Applicable	"$21,737.78"	"$26,506.58"	"$15,896.00"	Not Applicable	"$13,909.00"	"$27,818.00"	"$13,909.00"	"$27,818.00"
CAGE SPNL 39X16MM ROI-A 6D 30MM MEDIAN STRL LF IR5327P	C1821	SUPPLY/IMPLANTS	"$39,739.00"	Outpatient	"$19,869.50"	Not Applicable	"$21,737.23"	"$26,505.91"	"$15,895.60"	Not Applicable	"$13,908.65"	"$27,817.30"	"$13,908.65"	"$27,817.30"
CAGE SPNL 36X9.5-14MM ROI-A VERTEBRIDGE 10D LRDTC 27MM IR 5234 P	C1821	SUPPLY/IMPLANTS	"$39,739.00"	Outpatient	"$19,869.50"	Not Applicable	"$21,737.23"	"$26,505.91"	"$15,895.60"	Not Applicable	"$13,908.65"	"$27,817.30"	"$13,908.65"	"$27,817.30"
CAGE SPNL 36X11.5-14MM ROI-A VERTEBRIDGE 6D LRDTC 27MM IR 5225 P	C1821	SUPPLY/IMPLANTS	"$39,739.00"	Outpatient	"$19,869.50"	Not Applicable	"$21,737.23"	"$26,505.91"	"$15,895.60"	Not Applicable	"$13,908.65"	"$27,817.30"	"$13,908.65"	"$27,817.30"
CAGE SPNL 36X7.5-12MM ROI-A VERTEBRIDGE 10D LRDTC 27MM IR 5232 P	C1821	SUPPLY/IMPLANTS	"$39,739.00"	Outpatient	"$19,869.50"	Not Applicable	"$21,737.23"	"$26,505.91"	"$15,895.60"	Not Applicable	"$13,908.65"	"$27,817.30"	"$13,908.65"	"$27,817.30"
IMPLANT MEDIAN 12MM X 30 X 30MM 6 IR5323P	C1821	SUPPLY/IMPLANTS	"$39,739.00"	Outpatient	"$19,869.50"	Not Applicable	"$21,737.23"	"$26,505.91"	"$15,895.60"	Not Applicable	"$13,908.65"	"$27,817.30"	"$13,908.65"	"$27,817.30"
SYSTEM LEAD DELIVERY ACUITY BREAK-AWAY ALDS	C1900	PACE MAKER	"$39,728.00"	Outpatient	"$19,864.00"	Not Applicable	"$21,731.22"	"$26,498.58"	"$15,891.20"	Not Applicable	"$13,904.80"	"$27,809.60"	"$13,904.80"	"$27,809.60"
CAGE SPNL 36X7.5-10MM ROI-A VERTEBRIDGE 6D LRDTC 27MM MEDIAN IR 5221 P	C1821	SUPPLY/IMPLANTS	"$39,709.00"	Outpatient	"$19,854.50"	Not Applicable	"$21,720.82"	"$26,485.90"	"$15,883.60"	Not Applicable	"$13,898.15"	"$27,796.30"	"$13,898.15"	"$27,796.30"
CAGE SPNL 36X9.5-12MM ROI-A VERTEBRIDGE 6D LRDTC 27MM MEDIAN IR 5223 P	C1821	SUPPLY/IMPLANTS	"$39,709.00"	Outpatient	"$19,854.50"	Not Applicable	"$21,720.82"	"$26,485.90"	"$15,883.60"	Not Applicable	"$13,898.15"	"$27,796.30"	"$13,898.15"	"$27,796.30"
CAGE SPNL 36X7.5-14MM ROI-A VERTEBRIDGE 14D LRDTC 27MM IR 5243 P	C1821	SUPPLY/IMPLANTS	"$39,709.00"	Outpatient	"$19,854.50"	Not Applicable	"$21,720.82"	"$26,485.90"	"$15,883.60"	Not Applicable	"$13,898.15"	"$27,796.30"	"$13,898.15"	"$27,796.30"
CAGE SPNL 39X10MM ROI-A 6D 30MM MEDIAN STRL LF IR5321P	C1821	SUPPLY/IMPLANTS	"$39,709.00"	Outpatient	"$19,854.50"	Not Applicable	"$21,720.82"	"$26,485.90"	"$15,883.60"	Not Applicable	"$13,898.15"	"$27,796.30"	"$13,898.15"	"$27,796.30"
CAGE SPNL 55X18X10MM CRNT XL PEEK RADOPQ TLIF NS LF 6910855	C1821	SUPPLY/IMPLANTS	"$39,698.00"	Outpatient	"$19,849.00"	Not Applicable	"$21,714.81"	"$26,478.57"	"$15,879.20"	Not Applicable	"$13,894.30"	"$27,788.60"	"$13,894.30"	"$27,788.60"
CAGE SPNL 55X18X8MM CRNT 10D XL PEEK LMBR INTRBD FS NS LF 6980855	C1821	SUPPLY/IMPLANTS	"$39,698.00"	Outpatient	"$19,849.00"	Not Applicable	"$21,714.81"	"$26,478.57"	"$15,879.20"	Not Applicable	"$13,894.30"	"$27,788.60"	"$13,894.30"	"$27,788.60"
CAGE SPNL 50X18X8MM CRNT 10D XL PEEK LMBR INTRBD FS NS LF 6980850	C1821	SUPPLY/IMPLANTS	"$39,669.00"	Outpatient	"$19,834.50"	Not Applicable	"$21,698.94"	"$26,459.22"	"$15,867.60"	Not Applicable	"$13,884.15"	"$27,768.30"	"$13,884.15"	"$27,768.30"
CAGE SPNL 50X18X12MM CRNT 10D XL PEEK LMBR INTRBD FS NS LF 6981250	C1821	SUPPLY/IMPLANTS	"$39,669.00"	Outpatient	"$19,834.50"	Not Applicable	"$21,698.94"	"$26,459.22"	"$15,867.60"	Not Applicable	"$13,884.15"	"$27,768.30"	"$13,884.15"	"$27,768.30"
SPCR SPNL 45X18X10MM AVS ARIA 0D PEEK-OPTM INTVRTB BD FSN NS 48750110	C1821	SUPPLY/IMPLANTS	"$39,646.00"	Outpatient	"$19,823.00"	Not Applicable	"$21,686.36"	"$26,443.88"	"$15,858.40"	Not Applicable	"$13,876.10"	"$27,752.20"	"$13,876.10"	"$27,752.20"
GFT SFT TIS 70MM 4-5MM AVANCE NRV ALGRF STRL 411270	C1763	SUPPLY/IMPLANTS	"$39,602.00"	Outpatient	"$19,801.00"	Not Applicable	"$21,662.29"	"$26,414.53"	"$15,840.80"	Not Applicable	"$13,860.70"	"$27,721.40"	"$13,860.70"	"$27,721.40"
PLT 2MM ANG LT MXL 7X23 HL RECON MATRIXMANDIBLE BN PSPC SD449.503A	C1713	SUPPLY/IMPLANTS	"$39,593.00"	Outpatient	"$19,796.50"	"$1,365.15"	"$21,657.37"	"$26,408.53"	"$15,837.20"	Not Applicable	"$13,857.55"	"$27,715.10"	"$1,365.15"	"$27,715.10"
PLT 2MM ANG MXL RT 7X23 HL RECON MATRIXMANDIBLE BN PSPC SD449.504A	C1713	SUPPLY/IMPLANTS	"$39,593.00"	Outpatient	"$19,796.50"	"$1,365.15"	"$21,657.37"	"$26,408.53"	"$15,837.20"	Not Applicable	"$13,857.55"	"$27,715.10"	"$1,365.15"	"$27,715.10"
Angioplasty Chronic Total Occlusion Additional	92944	CARDIAC CATH LAB	"$36,450.00"	Outpatient	"$18,225.00"	"$30,568.87"	"$21,651.30"	"$8,056.00"	"$14,580.00"	"$7,310.00"	"$12,757.50"	"$25,515.00"	"$7,310.00"	"$30,568.87"
INDIGO CATHETER 12 + LIGHTNING ASPIRATION TUBING LITNG12HTORQ100		STERILE SUPPLY	"$39,561.00"	Outpatient	"$19,780.50"	Not Applicable	"$21,639.87"	"$26,387.19"	"$15,824.40"	Not Applicable	"$13,846.35"	"$27,692.70"	"$13,846.35"	"$27,692.70"
STEM HUM 100MM 4MM ELB 840004410		STERILE SUPPLY	"$39,488.00"	Outpatient	"$19,744.00"	Not Applicable	"$21,599.94"	"$26,338.50"	"$15,795.20"	Not Applicable	"$13,820.80"	"$27,641.60"	"$13,820.80"	"$27,641.60"
15054-1090-03 - lanreotide 90 mg/0.3 mL Soln	J1930	PHARMACY	"$39,472.00"	Outpatient	"$19,736.00"	$72.44	"$21,591.18"	"$26,327.82"	"$15,788.80"	Not Applicable	"$13,815.20"	"$27,630.40"	$72.44	"$27,630.40"
PLT 2MM HEMI MNDB PRM RECON CSTM BN 7830020	C1713	SUPPLY/IMPLANTS	"$39,457.00"	Outpatient	"$19,728.50"	"$1,365.15"	"$21,582.98"	"$26,317.82"	"$15,782.80"	Not Applicable	"$13,809.95"	"$27,619.90"	"$1,365.15"	"$27,619.90"
PLT 200X200X.6MM CRNFCL TI CNTR MESH RGD NEURO LOPRFL BN NS 421.535	C1713	SUPPLY/IMPLANTS	"$39,451.00"	Outpatient	"$19,725.50"	"$1,365.15"	"$21,579.70"	"$26,313.82"	"$15,780.40"	Not Applicable	"$13,807.85"	"$27,615.70"	"$1,365.15"	"$27,615.70"
STNT HEP 6MM 6FR SPRFC FEM ART ILIUM 10CM DLV SYS VBHN VBJ061002	C1884	SUPPLY/IMPLANTS	"$39,428.00"	Outpatient	"$19,714.00"	Not Applicable	"$21,567.12"	"$26,298.48"	"$15,771.20"	Not Applicable	"$13,799.80"	"$27,599.60"	"$13,799.80"	"$27,599.60"
STEM SHOULDER PRIMARY 13 X 55MM 11613	C1776	SUPPLY/IMPLANTS	"$39,399.00"	Outpatient	"$19,699.50"	Not Applicable	"$21,551.25"	"$26,279.13"	"$15,759.60"	Not Applicable	"$13,789.65"	"$27,579.30"	"$13,789.65"	"$27,579.30"
CATH CRYABL 95CM 10.5FR 23MM ARCTIC FRN ADV STRL LF DISP 2AF234		STERILE SUPPLY	"$39,189.00"	Outpatient	"$19,594.50"	Not Applicable	"$21,436.38"	"$26,139.06"	"$15,675.60"	Not Applicable	"$13,716.15"	"$27,432.30"	"$13,716.15"	"$27,432.30"
CATH CRYABL 95CM 10.5FR 28MM ARCTIC FRN ADV STRL LF DISP 2AF284		STERILE SUPPLY	"$39,189.00"	Outpatient	"$19,594.50"	Not Applicable	"$21,436.38"	"$26,139.06"	"$15,675.60"	Not Applicable	"$13,716.15"	"$27,432.30"	"$13,716.15"	"$27,432.30"
CAGE LUMBAR  NOVEL SD 9 X 28 X 13 N64817-013	C1821	SUPPLY/IMPLANTS	"$39,187.00"	Outpatient	"$19,593.50"	Not Applicable	"$21,435.29"	"$26,137.73"	"$15,674.80"	Not Applicable	"$13,715.45"	"$27,430.90"	"$13,715.45"	"$27,430.90"
CAGE NOVEL SD 14 X 28 X 9 NB64817-014	C1821	SUPPLY/IMPLANTS	"$39,158.00"	Outpatient	"$19,579.00"	Not Applicable	"$21,419.43"	"$26,118.39"	"$15,663.20"	Not Applicable	"$13,705.30"	"$27,410.60"	"$13,705.30"	"$27,410.60"
Pacemaker-Convert Sngl Chamb to Dual Chamber Sys	33214	CARDIAC CATH LAB	"$39,132.00"	Outpatient	"$19,566.00"	"$24,898.20"	"$21,405.20"	"$1,592.00"	"$15,652.80"	"$12,306.00"	"$13,696.20"	"$27,392.40"	"$1,592.00"	"$27,392.40"
CMPNT FEM 2 KN RT TL STAB TRTHLN COCR 5512-F-202	C1776	SUPPLY/IMPLANTS	"$39,115.00"	Outpatient	"$19,557.50"	Not Applicable	"$21,395.91"	"$26,089.71"	"$15,646.00"	Not Applicable	"$13,690.25"	"$27,380.50"	"$13,690.25"	"$27,380.50"
END CAP SPNL 24-33MM 18MM X-COR 2 TI ATLCK NS 7180033A	C1713	SUPPLY/IMPLANTS	"$39,037.00"	Outpatient	"$19,518.50"	"$1,365.15"	"$21,353.24"	"$26,037.68"	"$15,614.80"	Not Applicable	"$13,662.95"	"$27,325.90"	"$1,365.15"	"$27,325.90"
IMPL CRNL PEEK PTSPC NS LF SD800.402	C1713	SUPPLY/IMPLANTS	"$39,026.00"	Outpatient	"$19,513.00"	"$1,365.15"	"$21,347.22"	"$26,030.34"	"$15,610.40"	Not Applicable	"$13,659.10"	"$27,318.20"	"$1,365.15"	"$27,318.20"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.455	C1713	SUPPLY/IMPLANTS	"$39,026.00"	Outpatient	"$19,513.00"	"$1,365.15"	"$21,347.22"	"$26,030.34"	"$15,610.40"	Not Applicable	"$13,659.10"	"$27,318.20"	"$1,365.15"	"$27,318.20"
STNT INTRCRAN 4.5MM 30MM NRFRM EZ MCDLVR SYS N3EZ4530		SUPPLY/IMPLANTS	"$38,906.00"	Outpatient	"$19,453.00"	Not Applicable	"$21,281.58"	"$25,950.30"	"$15,562.40"	Not Applicable	"$13,617.10"	"$27,234.20"	"$13,617.10"	"$27,234.20"
STNT INTRCRAN 3MM 15MM NRFRM EZ N3EZ3015		SUPPLY/IMPLANTS	"$38,906.00"	Outpatient	"$19,453.00"	Not Applicable	"$21,281.58"	"$25,950.30"	"$15,562.40"	Not Applicable	"$13,617.10"	"$27,234.20"	"$13,617.10"	"$27,234.20"
CUFF URETHRAL AMS 800 INHIBIZONE L5 CM SPHINCTER OCCLUSIVE S 72404132	C1815	SUPPLY/IMPLANTS	"$38,835.00"	Outpatient	"$19,417.50"	Not Applicable	"$21,242.75"	"$25,902.95"	"$15,534.00"	Not Applicable	"$13,592.25"	"$27,184.50"	"$13,592.25"	"$27,184.50"
PLT 2.4MM ANG MNDB LT TI 7X23 HL RECON MATRIXMANDIBLE BN SD449.510	C1713	SUPPLY/IMPLANTS	"$38,806.00"	Outpatient	"$19,403.00"	"$1,365.15"	"$21,226.88"	"$25,883.60"	"$15,522.40"	Not Applicable	"$13,582.10"	"$27,164.20"	"$1,365.15"	"$27,164.20"
PLT 2.5MM ANG RT MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.511	C1713	SUPPLY/IMPLANTS	"$38,806.00"	Outpatient	"$19,403.00"	"$1,365.15"	"$21,226.88"	"$25,883.60"	"$15,522.40"	Not Applicable	"$13,582.10"	"$27,164.20"	"$1,365.15"	"$27,164.20"
SPCR SPNL 27MMX13MM CPSTN CNTRL 12D PEEK INTRBD FS STRL LF 4011327	C1821	SUPPLY/IMPLANTS	"$38,784.00"	Outpatient	"$19,392.00"	Not Applicable	"$21,214.85"	"$25,868.93"	"$15,513.60"	Not Applicable	"$13,574.40"	"$27,148.80"	"$13,574.40"	"$27,148.80"
SPCR SPNL 27MMX13MM CPSTN CNTRL 6D PEEK INTRBD FS STRL LF 4001327	C1821	SUPPLY/IMPLANTS	"$38,761.00"	Outpatient	"$19,380.50"	Not Applicable	"$21,202.27"	"$25,853.59"	"$15,504.40"	Not Applicable	"$13,566.35"	"$27,132.70"	"$13,566.35"	"$27,132.70"
SPCR SPNL 27MMX14MM CPSTN CNTRL 12D PEEK INTRBD FS STRL LF 4011427	C1821	SUPPLY/IMPLANTS	"$38,761.00"	Outpatient	"$19,380.50"	Not Applicable	"$21,202.27"	"$25,853.59"	"$15,504.40"	Not Applicable	"$13,566.35"	"$27,132.70"	"$13,566.35"	"$27,132.70"
SPCR SPNL 27MMX14MM CPSTN CNTRL 6D PEEK INTRBD FS STRL LF 4001427	C1821	SUPPLY/IMPLANTS	"$38,761.00"	Outpatient	"$19,380.50"	Not Applicable	"$21,202.27"	"$25,853.59"	"$15,504.40"	Not Applicable	"$13,566.35"	"$27,132.70"	"$13,566.35"	"$27,132.70"
BODY BROACHED 60MM ARCOS E HI OFST HIP TI MDLR FEM REV SYS 11301115	C1776	SUPPLY/IMPLANTS	"$38,740.00"	Outpatient	"$19,370.00"	Not Applicable	"$21,190.78"	"$25,839.58"	"$15,496.00"	Not Applicable	"$13,559.00"	"$27,118.00"	"$13,559.00"	"$27,118.00"
SPCR SPNL 27MMX13MM CPSTN CNTRL 0D PEEK INTRBD FS STRL LF 3991327	C1821	SUPPLY/IMPLANTS	"$38,735.00"	Outpatient	"$19,367.50"	Not Applicable	"$21,188.05"	"$25,836.25"	"$15,494.00"	Not Applicable	"$13,557.25"	"$27,114.50"	"$13,557.25"	"$27,114.50"
AV FISTULA ANGIOGRAM AND ANGIOPLASTY	36902	CARDIAC CATH LAB	"$38,690.00"	Outpatient	"$19,345.00"	"$10,228.46"	"$21,163.43"	"$25,806.23"	"$15,476.00"	"$7,310.00"	"$13,541.50"	"$27,083.00"	"$7,310.00"	"$27,083.00"
VLV AOR 34MM 25MM FRSTL BPRTH PRCN 3MM ROOT STRL FR995-25		STERILE SUPPLY	"$38,679.00"	Outpatient	"$19,339.50"	Not Applicable	"$21,157.41"	"$25,798.89"	"$15,471.60"	Not Applicable	"$13,537.65"	"$27,075.30"	"$13,537.65"	"$27,075.30"
LEAD PCNG 59CM ECRDM ETAK RLNC 4-ST 1 COIL PSV FX IMPL 282		STERILE SUPPLY	"$38,616.00"	Outpatient	"$19,308.00"	Not Applicable	"$21,122.95"	"$25,756.87"	"$15,446.40"	Not Applicable	"$13,515.60"	"$27,031.20"	"$13,515.60"	"$27,031.20"
LEAD PCNG 59CM ECRDM ETAK RLNC 4-ST 2 COIL DF-4 TRM CNCT 285		STERILE SUPPLY	"$38,616.00"	Outpatient	"$19,308.00"	Not Applicable	"$21,122.95"	"$25,756.87"	"$15,446.40"	Not Applicable	"$13,515.60"	"$27,031.20"	"$13,515.60"	"$27,031.20"
LEAD PCNG 64CM ECRDM ETAK RLNC 4 ST 2 COIL ACTFX CARDVRT 286		STERILE SUPPLY	"$38,616.00"	Outpatient	"$19,308.00"	Not Applicable	"$21,122.95"	"$25,756.87"	"$15,446.40"	Not Applicable	"$13,515.60"	"$27,031.20"	"$13,515.60"	"$27,031.20"
LEAD PCNG 59CM ECRDM ETAK RLNC 1 COIL ACT DF4 TRM CNCT 292		STERILE SUPPLY	"$38,616.00"	Outpatient	"$19,308.00"	Not Applicable	"$21,122.95"	"$25,756.87"	"$15,446.40"	Not Applicable	"$13,515.60"	"$27,031.20"	"$13,515.60"	"$27,031.20"
STEM FEM 8IN 13.5MM 12/14 SM STAT STRG TPR SOL POR 43MM HIP 157201136	C1776	SUPPLY/IMPLANTS	"$38,605.00"	Outpatient	"$19,302.50"	Not Applicable	"$21,116.94"	"$25,749.54"	"$15,442.00"	Not Applicable	"$13,511.75"	"$27,023.50"	"$13,511.75"	"$27,023.50"
INST FX RDC APL NS STRNL ZIPFIX 03.501.080		STERILE SUPPLY	"$38,584.00"	Outpatient	"$19,292.00"	Not Applicable	"$21,105.45"	"$25,735.53"	"$15,433.60"	Not Applicable	"$13,504.40"	"$27,008.80"	"$13,504.40"	"$27,008.80"
OCLR CV 4MM 22MM 32-36MM SPT 2 DISK SLF XPD RADOPQ BAND DLV 9-ASD-022		STERILE SUPPLY	"$38,470.00"	Outpatient	"$19,235.00"	Not Applicable	"$21,043.09"	"$25,659.49"	"$15,388.00"	Not Applicable	"$13,464.50"	"$26,929.00"	"$13,464.50"	"$26,929.00"
DEVICE  OCCLUDER 15MM SEPTAL 9-ASD-015	C1817	SUPPLY/IMPLANTS	"$38,460.00"	Outpatient	"$19,230.00"	Not Applicable	"$21,037.62"	"$25,652.82"	"$15,384.00"	Not Applicable	"$13,461.00"	"$26,922.00"	"$13,461.00"	"$26,922.00"
DEVICE  30MM SEPTAL OCCLUDER 9-ASD-030	C1817	SUPPLY/IMPLANTS	"$38,460.00"	Outpatient	"$19,230.00"	Not Applicable	"$21,037.62"	"$25,652.82"	"$15,384.00"	Not Applicable	"$13,461.00"	"$26,922.00"	"$13,461.00"	"$26,922.00"
DEVISE 32MM SEPTAL OCCLUDER 9-ASD-032	C1817	SUPPLY/IMPLANTS	"$38,460.00"	Outpatient	"$19,230.00"	Not Applicable	"$21,037.62"	"$25,652.82"	"$15,384.00"	Not Applicable	"$13,461.00"	"$26,922.00"	"$13,461.00"	"$26,922.00"
DEVICE 12MM SEPTAL OCCLUDER 9-ASD-012	C1817	SUPPLY/IMPLANTS	"$38,430.00"	Outpatient	"$19,215.00"	Not Applicable	"$21,021.21"	"$25,632.81"	"$15,372.00"	Not Applicable	"$13,450.50"	"$26,901.00"	"$13,450.50"	"$26,901.00"
STEM HUM 122MM 10MM CMPRH PPS SHLDR 12-113560	C1776	SUPPLY/IMPLANTS	"$38,336.00"	Outpatient	"$19,168.00"	Not Applicable	"$20,969.79"	"$25,570.11"	"$15,334.40"	Not Applicable	"$13,417.60"	"$26,835.20"	"$13,417.60"	"$26,835.20"
PLT 2.5MM 2 ANG LG TI RECON MATRIXMANDIBLE BN NS PSPC SD449.514B	C1713	SUPPLY/IMPLANTS	"$38,321.00"	Outpatient	"$19,160.50"	"$1,365.15"	"$20,961.59"	"$25,560.11"	"$15,328.40"	Not Applicable	"$13,412.35"	"$26,824.70"	"$1,365.15"	"$26,824.70"
STEM HUM 128MM 13MM PRFT REUNION SHLDR STRL 5569-P-2013	C1776	SUPPLY/IMPLANTS	"$38,309.00"	Outpatient	"$19,154.50"	Not Applicable	"$20,955.02"	"$25,552.10"	"$15,323.60"	Not Applicable	"$13,408.15"	"$26,816.30"	"$13,408.15"	"$26,816.30"
STEM FEM 130MM 7.4MM 127D 7 41.5MM OFST SCRFT ADV PUREFIX TI 1601-07127	C1776	SUPPLY/IMPLANTS	"$38,144.00"	Outpatient	"$19,072.00"	Not Applicable	"$20,864.77"	"$25,442.05"	"$15,257.60"	Not Applicable	"$13,350.40"	"$26,700.80"	"$13,350.40"	"$26,700.80"
00002-7678-01 - ramucirumab 10 mg/mL Soln	J9308	PHARMACY	"$32,096.00"	Outpatient	"$16,048.00"	$63.45	"$20,862.40"	"$21,408.03"	"$12,838.40"	Not Applicable	"$11,233.60"	"$22,467.20"	$63.45	"$22,467.20"
STEM FEM 127D 11 SCRFT HIP PRFT ADV 1601-11127	C1776	SUPPLY/IMPLANTS	"$38,134.00"	Outpatient	"$19,067.00"	Not Applicable	"$20,859.30"	"$25,435.38"	"$15,253.60"	Not Applicable	"$13,346.90"	"$26,693.80"	"$13,346.90"	"$26,693.80"
STEM FEM 130MM 7.4MM 132D 7 37.5MM SCRFT PUREFIX TI PLSM 1601-07132	C1776	SUPPLY/IMPLANTS	"$38,096.00"	Outpatient	"$19,048.00"	Not Applicable	"$20,838.51"	"$25,410.03"	"$15,238.40"	Not Applicable	"$13,333.60"	"$26,667.20"	"$13,333.60"	"$26,667.20"
HNG XTRNFX DFS ANG KN LT KT STD FXTR SYS NS LF DISP 90110	C1713	SUPPLY/IMPLANTS	"$37,994.00"	Outpatient	"$18,997.00"	"$1,365.15"	"$20,782.72"	"$25,342.00"	"$15,197.60"	Not Applicable	"$13,297.90"	"$26,595.80"	"$1,365.15"	"$26,595.80"
SET XTRNFX RT KN ANGL HNG 90115	C1713	SUPPLY/IMPLANTS	"$37,994.00"	Outpatient	"$18,997.00"	"$1,365.15"	"$20,782.72"	"$25,342.00"	"$15,197.60"	Not Applicable	"$13,297.90"	"$26,595.80"	"$1,365.15"	"$26,595.80"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.401	C1713	SUPPLY/IMPLANTS	"$37,871.00"	Outpatient	"$18,935.50"	"$1,365.15"	"$20,715.44"	"$25,259.96"	"$15,148.40"	Not Applicable	"$13,254.85"	"$26,509.70"	"$1,365.15"	"$26,509.70"
IMPL CRNL PEEK-OPTM PTSPC NS SD800.454	C1713	SUPPLY/IMPLANTS	"$37,871.00"	Outpatient	"$18,935.50"	"$1,365.15"	"$20,715.44"	"$25,259.96"	"$15,148.40"	Not Applicable	"$13,254.85"	"$26,509.70"	"$1,365.15"	"$26,509.70"
LEAD KIT - DBS 39285-65	C1778	SUPPLY/IMPLANTS	"$37,794.00"	Outpatient	"$18,897.00"	Not Applicable	"$20,673.32"	"$25,208.60"	"$15,117.60"	Not Applicable	"$13,227.90"	"$26,455.80"	"$13,227.90"	"$26,455.80"
PACEMAKER CARDIAC QUADRA ALLURE MP 15 ML PULSE GENERATOR RES PM3562	C2621	PACE MAKER	"$37,760.00"	Outpatient	"$18,880.00"	Not Applicable	"$20,654.72"	"$25,185.92"	"$15,104.00"	Not Applicable	"$13,216.00"	"$26,432.00"	"$13,216.00"	"$26,432.00"
SPCR SPNL 25X11X14MM AVS UNILIF 0D WDG NOSE PEEK-OPTM HLW 48395140	C1821	SUPPLY/IMPLANTS	"$37,745.00"	Outpatient	"$18,872.50"	Not Applicable	"$20,646.52"	"$25,175.92"	"$15,098.00"	Not Applicable	"$13,210.75"	"$26,421.50"	"$13,210.75"	"$26,421.50"
GFT SFT TIS CRYOARTERY FEM POPLT ART R020	C1768	SUPPLY/IMPLANTS	"$37,745.00"	Outpatient	"$18,872.50"	Not Applicable	"$20,646.52"	"$25,175.92"	"$15,098.00"	Not Applicable	"$13,210.75"	"$26,421.50"	"$13,210.75"	"$26,421.50"
GFT SFT TIS 20-80+ CM 3-6MM CRYOVEIN SV EXC RST V010	C1768	SUPPLY/IMPLANTS	"$37,745.00"	Outpatient	"$18,872.50"	Not Applicable	"$20,646.52"	"$25,175.92"	"$15,098.00"	Not Applicable	"$13,210.75"	"$26,421.50"	"$13,210.75"	"$26,421.50"
PCMKR PROMRI ELUNA DR-T LD CLLR HOME MNTR SYS CRD 405430	C1785	PACE MAKER	"$37,738.00"	Outpatient	"$18,869.00"	Not Applicable	"$20,642.69"	"$25,171.25"	"$15,095.20"	Not Applicable	"$13,208.30"	"$26,416.60"	"$13,208.30"	"$26,416.60"
VLV MTRL 27MM CRP-ED PRIMNT MG BPRTH HRT 7300TFX27	C9354	SUPPLY/IMPLANTS	"$37,727.00"	Outpatient	"$18,863.50"	$20.52	"$20,636.67"	"$25,163.91"	"$15,090.80"	Not Applicable	"$13,204.45"	"$26,408.90"	$20.52	"$26,408.90"
VLV MTRL 29MM CRP-ED PRIMNT MAGNA BPRTH EASE HRT 7300TFX29MM	C9354	SUPPLY/IMPLANTS	"$37,727.00"	Outpatient	"$18,863.50"	$20.52	"$20,636.67"	"$25,163.91"	"$15,090.80"	Not Applicable	"$13,204.45"	"$26,408.90"	$20.52	"$26,408.90"
VLV MTRL 31MM CRP-ED PRIMNT MAGNA BPRTH EASE HRT 7300TFX31MM	C9354	SUPPLY/IMPLANTS	"$37,727.00"	Outpatient	"$18,863.50"	$20.52	"$20,636.67"	"$25,163.91"	"$15,090.80"	Not Applicable	"$13,204.45"	"$26,408.90"	$20.52	"$26,408.90"
VLV MTRL 33MM CRP-ED PRIMNT MAGNA BPRTH EASE HRT 7300TFX33MM	C9354	SUPPLY/IMPLANTS	"$37,727.00"	Outpatient	"$18,863.50"	$20.52	"$20,636.67"	"$25,163.91"	"$15,090.80"	Not Applicable	"$13,204.45"	"$26,408.90"	$20.52	"$26,408.90"
VLV MTRL 25MM CRP-ED PRIMNT MAGNA BPRTH EASE HRT 7300TFX25MM		SUPPLY/IMPLANTS	"$37,727.00"	Outpatient	"$18,863.50"	Not Applicable	"$20,636.67"	"$25,163.91"	"$15,090.80"	Not Applicable	"$13,204.45"	"$26,408.90"	"$13,204.45"	"$26,408.90"
CAGE SPINAL GIZA TITANIUM 7 D 10 D LORDOTIC H23-32 MM OD14 MM THORACOLUMBAR FIX INFERIOR ENDPLATE HO	C1821	SUPPLY/IMPLANTS	"$37,721.00"	Outpatient	"$18,860.50"	Not Applicable	"$20,633.39"	"$25,159.91"	"$15,088.40"	Not Applicable	"$13,202.35"	"$26,404.70"	"$13,202.35"	"$26,404.70"
CAGE SPINAL VLIFT TITANIUM H25 MM OD18 MM NONSTERILE LATEX F 48291825	C1821	SUPPLY/IMPLANTS	"$37,721.00"	Outpatient	"$18,860.50"	Not Applicable	"$20,633.39"	"$25,159.91"	"$15,088.40"	Not Applicable	"$13,202.35"	"$26,404.70"	"$13,202.35"	"$26,404.70"
AGE SPINAL INCORPORATE PEEK 10 D L12 MM X W14 MM X H42 MM TH 104-1-14124210	C1821	SUPPLY/IMPLANTS	"$37,717.00"	Outpatient	"$18,858.50"	Not Applicable	"$20,631.20"	"$25,157.24"	"$15,086.80"	Not Applicable	"$13,200.95"	"$26,401.90"	"$13,200.95"	"$26,401.90"
CAGE SPINAL INCORPORATE PEEK 0 D L12 MM X W14 MM X H50 MM TH 104-1-1412500	C1821	SUPPLY/IMPLANTS	"$37,717.00"	Outpatient	"$18,858.50"	Not Applicable	"$20,631.20"	"$25,157.24"	"$15,086.80"	Not Applicable	"$13,200.95"	"$26,401.90"	"$13,200.95"	"$26,401.90"
INCORPORATE VBR IMPLANT 14 W X 12 L X 38 H MM 10 DEGREE LORD 104-1-14123810	C1821	SUPPLY/IMPLANTS	"$37,717.00"	Outpatient	"$18,858.50"	Not Applicable	"$20,631.20"	"$25,157.24"	"$15,086.80"	Not Applicable	"$13,200.95"	"$26,401.90"	"$13,200.95"	"$26,401.90"
INCORPORATE VBR IMPLANT 14 W X 12 L X 38 H MM PARALLEL 104-1-141238	C1821	SUPPLY/IMPLANTS	"$37,717.00"	Outpatient	"$18,858.50"	Not Applicable	"$20,631.20"	"$25,157.24"	"$15,086.80"	Not Applicable	"$13,200.95"	"$26,401.90"	"$13,200.95"	"$26,401.90"
END CAP SPNL 21-27MM 18MM X-COR 2 TI ATLCK NS 7180027A	C1713	SUPPLY/IMPLANTS	"$37,716.00"	Outpatient	"$18,858.00"	"$1,365.15"	"$20,630.65"	"$25,156.57"	"$15,086.40"	Not Applicable	"$13,200.60"	"$26,401.20"	"$1,365.15"	"$26,401.20"
END CAP SPNL 28-41MM 18MM X-COR 2 TI ATLCK NS 7180041A	C1713	SUPPLY/IMPLANTS	"$37,716.00"	Outpatient	"$18,858.00"	"$1,365.15"	"$20,630.65"	"$25,156.57"	"$15,086.40"	Not Applicable	"$13,200.60"	"$26,401.20"	"$1,365.15"	"$26,401.20"
CAGE SPNL 32MM 22MM VLIFT TI LMBR INTRBD FS NS LF 48292232	C1821	SUPPLY/IMPLANTS	"$37,716.00"	Outpatient	"$18,858.00"	Not Applicable	"$20,630.65"	"$25,156.57"	"$15,086.40"	Not Applicable	"$13,200.60"	"$26,401.20"	"$13,200.60"	"$26,401.20"
PCMKR 3V ENTOVIS DR-T 2 CHMBR IS1 CNCT UNPLR/BP PACE 365 463	C1785	PACE MAKER	"$37,709.00"	Outpatient	"$18,854.50"	Not Applicable	"$20,626.82"	"$25,151.90"	"$15,083.60"	Not Applicable	"$13,198.15"	"$26,396.30"	"$13,198.15"	"$26,396.30"
SPCR SPNL 45X20X11MM TRANSCONTINENTAL MPEEK 6D LRDTC LAT 375.281	C1821	SUPPLY/IMPLANTS	"$37,709.00"	Outpatient	"$18,854.50"	Not Applicable	"$20,626.82"	"$25,151.90"	"$15,083.60"	Not Applicable	"$13,198.15"	"$26,396.30"	"$13,198.15"	"$26,396.30"
SPCR SPNL 45X20X13MM TRANSCONTINENTAL MPEEK LAT LMBR INTRBD 375.233	C1821	SUPPLY/IMPLANTS	"$37,709.00"	Outpatient	"$18,854.50"	Not Applicable	"$20,626.82"	"$25,151.90"	"$15,083.60"	Not Applicable	"$13,198.15"	"$26,396.30"	"$13,198.15"	"$26,396.30"
SPCR SPNL 55X20X9MM TRANSCONTINENTAL MPEEK 6D LRDTC LAT LMBR 375.479	C1821	SUPPLY/IMPLANTS	"$37,709.00"	Outpatient	"$18,854.50"	Not Applicable	"$20,626.82"	"$25,151.90"	"$15,083.60"	Not Applicable	"$13,198.15"	"$26,396.30"	"$13,198.15"	"$26,396.30"
SPCR SPNL 45X20X13MM TRANSCONTINENTAL MPEEK 6D LRDTC LAT 375.283	C1821	SUPPLY/IMPLANTS	"$37,709.00"	Outpatient	"$18,854.50"	Not Applicable	"$20,626.82"	"$25,151.90"	"$15,083.60"	Not Applicable	"$13,198.15"	"$26,396.30"	"$13,198.15"	"$26,396.30"
64406-0008-01 - natalizumab 300 mg / 15 mL Injection	J2323	PHARMACY	"$37,700.00"	Outpatient	"$18,850.00"	$22.97	"$20,621.90"	"$25,145.90"	"$15,080.00"	Not Applicable	"$13,195.00"	"$26,390.00"	$22.97	"$26,390.00"
CAGE SPINAL INCORPORATE PEEK 10 D LORDOTIC L12 MM X W14 MM X 104-1-14121410	C1821	SUPPLY/IMPLANTS	"$37,677.00"	Outpatient	"$18,838.50"	Not Applicable	"$20,609.32"	"$25,130.56"	"$15,070.80"	Not Applicable	"$13,186.95"	"$26,373.90"	"$13,186.95"	"$26,373.90"
PROS PENL TTN CLPLST LCK-OUT 11CM TCH NAR BS INFL FLD FIL EN2811	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 14CM TCH NAR BS INFL FLD FIL EN2814	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 16CM PMP SET INFL FLD FIL SFT ES2816	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 18CM PMP SET INFL FLD FIL SFT ES2818	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 20CM PMP SET INFL FLD FIL SFT ES2820	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 22CM PMP SET INFL FLD FIL SFT ES2822	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 11CM TCH NAR BS INFL FLD FIL EN2911	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 14CM TCH NAR BS INFL FLD FIL EN2914	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN CLPLST LCK-OUT 16CM PMP SET INFL FLD FIL SFT ES2916	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
PROS PENL TTN LCK-OUT PMP SET INFLAT SLF CNTN FLD FIL SCRT ES2920	C1813	SUPPLY/IMPLANTS	"$37,589.00"	Outpatient	"$18,794.50"	Not Applicable	"$20,561.18"	"$25,071.86"	"$15,035.60"	Not Applicable	"$13,156.15"	"$26,312.30"	"$13,156.15"	"$26,312.30"
STEM HUM 8MM CMNT REUNION SHLDR TL ARTHPL SYS 5569-C-2008	C1776	SUPPLY/IMPLANTS	"$37,552.00"	Outpatient	"$18,776.00"	Not Applicable	"$20,540.94"	"$25,047.18"	"$15,020.80"	Not Applicable	"$13,143.20"	"$26,286.40"	"$13,143.20"	"$26,286.40"
STEM HUM 17MM PRFT REUNION SHLDR TL ARTHPL SYS 5569-P-2017	C1776	SUPPLY/IMPLANTS	"$37,552.00"	Outpatient	"$18,776.00"	Not Applicable	"$20,540.94"	"$25,047.18"	"$15,020.80"	Not Applicable	"$13,143.20"	"$26,286.40"	"$13,143.20"	"$26,286.40"
STEM HUM 120MM 10MM REUNION HA SHLDR R5351-4510	C1776	SUPPLY/IMPLANTS	"$37,552.00"	Outpatient	"$18,776.00"	Not Applicable	"$20,540.94"	"$25,047.18"	"$15,020.80"	Not Applicable	"$13,143.20"	"$26,286.40"	"$13,143.20"	"$26,286.40"
Remove Replace PM Gen Single Lead	33227	CARDIAC CATH LAB	"$37,545.00"	Outpatient	"$18,772.50"	"$33,003.25"	"$20,537.12"	"$1,592.00"	"$15,018.00"	"$8,681.00"	"$13,140.75"	"$26,281.50"	"$1,592.00"	"$33,003.25"
PCMKR 8MM ADVISA DR MRI SURESCAN 2 CHMBR DGT TI PU SIL RBR A2DR01	C1785	PACE MAKER	"$37,445.00"	Outpatient	"$18,722.50"	Not Applicable	"$20,482.42"	"$24,975.82"	"$14,978.00"	Not Applicable	"$13,105.75"	"$26,211.50"	"$13,105.75"	"$26,211.50"
Right Heart Cath Implant Wireless Pressure Sensor	33289	CARDIAC CATH LAB	"$34,447.00"	Outpatient	"$17,223.50"	"$62,196.48"	"$20,461.52"	"$22,976.15"	"$13,778.80"	"$23,583.00"	"$12,056.45"	"$24,112.90"	"$12,056.45"	"$62,196.48"
CAGE SPINAL GIZA TITANIUM 7 D 10 48291437S	C1821	SUPPLY/IMPLANTS	"$37,365.00"	Outpatient	"$18,682.50"	Not Applicable	"$20,438.66"	"$24,922.46"	"$14,946.00"	Not Applicable	"$13,077.75"	"$26,155.50"	"$13,077.75"	"$26,155.50"
SET INST STD HUM NCB 237010000	C1713	SUPPLY/IMPLANTS	"$37,341.00"	Outpatient	"$18,670.50"	"$1,365.15"	"$20,425.53"	"$24,906.45"	"$14,936.40"	Not Applicable	"$13,069.35"	"$26,138.70"	"$1,365.15"	"$26,138.70"
SPCR SPNL 12X21MM FORTIFY 12MM NS LF 151.052	C1821	SUPPLY/IMPLANTS	"$37,313.00"	Outpatient	"$18,656.50"	Not Applicable	"$20,410.21"	"$24,887.77"	"$14,925.20"	Not Applicable	"$13,059.55"	"$26,119.10"	"$13,059.55"	"$26,119.10"
BODY CONE HIP FEM B STD OFST 60MM ARCOS TI STRL MDLR REV SYS 11301302	C1776	SUPPLY/IMPLANTS	"$37,250.00"	Outpatient	"$18,625.00"	Not Applicable	"$20,375.75"	"$24,845.75"	"$14,900.00"	Not Applicable	"$13,037.50"	"$26,075.00"	"$13,037.50"	"$26,075.00"
BODY CONE HIP FEM A STD OFST 60MM ARCOS TI STRL MDLR REV SYS 11301301	C1776	SUPPLY/IMPLANTS	"$37,250.00"	Outpatient	"$18,625.00"	Not Applicable	"$20,375.75"	"$24,845.75"	"$14,900.00"	Not Applicable	"$13,037.50"	"$26,075.00"	"$13,037.50"	"$26,075.00"
PCMKR THK6MM ZPHR XL DR 2 CHMBR IS-1 CNCT 52X44MM CRD 11CC 5826	C1785	PACE MAKER	"$37,204.00"	Outpatient	"$18,602.00"	Not Applicable	"$20,350.59"	"$24,815.07"	"$14,881.60"	Not Applicable	"$13,021.40"	"$26,042.80"	"$13,021.40"	"$26,042.80"
PCMKR REVO MRI SURESCAN IMPL PLS GNTR CRD 12.7CC 21.5GM RVDR01	C1785	PACE MAKER	"$37,129.00"	Outpatient	"$18,564.50"	Not Applicable	"$20,309.56"	"$24,765.04"	"$14,851.60"	Not Applicable	"$12,995.15"	"$25,990.30"	"$12,995.15"	"$25,990.30"
CAGE SPINAL CAPRI 7 D L12 MM X W14 MM X H27 MM STERILE LATEX 7501-21427L7-G2	C1821	SUPPLY/IMPLANTS	"$37,069.00"	Outpatient	"$18,534.50"	Not Applicable	"$20,276.74"	"$24,725.02"	"$14,827.60"	Not Applicable	"$12,974.15"	"$25,948.30"	"$12,974.15"	"$25,948.30"
69794-0203-01 - burosumab 20 mg/mL Soln	J0584	PHARMACY	"$37,053.00"	Outpatient	"$18,526.50"	$348.84	"$20,267.99"	"$24,714.35"	"$14,821.20"	Not Applicable	"$12,968.55"	"$25,937.10"	$348.84	"$25,937.10"
OGEN MESH CATH 30CM LEADDETACH 10-1328M		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
STM BN STRG CTHD FUSED CNCT 10-1318		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
STM BN OSTGN SPNE TI SIL IMPL WO MESH STRG 10-1320		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
STM BN OSTGN SPF SPNE MESH CTHD DTCH 10-1320M		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
STM BN OSTGN MN SPNE LD 2 MESH CTHD 40ML 10-1322M		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
STM BN 30CM STRG LD 2 CTHD 10-1322S		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
STM BN OSTGN MN 10-1328S		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
STM BN OSTGN MN STRG SPNE 2 CTHD 40ML 10-1348S		STERILE SUPPLY	"$36,915.00"	Outpatient	"$18,457.50"	Not Applicable	"$20,192.51"	"$24,622.31"	"$14,766.00"	Not Applicable	"$12,920.25"	"$25,840.50"	"$12,920.25"	"$25,840.50"
GD TLL HNDL TRGT SRG TIB NTR NL 249000513	C1713	SUPPLY/IMPLANTS	"$36,862.00"	Outpatient	"$18,431.00"	"$1,365.15"	"$20,163.51"	"$24,586.95"	"$14,744.80"	Not Applicable	"$12,901.70"	"$25,803.40"	"$1,365.15"	"$25,803.40"
Transluminal Peripheral Atherectomy Abd Aorta	0236T	DX X-RAY/ANGIO	"$36,851.00"	Outpatient	"$18,425.50"	"$31,950.11"	"$20,157.50"	"$1,592.00"	"$14,740.40"	"$8,681.00"	"$12,897.85"	"$25,795.70"	"$1,592.00"	"$31,950.11"
TRAY INST FEM NL ANTGRD 14-442001	C1713	SUPPLY/IMPLANTS	"$36,822.00"	Outpatient	"$18,411.00"	"$1,365.15"	"$20,141.63"	"$24,560.27"	"$14,728.80"	Not Applicable	"$12,887.70"	"$25,775.40"	"$1,365.15"	"$25,775.40"
TRAY STRL PHNX RTRGD INST FEM NL 14-444001		STERILE SUPPLY	"$36,822.00"	Outpatient	"$18,411.00"	Not Applicable	"$20,141.63"	"$24,560.27"	"$14,728.80"	Not Applicable	"$12,887.70"	"$25,775.40"	"$12,887.70"	"$25,775.40"
PACEMAKER ADVANTIO SR (1 LD) 8A32	C1786	PACE MAKER	"$36,758.00"	Outpatient	"$18,379.00"	Not Applicable	"$20,106.63"	"$24,517.59"	"$14,703.20"	Not Applicable	"$12,865.30"	"$25,730.60"	"$12,865.30"	"$25,730.60"
CAGE SPINAL GIZA TITANIUM 5 D 8 D LORDOTIC H18-22 MM OD14 MM 48291485S	C1821	SUPPLY/IMPLANTS	"$36,740.00"	Outpatient	"$18,370.00"	Not Applicable	"$20,096.78"	"$24,505.58"	"$14,696.00"	Not Applicable	"$12,859.00"	"$25,718.00"	"$12,859.00"	"$25,718.00"
PLT 2MM ANG MNDB LT TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.503	C1713	SUPPLY/IMPLANTS	"$36,700.00"	Outpatient	"$18,350.00"	"$1,365.15"	"$20,074.90"	"$24,478.90"	"$14,680.00"	Not Applicable	"$12,845.00"	"$25,690.00"	"$1,365.15"	"$25,690.00"
PLT 2MM ANG RT CRNMXF TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.504	C1713	SUPPLY/IMPLANTS	"$36,700.00"	Outpatient	"$18,350.00"	"$1,365.15"	"$20,074.90"	"$24,478.90"	"$14,680.00"	Not Applicable	"$12,845.00"	"$25,690.00"	"$1,365.15"	"$25,690.00"
COMPONENT FEMORAL SIZE 8 COBALT CHROMIUM LEFT TOTAL STABILIZ 5512-F-801	C1776	SUPPLY/IMPLANTS	"$36,622.00"	Outpatient	"$18,311.00"	Not Applicable	"$20,032.23"	"$24,426.87"	"$14,648.80"	Not Applicable	"$12,817.70"	"$25,635.40"	"$12,817.70"	"$25,635.40"
Carotid Angiography Cerebral Bilateral	36223	CARDIAC CATH LAB	"$36,597.00"	Outpatient	"$18,298.50"	"$11,105.17"	"$20,018.56"	"$24,410.20"	"$14,638.80"	"$7,310.00"	"$12,808.95"	"$25,617.90"	"$7,310.00"	"$25,617.90"
Angiography Carotid Internal Bilateral	36224	CARDIAC CATH LAB	"$36,597.00"	Outpatient	"$18,298.50"	"$18,161.90"	"$20,018.56"	"$24,410.20"	"$14,638.80"	"$7,310.00"	"$12,808.95"	"$25,617.90"	"$7,310.00"	"$25,617.90"
STEM FEM 102.5MM 133D 9 STD OFST TPR TPRLK MICROPLASTY PPS 51-106090	C1776	SUPPLY/IMPLANTS	"$36,520.00"	Outpatient	"$18,260.00"	Not Applicable	"$19,976.44"	"$24,358.84"	"$14,608.00"	Not Applicable	"$12,782.00"	"$25,564.00"	"$12,782.00"	"$25,564.00"
STEM HUM 55MM 7MM CMPRH POR MIC SHLDR RVRS SYS 113607	C1776	SUPPLY/IMPLANTS	"$36,506.00"	Outpatient	"$18,253.00"	Not Applicable	"$19,968.78"	"$24,349.50"	"$14,602.40"	Not Applicable	"$12,777.10"	"$25,554.20"	"$12,777.10"	"$25,554.20"
STEM HUM 122MM 8MM CMPRH PPS SHLDR 12-113558	C1776	SUPPLY/IMPLANTS	"$36,506.00"	Outpatient	"$18,253.00"	Not Applicable	"$19,968.78"	"$24,349.50"	"$14,602.40"	Not Applicable	"$12,777.10"	"$25,554.20"	"$12,777.10"	"$25,554.20"
STEM HUM 122MM 12MM CMPRH PPS SHLDR 12-113562	C1776	SUPPLY/IMPLANTS	"$36,506.00"	Outpatient	"$18,253.00"	Not Applicable	"$19,968.78"	"$24,349.50"	"$14,602.40"	Not Applicable	"$12,777.10"	"$25,554.20"	"$12,777.10"	"$25,554.20"
CK SRS - Single Fraction	G0339	RADIATION RX	"$36,476.00"	Outpatient	"$18,238.00"	"$16,050.98"	"$19,952.37"	"$1,592.00"	"$14,590.40"	"$16,448.00"	"$12,766.60"	"$25,533.20"	"$1,592.00"	"$25,533.20"
Translum Periph Atherect Brachiocephalic Each	0237T	CARDIAC CATH LAB	"$36,446.00"	Outpatient	"$18,223.00"	"$31,950.11"	"$19,935.96"	"$1,592.00"	"$14,578.40"	"$8,681.00"	"$12,756.10"	"$25,512.20"	"$1,592.00"	"$31,950.11"
Arthrectomy Open Perc Visceral Art Each Vessel	0235T	CARDIAC CATH LAB	"$36,446.00"	Outpatient	"$18,223.00"	Not Applicable	"$19,935.96"	"$1,592.00"	"$14,578.40"	"$1,563.00"	"$12,756.10"	"$25,512.20"	"$1,563.00"	"$25,512.20"
GFT SFT TIS REINF BIODESIGN 20CM HRN REPR G56580	C1763	SUPPLY/IMPLANTS	"$36,427.00"	Outpatient	"$18,213.50"	Not Applicable	"$19,925.57"	"$24,296.81"	"$14,570.80"	Not Applicable	"$12,749.45"	"$25,498.90"	"$12,749.45"	"$25,498.90"
PLT 2.8MM LT MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS PSPC SD449.517B	C1713	SUPPLY/IMPLANTS	"$36,399.00"	Outpatient	"$18,199.50"	"$1,365.15"	"$19,910.25"	"$24,278.13"	"$14,559.60"	Not Applicable	"$12,739.65"	"$25,479.30"	"$1,365.15"	"$25,479.30"
PLT 2.8MM ANG RT CRNMXF TI 7X23 HL RECON MATRIXMANDIBLE BN SD449.518B	C1713	SUPPLY/IMPLANTS	"$36,399.00"	Outpatient	"$18,199.50"	"$1,365.15"	"$19,910.25"	"$24,278.13"	"$14,559.60"	Not Applicable	"$12,739.65"	"$25,479.30"	"$1,365.15"	"$25,479.30"
TCAT INST/RPL PERM LDLS PCM RV W/IMG	33274	CARDIAC CATH LAB	"$36,395.00"	Outpatient	"$18,197.50"	"$32,548.47"	"$19,908.07"	"$24,275.47"	"$14,558.00"	"$15,995.00"	"$12,738.25"	"$25,476.50"	"$12,738.25"	"$32,548.47"
60432-0834-60 - lindane top 1% Sha 60 ml	J3490	PHARMACY	"$36,378.00"	Outpatient	"$18,189.00"	Not Applicable	"$19,898.77"	"$24,264.13"	"$14,551.20"	Not Applicable	"$12,732.30"	"$25,464.60"	"$12,732.30"	"$25,464.60"
BODY CONE HIP FEM A HI OFST 50MM ARCOS TI STRL MDLR REV SYS 11-301310	C1776	SUPPLY/IMPLANTS	"$36,330.00"	Outpatient	"$18,165.00"	Not Applicable	"$19,872.51"	"$24,232.11"	"$14,532.00"	Not Applicable	"$12,715.50"	"$25,431.00"	"$12,715.50"	"$25,431.00"
PLT 2.5MM MNDB 2 ANG RECON MATRIXMANDIBLE BN PSPC SD449.513B	C1713	SUPPLY/IMPLANTS	"$36,312.00"	Outpatient	"$18,156.00"	"$1,365.15"	"$19,862.66"	"$24,220.10"	"$14,524.80"	Not Applicable	"$12,709.20"	"$25,418.40"	"$1,365.15"	"$25,418.40"
END CAP SPINAL X-CORE 2 TITANIUM H35-55 MM OD18 MM AUTOLOCK 7180055A	C1713	SUPPLY/IMPLANTS	"$36,308.00"	Outpatient	"$18,154.00"	"$1,365.15"	"$19,860.48"	"$24,217.44"	"$14,523.20"	Not Applicable	"$12,707.80"	"$25,415.60"	"$1,365.15"	"$25,415.60"
COMPONENT FEMORAL GMRS COCR SMALL L65 MM KNEE LEFT 6495-2-010	C1776	SUPPLY/IMPLANTS	"$36,270.00"	Outpatient	"$18,135.00"	Not Applicable	"$19,839.69"	"$24,192.09"	"$14,508.00"	Not Applicable	"$12,694.50"	"$25,389.00"	"$12,694.50"	"$25,389.00"
RADIOLUCENT FBAR 466182		STERILE SUPPLY	"$36,264.00"	Outpatient	"$18,132.00"	Not Applicable	"$19,836.41"	"$24,188.09"	"$14,505.60"	Not Applicable	"$12,692.40"	"$25,384.80"	"$12,692.40"	"$25,384.80"
CAGE SPNL 50X18X10MM CRNT XL PEEK RADOPQ TLIF NS LF 6910850		SUPPLY/IMPLANTS	"$36,162.00"	Outpatient	"$18,081.00"	Not Applicable	"$19,780.61"	"$24,120.05"	"$14,464.80"	Not Applicable	"$12,656.70"	"$25,313.40"	"$12,656.70"	"$25,313.40"
CAGE SPNL 45X18X10MM CRNT XL PEEK RADOPQ TLIF NS LF 6910845		SUPPLY/IMPLANTS	"$36,162.00"	Outpatient	"$18,081.00"	Not Applicable	"$19,780.61"	"$24,120.05"	"$14,464.80"	Not Applicable	"$12,656.70"	"$25,313.40"	"$12,656.70"	"$25,313.40"
LEAD NRSTM SPNL CORD 65CM 1.3MM SPC THK1.9MM CRV THN NAR 39286-65	C1778	SUPPLY/IMPLANTS	"$36,146.00"	Outpatient	"$18,073.00"	Not Applicable	"$19,771.86"	"$24,109.38"	"$14,458.40"	Not Applicable	"$12,651.10"	"$25,302.20"	"$12,651.10"	"$25,302.20"
VLV AOR 17.5MM 25MM MSC UL CNCH BPRTH STNT HLDR SW RING PRCN 305U225		SUPPLY/IMPLANTS	"$36,146.00"	Outpatient	"$18,073.00"	Not Applicable	"$19,771.86"	"$24,109.38"	"$14,458.40"	Not Applicable	"$12,651.10"	"$25,302.20"	"$12,651.10"	"$25,302.20"
VLV AOR 18.5MM 27MM MSC UL CNCH BPRTH STNT HLDR SW RING PRCN 305U227		SUPPLY/IMPLANTS	"$36,146.00"	Outpatient	"$18,073.00"	Not Applicable	"$19,771.86"	"$24,109.38"	"$14,458.40"	Not Applicable	"$12,651.10"	"$25,302.20"	"$12,651.10"	"$25,302.20"
VLV MTRL 25MM MSC CNCH 310C25		SUPPLY/IMPLANTS	"$36,146.00"	Outpatient	"$18,073.00"	Not Applicable	"$19,771.86"	"$24,109.38"	"$14,458.40"	Not Applicable	"$12,651.10"	"$25,302.20"	"$12,651.10"	"$25,302.20"
VLV MTRL 29MM 38MM 26MM MSC CNCH 20.5MM BIO STNT SCLP SW 310C29		SUPPLY/IMPLANTS	"$36,146.00"	Outpatient	"$18,073.00"	Not Applicable	"$19,771.86"	"$24,109.38"	"$14,458.40"	Not Applicable	"$12,651.10"	"$25,302.20"	"$12,651.10"	"$25,302.20"
VLV MTRL 31MM 41MM 28MM MSC CNCH 22MM BIO STNT SCLP SEWN 310C31		SUPPLY/IMPLANTS	"$36,146.00"	Outpatient	"$18,073.00"	Not Applicable	"$19,771.86"	"$24,109.38"	"$14,458.40"	Not Applicable	"$12,651.10"	"$25,302.20"	"$12,651.10"	"$25,302.20"
PROS PENL TTN CLPLST LCK-OUT 18CM PMP SET INFL FLD FIL SFT ES2918	C1813	SUPPLY/IMPLANTS	"$36,110.00"	Outpatient	"$18,055.00"	Not Applicable	"$19,752.17"	"$24,085.37"	"$14,444.00"	Not Applicable	"$12,638.50"	"$25,277.00"	"$12,638.50"	"$25,277.00"
PROS PENL TTN CLPLST LCK-OUT 22CM PMP SET INFL FLD FIL SFT ES2922	C1813	SUPPLY/IMPLANTS	"$36,110.00"	Outpatient	"$18,055.00"	Not Applicable	"$19,752.17"	"$24,085.37"	"$14,444.00"	Not Applicable	"$12,638.50"	"$25,277.00"	"$12,638.50"	"$25,277.00"
PROS PENL TTN LCK-OUT 16CM PMP SET SCRT BFLX SIL HDRPH LF 0D ESR916	C2622	SUPPLY/IMPLANTS	"$36,087.00"	Outpatient	"$18,043.50"	Not Applicable	"$19,739.59"	"$24,070.03"	"$14,434.80"	Not Applicable	"$12,630.45"	"$25,260.90"	"$12,630.45"	"$25,260.90"
PROS PENL TTN LCK-OUT 14CM PMP SET 1 TCH RELS INFL SFT MLD ESR914	C2622	SUPPLY/IMPLANTS	"$36,087.00"	Outpatient	"$18,043.50"	Not Applicable	"$19,739.59"	"$24,070.03"	"$14,434.80"	Not Applicable	"$12,630.45"	"$25,260.90"	"$12,630.45"	"$25,260.90"
PROS PENL TTN LCK-OUT 20CM PMP SET 1 TCH RELS INFL SFT MLD ESR920	C2622	SUPPLY/IMPLANTS	"$36,087.00"	Outpatient	"$18,043.50"	Not Applicable	"$19,739.59"	"$24,070.03"	"$14,434.80"	Not Applicable	"$12,630.45"	"$25,260.90"	"$12,630.45"	"$25,260.90"
PROS PENL TTN LCK-OUT 22CM PMP SET 1 TCH RELS INFL SFT MLD ESR922	C2622	SUPPLY/IMPLANTS	"$36,087.00"	Outpatient	"$18,043.50"	Not Applicable	"$19,739.59"	"$24,070.03"	"$14,434.80"	Not Applicable	"$12,630.45"	"$25,260.90"	"$12,630.45"	"$25,260.90"
PROS PENL TTN LCK-OUT 18CM PMP SET 1 TCH RELS INFL SFT MLD ESR918	C1813	SUPPLY/IMPLANTS	"$36,087.00"	Outpatient	"$18,043.50"	Not Applicable	"$19,739.59"	"$24,070.03"	"$14,434.80"	Not Applicable	"$12,630.45"	"$25,260.90"	"$12,630.45"	"$25,260.90"
DISC INTVRTB 14MM 7MM PSTG LP CSPN TI 6972470	C1713	SUPPLY/IMPLANTS	"$36,061.00"	Outpatient	"$18,030.50"	"$1,365.15"	"$19,725.37"	"$24,052.69"	"$14,424.40"	Not Applicable	"$12,621.35"	"$25,242.70"	"$1,365.15"	"$25,242.70"
DISC INTVRTB 16MM 7MM PSTG LP CSPN TI 6972670	C1713	SUPPLY/IMPLANTS	"$36,061.00"	Outpatient	"$18,030.50"	"$1,365.15"	"$19,725.37"	"$24,052.69"	"$14,424.40"	Not Applicable	"$12,621.35"	"$25,242.70"	"$1,365.15"	"$25,242.70"
DISC INTVRTB 16MM 6MM PSTG LP CSPN TI 6972660	C1713	SUPPLY/IMPLANTS	"$36,055.00"	Outpatient	"$18,027.50"	"$1,365.15"	"$19,722.09"	"$24,048.69"	"$14,422.00"	Not Applicable	"$12,619.25"	"$25,238.50"	"$1,365.15"	"$25,238.50"
CAGE SPNL 36X9.5-16MM ROI-A 14D LORDOSIS 27MM MEDIAN 5.24CC IR5245P	C1821	SUPPLY/IMPLANTS	"$36,012.00"	Outpatient	"$18,006.00"	Not Applicable	"$19,698.56"	"$24,020.00"	"$14,404.80"	Not Applicable	"$12,604.20"	"$25,208.40"	"$12,604.20"	"$25,208.40"
CAGE SPNL 20MM 18MM VLIFT TI LMBR INTRBD FS NS LF 48291820	C1821	SUPPLY/IMPLANTS	"$36,012.00"	Outpatient	"$18,006.00"	Not Applicable	"$19,698.56"	"$24,020.00"	"$14,404.80"	Not Applicable	"$12,604.20"	"$25,208.40"	"$12,604.20"	"$25,208.40"
CAGE SPNL 30X11.5-14MM ROI-A VERTEBRIDGE 6D LRDTC 27MM OBLQ IR 4226 P	C1821	SUPPLY/IMPLANTS	"$36,012.00"	Outpatient	"$18,006.00"	Not Applicable	"$19,698.56"	"$24,020.00"	"$14,404.80"	Not Applicable	"$12,604.20"	"$25,208.40"	"$12,604.20"	"$25,208.40"
CAGE SPNL 30X9.5-12MM ROI-A VERTEBRIDGE 6D LRDTC 27MM OBLQ IR 4224 P	C1821	SUPPLY/IMPLANTS	"$36,012.00"	Outpatient	"$18,006.00"	Not Applicable	"$19,698.56"	"$24,020.00"	"$14,404.80"	Not Applicable	"$12,604.20"	"$25,208.40"	"$12,604.20"	"$25,208.40"
LUMBAR SPACE LORDOTIC 12MM 25200-114-S	C1821	SUPPLY/IMPLANTS	"$36,012.00"	Outpatient	"$18,006.00"	Not Applicable	"$19,698.56"	"$24,020.00"	"$14,404.80"	Not Applicable	"$12,604.20"	"$25,208.40"	"$12,604.20"	"$25,208.40"
LUMBAR SPACE LORDOTIC 12MM 25200-110-S	C1821	SUPPLY/IMPLANTS	"$36,012.00"	Outpatient	"$18,006.00"	Not Applicable	"$19,698.56"	"$24,020.00"	"$14,404.80"	Not Applicable	"$12,604.20"	"$25,208.40"	"$12,604.20"	"$25,208.40"
STEM ULN 75MM NEXEL 4 RT 840002407	C1776	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 6 DEGREE 14 MM HEIGHT ASTS-MD0614	C9363	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	$38.51	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	$38.51	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 12 DEGREE 12 MM HEIGH ASTS-MD1212	C9363	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	$38.51	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	$38.51	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 6 DEGREE 12 MM HEIGHT ASTS-MD0612	C9363	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	$38.51	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	$38.51	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 12 DEGREE 14 MM HEIGH ASTS-MD1214	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 12 DEGREE 12 MM HEIGH ASTS-LG1212	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 6 DEGREE 10 MM HEIGHT ASTS-LG0610	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 6 DEGREE 8 MM HEIGHT ASTS-LG0608	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 6 DEGREE 16 MM HEIGHT ASTS-LG0616	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 12 DEGREE 8 MM HEIGHT ASTS-LG1208	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 12 DEGREE 10 MM HEIGH ASTS-LG1210	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 12 DEGREE 14 MM HEIGH ASTS-LG1214	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 12 DEGREE 16 MM HEIGH ASTS-LG1216	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIORF SPINE TRUSS SYSTEM 36 X 24 MM 6 DEGREE 8 MM HEIGHT ASTS-MD0608	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 6 DEGREE 10 MM HEIGHT ASTS-MD0610	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 6 DEGREE 16 MM HEIGHT ASTS-MD0616	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 12 DEGREE 8 MM HEIGHT ASTS-MD1208	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 12 DEGREE 10 MM HEIGH ASTS-MD1210	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 36 X 24 MM 12 DEGREE 16 MM HEIGH ASTS-MD1216	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 6 DEGREE 8 MM HEIGHT ASTS-SM0608	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 6 DEGREE 10 MM HEIGHT ASTS-SM0610	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 6 DEGREE 12 MM HEIGHT ASTS-SM0612	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 6 DEGREE 14 MM HEIGHT ASTS-SM0614	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 6 DEGREE 16 MM HEIGHT ASTS-SM0616	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 12 DEGREE 8 MM HEIGHT ASTS-SM1208	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 12 DEGREE 10 MM HEIGH ASTS-SM1210	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 12 DEGREE 12 MM HEIGH ASTS-SM1212	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 12 DEGREE 14 MM HEIGH ASTS-SM1214	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 32 X 21 MM 12 DEGREE 16 MM HEIGH ASTS-SM1216	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 32 X 21 MM 16 DE ASTS-SM1614	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 32 X 21 MM 16 DE ASTS-SM1616	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 32 X 21 MM 20 DE ASTS-SM2014	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 32 X 21 MM 20 DE ASTS-SM2016	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 32 X 21 MM 25 DE ASTS-SM2516	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 32 X 21 MM 25 DE ASTS-SM2518	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 36 X 24 MM 16 DE ASTS-MD1614	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 36 X 24 MM 16 DE ASTS-MD1616	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 36 X 24 MM 20 DE ASTS-MD2014	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 36 X 24 MM 20 DE ASTS-MD2016	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 36 X 24 MM 25 DE ASTS-MD2516	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 36 X 24 MM 25 DE ASTS-MD2518	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 40 X 27 MM 16 DE ASTS-LG1614	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 40 X 27 MM 16 DE ASTS-LG1616	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 40 X 27 MM 20 DE ASTS-LG2014	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 40 X 27 MM 20 DE ASTS-LG2016	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 40 X 27 MM 25 DE ASTS-LG2516	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  HYPER LORDOTIC 40 X 27 MM 25 DE ASTS-LG2518	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 32 X 21 MM 6 DEGREE ASTS-SM0610-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 32 X 21 MM 6 DEGREE ASTS-SM0612-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 32 X 21 MM 6 DEGREE ASTS-SM0614-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 32 X 21 MM 12 DEGRE ASTS-SM1210-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 32 X 21 MM 12 DEGRE ASTS-SM1212-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 32 X 21 MM 12 DEGRE ASTS-SM1214-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 36 X 24 MM 6 DEGREE ASTS-MD0610-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 36 X 24 MM 6 DEGREE ASTS-MD0612-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 36 X 24 MM 6 DEGREE ASTS-MD0614-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 36 X 24 MM 12 DEGRE ASTS-MD1210-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 36 X 24 MM 12 DEGRE ASTS-MD1212-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 36 X 24 MM 12 DEGRE ASTS-MD1214-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 40 X 27 MM 6 DEGREE ASTS-LG0610-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 40 X 27 MM 6 DEGREE ASTS-LG0612-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 40 X 27 MM 6 DEGREE ASTS-LG0614-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 40 X 27 MM 12 DEGRE ASTS-LG1210-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 40 X 27 MM 12 DEGRE ASTS-LG1212-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM  LOW PROFILE 40 X 27 MM 12 DEGRE ASTS-LG1214-LP	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
SPACER 4-WEB TRUSS LARGE 40 X2714 X10MM 6 DEG ASTS-LG-0610	C1821	SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 6 DEGREE 14 MM HEIGHT ASTS-LG0614		STERILE SUPPLY	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
ANTERIOR SPINE TRUSS SYSTEM 40 X 27 MM 6 DEGREE 12 MM HEIGHT ASTS-LG0612		STERILE SUPPLY	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
CAGE SPNL 34X24X12MM BRIGADE 12D TI NS LF 6951234		SUPPLY/IMPLANTS	"$36,002.00"	Outpatient	"$18,001.00"	Not Applicable	"$19,693.09"	"$24,013.33"	"$14,400.80"	Not Applicable	"$12,600.70"	"$25,201.40"	"$12,600.70"	"$25,201.40"
CAGE ALIFTITANIUM  MEDIUM 8MM 6 DEG ASTS-MD0608-T	C1821	SUPPLY/IMPLANTS	"$35,996.00"	Outpatient	"$17,998.00"	Not Applicable	"$19,689.81"	"$24,009.33"	"$14,398.40"	Not Applicable	"$12,598.60"	"$25,197.20"	"$12,598.60"	"$25,197.20"
CAGE SPNL 28X11X12MM 0D TRITANIUM PLIF STRL LF 48953120	C1821	SUPPLY/IMPLANTS	"$35,996.00"	Outpatient	"$17,998.00"	Not Applicable	"$19,689.81"	"$24,009.33"	"$14,398.40"	Not Applicable	"$12,598.60"	"$25,197.20"	"$12,598.60"	"$25,197.20"
CAGE SPNL 23X11X12MM 6D LRDTC TRITANIUM PLIF STRL LF 48951126	C1821	SUPPLY/IMPLANTS	"$35,996.00"	Outpatient	"$17,998.00"	Not Applicable	"$19,689.81"	"$24,009.33"	"$14,398.40"	Not Applicable	"$12,598.60"	"$25,197.20"	"$12,598.60"	"$25,197.20"
VLV MTRL 33MM 43MM 30MM MSC CNCH 23MM BIO STNT SCLP SEWN 310C33		SUPPLY/IMPLANTS	"$35,967.00"	Outpatient	"$17,983.50"	Not Applicable	"$19,673.95"	"$23,989.99"	"$14,386.80"	Not Applicable	"$12,588.45"	"$25,176.90"	"$12,588.45"	"$25,176.90"
COMPONENT FEMORAL GMRS STANDARD L65 MM KNEE LEFT STERILE 6495-2-030		SUPPLY/IMPLANTS	"$35,904.00"	Outpatient	"$17,952.00"	Not Applicable	"$19,639.49"	"$23,947.97"	"$14,361.60"	Not Applicable	"$12,566.40"	"$25,132.80"	"$12,566.40"	"$25,132.80"
CUFF URETHRAL AMS 800 INHIBIZONE L5.5 CM SPHINCTER OCCLUSIVE 72404133	C1815	SUPPLY/IMPLANTS	"$35,899.00"	Outpatient	"$17,949.50"	Not Applicable	"$19,636.75"	"$23,944.63"	"$14,359.60"	Not Applicable	"$12,564.65"	"$25,129.30"	"$12,564.65"	"$25,129.30"
TISSUE ALLODERM SELECT REGENERATIVE MATRIX CXL1519P	Q4116	SUPPLY/IMPLANTS	"$35,834.00"	Outpatient	"$17,917.00"	$34.22	"$19,601.20"	"$23,901.28"	"$14,333.60"	Not Applicable	"$12,541.90"	"$25,083.80"	$34.22	"$25,083.80"
VALVE SHUNT CODMAN HAKIM CYLINDRICAL PROGRAMMABLE STRAIGHT C 823115		STERILE SUPPLY	"$35,826.00"	Outpatient	"$17,913.00"	Not Applicable	"$19,596.82"	"$23,895.94"	"$14,330.40"	Not Applicable	"$12,539.10"	"$25,078.20"	"$12,539.10"	"$25,078.20"
PTCA Internal Mammary Revas	92938	CARDIAC CATH LAB	"$32,950.00"	Outpatient	"$16,475.00"	"$30,568.87"	"$19,572.30"	"$8,056.00"	"$13,180.00"	"$7,310.00"	"$11,532.50"	"$23,065.00"	"$7,310.00"	"$30,568.87"
Perc Card Stent Ath Angio	92934	CARDIAC CATH LAB	"$32,950.00"	Outpatient	"$16,475.00"	"$30,568.87"	"$19,572.30"	"$8,056.00"	"$13,180.00"	"$7,310.00"	"$11,532.50"	"$23,065.00"	"$7,310.00"	"$30,568.87"
64764-0300-20 - vedolizumab 300 mg Powd	J3380	PHARMACY	"$35,765.00"	Outpatient	"$17,882.50"	$21.93	"$19,563.46"	"$23,855.26"	"$14,306.00"	Not Applicable	"$12,517.75"	"$25,035.50"	$21.93	"$25,035.50"
SET INST STD FEM NCB 237030000	C1713	SUPPLY/IMPLANTS	"$35,757.00"	Outpatient	"$17,878.50"	"$1,365.15"	"$19,559.08"	"$23,849.92"	"$14,302.80"	Not Applicable	"$12,514.95"	"$25,029.90"	"$1,365.15"	"$25,029.90"
POST FX 40MM 6.5MM LOPRFL ACL PCL BCORT TI NS AR-1366NS-40	C1713	SUPPLY/IMPLANTS	"$35,723.00"	Outpatient	"$17,861.50"	"$1,365.15"	"$19,540.48"	"$23,827.24"	"$14,289.20"	Not Applicable	"$12,503.05"	"$25,006.10"	"$1,365.15"	"$25,006.10"
CMPNT FEM E 68X61.5MM KN RT STSCR CMNT REV LCCK OPTN NXGN 599401592	C1776	SUPPLY/IMPLANTS	"$35,686.00"	Outpatient	"$17,843.00"	Not Applicable	"$19,520.24"	"$23,802.56"	"$14,274.40"	Not Applicable	"$12,490.10"	"$24,980.20"	"$12,490.10"	"$24,980.20"
SPCR SPNL 26MMX12MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991226	C1821	SUPPLY/IMPLANTS	"$35,682.00"	Outpatient	"$17,841.00"	Not Applicable	"$19,518.05"	"$23,799.89"	"$14,272.80"	Not Applicable	"$12,488.70"	"$24,977.40"	"$12,488.70"	"$24,977.40"
SPCR SPNL 26MMX14MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991426	C1821	SUPPLY/IMPLANTS	"$35,682.00"	Outpatient	"$17,841.00"	Not Applicable	"$19,518.05"	"$23,799.89"	"$14,272.80"	Not Applicable	"$12,488.70"	"$24,977.40"	"$12,488.70"	"$24,977.40"
SPCR SPNL 26MMX11MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991126	C1821	SUPPLY/IMPLANTS	"$35,682.00"	Outpatient	"$17,841.00"	Not Applicable	"$19,518.05"	"$23,799.89"	"$14,272.80"	Not Applicable	"$12,488.70"	"$24,977.40"	"$12,488.70"	"$24,977.40"
PLT 2.5MM ANG MNDB TI BN NS SD480.100	C1713	SUPPLY/IMPLANTS	"$35,658.00"	Outpatient	"$17,829.00"	"$1,365.15"	"$19,504.93"	"$23,783.89"	"$14,263.20"	Not Applicable	"$12,480.30"	"$24,960.60"	"$1,365.15"	"$24,960.60"
GFT SNTH TISS CA PHOS CA SLF 15CC PRO-DNS INJ BCMPS RGNRT 87SR-CK15		STERILE SUPPLY	"$35,582.00"	Outpatient	"$17,791.00"	Not Applicable	"$19,463.35"	"$23,733.19"	"$14,232.80"	Not Applicable	"$12,453.70"	"$24,907.40"	"$12,453.70"	"$24,907.40"
PCMKR .75CM ACLD MRI LTD NXT PACESAFE EASYVIEW 2 CHMBR IS1 L331	C1785	PACE MAKER	"$35,573.00"	Outpatient	"$17,786.50"	Not Applicable	"$19,458.43"	"$23,727.19"	"$14,229.20"	Not Applicable	"$12,450.55"	"$24,901.10"	"$12,450.55"	"$24,901.10"
PCMKR .75CM ACLD 2 CHMBR RA RV IS1 CNCT 4.45X5.02CM CRD 13.7 L311	C1785	PACE MAKER	"$35,566.00"	Outpatient	"$17,783.00"	Not Applicable	"$19,454.60"	"$23,722.52"	"$14,226.40"	Not Applicable	"$12,448.10"	"$24,896.20"	"$12,448.10"	"$24,896.20"
PLT 2MM ANG PREBNT TI LCK 2 RECON MATRIXMANDIBLE BN NS PRPC SD449.507B	C1713	SUPPLY/IMPLANTS	"$35,561.00"	Outpatient	"$17,780.50"	"$1,365.15"	"$19,451.87"	"$23,719.19"	"$14,224.40"	Not Applicable	"$12,446.35"	"$24,892.70"	"$1,365.15"	"$24,892.70"
SPCR SPNL 26MMX10MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991026	C1821	SUPPLY/IMPLANTS	"$35,528.00"	Outpatient	"$17,764.00"	Not Applicable	"$19,433.82"	"$23,697.18"	"$14,211.20"	Not Applicable	"$12,434.80"	"$24,869.60"	"$12,434.80"	"$24,869.60"
SPCR SPNL 26MMX13MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991326	C1821	SUPPLY/IMPLANTS	"$35,505.00"	Outpatient	"$17,752.50"	Not Applicable	"$19,421.24"	"$23,681.84"	"$14,202.00"	Not Applicable	"$12,426.75"	"$24,853.50"	"$12,426.75"	"$24,853.50"
CUFF URTH A800 OCL INHBZN SIL-EL 4.5CM SPHNCR 72404131	C1815	SUPPLY/IMPLANTS	"$35,504.00"	Outpatient	"$17,752.00"	Not Applicable	"$19,420.69"	"$23,681.17"	"$14,201.60"	Not Applicable	"$12,426.40"	"$24,852.80"	"$12,426.40"	"$24,852.80"
CMPNT FEM 6 KN RT TL STAB TRTHLN COCR 5512-F-602		SUPPLY/IMPLANTS	"$35,500.00"	Outpatient	"$17,750.00"	Not Applicable	"$19,418.50"	"$23,678.50"	"$14,200.00"	Not Applicable	"$12,425.00"	"$24,850.00"	"$12,425.00"	"$24,850.00"
Insertion/Change Pacemaker	33208	CARDIAC CATH LAB	"$35,490.00"	Outpatient	"$17,745.00"	"$24,898.20"	"$19,413.03"	"$1,592.00"	"$14,196.00"	"$12,306.00"	"$12,421.50"	"$24,843.00"	"$1,592.00"	"$24,898.20"
Insert/Replace Pacemaker Perm Ventricular	33207	CARDIAC CATH LAB	"$35,490.00"	Outpatient	"$17,745.00"	"$21,295.96"	"$19,413.03"	"$1,592.00"	"$14,196.00"	"$8,681.00"	"$12,421.50"	"$24,843.00"	"$1,592.00"	"$24,843.00"
Permanent Pacemaker Atrial Procedure	33206	CARDIAC CATH LAB	"$35,490.00"	Outpatient	"$17,745.00"	"$21,295.96"	"$19,413.03"	"$1,592.00"	"$14,196.00"	"$8,681.00"	"$12,421.50"	"$24,843.00"	"$1,592.00"	"$24,843.00"
CAGE SPNL 23X9X9MM CNCRD PRLL BLT NOSE CFRP RADOPQ PLIF TLIF 187823109	C1821	SUPPLY/IMPLANTS	"$35,448.00"	Outpatient	"$17,724.00"	Not Applicable	"$19,390.06"	"$23,643.82"	"$14,179.20"	Not Applicable	"$12,406.80"	"$24,813.60"	"$12,406.80"	"$24,813.60"
CMPNT FEM 7 KN RT TL STAB TRTHLN COCR 5512-F-702	C1776	SUPPLY/IMPLANTS	"$35,357.00"	Outpatient	"$17,678.50"	Not Applicable	"$19,340.28"	"$23,583.12"	"$14,142.80"	Not Applicable	"$12,374.95"	"$24,749.90"	"$12,374.95"	"$24,749.90"
DRVR HBRD SRG TROCH 27950		STERILE SUPPLY	"$35,329.00"	Outpatient	"$17,664.50"	Not Applicable	"$19,324.96"	"$23,564.44"	"$14,131.60"	Not Applicable	"$12,365.15"	"$24,730.30"	"$12,365.15"	"$24,730.30"
KIT SPNL AFFIRM 15U ULT VCF 658.924S		STERILE SUPPLY	"$35,315.00"	Outpatient	"$17,657.50"	Not Applicable	"$19,317.31"	"$23,555.11"	"$14,126.00"	Not Applicable	"$12,360.25"	"$24,720.50"	"$12,360.25"	"$24,720.50"
STEM HUM 14MM PRFT REUNION SHLDR 5569-P-2014	C1776	SUPPLY/IMPLANTS	"$35,296.00"	Outpatient	"$17,648.00"	Not Applicable	"$19,306.91"	"$23,542.43"	"$14,118.40"	Not Applicable	"$12,353.60"	"$24,707.20"	"$12,353.60"	"$24,707.20"
CMPNT FEM 6 KN LT TL STAB TRTHLN COCR 5512-F-601	C1776	SUPPLY/IMPLANTS	"$35,176.00"	Outpatient	"$17,588.00"	Not Applicable	"$19,241.27"	"$23,462.39"	"$14,070.40"	Not Applicable	"$12,311.60"	"$24,623.20"	"$12,311.60"	"$24,623.20"
CMPNT FEM 5 KN RT TS TRTHLN COCR 5512-F-502	C1776	SUPPLY/IMPLANTS	"$35,176.00"	Outpatient	"$17,588.00"	Not Applicable	"$19,241.27"	"$23,462.39"	"$14,070.40"	Not Applicable	"$12,311.60"	"$24,623.20"	"$12,311.60"	"$24,623.20"
CMPNT FEM 3 KN LT TL STAB TRTHLN COCR 5512-F-301		SUPPLY/IMPLANTS	"$35,176.00"	Outpatient	"$17,588.00"	Not Applicable	"$19,241.27"	"$23,462.39"	"$14,070.40"	Not Applicable	"$12,311.60"	"$24,623.20"	"$12,311.60"	"$24,623.20"
Patent Foramen Ovale Arterial Septal Defect Closure	93580	CARDIAC CATH LAB	"$35,151.00"	Outpatient	"$17,575.50"	"$15,735.19"	"$19,227.60"	"$8,056.00"	"$14,060.40"	"$12,306.00"	"$12,302.85"	"$24,605.70"	"$8,056.00"	"$24,605.70"
VLV AOR 10CM 19MM 20MM 16.7MM MSTR HP GLWV VSLV LO POR GFT 19VAVGJ-515		SUPPLY/IMPLANTS	"$35,143.00"	Outpatient	"$17,571.50"	Not Applicable	"$19,223.22"	"$23,440.38"	"$14,057.20"	Not Applicable	"$12,300.05"	"$24,600.10"	"$12,300.05"	"$24,600.10"
VLV AOR 10CM 21MM 22MM 18.6MM GLWV VSLV MSTR HP GFT XPD CUF 21VAVGJ-515		SUPPLY/IMPLANTS	"$35,143.00"	Outpatient	"$17,571.50"	Not Applicable	"$19,223.22"	"$23,440.38"	"$14,057.20"	Not Applicable	"$12,300.05"	"$24,600.10"	"$12,300.05"	"$24,600.10"
VLV AOR 10CM 27MM 36MM 28MM GLWV VSLV MSTR HP 0 PRECLOT COMP 27VAVGJ-515		SUPPLY/IMPLANTS	"$35,143.00"	Outpatient	"$17,571.50"	Not Applicable	"$19,223.22"	"$23,440.38"	"$14,057.20"	Not Applicable	"$12,300.05"	"$24,600.10"	"$12,300.05"	"$24,600.10"
VLV AOR 29MM 30MM GLWV VSLV MSTR HP MECH CNDT XPD CUF LO GFT 29VAVGJ-515		SUPPLY/IMPLANTS	"$35,143.00"	Outpatient	"$17,571.50"	Not Applicable	"$19,223.22"	"$23,440.38"	"$14,057.20"	Not Applicable	"$12,300.05"	"$24,600.10"	"$12,300.05"	"$24,600.10"
VLV AOR 25MM 26MM GLWV VSLV MSTR HP MECH CNDT XPD CUF GFT 25VAVGJ-515		SUPPLY/IMPLANTS	"$35,143.00"	Outpatient	"$17,571.50"	Not Applicable	"$19,223.22"	"$23,440.38"	"$14,057.20"	Not Applicable	"$12,300.05"	"$24,600.10"	"$12,300.05"	"$24,600.10"
VLV MTRL 31MM MSTR HMSHLD 12CM MECH LO POR GFT MR 31CAVGJ-514 00		SUPPLY/IMPLANTS	"$35,143.00"	Outpatient	"$17,571.50"	Not Applicable	"$19,223.22"	"$23,440.38"	"$14,057.20"	Not Applicable	"$12,300.05"	"$24,600.10"	"$12,300.05"	"$24,600.10"
VLV AOR 23MM 24MM GLWV VSLV MSTR HP MECH CNDT XPD CUF GFT 23VAVGJ-515		SUPPLY/IMPLANTS	"$35,123.00"	Outpatient	"$17,561.50"	Not Applicable	"$19,212.28"	"$23,427.04"	"$14,049.20"	Not Applicable	"$12,293.05"	"$24,586.10"	"$12,293.05"	"$24,586.10"
STEM HUM 133MM 15MM PRFT REUNION SHLDR STRL 5569-P-2015	C1776	SUPPLY/IMPLANTS	"$35,122.00"	Outpatient	"$17,561.00"	Not Applicable	"$19,211.73"	"$23,426.37"	"$14,048.80"	Not Applicable	"$12,292.70"	"$24,585.40"	"$12,292.70"	"$24,585.40"
STEM HUM 9MM PRFT REUNION T/S ARTHPL 5569-P-2009	C1776	SUPPLY/IMPLANTS	"$35,122.00"	Outpatient	"$17,561.00"	Not Applicable	"$19,211.73"	"$23,426.37"	"$14,048.80"	Not Applicable	"$12,292.70"	"$24,585.40"	"$12,292.70"	"$24,585.40"
STEM HUM 123MM 10MM PRFT REUNION SHLDR STRL 5569-P-2010	C1776	SUPPLY/IMPLANTS	"$35,122.00"	Outpatient	"$17,561.00"	Not Applicable	"$19,211.73"	"$23,426.37"	"$14,048.80"	Not Applicable	"$12,292.70"	"$24,585.40"	"$12,292.70"	"$24,585.40"
BODY CONE ARCOS TITANIUM A STANDARD OFFSET H50 MM HIP FEMORA 11-301300	C1776	SUPPLY/IMPLANTS	"$35,059.00"	Outpatient	"$17,529.50"	Not Applicable	"$19,177.27"	"$23,384.35"	"$14,023.60"	Not Applicable	"$12,270.65"	"$24,541.30"	"$12,270.65"	"$24,541.30"
SYSTEM ADVISA SR MRI  PEEM ADVISASRMRIPEEM	C1786	PACE MAKER	"$35,027.00"	Outpatient	"$17,513.50"	Not Applicable	"$19,159.77"	"$23,363.01"	"$14,010.80"	Not Applicable	"$12,259.45"	"$24,518.90"	"$12,259.45"	"$24,518.90"
ADVISA MRI SYSTEM MEEE ADVISAMRIPEEM SYSTEM		STERILE SUPPLY	"$35,019.00"	Outpatient	"$17,509.50"	Not Applicable	"$19,155.39"	"$23,357.67"	"$14,007.60"	Not Applicable	"$12,256.65"	"$24,513.30"	"$12,256.65"	"$24,513.30"
VLV AOR 17.5MM 25MM HNCK II ULT CNCH BPRTH STNT HLDR SW RING T505U225		SUPPLY/IMPLANTS	"$34,981.00"	Outpatient	"$17,490.50"	Not Applicable	"$19,134.61"	"$23,332.33"	"$13,992.40"	Not Applicable	"$12,243.35"	"$24,486.70"	"$12,243.35"	"$24,486.70"
SPCR SPNL 36X28X13.5-7.4MM SYNFIX EVOL 14D MED BLT NOSE PEEK 08.815.223S	C1821	SUPPLY/IMPLANTS	"$34,963.00"	Outpatient	"$17,481.50"	Not Applicable	"$19,124.76"	"$23,320.32"	"$13,985.20"	Not Applicable	"$12,237.05"	"$24,474.10"	"$12,237.05"	"$24,474.10"
SPCR SPNL 32X25X10.5-6.9MM SYNFIX EVOL 10D SM BLT NOSE PEEK 08.815.111S	C1821	SUPPLY/IMPLANTS	"$34,963.00"	Outpatient	"$17,481.50"	Not Applicable	"$19,124.76"	"$23,320.32"	"$13,985.20"	Not Applicable	"$12,237.05"	"$24,474.10"	"$12,237.05"	"$24,474.10"
Insert/Replace Pacer Gen Sngl Atri/ventric	33212	CARDIAC CATH LAB	"$34,885.00"	Outpatient	"$17,442.50"	"$16,411.72"	"$19,082.10"	"$1,771.00"	"$13,954.00"	"$8,681.00"	"$12,209.75"	"$24,419.50"	"$1,771.00"	"$24,419.50"
VALVE AORTIC TRIFECTA GLIDE TITANIUM POLYESTER BOVINE PORCIN TFGT-25A		SUPPLY/IMPLANTS	"$34,856.00"	Outpatient	"$17,428.00"	Not Applicable	"$19,066.23"	"$23,248.95"	"$13,942.40"	Not Applicable	"$12,199.60"	"$24,399.20"	"$12,199.60"	"$24,399.20"
VALVE AORTIC TRIFECTA GLIDE PORCINE BOVINE PERICARDIUM TITAN TFGT-27A		SUPPLY/IMPLANTS	"$34,856.00"	Outpatient	"$17,428.00"	Not Applicable	"$19,066.23"	"$23,248.95"	"$13,942.40"	Not Applicable	"$12,199.60"	"$24,399.20"	"$12,199.60"	"$24,399.20"
VLV AOR 15MM 24MM 19MM TRIFECTA GLD RADOPQ TI PLSTR BVN PRCN TFGT-19A		STERILE SUPPLY	"$34,841.00"	Outpatient	"$17,420.50"	Not Applicable	"$19,058.03"	"$23,238.95"	"$13,936.40"	Not Applicable	"$12,194.35"	"$24,388.70"	"$12,194.35"	"$24,388.70"
PLT 32MM 38MM INTVRTB LCK ENZA BN NS CB-001-001	C1713	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	"$1,365.15"	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$1,365.15"	"$24,383.80"
CAGE ALIF  34 X 28 X 17 1031-342-817	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
CAGE ALIF 30 X 26 X 13 1031-302-613	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
CAGE SPNL 40X15MM ENDOSKELETON TAS 12D LRDTC 27MM XL TI ALIF 2312-0315-N	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
SPCR SPNL 23X13MM ENZA 15D LRDTC 28MM NS LF CB-001-020	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
SPCR SPNL 26X13MM ENZA 8D LRDTC 32MM NS LF CB-001-008	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
SPCR SPNL 28X13MM ENZA 8D LRDTC 23MM NS LF CB-001-002	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
SPCR SPNL 23X11MM ENZA 15D LRDTC 28MM NS LF CB-001-019	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
SPCR SPNL 26X15MM ENZA 8D LRDTC 32MM NS LF CB-001-009	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
SPCR SPNL 28X15MM ENZA 8D LRDTC 23MM NS LF CB-001-003	C1821	SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
CAGE SPNL 40X16MM ENDOSKELETON TAS 12D LRDTC 27MM XL TI ALIF 2312-0316		SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
VLV AOR 17MM 28MM 23MM TRIFECTA GLD LINX RADOPQ SW CUF TI TFGT-23A		SUPPLY/IMPLANTS	"$34,834.00"	Outpatient	"$17,417.00"	Not Applicable	"$19,054.20"	"$23,234.28"	"$13,933.60"	Not Applicable	"$12,191.90"	"$24,383.80"	"$12,191.90"	"$24,383.80"
SCREW BONE TIGER L50 MM OD6.5 MM SPINE CANNULATED 5500 SERIES MIS 77565-50	C1713	SUPPLY/IMPLANTS	"$34,820.00"	Outpatient	"$17,410.00"	"$1,365.15"	"$19,046.54"	"$23,224.94"	"$13,928.00"	Not Applicable	"$12,187.00"	"$24,374.00"	"$1,365.15"	"$24,374.00"
"SPACER ALIF ENZA 17MM, 8DEG, 23 X 28MM CB001-004"	C1821	SUPPLY/IMPLANTS	"$34,820.00"	Outpatient	"$17,410.00"	Not Applicable	"$19,046.54"	"$23,224.94"	"$13,928.00"	Not Applicable	"$12,187.00"	"$24,374.00"	"$12,187.00"	"$24,374.00"
PLT LCK AVS ANCH-L BN NS 48667000	C1713	SUPPLY/IMPLANTS	"$34,814.00"	Outpatient	"$17,407.00"	"$1,365.15"	"$19,043.26"	"$23,220.94"	"$13,925.60"	Not Applicable	"$12,184.90"	"$24,369.80"	"$1,365.15"	"$24,369.80"
SCR BN SPNE 25MM 5MM AVS ANCH-L NS 48665025	C1713	SUPPLY/IMPLANTS	"$34,814.00"	Outpatient	"$17,407.00"	"$1,365.15"	"$19,043.26"	"$23,220.94"	"$13,925.60"	Not Applicable	"$12,184.90"	"$24,369.80"	"$1,365.15"	"$24,369.80"
CAGE SPNL 26X13MM ENZA 15D LRDTC 32MM NS LF CB-001-026	C1821	SUPPLY/IMPLANTS	"$34,814.00"	Outpatient	"$17,407.00"	Not Applicable	"$19,043.26"	"$23,220.94"	"$13,925.60"	Not Applicable	"$12,184.90"	"$24,369.80"	"$12,184.90"	"$24,369.80"
"SPACER ALIF ENZA 13MM, MEDIUM, 8 DEGREE CV-001-008"	C1821	SUPPLY/IMPLANTS	"$34,814.00"	Outpatient	"$17,407.00"	Not Applicable	"$19,043.26"	"$23,220.94"	"$13,925.60"	Not Applicable	"$12,184.90"	"$24,369.80"	"$12,184.90"	"$24,369.80"
"SPACER ENZA 11MM, 15 DEG,  23 X 28MM, SMALL CV-001-019"	C1821	SUPPLY/IMPLANTS	"$34,814.00"	Outpatient	"$17,407.00"	Not Applicable	"$19,043.26"	"$23,220.94"	"$13,925.60"	Not Applicable	"$12,184.90"	"$24,369.80"	"$12,184.90"	"$24,369.80"
SPCR SPNL 26X11MM ENZA 8D LRDTC 32MM NS LF CB-001-007	C1821	SUPPLY/IMPLANTS	"$34,814.00"	Outpatient	"$17,407.00"	Not Applicable	"$19,043.26"	"$23,220.94"	"$13,925.60"	Not Applicable	"$12,184.90"	"$24,369.80"	"$12,184.90"	"$24,369.80"
VLV AOR 16MM 26MM 21MM TRIFECTA GLD LINX RADOPQ SW CUF TI TFGT-21A		STERILE SUPPLY	"$34,814.00"	Outpatient	"$17,407.00"	Not Applicable	"$19,043.26"	"$23,220.94"	"$13,925.60"	Not Applicable	"$12,184.90"	"$24,369.80"	"$12,184.90"	"$24,369.80"
LEAD PCNG 59CM ECRDL ETAK RLNC 2 SHOCK COIL GORE 295	C1899	PACE MAKER	"$34,808.00"	Outpatient	"$17,404.00"	Not Applicable	"$19,039.98"	"$23,216.94"	"$13,923.20"	Not Applicable	"$12,182.80"	"$24,365.60"	"$12,182.80"	"$24,365.60"
GFT BN CLGN MTRX 2-4CM ALGRF PURION PRC AGT-5440	C9363	SUPPLY/IMPLANTS	"$34,802.00"	Outpatient	"$17,401.00"	$38.51	"$19,036.69"	"$23,212.93"	"$13,920.80"	Not Applicable	"$12,180.70"	"$24,361.40"	$38.51	"$24,361.40"
25682-0001-01 - eculizumab 10 mg/mL Soln	J1300	PHARMACY	"$34,677.00"	Outpatient	"$17,338.50"	$230.48	"$18,968.32"	"$23,129.56"	"$13,870.80"	Not Applicable	"$12,136.95"	"$24,273.90"	$230.48	"$24,273.90"
2.0MM CURVILINEAR DISTRACTOR R100RIGHT 04.500.100	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
2.0MM CURVILINEAR DISTRACTOR R100LEFT 04.500.101	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
2.0MM CURVILINEAR DISTRACTOR R30RIGHT 04.500.130	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
2.0MM CURVILINEAR DISTRACTOR R30LEFT 04.500.131	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
2.0MM CURVILINEAR DISTRACTOR R50RIGHT 04.500.150	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
2.0MM CURVILINEAR DISTRACTOR R50LEFT 04.500.151	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
2.0MM CURVILINEAR DISTRACTOR R70RIGHT 04.500.170	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
2.0MM CURVILINEAR DISTRACTOR R70LEFT 04.500.171	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
BODY DSTRCT 100MM RDS STRG TI MNDB CURVILINEAR NS 04.500.018	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
BODY DSTRCT 40MM RDS STRG TI MNDB RT CURVILINEAR 2MM LCK SCR 04.500.140	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
BODY DSTRCT 40MM RDS STRG TI MNDB LT CURVILINEAR 2MM LCK SCR 04.500.141	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 100MM RDS TI MNDB RT CURVILINEAR MESH FTPLT 1.3MM 04.500.200	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 100MM RDS TI MNDB LT CURVILINEAR MESH FTPLT 1.3MM 04.500.201	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG STRG TI MNDB MESH FTPLT 1.3MM SCR PED NS 04.500.218	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 30MM RDS TI MNDB RT CURVILINEAR MESH FTPLT 1.3MM 04.500.230	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 30MM RDS TI MNDB LT CURVILINEAR MESH FTPLT 1.3MM 04.500.231	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 40MM RDS STRG TI MNDB RT CURVILINEAR MESH FTPLT 04.500.240	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 40MM RDS STRG TI MNDB LT CURVILINEAR MESH FTPLT 04.500.241	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 50MM RDS TI MNDB RT CURVILINEAR MESH FTPLT 1.3MM 04.500.250	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 50MM RDS TI MNDB LT CURVILINEAR MESH FTPLT 1.3MM 04.500.251	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 70MM RDS TI MNDB RT CURVILINEAR MESH FTPLT 1.3MM 04.500.270	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
DSTRCT SRG 70MM RDS TI MNDB LT CURVILINEAR MESH FTPLT 1.3MM 04.500.271	C1713	SUPPLY/IMPLANTS	"$34,671.00"	Outpatient	"$17,335.50"	"$1,365.15"	"$18,965.04"	"$23,125.56"	"$13,868.40"	Not Applicable	"$12,134.85"	"$24,269.70"	"$1,365.15"	"$24,269.70"
CMPNT FEM 60MM KN RT POST STAB VNGRD TI STRL CP113634	C1776	SUPPLY/IMPLANTS	"$34,651.00"	Outpatient	"$17,325.50"	Not Applicable	"$18,954.10"	"$23,112.22"	"$13,860.40"	Not Applicable	"$12,127.85"	"$24,255.70"	"$12,127.85"	"$24,255.70"
ROD 50MM 475005050	C1713	SUPPLY/IMPLANTS	"$34,651.00"	Outpatient	"$17,325.50"	"$1,365.15"	"$18,954.10"	"$23,112.22"	"$13,860.40"	Not Applicable	"$12,127.85"	"$24,255.70"	"$1,365.15"	"$24,255.70"
CAGE SPNL 32X11MM VAULT 15D LRDTC PEEK RADOPQ ALIF NS 10-C3215-11	C1821	SUPPLY/IMPLANTS	"$34,651.00"	Outpatient	"$17,325.50"	Not Applicable	"$18,954.10"	"$23,112.22"	"$13,860.40"	Not Applicable	"$12,127.85"	"$24,255.70"	"$12,127.85"	"$24,255.70"
CMPNT FEM 4 KN RT TL STAB TRTHLN COCR 5512-F-402	C1776	SUPPLY/IMPLANTS	"$34,645.00"	Outpatient	"$17,322.50"	Not Applicable	"$18,950.82"	"$23,108.22"	"$13,858.00"	Not Applicable	"$12,125.75"	"$24,251.50"	"$12,125.75"	"$24,251.50"
CAGE SPNL 34X24X10MM MLX 4D TI NS LF 4103424	C1821	SUPPLY/IMPLANTS	"$34,640.00"	Outpatient	"$17,320.00"	Not Applicable	"$18,948.08"	"$23,104.88"	"$13,856.00"	Not Applicable	"$12,124.00"	"$24,248.00"	"$12,124.00"	"$24,248.00"
CAGE SPNL 34X24X12MM MLX 4D NS LF 4123424	C1821	SUPPLY/IMPLANTS	"$34,640.00"	Outpatient	"$17,320.00"	Not Applicable	"$18,948.08"	"$23,104.88"	"$13,856.00"	Not Applicable	"$12,124.00"	"$24,248.00"	"$12,124.00"	"$24,248.00"
CAGE SPNL 34X24X8MM MLX 4D TI NS LF 4083424	C1821	SUPPLY/IMPLANTS	"$34,640.00"	Outpatient	"$17,320.00"	Not Applicable	"$18,948.08"	"$23,104.88"	"$13,856.00"	Not Applicable	"$12,124.00"	"$24,248.00"	"$12,124.00"	"$24,248.00"
CAGE SPNL 34X24X8MM MLX 8D NS LF 8083424	C1821	SUPPLY/IMPLANTS	"$34,640.00"	Outpatient	"$17,320.00"	Not Applicable	"$18,948.08"	"$23,104.88"	"$13,856.00"	Not Applicable	"$12,124.00"	"$24,248.00"	"$12,124.00"	"$24,248.00"
CAGE SPINAL MLX TITANIUM 8 D L34 MM X W24 MM X H10 MM NONSTERILE LATEX FREE 8103424	C1821	SUPPLY/IMPLANTS	"$34,639.00"	Outpatient	"$17,319.50"	Not Applicable	"$18,947.53"	"$23,104.21"	"$13,855.60"	Not Applicable	"$12,123.65"	"$24,247.30"	"$12,123.65"	"$24,247.30"
"Perc Chronic Total Occl Perc Bypass Graft, Stent, Atherectomy"	92943	CARDIAC CATH LAB	"$31,898.00"	Outpatient	"$15,949.00"	"$30,568.87"	"$18,947.41"	"$8,056.00"	"$12,759.20"	"$7,310.00"	"$11,164.30"	"$22,328.60"	"$7,310.00"	"$30,568.87"
"Perc Bypass Graft, Stent, Arthectomy, PTCA One Vessel"	92937	CARDIAC CATH LAB	"$31,898.00"	Outpatient	"$15,949.00"	"$30,568.87"	"$18,947.41"	"$8,056.00"	"$12,759.20"	"$7,310.00"	"$11,164.30"	"$22,328.60"	"$7,310.00"	"$30,568.87"
Coronary Atherectomy with Intracoronary Stent Single	92933	CARDIAC CATH LAB	"$31,898.00"	Outpatient	"$15,949.00"	"$30,568.87"	"$18,947.41"	"$8,056.00"	"$12,759.20"	"$7,310.00"	"$11,164.30"	"$22,328.60"	"$7,310.00"	"$30,568.87"
Coronary Stent Add'l Vessel	92929	CARDIAC CATH LAB	"$31,898.00"	Outpatient	"$15,949.00"	"$30,568.87"	"$18,947.41"	"$8,056.00"	"$12,759.20"	"$7,310.00"	"$11,164.30"	"$22,328.60"	"$7,310.00"	"$30,568.87"
CAGE SPNL 32X13MM VAULT 8D LRDTC PEEK RADOPQ ALIF NS 10-C3208-13	C1821	SUPPLY/IMPLANTS	"$34,636.00"	Outpatient	"$17,318.00"	Not Applicable	"$18,945.89"	"$23,102.21"	"$13,854.40"	Not Applicable	"$12,122.60"	"$24,245.20"	"$12,122.60"	"$24,245.20"
CAGE SPNL 32X11MM VAULT 8D LRDTC PEEK RADOPQ ALIF NS 10-C3208-11	C1821	SUPPLY/IMPLANTS	"$34,636.00"	Outpatient	"$17,318.00"	Not Applicable	"$18,945.89"	"$23,102.21"	"$13,854.40"	Not Applicable	"$12,122.60"	"$24,245.20"	"$12,122.60"	"$24,245.20"
SPCR SPNL 16MM PRIMTR 8D LRDTC LG VERT BD REPL 3493316	C1821	SUPPLY/IMPLANTS	"$34,636.00"	Outpatient	"$17,318.00"	Not Applicable	"$18,945.89"	"$23,102.21"	"$13,854.40"	Not Applicable	"$12,122.60"	"$24,245.20"	"$12,122.60"	"$24,245.20"
BONE PACER ALLOCRAFT L 16MM X 12 DEG 45216	C1763	SUPPLY/IMPLANTS	"$34,634.00"	Outpatient	"$17,317.00"	Not Applicable	"$18,944.80"	"$23,100.88"	"$13,853.60"	Not Applicable	"$12,121.90"	"$24,243.80"	"$12,121.90"	"$24,243.80"
BONE PACER ALLOCRAFT L 10MM X 8 DEG 45810	C1763	SUPPLY/IMPLANTS	"$34,634.00"	Outpatient	"$17,317.00"	Not Applicable	"$18,944.80"	"$23,100.88"	"$13,853.60"	Not Applicable	"$12,121.90"	"$24,243.80"	"$12,121.90"	"$24,243.80"
BONE PACER ALLOCRAFT L 12MM X 12 DEG 45212	C1763	SUPPLY/IMPLANTS	"$34,634.00"	Outpatient	"$17,317.00"	Not Applicable	"$18,944.80"	"$23,100.88"	"$13,853.60"	Not Applicable	"$12,121.90"	"$24,243.80"	"$12,121.90"	"$24,243.80"
GFT BN 14MM ALGRF 8D LRDTC 45814	C1763	SUPPLY/IMPLANTS	"$34,634.00"	Outpatient	"$17,317.00"	Not Applicable	"$18,944.80"	"$23,100.88"	"$13,853.60"	Not Applicable	"$12,121.90"	"$24,243.80"	"$12,121.90"	"$24,243.80"
PCMKR THK6MM SM ASSURITY 2 CHMBR IS-1 CNCT 50X47MM CRD 10.4 PM2240	C1785	PACE MAKER	"$34,632.00"	Outpatient	"$17,316.00"	Not Applicable	"$18,943.70"	"$23,099.54"	"$13,852.80"	Not Applicable	"$12,121.20"	"$24,242.40"	"$12,121.20"	"$24,242.40"
SYS CRD PCMKR LD 2 CHMBR IS-1 CNCT ASSURITY THK6MM SM 50X47 PM2240 SYSTEM	C1785	PACE MAKER	"$34,632.00"	Outpatient	"$17,316.00"	Not Applicable	"$18,943.70"	"$23,099.54"	"$13,852.80"	Not Applicable	"$12,121.20"	"$24,242.40"	"$12,121.20"	"$24,242.40"
LEAD PCNG 45CM 9FR Q-TRK TRPLR ELTRD PU 3400		SUPPLY/IMPLANTS	"$34,632.00"	Outpatient	"$17,316.00"	Not Applicable	"$18,943.70"	"$23,099.54"	"$13,852.80"	Not Applicable	"$12,121.20"	"$24,242.40"	"$12,121.20"	"$24,242.40"
PLT 20MMX11MM 6D SPNE INTERCONTINENTAL BN 187.061	C1713	SUPPLY/IMPLANTS	"$34,613.00"	Outpatient	"$17,306.50"	"$1,365.15"	"$18,933.31"	"$23,086.87"	"$13,845.20"	Not Applicable	"$12,114.55"	"$24,229.10"	"$1,365.15"	"$24,229.10"
PLT 20MMX15MM 6D SPNE INTERCONTINENTAL BN 187.065	C1713	SUPPLY/IMPLANTS	"$34,613.00"	Outpatient	"$17,306.50"	"$1,365.15"	"$18,933.31"	"$23,086.87"	"$13,845.20"	Not Applicable	"$12,114.55"	"$24,229.10"	"$1,365.15"	"$24,229.10"
PLT 20MMX13MM 0D SPNE INTERCONTINENTAL BN 187.013	C1713	SUPPLY/IMPLANTS	"$34,613.00"	Outpatient	"$17,306.50"	"$1,365.15"	"$18,933.31"	"$23,086.87"	"$13,845.20"	Not Applicable	"$12,114.55"	"$24,229.10"	"$1,365.15"	"$24,229.10"
PLT 20MMX9MM 6D SPNE INTERCONTINENTAL BN 187.059	C1713	SUPPLY/IMPLANTS	"$34,613.00"	Outpatient	"$17,306.50"	"$1,365.15"	"$18,933.31"	"$23,086.87"	"$13,845.20"	Not Applicable	"$12,114.55"	"$24,229.10"	"$1,365.15"	"$24,229.10"
GFT BN AMNIO TISS 6X4CM 2 LYR REPST DSGN AMNIOHEAL + TAH1406	C9363	SUPPLY/IMPLANTS	"$34,597.00"	Outpatient	"$17,298.50"	$38.51	"$18,924.56"	"$23,076.20"	"$13,838.80"	Not Applicable	"$12,108.95"	"$24,217.90"	$38.51	"$24,217.90"
GFT STNT 156MM 16-13MM 16FR ENDURANT II EVAS NTNL PLSTR ETLW1613C156E	C1874	SUPPLY/IMPLANTS	"$34,562.00"	Outpatient	"$17,281.00"	Not Applicable	"$18,905.41"	"$23,052.85"	"$13,824.80"	Not Applicable	"$12,096.70"	"$24,193.40"	"$12,096.70"	"$24,193.40"
GFT STNT 49MM 36MM 20FR ENDURANT II EVAS PLSTR NTNL AOR XTN ETCF3636C49E	C1884	SUPPLY/IMPLANTS	"$34,562.00"	Outpatient	"$17,281.00"	Not Applicable	"$18,905.41"	"$23,052.85"	"$13,824.80"	Not Applicable	"$12,096.70"	"$24,193.40"	"$12,096.70"	"$24,193.40"
GFT STNT 156MM 16-10MM 16FR ENDURANT II EVAS NTNL PLSTR ETLW1610C156E	C1876	SUPPLY/IMPLANTS	"$34,562.00"	Outpatient	"$17,281.00"	Not Applicable	"$18,905.41"	"$23,052.85"	"$13,824.80"	Not Applicable	"$12,096.70"	"$24,193.40"	"$12,096.70"	"$24,193.40"
PCMKR THK6MM ZPHR SR 1 CHMBR RR IS-1 CNCT 44X41MM CRD 8CC 17 5620	C1786	PACE MAKER	"$34,546.00"	Outpatient	"$17,273.00"	Not Applicable	"$18,896.66"	"$23,042.18"	"$13,818.40"	Not Applicable	"$12,091.10"	"$24,182.20"	"$12,091.10"	"$24,182.20"
MESH FRNTL MATRIXNEURO 109X78X.6MM TI CNTR DYNMC STRL AU 04.503.157S	C1713	SUPPLY/IMPLANTS	"$34,534.00"	Outpatient	"$17,267.00"	"$1,365.15"	"$18,890.10"	"$23,034.18"	"$13,813.60"	Not Applicable	"$12,086.90"	"$24,173.80"	"$1,365.15"	"$24,173.80"
MESH MATRIXNEURO .6MM TI CNTR UNV DYNMC 109MM STRL AU 04.503.158S	C1713	SUPPLY/IMPLANTS	"$34,534.00"	Outpatient	"$17,267.00"	"$1,365.15"	"$18,890.10"	"$23,034.18"	"$13,813.60"	Not Applicable	"$12,086.90"	"$24,173.80"	"$1,365.15"	"$24,173.80"
COMPONENT FEMORAL SIZE 4 COBALT CHROMIUM LEFT TOTAL STABILIZ 5512-F-401	C1776	SUPPLY/IMPLANTS	"$34,485.00"	Outpatient	"$17,242.50"	Not Applicable	"$18,863.30"	"$23,001.50"	"$13,794.00"	Not Applicable	"$12,069.75"	"$24,139.50"	"$12,069.75"	"$24,139.50"
CMPNT FEM 5 KN LT TL STAB TRTHLN COCR 5512-F-501	C1776	SUPPLY/IMPLANTS	"$34,482.00"	Outpatient	"$17,241.00"	Not Applicable	"$18,861.65"	"$22,999.49"	"$13,792.80"	Not Applicable	"$12,068.70"	"$24,137.40"	"$12,068.70"	"$24,137.40"
PCMKR ADAPTA DR 2 CHMBR IS-1 CNCT GNTR CRD 12.1CC 27.1GM ADDR01	C1785	PACE MAKER	"$34,464.00"	Outpatient	"$17,232.00"	Not Applicable	"$18,851.81"	"$22,987.49"	"$13,785.60"	Not Applicable	"$12,062.40"	"$24,124.80"	"$12,062.40"	"$24,124.80"
STEM HUM 123MM 10MM CMNT REUNION SHLDR STRL 5569-C-2010	C1776	SUPPLY/IMPLANTS	"$34,441.00"	Outpatient	"$17,220.50"	Not Applicable	"$18,839.23"	"$22,972.15"	"$13,776.40"	Not Applicable	"$12,054.35"	"$24,108.70"	"$12,054.35"	"$24,108.70"
STEM HUM 12MM CMNT REUNION T/S ARTHPL 5569-C-2012	C1776	SUPPLY/IMPLANTS	"$34,441.00"	Outpatient	"$17,220.50"	Not Applicable	"$18,839.23"	"$22,972.15"	"$13,776.40"	Not Applicable	"$12,054.35"	"$24,108.70"	"$12,054.35"	"$24,108.70"
JIG PSTN 130D JMB 903002092		SUPPLY/IMPLANTS	"$34,435.00"	Outpatient	"$17,217.50"	Not Applicable	"$18,835.95"	"$22,968.15"	"$13,774.00"	Not Applicable	"$12,052.25"	"$24,104.50"	"$12,052.25"	"$24,104.50"
PLT 2.5MM 2 ANG SM TI RECON MATRIXMANDIBLE BN NS PSPC SD449.512B	C1713	SUPPLY/IMPLANTS	"$34,412.00"	Outpatient	"$17,206.00"	"$1,365.15"	"$18,823.36"	"$22,952.80"	"$13,764.80"	Not Applicable	"$12,044.20"	"$24,088.40"	"$1,365.15"	"$24,088.40"
STEM HUM 118MM 9MM CMNT REUNION TSA STRL 5569-C-2009	C1776	SUPPLY/IMPLANTS	"$34,408.00"	Outpatient	"$17,204.00"	Not Applicable	"$18,821.18"	"$22,950.14"	"$13,763.20"	Not Applicable	"$12,042.80"	"$24,085.60"	"$12,042.80"	"$24,085.60"
PCMKR THK6MM ZPHR DR 2 CHMBR IS-1 CNCT 44X43MM CRD 8.5CC 18 5820	C1785	PACE MAKER	"$34,401.00"	Outpatient	"$17,200.50"	Not Applicable	"$18,817.35"	"$22,945.47"	"$13,760.40"	Not Applicable	"$12,040.35"	"$24,080.70"	"$12,040.35"	"$24,080.70"
PROSTHESIS PENILE SPECTRA 720056-02	C2622	SUPPLY/IMPLANTS	"$34,399.00"	Outpatient	"$17,199.50"	Not Applicable	"$18,816.25"	"$22,944.13"	"$13,759.60"	Not Applicable	"$12,039.65"	"$24,079.30"	"$12,039.65"	"$24,079.30"
CMPNT FEM 15D ANTEVERT KN RT TROCH GMRS 6495-1-202	C1776	SUPPLY/IMPLANTS	"$34,392.00"	Outpatient	"$17,196.00"	Not Applicable	"$18,812.42"	"$22,939.46"	"$13,756.80"	Not Applicable	"$12,037.20"	"$24,074.40"	"$12,037.20"	"$24,074.40"
PSPC MATRIXMANDIBLE 20 HOLE RECON PLATE 2.5MM THICK SD449.509	C1713	SUPPLY/IMPLANTS	"$34,387.00"	Outpatient	"$17,193.50"	"$1,365.15"	"$18,809.69"	"$22,936.13"	"$13,754.80"	Not Applicable	"$12,035.45"	"$24,070.90"	"$1,365.15"	"$24,070.90"
INTERBODY ALIF COROENT 8027108	C1713	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	"$1,365.15"	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$1,365.15"	"$24,061.80"
CAGE 36 X 24 X 14MM 2307-0114	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE 36 X 24 X 12MM 2307-0112	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE ALIF 12MM/ 6 DEG ASTS-SM0612-T	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE ALIF MEDIUM 14MM 6 DEGREE ASTS-MD0614-T	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE MIDLINE II-TI 33MM X 15MM X 16 DEGREES M331516C	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE MIDLINE II TI 33MM X 15MM X 12 DEGREES M331512C	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE SPNL 42X30X6MM BS 15D TI NS LF 6953615	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE SPNL 42X30X8MM BS 15D TI NS LF 6953815	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE SPNL 42X30X8MM BS 10D TI NS LF 6953810	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
CAGE SPNL 38X28X6MM BS 10D TI NS LF 6952610	C1821	SUPPLY/IMPLANTS	"$34,374.00"	Outpatient	"$17,187.00"	Not Applicable	"$18,802.58"	"$22,927.46"	"$13,749.60"	Not Applicable	"$12,030.90"	"$24,061.80"	"$12,030.90"	"$24,061.80"
ALIF SPIRA 17MM 8 DEG 26X 32 SPA-2632-0817	C1821	SUPPLY/IMPLANTS	"$34,362.00"	Outpatient	"$17,181.00"	Not Applicable	"$18,796.01"	"$22,919.45"	"$13,744.80"	Not Applicable	"$12,026.70"	"$24,053.40"	"$12,026.70"	"$24,053.40"
CAGE ALIF SPIRA 13MM X 23X26 8 DEGREE SPA-2326-0813	C1821	SUPPLY/IMPLANTS	"$34,362.00"	Outpatient	"$17,181.00"	Not Applicable	"$18,796.01"	"$22,919.45"	"$13,744.80"	Not Applicable	"$12,026.70"	"$24,053.40"	"$12,026.70"	"$24,053.40"
CAGE OLIF 14 X 22 X 55 8202002	C1821	SUPPLY/IMPLANTS	"$34,362.00"	Outpatient	"$17,181.00"	Not Applicable	"$18,796.01"	"$22,919.45"	"$13,744.80"	Not Applicable	"$12,026.70"	"$24,053.40"	"$12,026.70"	"$24,053.40"
CAGE SPNL 42X30X10MM BS 10D TI NS LF 6953010	C1821	SUPPLY/IMPLANTS	"$34,362.00"	Outpatient	"$17,181.00"	Not Applicable	"$18,796.01"	"$22,919.45"	"$13,744.80"	Not Applicable	"$12,026.70"	"$24,053.40"	"$12,026.70"	"$24,053.40"
CAGE SPNL 32X13MM SPIRA 8D LRDTC 26MM BCNVX OPN MTRX ALIF NS SPA-2632-0813	C1821	SUPPLY/IMPLANTS	"$34,362.00"	Outpatient	"$17,181.00"	Not Applicable	"$18,796.01"	"$22,919.45"	"$13,744.80"	Not Applicable	"$12,026.70"	"$24,053.40"	"$12,026.70"	"$24,053.40"
CAGE SPNL 55X22X10MM MODL 10D XL W STRL LF 1221055P2	C1821	SUPPLY/IMPLANTS	"$34,362.00"	Outpatient	"$17,181.00"	Not Applicable	"$18,796.01"	"$22,919.45"	"$13,744.80"	Not Applicable	"$12,026.70"	"$24,053.40"	"$12,026.70"	"$24,053.40"
CAGE SPINAL RENOVIS TESERA 7 D LORDOTIC D26 MM W30 MM X H11 MM STERILE LATEX FREE ALIF 1031-302-611	C1821	SUPPLY/IMPLANTS	"$34,362.00"	Outpatient	"$17,181.00"	Not Applicable	"$18,796.01"	"$22,919.45"	"$13,744.80"	Not Applicable	"$12,026.70"	"$24,053.40"	"$12,026.70"	"$24,053.40"
MAJOR JOINT REPLACEMENT OR REATTACHMENT WITHOUT MCC HIPS KNE DRG 470SN	C1776	SUPPLY/IMPLANTS	"$34,325.00"	Outpatient	"$17,162.50"	Not Applicable	"$18,775.78"	"$22,894.78"	"$13,730.00"	Not Applicable	"$12,013.75"	"$24,027.50"	"$12,013.75"	"$24,027.50"
MAJOR JOINT REPLACEMENT OR REATTACHMENT WITHOUT MCC HIPS KNE DRG 470ZB	C1776	SUPPLY/IMPLANTS	"$34,325.00"	Outpatient	"$17,162.50"	Not Applicable	"$18,775.78"	"$22,894.78"	"$13,730.00"	Not Applicable	"$12,013.75"	"$24,027.50"	"$12,013.75"	"$24,027.50"
VANGUARD TOTAL KNEE CONSTRUCT VKC	C1776	SUPPLY/IMPLANTS	"$34,325.00"	Outpatient	"$17,162.50"	Not Applicable	"$18,775.78"	"$22,894.78"	"$13,730.00"	Not Applicable	"$12,013.75"	"$24,027.50"	"$12,013.75"	"$24,027.50"
RESTORIS MCK UNI ONLAY 210033	C1776	SUPPLY/IMPLANTS	"$34,319.00"	Outpatient	"$17,159.50"	Not Applicable	"$18,772.49"	"$22,890.77"	"$13,727.60"	Not Applicable	"$12,011.65"	"$24,023.30"	"$12,011.65"	"$24,023.30"
LINR ACTB 54MM 28MM 45D JJ LNGVT CNSTRN HIP 875801128	C1776	SUPPLY/IMPLANTS	"$34,312.00"	Outpatient	"$17,156.00"	Not Applicable	"$18,768.66"	"$22,886.10"	"$13,724.80"	Not Applicable	"$12,009.20"	"$24,018.40"	"$12,009.20"	"$24,018.40"
DEV TRGT ARM ENTRY PRTL TROCH VERSANAIL 2810-13-010	C1713	SUPPLY/IMPLANTS	"$34,283.00"	Outpatient	"$17,141.50"	"$1,365.15"	"$18,752.80"	"$22,866.76"	"$13,713.20"	Not Applicable	"$11,999.05"	"$23,998.10"	"$1,365.15"	"$23,998.10"
ANCHOR HUMERAL SIDUS LARGE H22 MM OD32 MM SHOULDER STEM FREE 0104555130	C1776	SUPPLY/IMPLANTS	"$34,275.00"	Outpatient	"$17,137.50"	Not Applicable	"$18,748.43"	"$22,861.43"	"$13,710.00"	Not Applicable	"$11,996.25"	"$23,992.50"	"$11,996.25"	"$23,992.50"
LEAD PCNG 64CM 9FR ECRDM ETAK RLNC 2 COIL TINE BP PSV FX 148		STERILE SUPPLY	"$34,261.00"	Outpatient	"$17,130.50"	Not Applicable	"$18,740.77"	"$22,852.09"	"$13,704.40"	Not Applicable	"$11,991.35"	"$23,982.70"	"$11,991.35"	"$23,982.70"
GFT SFT TIS 8X4CM AMNIOHEAL + AMNIO MEMBR 2 LYR REPST TAH1408	C9362	SUPPLY/IMPLANTS	"$34,241.00"	Outpatient	"$17,120.50"	$110.85	"$18,729.83"	"$22,838.75"	"$13,696.40"	Not Applicable	"$11,984.35"	"$23,968.70"	$110.85	"$23,968.70"
ANCHOR HUMERAL SIDUS SHOULDER STEM FREE STERILE LATEX FREE D 0104555110	C1713	SUPPLY/IMPLANTS	"$34,239.00"	Outpatient	"$17,119.50"	"$1,365.15"	"$18,728.73"	"$22,837.41"	"$13,695.60"	Not Applicable	"$11,983.65"	"$23,967.30"	"$1,365.15"	"$23,967.30"
GFT BN CLLR BN MTRX 10ML OSTEOCEL + 5013010	C1713	SUPPLY/IMPLANTS	"$34,238.00"	Outpatient	"$17,119.00"	"$1,365.15"	"$18,728.19"	"$22,836.75"	"$13,695.20"	Not Applicable	"$11,983.30"	"$23,966.60"	"$1,365.15"	"$23,966.60"
SPCR SPNL 26X10X10-15MM CLBR 4D LRDTC NS LF 194.226	C1821	SUPPLY/IMPLANTS	"$34,228.00"	Outpatient	"$17,114.00"	Not Applicable	"$18,722.72"	"$22,830.08"	"$13,691.20"	Not Applicable	"$11,979.80"	"$23,959.60"	"$11,979.80"	"$23,959.60"
DISC INTVRTB 6MM PRODISC-C MED DP SPNE CRV COCR TI UHMWPE 09.820.036S	C1713	SUPPLY/IMPLANTS	"$34,222.00"	Outpatient	"$17,111.00"	"$1,365.15"	"$18,719.43"	"$22,826.07"	"$13,688.80"	Not Applicable	"$11,977.70"	"$23,955.40"	"$1,365.15"	"$23,955.40"
IMPL URO INHBZN SIL-EL CNTRL PMP A800 SPHNCR 72404127	C1815	SUPPLY/IMPLANTS	"$34,187.00"	Outpatient	"$17,093.50"	Not Applicable	"$18,700.29"	"$22,802.73"	"$13,674.80"	Not Applicable	"$11,965.45"	"$23,930.90"	"$11,965.45"	"$23,930.90"
STEM FEM 152MM 133D 16 HI OFST TPR TPRLK PPS HIP TY 1 PRFT 51-104160	C1776	SUPPLY/IMPLANTS	"$34,156.00"	Outpatient	"$17,078.00"	Not Applicable	"$18,683.33"	"$22,782.05"	"$13,662.40"	Not Applicable	"$11,954.60"	"$23,909.20"	"$11,954.60"	"$23,909.20"
STNT PNCR 15MM 24MM 10MM 146MM 138MM 10.8FR CAUT ENH DLV SYS M00553650	C1876	SUPPLY/IMPLANTS	"$34,152.00"	Outpatient	"$17,076.00"	Not Applicable	"$18,681.14"	"$22,779.38"	"$13,660.80"	Not Applicable	"$11,953.20"	"$23,906.40"	"$11,953.20"	"$23,906.40"
COMPONENT FEMORAL VANGUARD 360 POROUS L65 MM KNEE LEFT STERI 185284	C1776	SUPPLY/IMPLANTS	"$34,122.00"	Outpatient	"$17,061.00"	Not Applicable	"$18,664.73"	"$22,759.37"	"$13,648.80"	Not Applicable	"$11,942.70"	"$23,885.40"	"$11,942.70"	"$23,885.40"
25682-0022-01 - ravulizumab 10 mg/mL Soln	J1303	PHARMACY	"$34,055.00"	Outpatient	"$17,027.50"	$216.46	"$18,628.09"	"$22,714.69"	"$13,622.00"	Not Applicable	"$11,919.25"	"$23,838.50"	$216.46	"$23,838.50"
GFT STNT 120MM 34MM 17FR AFX ACTIVESEAL STRATA STRG EVAS ABD A34-34/C100-O20	C1883	SUPPLY/IMPLANTS	"$34,044.00"	Outpatient	"$17,022.00"	Not Applicable	"$18,622.07"	"$22,707.35"	"$13,617.60"	Not Applicable	"$11,915.40"	"$23,830.80"	"$11,915.40"	"$23,830.80"
LEAD NRSTM VAGUS NRV 43CM 3MM PERENNIAFLEX SIL BP EPLP AND 304	C1778	SUPPLY/IMPLANTS	"$34,031.00"	Outpatient	"$17,015.50"	Not Applicable	"$18,614.96"	"$22,698.68"	"$13,612.40"	Not Applicable	"$11,910.85"	"$23,821.70"	"$11,910.85"	"$23,821.70"
FTPLT BN 20MM TI MNDB RT 1 VCTR DSTRCT BD NS 487.962	C1713	SUPPLY/IMPLANTS	"$34,004.00"	Outpatient	"$17,002.00"	"$1,365.15"	"$18,600.19"	"$22,680.67"	"$13,601.60"	Not Applicable	"$11,901.40"	"$23,802.80"	"$1,365.15"	"$23,802.80"
FTPLT BN 20MM TI MNDB LT 1 VCTR DSTRCT BD NS 487.963	C1713	SUPPLY/IMPLANTS	"$34,004.00"	Outpatient	"$17,002.00"	"$1,365.15"	"$18,600.19"	"$22,680.67"	"$13,601.60"	Not Applicable	"$11,901.40"	"$23,802.80"	"$1,365.15"	"$23,802.80"
FTPLT BN 30MM TI MNDB RT 1 VCTR DSTRCT BD NS 487.964	C1713	SUPPLY/IMPLANTS	"$34,004.00"	Outpatient	"$17,002.00"	"$1,365.15"	"$18,600.19"	"$22,680.67"	"$13,601.60"	Not Applicable	"$11,901.40"	"$23,802.80"	"$1,365.15"	"$23,802.80"
FTPLT BN 30MM TI MNDB LT 1 VCTR DSTRCT BD NS 487.965	C1713	SUPPLY/IMPLANTS	"$34,004.00"	Outpatient	"$17,002.00"	"$1,365.15"	"$18,600.19"	"$22,680.67"	"$13,601.60"	Not Applicable	"$11,901.40"	"$23,802.80"	"$1,365.15"	"$23,802.80"
SET PLT NCB HUM 237010100	C1713	SUPPLY/IMPLANTS	"$33,977.00"	Outpatient	"$16,988.50"	"$1,365.15"	"$18,585.42"	"$22,662.66"	"$13,590.80"	Not Applicable	"$11,891.95"	"$23,783.90"	"$1,365.15"	"$23,783.90"
00078-0825-81 - octreotide 30 mg Powd	J2353	PHARMACY	"$33,949.00"	Outpatient	"$16,974.50"	$216.22	"$18,570.10"	"$22,643.98"	"$13,579.60"	Not Applicable	"$11,882.15"	"$23,764.30"	$216.22	"$23,764.30"
GFT STNT 93MM 16MM 14FR ENDURANT II 2 BRCH EVAS ILC NTNL ETLW1616C93E	C1876	SUPPLY/IMPLANTS	"$33,944.00"	Outpatient	"$16,972.00"	Not Applicable	"$18,567.37"	"$22,640.65"	"$13,577.60"	Not Applicable	"$11,880.40"	"$23,760.80"	"$11,880.40"	"$23,760.80"
GFT STNT 82MM 16-16MM 14FR ENDURANT II EVAS NTNL PLSTR HDRPH ETLW1616C82E	C1876	SUPPLY/IMPLANTS	"$33,944.00"	Outpatient	"$16,972.00"	Not Applicable	"$18,567.37"	"$22,640.65"	"$13,577.60"	Not Applicable	"$11,880.40"	"$23,760.80"	"$11,880.40"	"$23,760.80"
FXTR XTRNFX VSN ANKL C VAR CMPLT TOP TRY UNLAT NS LF DISP 20390	C1713	SUPPLY/IMPLANTS	"$33,936.00"	Outpatient	"$16,968.00"	"$1,365.15"	"$18,562.99"	"$22,635.31"	"$13,574.40"	Not Applicable	"$11,877.60"	"$23,755.20"	"$1,365.15"	"$23,755.20"
ETEX EQUIVABONE 10CC 76-6022		SUPPLY/IMPLANTS	"$33,909.00"	Outpatient	"$16,954.50"	Not Applicable	"$18,548.22"	"$22,617.30"	"$13,563.60"	Not Applicable	"$11,868.15"	"$23,736.30"	"$11,868.15"	"$23,736.30"
IO-FLEX 7.5 CONTRA SYSTEM IO-K088-CP-7.5SC		STERILE SUPPLY	"$33,908.00"	Outpatient	"$16,954.00"	Not Applicable	"$18,547.68"	"$22,616.64"	"$13,563.20"	Not Applicable	"$11,867.80"	"$23,735.60"	"$11,867.80"	"$23,735.60"
SYSTEM 7.5 FLEX CONTRA IO-KO8CP-7.5		STERILE SUPPLY	"$33,908.00"	Outpatient	"$16,954.00"	Not Applicable	"$18,547.68"	"$22,616.64"	"$13,563.20"	Not Applicable	"$11,867.80"	"$23,735.60"	"$11,867.80"	"$23,735.60"
7.5 LPSI SYSTEM IO-K03-IP-7.5SC	C1713	SUPPLY/IMPLANTS	"$33,904.00"	Outpatient	"$16,952.00"	"$1,365.15"	"$18,545.49"	"$22,613.97"	"$13,561.60"	Not Applicable	"$11,866.40"	"$23,732.80"	"$1,365.15"	"$23,732.80"
KIT DCMPRS SPNE 7.5MM MCBLD SD CTR SHVR IO-MBS7.5SC	C1713	SUPPLY/IMPLANTS	"$33,904.00"	Outpatient	"$16,952.00"	"$1,365.15"	"$18,545.49"	"$22,613.97"	"$13,561.60"	Not Applicable	"$11,866.40"	"$23,732.80"	"$1,365.15"	"$23,732.80"
CURETTE DILATOR IPSI PROBE 1O-K01- IP-5.5		STERILE SUPPLY	"$33,904.00"	Outpatient	"$16,952.00"	Not Applicable	"$18,545.49"	"$22,613.97"	"$13,561.60"	Not Applicable	"$11,866.40"	"$23,732.80"	"$11,866.40"	"$23,732.80"
CAGE SPNL 28X10X10MM CASCADIA CNVX TI POR ANTM NAR INTBDY 6101-2102810NC-G2	C1821	SUPPLY/IMPLANTS	"$33,848.00"	Outpatient	"$16,924.00"	Not Applicable	"$18,514.86"	"$22,576.62"	"$13,539.20"	Not Applicable	"$11,846.80"	"$23,693.60"	"$11,846.80"	"$23,693.60"
CMPNT TIB ANKL 40X33MM LG STAR COCRMO TI PLSM SPRY 400-263	C1776	SUPPLY/IMPLANTS	"$33,845.00"	Outpatient	"$16,922.50"	Not Applicable	"$18,513.22"	"$22,574.62"	"$13,538.00"	Not Applicable	"$11,845.75"	"$23,691.50"	"$11,845.75"	"$23,691.50"
CAGE CASCADIA 10 X 22 X 14 6101-22102214NC-G2	C1821	SUPPLY/IMPLANTS	"$33,842.00"	Outpatient	"$16,921.00"	Not Applicable	"$18,511.57"	"$22,572.61"	"$13,536.80"	Not Applicable	"$11,844.70"	"$23,689.40"	"$11,844.70"	"$23,689.40"
SPRDR DNFX VS SRG 14510P		STERILE SUPPLY	"$33,821.00"	Outpatient	"$16,910.50"	Not Applicable	"$18,500.09"	"$22,558.61"	"$13,528.40"	Not Applicable	"$11,837.35"	"$23,674.70"	"$11,837.35"	"$23,674.70"
CORPECTOMY SPACER OPEN MATRIX SPIRA V 27MM H 0DEG 7 DEG SPV-12145-0727	C1821	SUPPLY/IMPLANTS	"$33,752.00"	Outpatient	"$16,876.00"	Not Applicable	"$18,462.34"	"$22,512.58"	"$13,500.80"	Not Applicable	"$11,813.20"	"$23,626.40"	"$11,813.20"	"$23,626.40"
PLT 2MM MED TI 2 RECON PTSPC CNTR MATRIXMANDIBLE BN SD449.506B	C1713	SUPPLY/IMPLANTS	"$33,748.00"	Outpatient	"$16,874.00"	"$1,365.15"	"$18,460.16"	"$22,509.92"	"$13,499.20"	Not Applicable	"$11,811.80"	"$23,623.60"	"$1,365.15"	"$23,623.60"
PCMKR AZURE WIRELESSLY CRD W1DR01	C1785	PACE MAKER	"$33,719.00"	Outpatient	"$16,859.50"	Not Applicable	"$18,444.29"	"$22,490.57"	"$13,487.60"	Not Applicable	"$11,801.65"	"$23,603.30"	"$11,801.65"	"$23,603.30"
STEM HUM 66MM PRFT AQLS ASCND FLX PTC 132.5D 1B STD SHLDR DWF601B	C1776	SUPPLY/IMPLANTS	"$33,709.00"	Outpatient	"$16,854.50"	Not Applicable	"$18,438.82"	"$22,483.90"	"$13,483.60"	Not Applicable	"$11,798.15"	"$23,596.30"	"$11,798.15"	"$23,596.30"
CAGE CARPECTOMY 26MM CP64713-126	C1821	SUPPLY/IMPLANTS	"$33,690.00"	Outpatient	"$16,845.00"	Not Applicable	"$18,428.43"	"$22,471.23"	"$13,476.00"	Not Applicable	"$11,791.50"	"$23,583.00"	"$11,791.50"	"$23,583.00"
PACEMARKER LEAD ELUNA 8 DT-T 394696	C1898	PACE MAKER	"$33,672.00"	Outpatient	"$16,836.00"	Not Applicable	"$18,418.58"	"$22,459.22"	"$13,468.80"	Not Applicable	"$11,785.20"	"$23,570.40"	"$11,785.20"	"$23,570.40"
TRAY STOR NS 480000001		STERILE SUPPLY	"$33,656.00"	Outpatient	"$16,828.00"	Not Applicable	"$18,409.83"	"$22,448.55"	"$13,462.40"	Not Applicable	"$11,779.60"	"$23,559.20"	"$11,779.60"	"$23,559.20"
PCMKR PROMRI 2 CHMBR CRD ELUNA DR-T 394969	C1785	PACE MAKER	"$33,655.00"	Outpatient	"$16,827.50"	Not Applicable	"$18,409.29"	"$22,447.89"	"$13,462.00"	Not Applicable	"$11,779.25"	"$23,558.50"	"$11,779.25"	"$23,558.50"
AUG ACTB 54MM STRG HIP TRB MTL BTRS REV SYS 489400154	C1776	SUPPLY/IMPLANTS	"$33,604.00"	Outpatient	"$16,802.00"	Not Applicable	"$18,381.39"	"$22,413.87"	"$13,441.60"	Not Applicable	"$11,761.40"	"$23,522.80"	"$11,761.40"	"$23,522.80"
PLT 2.8MM MNDB TI 20 HL RECON MATRIXMANDIBLE BN NS SD449.516	C1713	SUPPLY/IMPLANTS	"$33,598.00"	Outpatient	"$16,799.00"	"$1,365.15"	"$18,378.11"	"$22,409.87"	"$13,439.20"	Not Applicable	"$11,759.30"	"$23,518.60"	"$1,365.15"	"$23,518.60"
CMPNT FEM 7 KN RT POST STAB BEAD TRTHLN PA 5516-F-702	C1776	SUPPLY/IMPLANTS	"$33,551.00"	Outpatient	"$16,775.50"	Not Applicable	"$18,352.40"	"$22,378.52"	"$13,420.40"	Not Applicable	"$11,742.85"	"$23,485.70"	"$11,742.85"	"$23,485.70"
CMPNT FEM 5 KN LT POST STAB BEAD TRTHLN PA 5516F501	C1776	SUPPLY/IMPLANTS	"$33,551.00"	Outpatient	"$16,775.50"	Not Applicable	"$18,352.40"	"$22,378.52"	"$13,420.40"	Not Applicable	"$11,742.85"	"$23,485.70"	"$11,742.85"	"$23,485.70"
CMPNT FEM 6 KN RT POST STAB BEAD TRTHLN PA 5516F602	C1776	SUPPLY/IMPLANTS	"$33,551.00"	Outpatient	"$16,775.50"	Not Applicable	"$18,352.40"	"$22,378.52"	"$13,420.40"	Not Applicable	"$11,742.85"	"$23,485.70"	"$11,742.85"	"$23,485.70"
PLT 45MM SPNE LMBR TI 1 LVL ANTEGRA BN 31MM NS 04.102.145	C1713	SUPPLY/IMPLANTS	"$33,525.00"	Outpatient	"$16,762.50"	"$1,365.15"	"$18,338.18"	"$22,361.18"	"$13,410.00"	Not Applicable	"$11,733.75"	"$23,467.50"	"$1,365.15"	"$23,467.50"
DSTRCT 40MM MDFC ASMB SRG TI NS 487.982	C1713	SUPPLY/IMPLANTS	"$33,522.00"	Outpatient	"$16,761.00"	"$1,365.15"	"$18,336.53"	"$22,359.17"	"$13,408.80"	Not Applicable	"$11,732.70"	"$23,465.40"	"$1,365.15"	"$23,465.40"
OCLR CV 7MM 6-4MM 10MM DCT SLF EXPANDABLE SCR PSTN RTNT SKRT 9-PDA-004	C1817	SUPPLY/IMPLANTS	"$33,521.00"	Outpatient	"$16,760.50"	Not Applicable	"$18,335.99"	"$22,358.51"	"$13,408.40"	Not Applicable	"$11,732.35"	"$23,464.70"	"$11,732.35"	"$23,464.70"
OCLR CV 7MM 8-6MM 12MM DCT SLF EXPANDABLE SCR PSTN RTNT SKRT 9-PDA-005		STERILE SUPPLY	"$33,521.00"	Outpatient	"$16,760.50"	Not Applicable	"$18,335.99"	"$22,358.51"	"$13,408.40"	Not Applicable	"$11,732.35"	"$23,464.70"	"$11,732.35"	"$23,464.70"
OCLR CV 4.25MM 10MM 4MM DCT SLF XPD RADOPQ RTNT DISC AMPLZR 9-PDA2-04-04		STERILE SUPPLY	"$33,521.00"	Outpatient	"$16,760.50"	Not Applicable	"$18,335.99"	"$22,358.51"	"$13,408.40"	Not Applicable	"$11,732.35"	"$23,464.70"	"$11,732.35"	"$23,464.70"
OCLR CV 4.25MM 12MM 6MM DCT SLF XPD RADOPQ RTNT DISC AMPLZR 9-PDA2-06-04		STERILE SUPPLY	"$33,521.00"	Outpatient	"$16,760.50"	Not Applicable	"$18,335.99"	"$22,358.51"	"$13,408.40"	Not Applicable	"$11,732.35"	"$23,464.70"	"$11,732.35"	"$23,464.70"
SYSTEM PACEMAKER ADVISE MRI SURESCAN A3SR01SYSTEM	C1786	PACE MAKER	"$33,432.00"	Outpatient	"$16,716.00"	Not Applicable	"$18,287.30"	"$22,299.14"	"$13,372.80"	Not Applicable	"$11,701.20"	"$23,402.40"	"$11,701.20"	"$23,402.40"
50242-0145-01 - pertuzumab 420 mg Soln	J9306	PHARMACY	"$28,133.00"	Outpatient	"$14,066.50"	$12.55	"$18,286.45"	"$18,764.71"	"$11,253.20"	Not Applicable	"$9,846.55"	"$19,693.10"	$12.55	"$19,693.10"
BIOCOR STENTED TISSUE MITRAL VALVE BIO-25MM-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VALVE AORTIC EPIC FLEXFIT LINX AC PORCINE PERICARDIAL LOW PR ESP100-25-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VALVE AORTIC EPIC FLEXFIT LINX AC PORCINE PERICARDIAL LOW PR ESP100-19-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VALVE AORTIC EPIC FLEXFIT LINX AC PORCINE PERICARDIAL LOW PR ESP100-27-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VALVE AORTIC EPIC FLEXFIT LINX AC PORCINE PERICARDIAL LOW PR ESP100-23-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VALVE AORTIC EPIC FLEXFIT LINX AC PORCINE PERICARDIAL LOW PR ESP100-21-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VALVE BIOCOR STENTED 31MM BIO-31MM-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VALVE 33MM BIOCOR STENTED MITRAL BIO-33MM-00		SUPPLY/IMPLANTS	"$33,413.00"	Outpatient	"$16,706.50"	Not Applicable	"$18,276.91"	"$22,286.47"	"$13,365.20"	Not Applicable	"$11,694.55"	"$23,389.10"	"$11,694.55"	"$23,389.10"
VLV MTRL 25MM 23MM EP FLEXFIT 16MM BPRTH STNT HLDR LOPRFL E100-25M-00		SUPPLY/IMPLANTS	"$33,367.00"	Outpatient	"$16,683.50"	Not Applicable	"$18,251.75"	"$22,255.79"	"$13,346.80"	Not Applicable	"$11,678.45"	"$23,356.90"	"$11,678.45"	"$23,356.90"
VLV MTRL 33MM 31MM EP FLEXFIT 20MM BPRTH STNT HLDR PRCN E100-33M-00		SUPPLY/IMPLANTS	"$33,367.00"	Outpatient	"$16,683.50"	Not Applicable	"$18,251.75"	"$22,255.79"	"$13,346.80"	Not Applicable	"$11,678.45"	"$23,356.90"	"$11,678.45"	"$23,356.90"
DEV TRGT FEM DIST SS NCB NS RT PLT MIS 200024070	C1713	SUPPLY/IMPLANTS	"$33,342.00"	Outpatient	"$16,671.00"	"$1,365.15"	"$18,238.07"	"$22,239.11"	"$13,336.80"	Not Applicable	"$11,669.70"	"$23,339.40"	"$1,365.15"	"$23,339.40"
DEV TRGT FEM DIST SS NCB NS LT PLT MIS 200024071	C1713	SUPPLY/IMPLANTS	"$33,342.00"	Outpatient	"$16,671.00"	"$1,365.15"	"$18,238.07"	"$22,239.11"	"$13,336.80"	Not Applicable	"$11,669.70"	"$23,339.40"	"$1,365.15"	"$23,339.40"
Transluminal Periph Artherectomy Iliac Artery	0238T	CARDIAC CATH LAB	"$33,339.00"	Outpatient	"$16,669.50"	"$31,950.11"	"$18,236.43"	"$1,592.00"	"$13,335.60"	"$8,681.00"	"$11,668.65"	"$23,337.30"	"$1,592.00"	"$31,950.11"
CAGE SPINAL CASCADIA TITANIUM POROUS 10 D L28 MM X W36 MM X 6101-2283613AL10-G2	C1713	SUPPLY/IMPLANTS	"$33,314.00"	Outpatient	"$16,657.00"	"$1,365.15"	"$18,222.76"	"$22,220.44"	"$13,325.60"	Not Applicable	"$11,659.90"	"$23,319.80"	"$1,365.15"	"$23,319.80"
VLV SHNT CERTAS INLN 828800PL		STERILE SUPPLY	"$33,314.00"	Outpatient	"$16,657.00"	Not Applicable	"$18,222.76"	"$22,220.44"	"$13,325.60"	Not Applicable	"$11,659.90"	"$23,319.80"	"$11,659.90"	"$23,319.80"
(BC2) PINNACLE ALTRX POLYTHYLENE ACETABULAR LINER	C1776	SUPPLY/IMPLANTS	"$33,298.00"	Outpatient	"$16,649.00"	Not Applicable	"$18,214.01"	"$22,209.77"	"$13,319.20"	Not Applicable	"$11,654.30"	"$23,308.60"	"$11,654.30"	"$23,308.60"
(BC2) BIOLOX DELTA TS CERAMIC FEMORAL HEAD REVISION	C1776	SUPPLY/IMPLANTS	"$33,298.00"	Outpatient	"$16,649.00"	Not Applicable	"$18,214.01"	"$22,209.77"	"$13,319.20"	Not Applicable	"$11,654.30"	"$23,308.60"	"$11,654.30"	"$23,308.60"
DEV STAB 45MM SPNE PLV SPIRE CD HZN 9240100	C1713	SUPPLY/IMPLANTS	"$33,293.00"	Outpatient	"$16,646.50"	"$1,365.15"	"$18,211.27"	"$22,206.43"	"$13,317.20"	Not Applicable	"$11,652.55"	"$23,305.10"	"$1,365.15"	"$23,305.10"
CMPNT FEM 6N NAR KN LT POST STAB LEGION OXNM 71421266	C1776	SUPPLY/IMPLANTS	"$33,289.00"	Outpatient	"$16,644.50"	Not Applicable	"$18,209.08"	"$22,203.76"	"$13,315.60"	Not Applicable	"$11,651.15"	"$23,302.30"	"$11,651.15"	"$23,302.30"
COMPONENT FEMORAL LEGION OXINIUM 5N NARROW KNEE RIGHT POSTER 71421275	C1776	SUPPLY/IMPLANTS	"$33,288.00"	Outpatient	"$16,644.00"	Not Applicable	"$18,208.54"	"$22,203.10"	"$13,315.20"	Not Applicable	"$11,650.80"	"$23,301.60"	"$11,650.80"	"$23,301.60"
PACEMAKER CARDIAC ASSURITY MRI DR RF MERLINPKG PM2272 CELL	C1785	PACE MAKER	"$33,274.00"	Outpatient	"$16,637.00"	Not Applicable	"$18,200.88"	"$22,193.76"	"$13,309.60"	Not Applicable	"$11,645.90"	"$23,291.80"	"$11,645.90"	"$23,291.80"
CATH CV PALINDROME 28FR 45CM 2 LUM VENATRAC 8888145041		SUPPLY/IMPLANTS	"$33,272.00"	Outpatient	"$16,636.00"	Not Applicable	"$18,199.78"	"$22,192.42"	"$13,308.80"	Not Applicable	"$11,645.20"	"$23,290.40"	"$11,645.20"	"$23,290.40"
PCMKR ELUNA SR-T PROMRI CRD 394971	C1786	PACE MAKER	"$33,265.00"	Outpatient	"$16,632.50"	Not Applicable	"$18,195.96"	"$22,187.76"	"$13,306.00"	Not Applicable	"$11,642.75"	"$23,285.50"	"$11,642.75"	"$23,285.50"
PCMKR THK6MM ASSURITY MRI 2 CHMBR IS-1 CNCT 50X47MM CRD 10.4 PM2272	C1785	PACE MAKER	"$33,265.00"	Outpatient	"$16,632.50"	Not Applicable	"$18,195.96"	"$22,187.76"	"$13,306.00"	Not Applicable	"$11,642.75"	"$23,285.50"	"$11,642.75"	"$23,285.50"
CAGE SPNL 28X10X14MM CASCADIA CNVX TI POR ANTM NAR INTBDY 6101-2102814NC-G2	C1821	SUPPLY/IMPLANTS	"$33,265.00"	Outpatient	"$16,632.50"	Not Applicable	"$18,195.96"	"$22,187.76"	"$13,306.00"	Not Applicable	"$11,642.75"	"$23,285.50"	"$11,642.75"	"$23,285.50"
RCDR CRD CNFRM RX SM SLIM 1 TCH PRGM DATA STOR RMT MNTR DM3500	C1764	SUPPLY/IMPLANTS	"$33,254.00"	Outpatient	"$16,627.00"	Not Applicable	"$18,189.94"	"$22,180.42"	"$13,301.60"	Not Applicable	"$11,638.90"	"$23,277.80"	"$11,638.90"	"$23,277.80"
CATHETER SUCTION CLOTTRIEVER L105 CM OD16 MM STERILE LATEX FREE DISPOSABLE 40-102		STERILE SUPPLY	"$33,253.00"	Outpatient	"$16,626.50"	Not Applicable	"$18,189.39"	"$22,179.75"	"$13,301.20"	Not Applicable	"$11,638.55"	"$23,277.10"	"$11,638.55"	"$23,277.10"
PACEMAKER SYSTEM ADDRL ADDRL	C1785	PACE MAKER	"$33,251.00"	Outpatient	"$16,625.50"	Not Applicable	"$18,188.30"	"$22,178.42"	"$13,300.40"	Not Applicable	"$11,637.85"	"$23,275.70"	"$11,637.85"	"$23,275.70"
SPHR EMBL WHT ONCOZENE 40UM +- 10UM MIC NRDCT CLBRT 3ML 10430-US1		STERILE SUPPLY	"$33,251.00"	Outpatient	"$16,625.50"	Not Applicable	"$18,188.30"	"$22,178.42"	"$13,300.40"	Not Applicable	"$11,637.85"	"$23,275.70"	"$11,637.85"	"$23,275.70"
PCMKR ETRINSA 8 2 CHMBR IMPL RR CRD DR-T 394931	C1785	PACE MAKER	"$33,250.00"	Outpatient	"$16,625.00"	Not Applicable	"$18,187.75"	"$22,177.75"	"$13,300.00"	Not Applicable	"$11,637.50"	"$23,275.00"	"$11,637.50"	"$23,275.00"
SYSTEM ESSENTIO DR IS-1 L101S	C1785	PACE MAKER	"$33,250.00"	Outpatient	"$16,625.00"	Not Applicable	"$18,187.75"	"$22,177.75"	"$13,300.00"	Not Applicable	"$11,637.50"	"$23,275.00"	"$11,637.50"	"$23,275.00"
PCMKR ENTOVIS SR-T + CRD MRI 365 467	C1786	PACE MAKER	"$33,248.00"	Outpatient	"$16,624.00"	Not Applicable	"$18,186.66"	"$22,176.42"	"$13,299.20"	Not Applicable	"$11,636.80"	"$23,273.60"	"$11,636.80"	"$23,273.60"
VLV MTRL 27MM HNCK II CNCH 19MM BPRTH STNT HLDR PRCN T510C27		SUPPLY/IMPLANTS	"$33,232.00"	Outpatient	"$16,616.00"	Not Applicable	"$18,177.90"	"$22,165.74"	"$13,292.80"	Not Applicable	"$11,631.20"	"$23,262.40"	"$11,631.20"	"$23,262.40"
STEM HUM 122MM 6MM RVRS CMPRH MACROBOND SHLDR 11113556	C1776	SUPPLY/IMPLANTS	"$33,219.00"	Outpatient	"$16,609.50"	Not Applicable	"$18,170.79"	"$22,157.07"	"$13,287.60"	Not Applicable	"$11,626.65"	"$23,253.30"	"$11,626.65"	"$23,253.30"
CMPNT FEM 4 KN RT POST STAB GNS2 LEGION SPC 71423234	C1776	SUPPLY/IMPLANTS	"$33,207.00"	Outpatient	"$16,603.50"	Not Applicable	"$18,164.23"	"$22,149.07"	"$13,282.80"	Not Applicable	"$11,622.45"	"$23,244.90"	"$11,622.45"	"$23,244.90"
CMPNT FEM 4 KN LT POST STAB GNS2 LEGION SPC 71423224	C1776	SUPPLY/IMPLANTS	"$33,207.00"	Outpatient	"$16,603.50"	Not Applicable	"$18,164.23"	"$22,149.07"	"$13,282.80"	Not Applicable	"$11,622.45"	"$23,244.90"	"$11,622.45"	"$23,244.90"
STEM FEM 99MM 127D 2 37MM OFST ACLD II V40 PUREFIX TI 30MM 6721-0230	C1776	SUPPLY/IMPLANTS	"$33,198.00"	Outpatient	"$16,599.00"	Not Applicable	"$18,159.31"	"$22,143.07"	"$13,279.20"	Not Applicable	"$11,619.30"	"$23,238.60"	"$11,619.30"	"$23,238.60"
STEM FEM 111MM 132D 6 TPR ACLD 35MM HIP MDLR STRL 6720-0635	C1776	SUPPLY/IMPLANTS	"$33,198.00"	Outpatient	"$16,599.00"	Not Applicable	"$18,159.31"	"$22,143.07"	"$13,279.20"	Not Applicable	"$11,619.30"	"$23,238.60"	"$11,619.30"	"$23,238.60"
STEM FEM 114MM 132D 7 TPR ACLD 37MM HIP MDLR STRL 6720-0737	C1776	SUPPLY/IMPLANTS	"$33,198.00"	Outpatient	"$16,599.00"	Not Applicable	"$18,159.31"	"$22,143.07"	"$13,279.20"	Not Applicable	"$11,619.30"	"$23,238.60"	"$11,619.30"	"$23,238.60"
STEM FEM 155MM 18MM 12 RSTR TI HA HIP 6012-1218	C1776	SUPPLY/IMPLANTS	"$33,197.00"	Outpatient	"$16,598.50"	Not Applicable	"$18,158.76"	"$22,142.40"	"$13,278.80"	Not Applicable	"$11,618.95"	"$23,237.90"	"$11,618.95"	"$23,237.90"
STEM FEM 114MM 127D 7 TPR ACLD 37MM HIP MDLR STRL 6721-0737	C1776	SUPPLY/IMPLANTS	"$33,195.00"	Outpatient	"$16,597.50"	Not Applicable	"$18,157.67"	"$22,141.07"	"$13,278.00"	Not Applicable	"$11,618.25"	"$23,236.50"	"$11,618.25"	"$23,236.50"
STEM FEM 105MM 132D 4 TPR ACLD 35MM HIP MDLR STRL 6720-0435	C1776	SUPPLY/IMPLANTS	"$33,195.00"	Outpatient	"$16,597.50"	Not Applicable	"$18,157.67"	"$22,141.07"	"$13,278.00"	Not Applicable	"$11,618.25"	"$23,236.50"	"$11,618.25"	"$23,236.50"
STEM FEM 108MM 132D 5 TPR ACLD 35MM HIP MDLR STRL 6720-0535	C1776	SUPPLY/IMPLANTS	"$33,195.00"	Outpatient	"$16,597.50"	Not Applicable	"$18,157.67"	"$22,141.07"	"$13,278.00"	Not Applicable	"$11,618.25"	"$23,236.50"	"$11,618.25"	"$23,236.50"
STEM FEM 134MM 133D 7 STD OFST TPR TPRLK PPS HIP TY 1 PRFT 51-100070	C1776	SUPPLY/IMPLANTS	"$33,130.00"	Outpatient	"$16,565.00"	Not Applicable	"$18,122.11"	"$22,097.71"	"$13,252.00"	Not Applicable	"$11,595.50"	"$23,191.00"	"$11,595.50"	"$23,191.00"
STEM FEM 148MM 133D 14 HI OFST TPR TPRLK PPS HIP TY 1 PRFT 51-104140	C1776	SUPPLY/IMPLANTS	"$33,130.00"	Outpatient	"$16,565.00"	Not Applicable	"$18,122.11"	"$22,097.71"	"$13,252.00"	Not Applicable	"$11,595.50"	"$23,191.00"	"$11,595.50"	"$23,191.00"
"STEM FEMORAL TAPERLOC 17 X 154MM, HIGH OFFSET 51-101170"	C1776	SUPPLY/IMPLANTS	"$33,130.00"	Outpatient	"$16,565.00"	Not Applicable	"$18,122.11"	"$22,097.71"	"$13,252.00"	Not Applicable	"$11,595.50"	"$23,191.00"	"$11,595.50"	"$23,191.00"
PLT 2MM ANG MNDB TI BN SD480.110	C1713	SUPPLY/IMPLANTS	"$33,129.00"	Outpatient	"$16,564.50"	"$1,365.15"	"$18,121.56"	"$22,097.04"	"$13,251.60"	Not Applicable	"$11,595.15"	"$23,190.30"	"$1,365.15"	"$23,190.30"
55513-0190-01 - pegfilgrastim 6 mg/0.6 ml Inj	J2505	PHARMACY	"$33,125.00"	Outpatient	"$16,562.50"	"$3,983.14"	"$18,119.38"	"$22,094.38"	"$13,250.00"	Not Applicable	"$11,593.75"	"$23,187.50"	"$3,983.14"	"$23,187.50"
55513-0192-01 - pegfilgrastim 6 mg / 0.6 mL Kit	J2505	PHARMACY	"$33,125.00"	Outpatient	"$16,562.50"	"$3,983.14"	"$18,119.38"	"$22,094.38"	"$13,250.00"	Not Applicable	"$11,593.75"	"$23,187.50"	"$3,983.14"	"$23,187.50"
STEM FEM 134MM 133D 7 HI OFST TPR TPRLK PPS HIP TY 1 FULL 51-101070	C1776	SUPPLY/IMPLANTS	"$33,109.00"	Outpatient	"$16,554.50"	Not Applicable	"$18,110.62"	"$22,083.70"	"$13,243.60"	Not Applicable	"$11,588.15"	"$23,176.30"	"$11,588.15"	"$23,176.30"
BNDR ROD PED LCK NL SYS 124777	C1713	SUPPLY/IMPLANTS	"$33,100.00"	Outpatient	"$16,550.00"	"$1,365.15"	"$18,105.70"	"$22,077.70"	"$13,240.00"	Not Applicable	"$11,585.00"	"$23,170.00"	"$1,365.15"	"$23,170.00"
CMPNT FEM SM 65X55MM KN LT MDLR ROT HNG GMRS TI 64811110	C1776	SUPPLY/IMPLANTS	"$33,093.00"	Outpatient	"$16,546.50"	Not Applicable	"$18,101.87"	"$22,073.03"	"$13,237.20"	Not Applicable	"$11,582.55"	"$23,165.10"	"$11,582.55"	"$23,165.10"
CAGE SPNL 36X15MM ENDOSKELETON TAS 12D LRDTC 24MM LG TI ALIF 2312-0215	C1821	SUPPLY/IMPLANTS	"$33,093.00"	Outpatient	"$16,546.50"	Not Applicable	"$18,101.87"	"$22,073.03"	"$13,237.20"	Not Applicable	"$11,582.55"	"$23,165.10"	"$11,582.55"	"$23,165.10"
CAGE SPNL 40X13MM ENDOSKELETON TAS 12D LRDTC 27MM XL TI ALIF 2312-0313	C1821	SUPPLY/IMPLANTS	"$33,093.00"	Outpatient	"$16,546.50"	Not Applicable	"$18,101.87"	"$22,073.03"	"$13,237.20"	Not Applicable	"$11,582.55"	"$23,165.10"	"$11,582.55"	"$23,165.10"
VALVE AORTIC PERIMOUNT MAGNA SIZE 23 300023		SUPPLY/IMPLANTS	"$33,093.00"	Outpatient	"$16,546.50"	Not Applicable	"$18,101.87"	"$22,073.03"	"$13,237.20"	Not Applicable	"$11,582.55"	"$23,165.10"	"$11,582.55"	"$23,165.10"
VLV AOR 19MM CRP-ED PRIMNT 300019MM		SUPPLY/IMPLANTS	"$33,093.00"	Outpatient	"$16,546.50"	Not Applicable	"$18,101.87"	"$22,073.03"	"$13,237.20"	Not Applicable	"$11,582.55"	"$23,165.10"	"$11,582.55"	"$23,165.10"
VLV AOR 15MM 21MM 26MM 20MM CRP-ED PRIMNT MG THERMAFIX SUP 300021MM		SUPPLY/IMPLANTS	"$33,093.00"	Outpatient	"$16,546.50"	Not Applicable	"$18,101.87"	"$22,073.03"	"$13,237.20"	Not Applicable	"$11,582.55"	"$23,165.10"	"$11,582.55"	"$23,165.10"
VLV AOR 25MM CRP-ED PRIMNT MG BPRTH PRICRD HRT STRL LF 300025MM		SUPPLY/IMPLANTS	"$33,093.00"	Outpatient	"$16,546.50"	Not Applicable	"$18,101.87"	"$22,073.03"	"$13,237.20"	Not Applicable	"$11,582.55"	"$23,165.10"	"$11,582.55"	"$23,165.10"
GFT SFT TIS AMNIOHEAL + AMNIO ALGRF 2 LYR PWDR REPST 200MG TAH2200		STERILE SUPPLY	"$33,079.00"	Outpatient	"$16,539.50"	Not Applicable	"$18,094.21"	"$22,063.69"	"$13,231.60"	Not Applicable	"$11,577.65"	"$23,155.30"	"$11,577.65"	"$23,155.30"
50242-0120-01 - tenecteplase 50 mg Powd	J3101	PHARMACY	"$33,060.00"	Outpatient	"$16,530.00"	$138.11	"$18,083.82"	"$22,051.02"	"$13,224.00"	Not Applicable	"$11,571.00"	"$23,142.00"	$138.11	"$23,142.00"
HUMERAL MONOBLOC CEMENTED EPIPHYSIS SIZE 1 130712110	C1776	SUPPLY/IMPLANTS	"$32,990.00"	Outpatient	"$16,495.00"	Not Applicable	"$18,045.53"	"$22,004.33"	"$13,196.00"	Not Applicable	"$11,546.50"	"$23,093.00"	"$11,546.50"	"$23,093.00"
STEM HUMERAL DELTA XTEND COCR 1 LONG LENGTH OD8 MM SHOULDER 130708110	C1776	SUPPLY/IMPLANTS	"$32,990.00"	Outpatient	"$16,495.00"	Not Applicable	"$18,045.53"	"$22,004.33"	"$13,196.00"	Not Applicable	"$11,546.50"	"$23,093.00"	"$11,546.50"	"$23,093.00"
STEM HUMERAL DELTA XTEND COCR 2 LONG LENGTH OD12 MM SHOULDER 130712-210	C1776	SUPPLY/IMPLANTS	"$32,990.00"	Outpatient	"$16,495.00"	Not Applicable	"$18,045.53"	"$22,004.33"	"$13,196.00"	Not Applicable	"$11,546.50"	"$23,093.00"	"$11,546.50"	"$23,093.00"
KIT XTRNFX HFMN 3 MSQTO A SCPL CLP SLF DRL APX PIN STRL 49229940S		STERILE SUPPLY	"$32,963.00"	Outpatient	"$16,481.50"	Not Applicable	"$18,030.76"	"$21,986.32"	"$13,185.20"	Not Applicable	"$11,537.05"	"$23,074.10"	"$11,537.05"	"$23,074.10"
FIXATION HOFFMAN 3 EXTERNAL 4922-09-940S		SUPPLY/IMPLANTS	"$32,963.00"	Outpatient	"$16,481.50"	Not Applicable	"$18,030.76"	"$21,986.32"	"$13,185.20"	Not Applicable	"$11,537.05"	"$23,074.10"	"$11,537.05"	"$23,074.10"
VLV AOR 20MM 29MM MSC UL CNCH STNT HLDR SW PRCN RING 305 305U229		SUPPLY/IMPLANTS	"$32,953.00"	Outpatient	"$16,476.50"	Not Applicable	"$18,025.29"	"$21,979.65"	"$13,181.20"	Not Applicable	"$11,533.55"	"$23,067.10"	"$11,533.55"	"$23,067.10"
VLV AOR 13.5MM 19MM MSC UL CNCH BPRTH STNT HLDR SW RING PRCN 305U219		SUPPLY/IMPLANTS	"$32,953.00"	Outpatient	"$16,476.50"	Not Applicable	"$18,025.29"	"$21,979.65"	"$13,181.20"	Not Applicable	"$11,533.55"	"$23,067.10"	"$11,533.55"	"$23,067.10"
VLV AOR 15MM 21MM MSC UL CNCH STNT HLDR SW PRCN RING 305 305U221		SUPPLY/IMPLANTS	"$32,953.00"	Outpatient	"$16,476.50"	Not Applicable	"$18,025.29"	"$21,979.65"	"$13,181.20"	Not Applicable	"$11,533.55"	"$23,067.10"	"$11,533.55"	"$23,067.10"
VLV AOR 16MM 23MM MSC UL CNCH STNT HLDR SW PRCN RING 305 305U223		SUPPLY/IMPLANTS	"$32,953.00"	Outpatient	"$16,476.50"	Not Applicable	"$18,025.29"	"$21,979.65"	"$13,181.20"	Not Applicable	"$11,533.55"	"$23,067.10"	"$11,533.55"	"$23,067.10"
VLV MTRL 27MM MSC CNCH 310C27		SUPPLY/IMPLANTS	"$32,953.00"	Outpatient	"$16,476.50"	Not Applicable	"$18,025.29"	"$21,979.65"	"$13,181.20"	Not Applicable	"$11,533.55"	"$23,067.10"	"$11,533.55"	"$23,067.10"
PLT 2MM ANG LT TI 7X23 HL RECON MATRIXMANDIBLE BN PTSPC PLT SD449.503B	C1713	SUPPLY/IMPLANTS	"$32,936.00"	Outpatient	"$16,468.00"	"$1,365.15"	"$18,015.99"	"$21,968.31"	"$13,174.40"	Not Applicable	"$11,527.60"	"$23,055.20"	"$1,365.15"	"$23,055.20"
PLT 2MM ANG RT CRNMXF TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.504B	C1713	SUPPLY/IMPLANTS	"$32,936.00"	Outpatient	"$16,468.00"	"$1,365.15"	"$18,015.99"	"$21,968.31"	"$13,174.40"	Not Applicable	"$11,527.60"	"$23,055.20"	"$1,365.15"	"$23,055.20"
Vascular Embolize/Occlude Organ	37243	OR/MINOR	"$32,933.00"	Outpatient	"$16,466.50"	"$11,009.75"	"$18,014.35"	"$1,592.00"	"$13,173.20"	"$8,681.00"	"$11,526.55"	"$23,053.10"	"$1,592.00"	"$23,053.10"
GRAFT STENT TRIVASCULAR OVATION PRIME OVATION IX PTFE OD12 F TV-IL1414120-J	C1874	SUPPLY/IMPLANTS	"$32,920.00"	Outpatient	"$16,460.00"	Not Applicable	"$18,007.24"	"$21,957.64"	"$13,168.00"	Not Applicable	"$11,522.00"	"$23,044.00"	"$11,522.00"	"$23,044.00"
GRAFT STENT TRIVASCULAR OVATION PRIME OVATION IX PTFE OD15 F TV-IL1428120-J	C1874	SUPPLY/IMPLANTS	"$32,920.00"	Outpatient	"$16,460.00"	Not Applicable	"$18,007.24"	"$21,957.64"	"$13,168.00"	Not Applicable	"$11,522.00"	"$23,044.00"	"$11,522.00"	"$23,044.00"
MODL ANTM CLR LG SD900.215	C1713	SUPPLY/IMPLANTS	"$32,919.00"	Outpatient	"$16,459.50"	"$1,365.15"	"$18,006.69"	"$21,956.97"	"$13,167.60"	Not Applicable	"$11,521.65"	"$23,043.30"	"$1,365.15"	"$23,043.30"
ENDOPROSTHESIS ILIAC LIMB 22 X 100MM TV-IL1422100-J	C1884	SUPPLY/IMPLANTS	"$32,912.00"	Outpatient	"$16,456.00"	Not Applicable	"$18,002.86"	"$21,952.30"	"$13,164.80"	Not Applicable	"$11,519.20"	"$23,038.40"	"$11,519.20"	"$23,038.40"
GFT STNT 160MM 12-14MM 12FR 10FR TRIVASCULAR OV PRM OV IX TV-IL1412160-J	C1884	SUPPLY/IMPLANTS	"$32,912.00"	Outpatient	"$16,456.00"	Not Applicable	"$18,002.86"	"$21,952.30"	"$13,164.80"	Not Applicable	"$11,519.20"	"$23,038.40"	"$11,519.20"	"$23,038.40"
GFT STNT 120MM 12-14MM 13FR 10FR TRIVASCULAR OV PRM OV IX 12 TV-IL1412120-J	C1884	SUPPLY/IMPLANTS	"$32,912.00"	Outpatient	"$16,456.00"	Not Applicable	"$18,002.86"	"$21,952.30"	"$13,164.80"	Not Applicable	"$11,519.20"	"$23,038.40"	"$11,519.20"	"$23,038.40"
GFT STNT 140MM 18-14MM 14MM 11FR TRIVASCULAR OV PRM OV IX 13 TV-IL1418140-J		SUPPLY/IMPLANTS	"$32,912.00"	Outpatient	"$16,456.00"	Not Applicable	"$18,002.86"	"$21,952.30"	"$13,164.80"	Not Applicable	"$11,519.20"	"$23,038.40"	"$11,519.20"	"$23,038.40"
GFT STNT 120MM 16-14MM 14MM 11FR TRIVASCULAR OV PRM OV IX 13 TV-IL1416120-J		SUPPLY/IMPLANTS	"$32,912.00"	Outpatient	"$16,456.00"	Not Applicable	"$18,002.86"	"$21,952.30"	"$13,164.80"	Not Applicable	"$11,519.20"	"$23,038.40"	"$11,519.20"	"$23,038.40"
APR IN CLP 86CM EANCHR CSST HELI-FX 12FR EVAR SA-85		STERILE SUPPLY	"$32,905.00"	Outpatient	"$16,452.50"	Not Applicable	"$17,999.04"	"$21,947.64"	"$13,162.00"	Not Applicable	"$11,516.75"	"$23,033.50"	"$11,516.75"	"$23,033.50"
SCR BN SPNE HA 40MM 10MM SI-LOK 139.504S	C1713	SUPPLY/IMPLANTS	"$32,902.00"	Outpatient	"$16,451.00"	"$1,365.15"	"$17,997.39"	"$21,945.63"	"$13,160.80"	Not Applicable	"$11,515.70"	"$23,031.40"	"$1,365.15"	"$23,031.40"
PACEMAKER CARDIAC ACCOLADE MRI SR IS 1 9H42	C1786	PACE MAKER	"$32,900.00"	Outpatient	"$16,450.00"	Not Applicable	"$17,996.30"	"$21,944.30"	"$13,160.00"	Not Applicable	"$11,515.00"	"$23,030.00"	"$11,515.00"	"$23,030.00"
PACEMAKER CARDIAC EDORA DR-T PROMRI SR-T 431749	C1786	PACE MAKER	"$32,900.00"	Outpatient	"$16,450.00"	Not Applicable	"$17,996.30"	"$21,944.30"	"$13,160.00"	Not Applicable	"$11,515.00"	"$23,030.00"	"$11,515.00"	"$23,030.00"
SYSTEM AZURE XT SR MRI MEEM AZUREXTSRMRIMEEM		PACE MAKER	"$32,879.00"	Outpatient	"$16,439.50"	Not Applicable	"$17,984.81"	"$21,930.29"	"$13,151.60"	Not Applicable	"$11,507.65"	"$23,015.30"	"$11,507.65"	"$23,015.30"
NUSHIELD 6 X 6CM NO-1660		STERILE SUPPLY	"$32,834.00"	Outpatient	"$16,417.00"	Not Applicable	"$17,960.20"	"$21,900.28"	"$13,133.60"	Not Applicable	"$11,491.90"	"$22,983.80"	"$11,491.90"	"$22,983.80"
GD SM HNDL TRGT SRG TIB NTR NL 249000510	C1713	SUPPLY/IMPLANTS	"$32,833.00"	Outpatient	"$16,416.50"	"$1,365.15"	"$17,959.65"	"$21,899.61"	"$13,133.20"	Not Applicable	"$11,491.55"	"$22,983.10"	"$1,365.15"	"$22,983.10"
GFT BN DBM PLGLY 10X2.5CM ALGRF RSRB REMODEL REPL MESH BG 7509510	C1713	SUPPLY/IMPLANTS	"$32,797.00"	Outpatient	"$16,398.50"	"$1,365.15"	"$17,939.96"	"$21,875.60"	"$13,118.80"	Not Applicable	"$11,478.95"	"$22,957.90"	"$1,365.15"	"$22,957.90"
BODY BROACHED RSTR 6 HIP PROX MDLR 6276-3-006	C1776	SUPPLY/IMPLANTS	"$32,784.00"	Outpatient	"$16,392.00"	Not Applicable	"$17,932.85"	"$21,866.93"	"$13,113.60"	Not Applicable	"$11,474.40"	"$22,948.80"	"$11,474.40"	"$22,948.80"
SET INST MDN 225500019	C1713	SUPPLY/IMPLANTS	"$32,768.00"	Outpatient	"$16,384.00"	"$1,365.15"	"$17,924.10"	"$21,856.26"	"$13,107.20"	Not Applicable	"$11,468.80"	"$22,937.60"	"$1,365.15"	"$22,937.60"
COMPONENT FEMORAL GMRS MEDIUM L70 MM X W61 MM KNEE LEFT MODU 6481-1-120	C1776	SUPPLY/IMPLANTS	"$32,741.00"	Outpatient	"$16,370.50"	Not Applicable	"$17,909.33"	"$21,838.25"	"$13,096.40"	Not Applicable	"$11,459.35"	"$22,918.70"	"$11,459.35"	"$22,918.70"
STEM HUM 130MM 13MM REUNION HA SHLDR R5351-4513	C1776	SUPPLY/IMPLANTS	"$32,739.00"	Outpatient	"$16,369.50"	Not Applicable	"$17,908.23"	"$21,836.91"	"$13,095.60"	Not Applicable	"$11,458.65"	"$22,917.30"	"$11,458.65"	"$22,917.30"
FXTR XTRNFX ANKL RDLCNT 20380	C1713	SUPPLY/IMPLANTS	"$32,728.00"	Outpatient	"$16,364.00"	"$1,365.15"	"$17,902.22"	"$21,829.58"	"$13,091.20"	Not Applicable	"$11,454.80"	"$22,909.60"	"$1,365.15"	"$22,909.60"
AUG TIB ASYM TRTHLN TRITANIUM B CONE KN LT MDL RL REV SYS 5549-A-221	C1776	SUPPLY/IMPLANTS	"$32,726.00"	Outpatient	"$16,363.00"	Not Applicable	"$17,901.12"	"$21,828.24"	"$13,090.40"	Not Applicable	"$11,454.10"	"$22,908.20"	"$11,454.10"	"$22,908.20"
STEM HUM 120MM 11MM REUNION HA SHLDR R5351-4511	C1776	SUPPLY/IMPLANTS	"$32,719.00"	Outpatient	"$16,359.50"	Not Applicable	"$17,897.29"	"$21,823.57"	"$13,087.60"	Not Applicable	"$11,451.65"	"$22,903.30"	"$11,451.65"	"$22,903.30"
GRAFT NERVE AVANCE NERVE L50 MM OD4-5 MM ALLOGRAFT NATURAL C 411250	C1762	SUPPLY/IMPLANTS	"$32,718.00"	Outpatient	"$16,359.00"	Not Applicable	"$17,896.75"	"$21,822.91"	"$13,087.20"	Not Applicable	"$11,451.30"	"$22,902.60"	"$11,451.30"	"$22,902.60"
STEM FEM 145MM 13MM 130D LATERALIZE OFST ECHO BMTRC TI POR 192113	C1776	SUPPLY/IMPLANTS	"$32,700.00"	Outpatient	"$16,350.00"	Not Applicable	"$17,886.90"	"$21,810.90"	"$13,080.00"	Not Applicable	"$11,445.00"	"$22,890.00"	"$11,445.00"	"$22,890.00"
STEM FEM 165MM 17MM 130D LATERALIZE OFST ECHO BMTRC TI POR 192117	C1776	SUPPLY/IMPLANTS	"$32,679.00"	Outpatient	"$16,339.50"	Not Applicable	"$17,875.41"	"$21,796.89"	"$13,071.60"	Not Applicable	"$11,437.65"	"$22,875.30"	"$11,437.65"	"$22,875.30"
PCMKR THK6MM ACT DR RF INVISILINK 2 CHMBR INDUCTIVE TELEM PM2210	C1785	PACE MAKER	"$32,649.00"	Outpatient	"$16,324.50"	Not Applicable	"$17,859.00"	"$21,776.88"	"$13,059.60"	Not Applicable	"$11,427.15"	"$22,854.30"	"$11,427.15"	"$22,854.30"
SCREW DISC 4MM SD 80/P 2915994	C1713	SUPPLY/IMPLANTS	"$32,591.00"	Outpatient	"$16,295.50"	"$1,365.15"	"$17,827.28"	"$21,738.20"	"$13,036.40"	Not Applicable	"$11,406.85"	"$22,813.70"	"$1,365.15"	"$22,813.70"
SPACER SYNFIX EVOLUTION LG DEEP/15MM HT/10 DEGREES STL 08.815.344S	C1821	SUPPLY/IMPLANTS	"$32,571.00"	Outpatient	"$16,285.50"	Not Applicable	"$17,816.34"	"$21,724.86"	"$13,028.40"	Not Applicable	"$11,399.85"	"$22,799.70"	"$11,399.85"	"$22,799.70"
SPCR SPNL 40X34X19-14.4MM SYNFIX EVOL 10D LG BLT NOSE PEEK 08.815.346S	C1821	SUPPLY/IMPLANTS	"$32,571.00"	Outpatient	"$16,285.50"	Not Applicable	"$17,816.34"	"$21,724.86"	"$13,028.40"	Not Applicable	"$11,399.85"	"$22,799.70"	"$11,399.85"	"$22,799.70"
SPACER SPINAL SYNFIX EVOLUTION PEEK 10 D MEDIUM BULLET NOSE L36 MM X W28 MM X H12-7.9 MM 3.3 CC RADI	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPACER SPINAL SYNFIX EVOLUTION PEEK 18 D MEDIUM BULLET NOSE L36 MM X W28 MM X H17-8.9 MM 4.1 CC RADI	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 36X28X13.5-9.4MM SYNFIX EVOL 10D MED BLT NOSE PEEK 08.815.213S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 36X28X10.5-8.4MM SYNFIX EVOL 6D MED BLT NOSE PEEK 08.815.201S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 40X31X12-9.6MM SYNFIX EVOL 6D LG BLT NOSE PEEK 08.815.302S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 40X31X15-10.4MM SYNFIX EVOL 10D LG BLT NOSE PEEK 08.815.314S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 40X34X13.5-11.1MM SYNFIX EVOL 6D LG BLT NOSE PEEK 08.815.333S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 40X34X17-12.4MM SYNFIX EVOL 10D LG BLT NOSE PEEK 08.815.345S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 40X34X17-10.4MM SYNFIX EVOL 14D LG BLT NOSE PEEK 08.815.355S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 40X31X13.5-8.9MM SYNFIX EVOL 10D LG BLT NOSE PEEK 08.815.313S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPCR SPNL 40X31X15-12.6MM SYNFIX EVOL 6D LG BLT NOSE PEEK 08.815.304S	C1821	SUPPLY/IMPLANTS	"$32,562.00"	Outpatient	"$16,281.00"	Not Applicable	"$17,811.41"	"$21,718.85"	"$13,024.80"	Not Applicable	"$11,396.70"	"$22,793.40"	"$11,396.70"	"$22,793.40"
SPACER SPINAL SYNFIX EVOLUTION PEEK 14 D MEDIUM BULLET NOSE L36 MM X W28 MM X H17-10.9 MM 4.5 CC RAD	C1821	SUPPLY/IMPLANTS	"$32,561.00"	Outpatient	"$16,280.50"	Not Applicable	"$17,810.87"	"$21,718.19"	"$13,024.40"	Not Applicable	"$11,396.35"	"$22,792.70"	"$11,396.35"	"$22,792.70"
SPACER SPINAL SYNFIX EVOLUTION PEEK 18 D LARGE BULLET NOSE L40 MM X W31 MM X H15-6 MM 3.9 CC RADIOPA	C1821	SUPPLY/IMPLANTS	"$32,561.00"	Outpatient	"$16,280.50"	Not Applicable	"$17,810.87"	"$21,718.19"	"$13,024.40"	Not Applicable	"$11,396.35"	"$22,792.70"	"$11,396.35"	"$22,792.70"
Implantable artificial cervical disc for anterior cervical f CDL-727	C1776	SUPPLY/IMPLANTS	"$32,532.00"	Outpatient	"$16,266.00"	Not Applicable	"$17,795.00"	"$21,698.84"	"$13,012.80"	Not Applicable	"$11,386.20"	"$22,772.40"	"$11,386.20"	"$22,772.40"
CERVICAL DISC 6 LARGE 17MM X 14MM D X6MM H	C1713	SUPPLY/IMPLANTS	"$32,532.00"	Outpatient	"$16,266.00"	"$1,365.15"	"$17,795.00"	"$21,698.84"	"$13,012.80"	Not Applicable	"$11,386.20"	"$22,772.40"	"$1,365.15"	"$22,772.40"
TISSUE AMNIOJECT 1.25 ML AGT-5125	C9363	SUPPLY/IMPLANTS	"$32,520.00"	Outpatient	"$16,260.00"	$38.51	"$17,788.44"	"$21,690.84"	"$13,008.00"	Not Applicable	"$11,382.00"	"$22,764.00"	$38.51	"$22,764.00"
PCMKR .75CM ESSENTIO PACESAFE RIGHTRATE EASYVIEW DR-EL TY RA L131	C1785	PACE MAKER	"$32,520.00"	Outpatient	"$16,260.00"	Not Applicable	"$17,788.44"	"$21,690.84"	"$13,008.00"	Not Applicable	"$11,382.00"	"$22,764.00"	"$11,382.00"	"$22,764.00"
PRESTIGE LP CERVICAL DISC 5 X 14MM TITANIUM CARBIDE COMPOSIT 6972450	C1776	SUPPLY/IMPLANTS	"$32,512.00"	Outpatient	"$16,256.00"	Not Applicable	"$17,784.06"	"$21,685.50"	"$13,004.80"	Not Applicable	"$11,379.20"	"$22,758.40"	"$11,379.20"	"$22,758.40"
DISC INTVRTB 14MM 6MM PSTG LP SPNE CRV TI STRL LF 6972460	C1713	SUPPLY/IMPLANTS	"$32,494.00"	Outpatient	"$16,247.00"	"$1,365.15"	"$17,774.22"	"$21,673.50"	"$12,997.60"	Not Applicable	"$11,372.90"	"$22,745.80"	"$1,365.15"	"$22,745.80"
DISC INTERVERTEBRAL MOBI-C D17 MM STANDARD W17 MM X H5 MM MB3775		SUPPLY/IMPLANTS	"$32,494.00"	Outpatient	"$16,247.00"	Not Applicable	"$17,774.22"	"$21,673.50"	"$12,997.60"	Not Applicable	"$11,372.90"	"$22,745.80"	"$11,372.90"	"$22,745.80"
TISSUE AMNIOJECT 2.0 ML AGT-5200	C9363	SUPPLY/IMPLANTS	"$32,481.00"	Outpatient	"$16,240.50"	$38.51	"$17,767.11"	"$21,664.83"	"$12,992.40"	Not Applicable	"$11,368.35"	"$22,736.70"	$38.51	"$22,736.70"
DISC INTERVERTEBRAL PRODISC-C COCR TITANIUM UHMWPE LARGE H5 09.820.045S		SUPPLY/IMPLANTS	"$32,444.00"	Outpatient	"$16,222.00"	Not Applicable	"$17,746.87"	"$21,640.15"	"$12,977.60"	Not Applicable	"$11,355.40"	"$22,710.80"	"$11,355.40"	"$22,710.80"
PRODISC C  IMPLANT LARGE 6MM STERILE 09.820.046S		SUPPLY/IMPLANTS	"$32,444.00"	Outpatient	"$16,222.00"	Not Applicable	"$17,746.87"	"$21,640.15"	"$12,977.60"	Not Applicable	"$11,355.40"	"$22,710.80"	"$11,355.40"	"$22,710.80"
55513-0956-01 - panitumumab 20 mg/mL Sol	J9303	PHARMACY	"$27,282.00"	Outpatient	"$13,641.00"	$125.49	"$17,733.30"	"$18,197.09"	"$10,912.80"	Not Applicable	"$9,548.70"	"$19,097.40"	$125.49	"$19,097.40"
COMPONENT FEMORAL LARGE KNEE RIGHT HRHK 6481-1-131	C1776	SUPPLY/IMPLANTS	"$32,407.00"	Outpatient	"$16,203.50"	Not Applicable	"$17,726.63"	"$21,615.47"	"$12,962.80"	Not Applicable	"$11,342.45"	"$22,684.90"	"$11,342.45"	"$22,684.90"
PLT 10MM SPNE LAT TI 2 HL XLP BN 7521010	C1713	SUPPLY/IMPLANTS	"$32,403.00"	Outpatient	"$16,201.50"	"$1,365.15"	"$17,724.44"	"$21,612.80"	"$12,961.20"	Not Applicable	"$11,341.05"	"$22,682.10"	"$1,365.15"	"$22,682.10"
PLT 12MM SPNE LAT TI 2 HL XLP BN 7521012	C1713	SUPPLY/IMPLANTS	"$32,403.00"	Outpatient	"$16,201.50"	"$1,365.15"	"$17,724.44"	"$21,612.80"	"$12,961.20"	Not Applicable	"$11,341.05"	"$22,682.10"	"$1,365.15"	"$22,682.10"
CMPNT FEM 6D MED 71X66MM KN LT ROT HNG PIN BMPR STP LD SHR 623401L	C1776	SUPPLY/IMPLANTS	"$32,326.00"	Outpatient	"$16,163.00"	Not Applicable	"$17,682.32"	"$21,561.44"	"$12,930.40"	Not Applicable	"$11,314.10"	"$22,628.20"	"$11,314.10"	"$22,628.20"
MESH 10X5IN RECT POLY-4-HB PHASIX SEPRA MFL RSRB SRG HRN 1201325	C1781	SUPPLY/IMPLANTS	"$32,310.00"	Outpatient	"$16,155.00"	Not Applicable	"$17,673.57"	"$21,550.77"	"$12,924.00"	Not Applicable	"$11,308.50"	"$22,617.00"	"$11,308.50"	"$22,617.00"
STNT VASC 4.5MM 22MM RECON DEV SLF EXPANDABLE DLV SYS ENTRP ENF452212	C1784	SUPPLY/IMPLANTS	"$32,301.00"	Outpatient	"$16,150.50"	Not Applicable	"$17,668.65"	"$21,544.77"	"$12,920.40"	Not Applicable	"$11,305.35"	"$22,610.70"	"$11,305.35"	"$22,610.70"
STNT VASC 4.5MM 28MM RECON DEV SLF EXPANDABLE DLV SYS ENTRP ENF452812	C1784	SUPPLY/IMPLANTS	"$32,301.00"	Outpatient	"$16,150.50"	Not Applicable	"$17,668.65"	"$21,544.77"	"$12,920.40"	Not Applicable	"$11,305.35"	"$22,610.70"	"$11,305.35"	"$22,610.70"
STNT VASC 4.5MM 37MM RECON DEV SLF EXPANDABLE DLV SYS ENTRP ENF453712	C1784	SUPPLY/IMPLANTS	"$32,301.00"	Outpatient	"$16,150.50"	Not Applicable	"$17,668.65"	"$21,544.77"	"$12,920.40"	Not Applicable	"$11,305.35"	"$22,610.70"	"$11,305.35"	"$22,610.70"
GFT SFT TIS 20X15CM PERMACOL THK1MM PRCN DRML CLGN STRL P101520	C9364	SUPPLY/IMPLANTS	"$32,285.00"	Outpatient	"$16,142.50"	$19.47	"$17,659.90"	"$21,534.10"	"$12,914.00"	Not Applicable	"$11,299.75"	"$22,599.50"	$19.47	"$22,599.50"
MODL TRN BNDL RECON LF VSP VSPRECONNM		STERILE SUPPLY	"$32,183.00"	Outpatient	"$16,091.50"	Not Applicable	"$17,604.10"	"$21,466.06"	"$12,873.20"	Not Applicable	"$11,264.05"	"$22,528.10"	"$11,264.05"	"$22,528.10"
COMPONENT FEMORAL VANGUARD TITANIUM L65 MM KNEE RIGHT POSTER CP113638	C1776	SUPPLY/IMPLANTS	"$32,154.00"	Outpatient	"$16,077.00"	Not Applicable	"$17,588.24"	"$21,446.72"	"$12,861.60"	Not Applicable	"$11,253.90"	"$22,507.80"	"$11,253.90"	"$22,507.80"
COMPONENT FEMORAL VANGUARD TITANIUM L65 MM KNEE LEFT POSTERI CP113639	C1776	SUPPLY/IMPLANTS	"$32,154.00"	Outpatient	"$16,077.00"	Not Applicable	"$17,588.24"	"$21,446.72"	"$12,861.60"	Not Applicable	"$11,253.90"	"$22,507.80"	"$11,253.90"	"$22,507.80"
PLT .5MM CRNMXF 3X21 HL PRT CNTRSNK DLT BN 7092047	C1713	SUPPLY/IMPLANTS	"$32,136.00"	Outpatient	"$16,068.00"	"$1,365.15"	"$17,578.39"	"$21,434.71"	"$12,854.40"	Not Applicable	"$11,247.60"	"$22,495.20"	"$1,365.15"	"$22,495.20"
PLT .75MM 3X21 HL PRT CNTRSNK BN 7092045	C1713	SUPPLY/IMPLANTS	"$32,136.00"	Outpatient	"$16,068.00"	"$1,365.15"	"$17,578.39"	"$21,434.71"	"$12,854.40"	Not Applicable	"$11,247.60"	"$22,495.20"	"$1,365.15"	"$22,495.20"
LEAD PCNG 58CM 7FR ECRDM DURATA SJ4 2 COIL TRUE BP CARDVRT 7121Q/58	C1895	PACE MAKER	"$32,118.00"	Outpatient	"$16,059.00"	Not Applicable	"$17,568.55"	"$21,422.71"	"$12,847.20"	Not Applicable	"$11,241.30"	"$22,482.60"	"$11,241.30"	"$22,482.60"
CMPNT FEM 62.5MM KN RT POST STAB CLS VNGRD TI CP113636	C1776	SUPPLY/IMPLANTS	"$32,117.00"	Outpatient	"$16,058.50"	Not Applicable	"$17,568.00"	"$21,422.04"	"$12,846.80"	Not Applicable	"$11,240.95"	"$22,481.90"	"$11,240.95"	"$22,481.90"
STEM HUM 16MM PRFT REUNION SHLDR TL ARTHPL SYS 5569-P-2016	C1776	SUPPLY/IMPLANTS	"$32,084.00"	Outpatient	"$16,042.00"	Not Applicable	"$17,549.95"	"$21,400.03"	"$12,833.60"	Not Applicable	"$11,229.40"	"$22,458.80"	"$11,229.40"	"$22,458.80"
STEM HUM 128MM 12MM PRFT REUNION SHLDR STRL 5569-P-2012	C1776	SUPPLY/IMPLANTS	"$32,084.00"	Outpatient	"$16,042.00"	Not Applicable	"$17,549.95"	"$21,400.03"	"$12,833.60"	Not Applicable	"$11,229.40"	"$22,458.80"	"$11,229.40"	"$22,458.80"
MAJOR SHOULDER OR ELBOW JOINT PROCEDURE WITH MCC/CC SHOULDER DRG 507SN	C1713	SUPPLY/IMPLANTS	"$32,084.00"	Outpatient	"$16,042.00"	"$1,365.15"	"$17,549.95"	"$21,400.03"	"$12,833.60"	Not Applicable	"$11,229.40"	"$22,458.80"	"$1,365.15"	"$22,458.80"
MAJOR SHOULDER OR ELBOW JOINT PROCEDURE WITH MCC/CC SHOULDER DRG 507ZB	C1713	SUPPLY/IMPLANTS	"$32,084.00"	Outpatient	"$16,042.00"	"$1,365.15"	"$17,549.95"	"$21,400.03"	"$12,833.60"	Not Applicable	"$11,229.40"	"$22,458.80"	"$1,365.15"	"$22,458.80"
MAJOR SHOULDER OR ELBOW JOINT PROCEDURE WITH MCC/CC SHOULDER DRG 507DS	C1713	SUPPLY/IMPLANTS	"$32,084.00"	Outpatient	"$16,042.00"	"$1,365.15"	"$17,549.95"	"$21,400.03"	"$12,833.60"	Not Applicable	"$11,229.40"	"$22,458.80"	"$1,365.15"	"$22,458.80"
AV Fistula Central Segment Angioplasty	36907	CARDIAC CATH LAB	"$32,080.00"	Outpatient	"$16,040.00"	"$6,548.38"	"$17,547.76"	"$21,397.36"	"$12,832.00"	$819.00	"$11,228.00"	"$22,456.00"	$819.00	"$22,456.00"
RESTORIS MCK BI ONLAY 210034	C1776	SUPPLY/IMPLANTS	"$32,076.00"	Outpatient	"$16,038.00"	Not Applicable	"$17,545.57"	"$21,394.69"	"$12,830.40"	Not Applicable	"$11,226.60"	"$22,453.20"	"$11,226.60"	"$22,453.20"
PCMKR EVIA DR-T CLS LANDLINE HM CRD 377846	C1785	PACE MAKER	"$32,066.00"	Outpatient	"$16,033.00"	Not Applicable	"$17,540.10"	"$21,388.02"	"$12,826.40"	Not Applicable	"$11,223.10"	"$22,446.20"	"$11,223.10"	"$22,446.20"
PCMKR THK6.5MM HOME MNTR EVIA DR-T 2 CHMBR RR UNPLR BP IS-1 359529	C1785	PACE MAKER	"$32,066.00"	Outpatient	"$16,033.00"	Not Applicable	"$17,540.10"	"$21,388.02"	"$12,826.40"	Not Applicable	"$11,223.10"	"$22,446.20"	"$11,223.10"	"$22,446.20"
PCMKR EVIA DR-T CLS GSM HM CLLR CRD 377847	C1785	PACE MAKER	"$32,066.00"	Outpatient	"$16,033.00"	Not Applicable	"$17,540.10"	"$21,388.02"	"$12,826.40"	Not Applicable	"$11,223.10"	"$22,446.20"	"$11,223.10"	"$22,446.20"
SPCR SPNL 26MMX8MM AVS NVGTR 0D PEEK RADOPQ HLW TLIF NS 48392080	C1821	SUPPLY/IMPLANTS	"$32,065.00"	Outpatient	"$16,032.50"	Not Applicable	"$17,539.56"	"$21,387.36"	"$12,826.00"	Not Applicable	"$11,222.75"	"$22,445.50"	"$11,222.75"	"$22,445.50"
GFT STNT 124MM 16-13MM 14FR ENDURANT II EVAS NTNL PLSTR ETLW1613C124E	C1874	SUPPLY/IMPLANTS	"$32,051.00"	Outpatient	"$16,025.50"	Not Applicable	"$17,531.90"	"$21,378.02"	"$12,820.40"	Not Applicable	"$11,217.85"	"$22,435.70"	"$11,217.85"	"$22,435.70"
GFT STNT 124MM 16-20MM 16FR ENDURANT II EVAS NTNL PLSTR ETLW1620C124E	C1876	SUPPLY/IMPLANTS	"$32,051.00"	Outpatient	"$16,025.50"	Not Applicable	"$17,531.90"	"$21,378.02"	"$12,820.40"	Not Applicable	"$11,217.85"	"$22,435.70"	"$11,217.85"	"$22,435.70"
GFT STNT 156MM 16-16MM 16FR ENDURANT II EVAS NTNL PLSTR ETLW1616C156E	C1884	SUPPLY/IMPLANTS	"$32,027.00"	Outpatient	"$16,013.50"	Not Applicable	"$17,518.77"	"$21,362.01"	"$12,810.80"	Not Applicable	"$11,209.45"	"$22,418.90"	"$11,209.45"	"$22,418.90"
STEM FEM 125MM 14MM STRG FLUT GMRS COCR HIP PRFT 6495-5-014	C1776	SUPPLY/IMPLANTS	"$32,004.00"	Outpatient	"$16,002.00"	Not Applicable	"$17,506.19"	"$21,346.67"	"$12,801.60"	Not Applicable	"$11,201.40"	"$22,402.80"	"$11,201.40"	"$22,402.80"
VLV AOR 19MM 16.7MM MSTR HP XPD CUF MECH ROT LFLT OPN 85D 19AEHPJ-505		SUPPLY/IMPLANTS	"$31,990.00"	Outpatient	"$15,995.00"	Not Applicable	"$17,498.53"	"$21,337.33"	"$12,796.00"	Not Applicable	"$11,196.50"	"$22,393.00"	"$11,196.50"	"$22,393.00"
VLV AOR 23MM 20.4MM MSTR HP XPD CUF MECH ROT LFLT OPN 85D 23AEHPJ-505		SUPPLY/IMPLANTS	"$31,990.00"	Outpatient	"$15,995.00"	Not Applicable	"$17,498.53"	"$21,337.33"	"$12,796.00"	Not Applicable	"$11,196.50"	"$22,393.00"	"$11,196.50"	"$22,393.00"
PLT 10 SPNE 4 HL DECADE BN NS XLIF 7140410	C1713	SUPPLY/IMPLANTS	"$31,988.00"	Outpatient	"$15,994.00"	"$1,365.15"	"$17,497.44"	"$21,336.00"	"$12,795.20"	Not Applicable	"$11,195.80"	"$22,391.60"	"$1,365.15"	"$22,391.60"
PLT 12 SPNE 4 HL DECADE BN NS XLIF 7140412	C1713	SUPPLY/IMPLANTS	"$31,988.00"	Outpatient	"$15,994.00"	"$1,365.15"	"$17,497.44"	"$21,336.00"	"$12,795.20"	Not Applicable	"$11,195.80"	"$22,391.60"	"$1,365.15"	"$22,391.60"
Implantable expandable TLIF cage 28-3144	C1821	SUPPLY/IMPLANTS	"$31,951.00"	Outpatient	"$15,975.50"	Not Applicable	"$17,477.20"	"$21,311.32"	"$12,780.40"	Not Applicable	"$11,182.85"	"$22,365.70"	"$11,182.85"	"$22,365.70"
PLT 2MM SM 2 ANG TI RECON MATRIXMANDIBLE BN SD449.505B	C1713	SUPPLY/IMPLANTS	"$31,947.00"	Outpatient	"$15,973.50"	"$1,365.15"	"$17,475.01"	"$21,308.65"	"$12,778.80"	Not Applicable	"$11,181.45"	"$22,362.90"	"$1,365.15"	"$22,362.90"
SYS CRD PCMKR ETRINSA DR-T CLS HOME MNTR 405421	C1785	PACE MAKER	"$31,939.00"	Outpatient	"$15,969.50"	Not Applicable	"$17,470.63"	"$21,303.31"	"$12,775.60"	Not Applicable	"$11,178.65"	"$22,357.30"	"$11,178.65"	"$22,357.30"
CAGE FLEXFIT AT0913	C1713	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	"$1,365.15"	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$1,365.15"	"$22,353.10"
CAGE FLEXFIT AT0912	C1713	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	"$1,365.15"	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$1,365.15"	"$22,353.10"
CAGE FLXFIT AT0910	C1713	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	"$1,365.15"	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$1,365.15"	"$22,353.10"
CAGE FLXFIT AT0908	C1713	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	"$1,365.15"	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$1,365.15"	"$22,353.10"
CAGE FLXFIT AT0909 AT0909	C1713	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	"$1,365.15"	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$1,365.15"	"$22,353.10"
FLXFIT CAGE AT0911	C1713	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	"$1,365.15"	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$1,365.15"	"$22,353.10"
CAGE 33MM X 13MM X 12 DEGREES ML II-TI M331312C	C1821	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	Not Applicable	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$11,176.55"	"$22,353.10"
SPCR SPNL 26X10X10MM RISE NS 193.112	C1821	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	Not Applicable	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$11,176.55"	"$22,353.10"
SPCR SPNL 11X14X27.5MM VBR-S CRV TRB MTL VERT BD REPL STRL 06-115-00271	C1821	SUPPLY/IMPLANTS	"$31,933.00"	Outpatient	"$15,966.50"	Not Applicable	"$17,467.35"	"$21,299.31"	"$12,773.20"	Not Applicable	"$11,176.55"	"$22,353.10"	"$11,176.55"	"$22,353.10"
CAGE SPNL 14X26MM BENGAL 12MM STD LRDTC THORLMBR CFRP STKBL 177306126		STERILE SUPPLY	"$31,923.00"	Outpatient	"$15,961.50"	Not Applicable	"$17,461.88"	"$21,292.64"	"$12,769.20"	Not Applicable	"$11,173.05"	"$22,346.10"	"$11,173.05"	"$22,346.10"
CAGE GIZA DIAM 14MM 23-32MM 25 DEG 48291422S	C1821	SUPPLY/IMPLANTS	"$31,918.00"	Outpatient	"$15,959.00"	Not Applicable	"$17,459.15"	"$21,289.31"	"$12,767.20"	Not Applicable	"$11,171.30"	"$22,342.60"	"$11,171.30"	"$22,342.60"
SHOULDER COMP SHRT ST/RGX GLD/VRSDL HD 98B00901502		STERILE SUPPLY	"$31,918.00"	Outpatient	"$15,959.00"	Not Applicable	"$17,459.15"	"$21,289.31"	"$12,767.20"	Not Applicable	"$11,171.30"	"$22,342.60"	"$11,171.30"	"$22,342.60"
TRINITY EVOLUTION 15CC 410115	C9363	SUPPLY/IMPLANTS	"$31,915.00"	Outpatient	"$15,957.50"	$38.51	"$17,457.51"	"$21,287.31"	"$12,766.00"	Not Applicable	"$11,170.25"	"$22,340.50"	$38.51	"$22,340.50"
ROD SPNL ANNEX 120MM 5.5MM STRG HLF JOG NS ADJ LVL SYS 1176752	C1713	SUPPLY/IMPLANTS	"$31,913.00"	Outpatient	"$15,956.50"	"$1,365.15"	"$17,456.41"	"$21,285.97"	"$12,765.20"	Not Applicable	"$11,169.55"	"$22,339.10"	"$1,365.15"	"$22,339.10"
CAGE SPNL 21/24X10X7-10MM ELT PRLL XPD INTRBD FS NS LF 541-0001	C1821	SUPPLY/IMPLANTS	"$31,913.00"	Outpatient	"$15,956.50"	Not Applicable	"$17,456.41"	"$21,285.97"	"$12,765.20"	Not Applicable	"$11,169.55"	"$22,339.10"	"$11,169.55"	"$22,339.10"
CAGE SPNL 21/24X10X8-11MM ELT 6D XPD INTRBD FS NS LF 541-0004	C1821	SUPPLY/IMPLANTS	"$31,913.00"	Outpatient	"$15,956.50"	Not Applicable	"$17,456.41"	"$21,285.97"	"$12,765.20"	Not Applicable	"$11,169.55"	"$22,339.10"	"$11,169.55"	"$22,339.10"
CAGE SPNL 22-34MM 12MM X-COR MN XPD VERT BD REPL NS LF 5962223	C1821	SUPPLY/IMPLANTS	"$31,913.00"	Outpatient	"$15,956.50"	Not Applicable	"$17,456.41"	"$21,285.97"	"$12,765.20"	Not Applicable	"$11,169.55"	"$22,339.10"	"$11,169.55"	"$22,339.10"
SPCR SPNL 11X14X23MM VBR-S CRV TRB MTL VERT BD REPL STRL 06-115-00231	C1821	SUPPLY/IMPLANTS	"$31,913.00"	Outpatient	"$15,956.50"	Not Applicable	"$17,456.41"	"$21,285.97"	"$12,765.20"	Not Applicable	"$11,169.55"	"$22,339.10"	"$11,169.55"	"$22,339.10"
SPCR SPNL 14X25MM NIKO 5D 12MM SM PEEK-OPTM CORPECTOMY NS LF 342.925	C1821	SUPPLY/IMPLANTS	"$31,913.00"	Outpatient	"$15,956.50"	Not Applicable	"$17,456.41"	"$21,285.97"	"$12,765.20"	Not Applicable	"$11,169.55"	"$22,339.10"	"$11,169.55"	"$22,339.10"
CAGE SPNL 17-24MM 12MM X-COR MN XPD VERT BD REPL NS LF 5962172		STERILE SUPPLY	"$31,913.00"	Outpatient	"$15,956.50"	Not Applicable	"$17,456.41"	"$21,285.97"	"$12,765.20"	Not Applicable	"$11,169.55"	"$22,339.10"	"$11,169.55"	"$22,339.10"
SLNG SUBURETHRAL ADV KT PP M 720088-01	C1771	SUPPLY/IMPLANTS	"$31,898.00"	Outpatient	"$15,949.00"	Not Applicable	"$17,448.21"	"$21,275.97"	"$12,759.20"	Not Applicable	"$11,164.30"	"$22,328.60"	"$11,164.30"	"$22,328.60"
VLV AOR 16MM 23MM HNCK II ULT CNCH BPRTH STNT HLDR SW RING T505U223	C1762	SUPPLY/IMPLANTS	"$31,891.00"	Outpatient	"$15,945.50"	Not Applicable	"$17,444.38"	"$21,271.30"	"$12,756.40"	Not Applicable	"$11,161.85"	"$22,323.70"	"$11,161.85"	"$22,323.70"
VLV AOR 15MM 21MM HNCK II ULT CNCH BPRTH STNT HLDR SW RING T505U221		SUPPLY/IMPLANTS	"$31,891.00"	Outpatient	"$15,945.50"	Not Applicable	"$17,444.38"	"$21,271.30"	"$12,756.40"	Not Applicable	"$11,161.85"	"$22,323.70"	"$11,161.85"	"$22,323.70"
50242-0087-01 - ado-trastuzumab emtansine 160 mg Powd	J9354	PHARMACY	"$26,831.00"	Outpatient	"$13,415.50"	$33.86	"$17,440.15"	"$17,896.28"	"$10,732.40"	Not Applicable	"$9,390.85"	"$18,781.70"	$33.86	"$18,781.70"
GFT STNT 100MM 34MM 17FR AFX ACTIVESEAL STRATA STRG EVAS AAA A34-34/C80-020	C1722	SUPPLY/IMPLANTS	"$31,876.00"	Outpatient	"$15,938.00"	Not Applicable	"$17,436.17"	"$21,261.29"	"$12,750.40"	Not Applicable	"$11,156.60"	"$22,313.20"	"$11,156.60"	"$22,313.20"
GFT NRV 50MM 3-4MM ADV ALGRF STRL 311250	C1763	SUPPLY/IMPLANTS	"$31,869.00"	Outpatient	"$15,934.50"	Not Applicable	"$17,432.34"	"$21,256.62"	"$12,747.60"	Not Applicable	"$11,154.15"	"$22,308.30"	"$11,154.15"	"$22,308.30"
AUG FEM 10MM TL STAB KN RT TRTHLN 6 5541-A-602	C1776	SUPPLY/IMPLANTS	"$31,837.00"	Outpatient	"$15,918.50"	Not Applicable	"$17,414.84"	"$21,235.28"	"$12,734.80"	Not Applicable	"$11,142.95"	"$22,285.90"	"$11,142.95"	"$22,285.90"
AUG TIB SMTR REV TRTHLN TRITANIUM D CONE KN 5549-A-140	C1776	SUPPLY/IMPLANTS	"$31,837.00"	Outpatient	"$15,918.50"	Not Applicable	"$17,414.84"	"$21,235.28"	"$12,734.80"	Not Applicable	"$11,142.95"	"$22,285.90"	"$11,142.95"	"$22,285.90"
455565 SCREWS BASE 230001500	C1713	SUPPLY/IMPLANTS	"$31,809.00"	Outpatient	"$15,904.50"	"$1,365.15"	"$17,399.52"	"$21,216.60"	"$12,723.60"	Not Applicable	"$11,133.15"	"$22,266.30"	"$1,365.15"	"$22,266.30"
CMPNT FEM 2.5 63X59MM KN RT CMNT CRCTE STAB PFC S TC3 STRL 960092	C1776	SUPPLY/IMPLANTS	"$31,791.00"	Outpatient	"$15,895.50"	Not Applicable	"$17,389.68"	"$21,204.60"	"$12,716.40"	Not Applicable	"$11,126.85"	"$22,253.70"	"$11,126.85"	"$22,253.70"
CMPNT FEM MED 70X61MM KN LT MDLR ROT HNG GMRS 64811120	C1776	SUPPLY/IMPLANTS	"$31,775.00"	Outpatient	"$15,887.50"	Not Applicable	"$17,380.93"	"$21,193.93"	"$12,710.00"	Not Applicable	"$11,121.25"	"$22,242.50"	"$11,121.25"	"$22,242.50"
COMPONENT FEMORAL GMRS TITANIUM MEDIUM L70 MM X W61 MM KNEE 64811121	C1776	SUPPLY/IMPLANTS	"$31,775.00"	Outpatient	"$15,887.50"	Not Applicable	"$17,380.93"	"$21,193.93"	"$12,710.00"	Not Applicable	"$11,121.25"	"$22,242.50"	"$11,121.25"	"$22,242.50"
BODY CONE HIP +0MM STD RSTR TI 19MM MDLR STRL REV SYS 6276-1-019	C1776	SUPPLY/IMPLANTS	"$31,772.00"	Outpatient	"$15,886.00"	Not Applicable	"$17,379.28"	"$21,191.92"	"$12,708.80"	Not Applicable	"$11,120.20"	"$22,240.40"	"$11,120.20"	"$22,240.40"
BODY CONE HIP PROX +0MM STD RSTR 23MM MDLR 6276-1-023	C1776	SUPPLY/IMPLANTS	"$31,772.00"	Outpatient	"$15,886.00"	Not Applicable	"$17,379.28"	"$21,191.92"	"$12,708.80"	Not Applicable	"$11,120.20"	"$22,240.40"	"$11,120.20"	"$22,240.40"
CMPNT FEM 4 71X65MM KN RT CMNT CRCTE STAB PFC S TC3 STRL 960089	C1776	SUPPLY/IMPLANTS	"$31,767.00"	Outpatient	"$15,883.50"	Not Applicable	"$17,376.55"	"$21,188.59"	"$12,706.80"	Not Applicable	"$11,118.45"	"$22,236.90"	"$11,118.45"	"$22,236.90"
COMPONENT FEMORAL PFC SIGMA TC3 3 L65 MM X W61 MM KNEE LEFT 96-0082	C1776	SUPPLY/IMPLANTS	"$31,767.00"	Outpatient	"$15,883.50"	Not Applicable	"$17,376.55"	"$21,188.59"	"$12,706.80"	Not Applicable	"$11,118.45"	"$22,236.90"	"$11,118.45"	"$22,236.90"
AUGMENT FEMORAL TRIATHLON TRITANIUM 1 2 KNEE RIGHT CENTRAL C 5549-A-622	C1874	SUPPLY/IMPLANTS	"$31,755.00"	Outpatient	"$15,877.50"	Not Applicable	"$17,369.99"	"$21,180.59"	"$12,702.00"	Not Applicable	"$11,114.25"	"$22,228.50"	"$11,114.25"	"$22,228.50"
AUGMENT FEMORAL TRIATHLON TRITANIUM 3 4 KNEE LEFT CENTRAL CO 5549-A-641	C1776	SUPPLY/IMPLANTS	"$31,755.00"	Outpatient	"$15,877.50"	Not Applicable	"$17,369.99"	"$21,180.59"	"$12,702.00"	Not Applicable	"$11,114.25"	"$22,228.50"	"$11,114.25"	"$22,228.50"
AUGMENT FEMORAL TRIATHLON TRITANIUM 7 8 KNEE LEFT CENTRAL CO 5549-A-671	C1776	SUPPLY/IMPLANTS	"$31,755.00"	Outpatient	"$15,877.50"	Not Applicable	"$17,369.99"	"$21,180.59"	"$12,702.00"	Not Applicable	"$11,114.25"	"$22,228.50"	"$11,114.25"	"$22,228.50"
AUGMENT FEMORAL TRIATHLON TRITANIUM 5 KNEE RIGHT CENTRAL CON 5549-A-652	C1776	SUPPLY/IMPLANTS	"$31,755.00"	Outpatient	"$15,877.50"	Not Applicable	"$17,369.99"	"$21,180.59"	"$12,702.00"	Not Applicable	"$11,114.25"	"$22,228.50"	"$11,114.25"	"$22,228.50"
AUGMENT FEMORAL TRIATHLON TRITANIUM 1 2 KNEE LEFT CENTRAL CO 5549-A-621	C1776	SUPPLY/IMPLANTS	"$31,755.00"	Outpatient	"$15,877.50"	Not Applicable	"$17,369.99"	"$21,180.59"	"$12,702.00"	Not Applicable	"$11,114.25"	"$22,228.50"	"$11,114.25"	"$22,228.50"
AUGMENT FEMORAL TRIATHLON TRITANIUM 5 KNEE LEFT CENTRAL CONE 5549-A-651	C1776	SUPPLY/IMPLANTS	"$31,755.00"	Outpatient	"$15,877.50"	Not Applicable	"$17,369.99"	"$21,180.59"	"$12,702.00"	Not Applicable	"$11,114.25"	"$22,228.50"	"$11,114.25"	"$22,228.50"
CASE INST 7 MM CNN SCR 114707001	C1713	SUPPLY/IMPLANTS	"$31,733.00"	Outpatient	"$15,866.50"	"$1,365.15"	"$17,357.95"	"$21,165.91"	"$12,693.20"	Not Applicable	"$11,106.55"	"$22,213.10"	"$1,365.15"	"$22,213.10"
GFT STNT 93MM 16-20MM 16FR ENDURANT II EVAS NTNL PLSTR HDRPH ETLW1620C93E		STERILE SUPPLY	"$31,732.00"	Outpatient	"$15,866.00"	Not Applicable	"$17,357.40"	"$21,165.24"	"$12,692.80"	Not Applicable	"$11,106.20"	"$22,212.40"	"$11,106.20"	"$22,212.40"
GFT STNT 124MM 16-16MM 14FR ENDURANT II EVAS NTNL PLSTR ETLW1616C124E	C1884	SUPPLY/IMPLANTS	"$31,729.00"	Outpatient	"$15,864.50"	Not Applicable	"$17,355.76"	"$21,163.24"	"$12,691.60"	Not Applicable	"$11,105.15"	"$22,210.30"	"$11,105.15"	"$22,210.30"
VLV MTRL 29MM 27MM EP FLEXFIT 19MM BPRTH STNT HLDR PRCN E100-29M-00		SUPPLY/IMPLANTS	"$31,666.00"	Outpatient	"$15,833.00"	Not Applicable	"$17,321.30"	"$21,121.22"	"$12,666.40"	Not Applicable	"$11,083.10"	"$22,166.20"	"$11,083.10"	"$22,166.20"
VLV MTRL 27MM 23MM EP FLEXFIT 16MM BPRTH STNT HLDR LOPRFL E100-27M-00		SUPPLY/IMPLANTS	"$31,666.00"	Outpatient	"$15,833.00"	Not Applicable	"$17,321.30"	"$21,121.22"	"$12,666.40"	Not Applicable	"$11,083.10"	"$22,166.20"	"$11,083.10"	"$22,166.20"
VLV MTRL 31MM 29MM EP FLEXFIT 20MM BPRTH STNT HLDR PRCN E100-31M-00		SUPPLY/IMPLANTS	"$31,666.00"	Outpatient	"$15,833.00"	Not Applicable	"$17,321.30"	"$21,121.22"	"$12,666.40"	Not Applicable	"$11,083.10"	"$22,166.20"	"$11,083.10"	"$22,166.20"
SPACER LUMBAR NOVEL SD 13 X 22 X 9 N64813-013	C1821	SUPPLY/IMPLANTS	"$31,617.00"	Outpatient	"$15,808.50"	Not Applicable	"$17,294.50"	"$21,088.54"	"$12,646.80"	Not Applicable	"$11,065.95"	"$22,131.90"	"$11,065.95"	"$22,131.90"
SPACER LUMBAR NOVEL SD 11 X 22 X 9 N64813-011	C1821	SUPPLY/IMPLANTS	"$31,617.00"	Outpatient	"$15,808.50"	Not Applicable	"$17,294.50"	"$21,088.54"	"$12,646.80"	Not Applicable	"$11,065.95"	"$22,131.90"	"$11,065.95"	"$22,131.90"
DISC ARTIFICIAL M6-C TITANIUM UHMWPE POLYMER D15 MM MEDIUM L CDM-635L	C1713	SUPPLY/IMPLANTS	"$31,584.00"	Outpatient	"$15,792.00"	"$1,365.15"	"$17,276.45"	"$21,066.53"	"$12,633.60"	Not Applicable	"$11,054.40"	"$22,108.80"	"$1,365.15"	"$22,108.80"
CMPNT FEM 3 KN RT TL STAB TRTHLN COCR 5512-F-302	C1776	SUPPLY/IMPLANTS	"$31,581.00"	Outpatient	"$15,790.50"	Not Applicable	"$17,274.81"	"$21,064.53"	"$12,632.40"	Not Applicable	"$11,053.35"	"$22,106.70"	"$11,053.35"	"$22,106.70"
MESH MATRIXNEURO 200X200X.6MM TI CRNL RECON RGD STRL AU 04.503.147S	C1713	SUPPLY/IMPLANTS	"$31,580.00"	Outpatient	"$15,790.00"	"$1,365.15"	"$17,274.26"	"$21,063.86"	"$12,632.00"	Not Applicable	"$11,053.00"	"$22,106.00"	"$1,365.15"	"$22,106.00"
RESTORIS MCK UNI ONLAY 180996	C1776	SUPPLY/IMPLANTS	"$31,548.00"	Outpatient	"$15,774.00"	Not Applicable	"$17,256.76"	"$21,042.52"	"$12,619.20"	Not Applicable	"$11,041.80"	"$22,083.60"	"$11,041.80"	"$22,083.60"
00074-3346-03 - leuprolide 22.5 mg/3 months PWDI	J9217	PHARMACY	"$26,542.00"	Outpatient	"$13,271.00"	$258.91	"$17,252.30"	"$17,703.51"	"$10,616.80"	Not Applicable	"$9,289.70"	"$18,579.40"	$258.91	"$18,579.40"
CMPNT FEM 7 KN RT CRCTE RTN BEAD TRTHLN PA 5517F702	C1776	SUPPLY/IMPLANTS	"$31,539.00"	Outpatient	"$15,769.50"	Not Applicable	"$17,251.83"	"$21,036.51"	"$12,615.60"	Not Applicable	"$11,038.65"	"$22,077.30"	"$11,038.65"	"$22,077.30"
CMPNT FEM 8 KN RT CRCTE RTN BEAD TRTHLN PA 5517F802	C1776	SUPPLY/IMPLANTS	"$31,539.00"	Outpatient	"$15,769.50"	Not Applicable	"$17,251.83"	"$21,036.51"	"$12,615.60"	Not Applicable	"$11,038.65"	"$22,077.30"	"$11,038.65"	"$22,077.30"
STNT PNCR 10MM 21MM 10MM 146MM 138MM 10.8FR CAUT ENH DLV SYS M00553640	C1874	SUPPLY/IMPLANTS	"$31,533.00"	Outpatient	"$15,766.50"	Not Applicable	"$17,248.55"	"$21,032.51"	"$12,613.20"	Not Applicable	"$11,036.55"	"$22,073.10"	"$11,036.55"	"$22,073.10"
STENT PANCREATIC AXIOS L10 MM OD20 MM STERILE LATEX FREE DIS M00553660	C1874	SUPPLY/IMPLANTS	"$31,522.00"	Outpatient	"$15,761.00"	Not Applicable	"$17,242.53"	"$21,025.17"	"$12,608.80"	Not Applicable	"$11,032.70"	"$22,065.40"	"$11,032.70"	"$22,065.40"
PLT 90X90MM CRNMXF TI MESH PREFRM BN 9200646	C1713	SUPPLY/IMPLANTS	"$31,520.00"	Outpatient	"$15,760.00"	"$1,365.15"	"$17,241.44"	"$21,023.84"	"$12,608.00"	Not Applicable	"$11,032.00"	"$22,064.00"	"$1,365.15"	"$22,064.00"
VLV AOR 19MM 29MM 34MM 28MM CRP-ED PRIMNT MG THERMAFIX SUP 300029MM		SUPPLY/IMPLANTS	"$31,516.00"	Outpatient	"$15,758.00"	Not Applicable	"$17,239.25"	"$21,021.17"	"$12,606.40"	Not Applicable	"$11,030.60"	"$22,061.20"	"$11,030.60"	"$22,061.20"
GFT BN CLLR BN MTRX 10CC OSTEOCEL PRO LG 5016010	C1713	SUPPLY/IMPLANTS	"$31,505.00"	Outpatient	"$15,752.50"	"$1,365.15"	"$17,233.24"	"$21,013.84"	"$12,602.00"	Not Applicable	"$11,026.75"	"$22,053.50"	"$1,365.15"	"$22,053.50"
DEVICE SEPTAL OCCLUDER  8MM 9-ASD-008		SUPPLY/IMPLANTS	"$31,483.00"	Outpatient	"$15,741.50"	Not Applicable	"$17,221.20"	"$20,999.16"	"$12,593.20"	Not Applicable	"$11,019.05"	"$22,038.10"	"$11,019.05"	"$22,038.10"
DEVICE 34MM SEPTAL OCCLUDER 9-ASD-034		SUPPLY/IMPLANTS	"$31,483.00"	Outpatient	"$15,741.50"	Not Applicable	"$17,221.20"	"$20,999.16"	"$12,593.20"	Not Applicable	"$11,019.05"	"$22,038.10"	"$11,019.05"	"$22,038.10"
DEVICE 13MM SEPTAL OCCLUDER 9-ASD-013		SUPPLY/IMPLANTS	"$31,483.00"	Outpatient	"$15,741.50"	Not Applicable	"$17,221.20"	"$20,999.16"	"$12,593.20"	Not Applicable	"$11,019.05"	"$22,038.10"	"$11,019.05"	"$22,038.10"
DEVICE 28MM SEPTAL OCCLUDER 9-ASD-028		SUPPLY/IMPLANTS	"$31,483.00"	Outpatient	"$15,741.50"	Not Applicable	"$17,221.20"	"$20,999.16"	"$12,593.20"	Not Applicable	"$11,019.05"	"$22,038.10"	"$11,019.05"	"$22,038.10"
PCMKR .75CM ESSENTIO PACESAFE RIGHTRATE EASYVIEW IS1 CNCT L110	C1786	PACE MAKER	"$31,464.00"	Outpatient	"$15,732.00"	Not Applicable	"$17,210.81"	"$20,986.49"	"$12,585.60"	Not Applicable	"$11,012.40"	"$22,024.80"	"$11,012.40"	"$22,024.80"
STEM ULN 47X6.7MM LTD EV M/SHRT ELB RT TI 30110	C1776	SUPPLY/IMPLANTS	"$31,452.00"	Outpatient	"$15,726.00"	Not Applicable	"$17,204.24"	"$20,978.48"	"$12,580.80"	Not Applicable	"$11,008.20"	"$22,016.40"	"$11,008.20"	"$22,016.40"
CMPNT TLR 35X36MM STAR MED ANKL LT COCRMO TI PLSM SPRY 400-257	C1776	SUPPLY/IMPLANTS	"$31,433.00"	Outpatient	"$15,716.50"	Not Applicable	"$17,193.85"	"$20,965.81"	"$12,573.20"	Not Applicable	"$11,001.55"	"$22,003.10"	"$11,001.55"	"$22,003.10"
GFT VASC 30+ CM FEM ART ALGRF CRPRS FA303	C1762	SUPPLY/IMPLANTS	"$31,366.00"	Outpatient	"$15,683.00"	Not Applicable	"$17,157.20"	"$20,921.12"	"$12,546.40"	Not Applicable	"$10,978.10"	"$21,956.20"	"$10,978.10"	"$21,956.20"
FEMORAL ARTERY 30CM LGMC1001		STERILE SUPPLY	"$31,366.00"	Outpatient	"$15,683.00"	Not Applicable	"$17,157.20"	"$20,921.12"	"$12,546.40"	Not Applicable	"$10,978.10"	"$21,956.20"	"$10,978.10"	"$21,956.20"
CMPNT FEM 3 65X61MM KN RT CMNT CRCTE STAB PFC S TC3 STRL 960088	C1776	SUPPLY/IMPLANTS	"$31,365.00"	Outpatient	"$15,682.50"	Not Applicable	"$17,156.66"	"$20,920.46"	"$12,546.00"	Not Applicable	"$10,977.75"	"$21,955.50"	"$10,977.75"	"$21,955.50"
PLT 64X8X2.5MM ANG MNDB CNDYL HD RT TI 5X20 HL LCK RECON BN 449.648	C1713	SUPPLY/IMPLANTS	"$31,365.00"	Outpatient	"$15,682.50"	"$1,365.15"	"$17,156.66"	"$20,920.46"	"$12,546.00"	Not Applicable	"$10,977.75"	"$21,955.50"	"$1,365.15"	"$21,955.50"
PLT 64X8X2.5MM ANG MNDB CNDYL HD LT TI 5X20 HL LCK RECON BN 449.649	C1713	SUPPLY/IMPLANTS	"$31,365.00"	Outpatient	"$15,682.50"	"$1,365.15"	"$17,156.66"	"$20,920.46"	"$12,546.00"	Not Applicable	"$10,977.75"	"$21,955.50"	"$1,365.15"	"$21,955.50"
SPCR SPNL 28X36X11MM CHESAPEAKE 10D LRDTC ANT LMBR STAB SYS 2013-21136L10	C1821	SUPPLY/IMPLANTS	"$31,352.00"	Outpatient	"$15,676.00"	Not Applicable	"$17,149.54"	"$20,911.78"	"$12,540.80"	Not Applicable	"$10,973.20"	"$21,946.40"	"$10,973.20"	"$21,946.40"
SPCR SPNL 28X36X13MM CHESAPEAKE 5D LRDTC ANT LMBR STAB SYS 2013-21336L5	C1821	SUPPLY/IMPLANTS	"$31,352.00"	Outpatient	"$15,676.00"	Not Applicable	"$17,149.54"	"$20,911.78"	"$12,540.80"	Not Applicable	"$10,973.20"	"$21,946.40"	"$10,973.20"	"$21,946.40"
GFT STNT 140MM 10-14MM 13FR 10FR TRIVASCULAR OV PRM OV IX 12 TV-IL1410140-J		STERILE SUPPLY	"$31,344.00"	Outpatient	"$15,672.00"	Not Applicable	"$17,145.17"	"$20,906.45"	"$12,537.60"	Not Applicable	"$10,970.40"	"$21,940.80"	"$10,970.40"	"$21,940.80"
SPCR SPNL 22MMX8MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD FS 2990822	C1821	SUPPLY/IMPLANTS	"$31,337.00"	Outpatient	"$15,668.50"	Not Applicable	"$17,141.34"	"$20,901.78"	"$12,534.80"	Not Applicable	"$10,967.95"	"$21,935.90"	"$10,967.95"	"$21,935.90"
SPCR SPNL 22MMX9MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD FS 2990922	C1821	SUPPLY/IMPLANTS	"$31,337.00"	Outpatient	"$15,668.50"	Not Applicable	"$17,141.34"	"$20,901.78"	"$12,534.80"	Not Applicable	"$10,967.95"	"$21,935.90"	"$10,967.95"	"$21,935.90"
GFT STNT 93MM 16-10MM 14FR ENDURANT II EVAS NTNL PLSTR HDRPH ETLW1610C93E	C1874	SUPPLY/IMPLANTS	"$31,249.00"	Outpatient	"$15,624.50"	Not Applicable	"$17,093.20"	"$20,843.08"	"$12,499.60"	Not Applicable	"$10,937.15"	"$21,874.30"	"$10,937.15"	"$21,874.30"
GFT STNT 82MM 20MM 16FR ENDURANT II EVAS PLSTR NTNL ILC XTN ETEW2020C82E	C1766	SUPPLY/IMPLANTS	"$31,247.00"	Outpatient	"$15,623.50"	Not Applicable	"$17,092.11"	"$20,841.75"	"$12,498.80"	Not Applicable	"$10,936.45"	"$21,872.90"	"$10,936.45"	"$21,872.90"
GFT EVAS 13.5CM 18MM 14.5-16.5MM XCLDR CNTRLT LG GRTX NTNL PLC181400	C1884	SUPPLY/IMPLANTS	"$31,245.00"	Outpatient	"$15,622.50"	Not Applicable	"$17,091.02"	"$20,840.42"	"$12,498.00"	Not Applicable	"$10,935.75"	"$21,871.50"	"$10,935.75"	"$21,871.50"
GFT EVAS 10CM 23MM 18.5-21.5MM XCLDR CNTRLT LG GRTX NTNL FEP PLC231000	C1884	SUPPLY/IMPLANTS	"$31,245.00"	Outpatient	"$15,622.50"	Not Applicable	"$17,091.02"	"$20,840.42"	"$12,498.00"	Not Applicable	"$10,935.75"	"$21,871.50"	"$10,935.75"	"$21,871.50"
JIG PSTN 125D INS AFFIXUS HIP FX NL SYS 2112-01-200	C1713	SUPPLY/IMPLANTS	"$31,228.00"	Outpatient	"$15,614.00"	"$1,365.15"	"$17,081.72"	"$20,829.08"	"$12,491.20"	Not Applicable	"$10,929.80"	"$21,859.60"	"$1,365.15"	"$21,859.60"
JIG PSTN 130D INS AFFIXUS HIP FX NL SYS 2112-01-201	C1713	SUPPLY/IMPLANTS	"$31,228.00"	Outpatient	"$15,614.00"	"$1,365.15"	"$17,081.72"	"$20,829.08"	"$12,491.20"	Not Applicable	"$10,929.80"	"$21,859.60"	"$1,365.15"	"$21,859.60"
CMPNT FEM MED PRT KN PHS 3 TWN PG UNCMP OXFD COCRMO 161469	C1776	SUPPLY/IMPLANTS	"$31,206.00"	Outpatient	"$15,603.00"	Not Applicable	"$17,069.68"	"$20,814.40"	"$12,482.40"	Not Applicable	"$10,922.10"	"$21,844.20"	"$10,922.10"	"$21,844.20"
LEAD ICD RV SVC 55CM 8.6FR SQ TENSI-LCK ISOGLIDE STRD ELUT 6947M55	C1899	PACE MAKER	"$31,205.00"	Outpatient	"$15,602.50"	Not Applicable	"$17,069.14"	"$20,813.74"	"$12,482.00"	Not Applicable	"$10,921.75"	"$21,843.50"	"$10,921.75"	"$21,843.50"
LEAD ICD 62CM 8.6FR SQ STRD ELUT SIL HLX 57MM 1 COIL TRPLR 6935M-62CM	C1899	PACE MAKER	"$31,205.00"	Outpatient	"$15,602.50"	Not Applicable	"$17,069.14"	"$20,813.74"	"$12,482.00"	Not Applicable	"$10,921.75"	"$21,843.50"	"$10,921.75"	"$21,843.50"
LEAD PCNG 58CM SQ SCR 1 COIL DFBR 693558	C1777	SUPPLY/IMPLANTS	"$31,203.00"	Outpatient	"$15,601.50"	Not Applicable	"$17,068.04"	"$20,812.40"	"$12,481.20"	Not Applicable	"$10,921.05"	"$21,842.10"	"$10,921.05"	"$21,842.10"
 CAGE SCREW ARTHREX ECLIPSE LARGE 41 mm AR-9301-41CPC	C1776	SUPPLY/IMPLANTS	"$31,194.00"	Outpatient	"$15,597.00"	Not Applicable	"$17,063.12"	"$20,806.40"	"$12,477.60"	Not Applicable	"$10,917.90"	"$21,835.80"	"$10,917.90"	"$21,835.80"
LEAD ICD RV 65CM LINOXSMART S DX DXMTHSN ACT 15MM 1 COIL 365 500	C1898	PACE MAKER	"$31,186.00"	Outpatient	"$15,593.00"	Not Applicable	"$17,058.74"	"$20,801.06"	"$12,474.40"	Not Applicable	"$10,915.10"	"$21,830.20"	"$10,915.10"	"$21,830.20"
CAGE SPNL 55X22X12MM CRNT XL W LRDTC PEEK LMBR INTRBD FS NS 6921255	C1821	SUPPLY/IMPLANTS	"$31,186.00"	Outpatient	"$15,593.00"	Not Applicable	"$17,058.74"	"$20,801.06"	"$12,474.40"	Not Applicable	"$10,915.10"	"$21,830.20"	"$10,915.10"	"$21,830.20"
CAGE SPNL 55X22X10MM CRNT XL W PEEK NS LF 6910255	C1821	SUPPLY/IMPLANTS	"$31,186.00"	Outpatient	"$15,593.00"	Not Applicable	"$17,058.74"	"$20,801.06"	"$12,474.40"	Not Applicable	"$10,915.10"	"$21,830.20"	"$10,915.10"	"$21,830.20"
CAGE SPNL 23X11X10MM 0D TRITANIUM PLIF STRL LF 48951100	C1821	SUPPLY/IMPLANTS	"$31,186.00"	Outpatient	"$15,593.00"	Not Applicable	"$17,058.74"	"$20,801.06"	"$12,474.40"	Not Applicable	"$10,915.10"	"$21,830.20"	"$10,915.10"	"$21,830.20"
ENTOVIS SR-T SYSTEM W/ GSM HM 398016	C1786	PACE MAKER	"$31,183.00"	Outpatient	"$15,591.50"	Not Applicable	"$17,057.10"	"$20,799.06"	"$12,473.20"	Not Applicable	"$10,914.05"	"$21,828.10"	"$10,914.05"	"$21,828.10"
SYS CRD PCMKR ELUNA SR-T PROMRI CLS HOME MNTR 405424	C1786	PACE MAKER	"$31,178.00"	Outpatient	"$15,589.00"	Not Applicable	"$17,054.37"	"$20,795.73"	"$12,471.20"	Not Applicable	"$10,912.30"	"$21,824.60"	"$10,912.30"	"$21,824.60"
FRAC ST/VRSDL HD 98B00902001		NON-STER SUPPLY	"$31,177.00"	Outpatient	"$15,588.50"	Not Applicable	"$17,053.82"	"$20,795.06"	"$12,470.80"	Not Applicable	"$10,911.95"	"$21,823.90"	"$10,911.95"	"$21,823.90"
MAJOR JOINT REPLACEMENT OR REATTACHMENT WITHOUT MCC HIP DRG DRG 470DS		SUPPLY/IMPLANTS	"$31,177.00"	Outpatient	"$15,588.50"	Not Applicable	"$17,053.82"	"$20,795.06"	"$12,470.80"	Not Applicable	"$10,911.95"	"$21,823.90"	"$10,911.95"	"$21,823.90"
ENDPLATE INTERVERTEBRAL DISC ACTIV L PLASMAPORE 0 D SMALL CO SW970K	C1713	SUPPLY/IMPLANTS	"$31,176.00"	Outpatient	"$15,588.00"	"$1,365.15"	"$17,053.27"	"$20,794.39"	"$12,470.40"	Not Applicable	"$10,911.60"	"$21,823.20"	"$1,365.15"	"$21,823.20"
ENDPLATE INTERVERTEBRAL DISC ACTIV L PLASMAPORE 6 D SMALL CO SW971K	C1713	SUPPLY/IMPLANTS	"$31,176.00"	Outpatient	"$15,588.00"	"$1,365.15"	"$17,053.27"	"$20,794.39"	"$12,470.40"	Not Applicable	"$10,911.60"	"$21,823.20"	"$1,365.15"	"$21,823.20"
COMP SHRT ST/VRSDL HD 98B00901702		STERILE SUPPLY	"$31,176.00"	Outpatient	"$15,588.00"	Not Applicable	"$17,053.27"	"$20,794.39"	"$12,470.40"	Not Applicable	"$10,911.60"	"$21,823.20"	"$10,911.60"	"$21,823.20"
FEMORAL CORE PLUG 16MM 45647016		STERILE SUPPLY	"$31,176.00"	Outpatient	"$15,588.00"	Not Applicable	"$17,053.27"	"$20,794.39"	"$12,470.40"	Not Applicable	"$10,911.60"	"$21,823.20"	"$10,911.60"	"$21,823.20"
EPLT SPNL 14MM SCR-C 6D 13MM SPHRCL CYL CRV TI COCRMO MLT 714.206S	C1713	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	"$1,365.15"	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$1,365.15"	"$21,820.40"
CAGE SPNL 32X13MM AERO-AL 8D 26MM LMBR ANT STRL LF 48922638	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 32X11MM AERO-AL 8D 26MM LMBR ANT STRL LF 48922618	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 23X11X12MM 0D TRITANIUM PLIF STRL LF 48951120	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 23X11X11MM 0D TRITANIUM PLIF STRL LF 48951110	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 23X11X8MM 0D TRITANIUM PLIF STRL LF 48951080	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 28X11X13MM 0D TRITANIUM PLIF STRL LF 48953130	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 60X22X12MM CRNT XL W LRDTC PEEK LMBR INTRBD FS NS 6921260	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 50X22X14MM CRNT XL W PEEK RADOPQ LMBR INTRBD FS NS 6914250	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 55X22X14MM CRNT 10D LRDTC XL W PEEK NS LF 6921455	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
CAGE SPNL 60X22X10MM CRNT XL W PEEK NS LF 6910260	C1821	SUPPLY/IMPLANTS	"$31,172.00"	Outpatient	"$15,586.00"	Not Applicable	"$17,051.08"	"$20,791.72"	"$12,468.80"	Not Applicable	"$10,910.20"	"$21,820.40"	"$10,910.20"	"$21,820.40"
EPLT INTVRTB DISC 12MM SCR-C 6D 11MM LRDTC SPNE CRV ANT 714.106S	C1713	SUPPLY/IMPLANTS	"$31,171.00"	Outpatient	"$15,585.50"	"$1,365.15"	"$17,050.54"	"$20,791.06"	"$12,468.40"	Not Applicable	"$10,909.85"	"$21,819.70"	"$1,365.15"	"$21,819.70"
CAGE PEEK 12MM X 28MM 67-281112	C1821	SUPPLY/IMPLANTS	"$31,171.00"	Outpatient	"$15,585.50"	Not Applicable	"$17,050.54"	"$20,791.06"	"$12,468.40"	Not Applicable	"$10,909.85"	"$21,819.70"	"$10,909.85"	"$21,819.70"
CAGE PEEK 11MM X 28MM 67-281111	C1821	SUPPLY/IMPLANTS	"$31,171.00"	Outpatient	"$15,585.50"	Not Applicable	"$17,050.54"	"$20,791.06"	"$12,468.40"	Not Applicable	"$10,909.85"	"$21,819.70"	"$10,909.85"	"$21,819.70"
CAGE TPLIF 8 X 24 X 9 DP2008	C1821	SUPPLY/IMPLANTS	"$31,171.00"	Outpatient	"$15,585.50"	Not Applicable	"$17,050.54"	"$20,791.06"	"$12,468.40"	Not Applicable	"$10,909.85"	"$21,819.70"	"$10,909.85"	"$21,819.70"
CAGE TPLIF 11 X 24 X 9 DP2011	C1821	SUPPLY/IMPLANTS	"$31,171.00"	Outpatient	"$15,585.50"	Not Applicable	"$17,050.54"	"$20,791.06"	"$12,468.40"	Not Applicable	"$10,909.85"	"$21,819.70"	"$10,909.85"	"$21,819.70"
PLATEAU SPACE 14X28MM LS-52-1028-14	C1821	SUPPLY/IMPLANTS	"$31,171.00"	Outpatient	"$15,585.50"	Not Applicable	"$17,050.54"	"$20,791.06"	"$12,468.40"	Not Applicable	"$10,909.85"	"$21,819.70"	"$10,909.85"	"$21,819.70"
STAGED BILATERAL PLATFORM KIT W/D HARDWARE MP-KIT-02D-ST		SUPPLY/IMPLANTS	"$31,169.00"	Outpatient	"$15,584.50"	Not Applicable	"$17,049.44"	"$20,789.72"	"$12,467.60"	Not Applicable	"$10,909.15"	"$21,818.30"	"$10,909.15"	"$21,818.30"
ADAPTA DR SYSTEM 2 ADAPTADRK2	C1785	PACE MAKER	"$31,153.00"	Outpatient	"$15,576.50"	Not Applicable	"$17,040.69"	"$20,779.05"	"$12,461.20"	Not Applicable	"$10,903.55"	"$21,807.10"	"$10,903.55"	"$21,807.10"
VLV SHNT HKM PRGM UNT DIST CATH PLAT INLN LP 120CM 823854	C1713	SUPPLY/IMPLANTS	"$31,136.00"	Outpatient	"$15,568.00"	"$1,365.15"	"$17,031.39"	"$20,767.71"	"$12,454.40"	Not Applicable	"$10,897.60"	"$21,795.20"	"$1,365.15"	"$21,795.20"
SPACER SPINAL FORTIFY D12 MM W12 MM X H33 MM NONSTERILE LATE 151.054	C1821	SUPPLY/IMPLANTS	"$31,105.00"	Outpatient	"$15,552.50"	Not Applicable	"$17,014.44"	"$20,747.04"	"$12,442.00"	Not Applicable	"$10,886.75"	"$21,773.50"	"$10,886.75"	"$21,773.50"
BSPLT TIB 2 KN LT CMNT M TPR LEGION TI NPOR 71420162	C1776	SUPPLY/IMPLANTS	"$31,069.00"	Outpatient	"$15,534.50"	Not Applicable	"$16,994.74"	"$20,723.02"	"$12,427.60"	Not Applicable	"$10,874.15"	"$21,748.30"	"$10,874.15"	"$21,748.30"
00173-0821-01 - ofatumumab 20 mg/mL Soln	J9302	PHARMACY	"$26,144.00"	Outpatient	"$13,072.00"	$59.40	"$16,993.60"	"$17,438.05"	"$10,457.60"	Not Applicable	"$9,150.40"	"$18,300.80"	$59.40	"$18,300.80"
CMPNT FEM 5 KN RT POST STAB GNS2 LEGION SPC 71423235	C1776	SUPPLY/IMPLANTS	"$31,030.00"	Outpatient	"$15,515.00"	Not Applicable	"$16,973.41"	"$20,697.01"	"$12,412.00"	Not Applicable	"$10,860.50"	"$21,721.00"	"$10,860.50"	"$21,721.00"
CMPNT FEM 5 KN LT POST STAB GNS2 LEGION SPC 71423225	C1776	SUPPLY/IMPLANTS	"$31,030.00"	Outpatient	"$15,515.00"	Not Applicable	"$16,973.41"	"$20,697.01"	"$12,412.00"	Not Applicable	"$10,860.50"	"$21,721.00"	"$10,860.50"	"$21,721.00"
STEM FEM 160MM 11MM 131.5D LATERALIZE OFST MLHD POR HIP STRL 11-104211	C1776	SUPPLY/IMPLANTS	"$30,980.00"	Outpatient	"$15,490.00"	Not Applicable	"$16,946.06"	"$20,663.66"	"$12,392.00"	Not Applicable	"$10,843.00"	"$21,686.00"	"$10,843.00"	"$21,686.00"
CUP ACTB 60MM MDLR MLHL REV HIP TRB MTL 620206020		STERILE SUPPLY	"$30,958.00"	Outpatient	"$15,479.00"	Not Applicable	"$16,934.03"	"$20,648.99"	"$12,383.20"	Not Applicable	"$10,835.30"	"$21,670.60"	"$10,835.30"	"$21,670.60"
CAGE SPNL 26X9X8MM CRNT 4D LG IMPCT PEEK-OPTM NS LF 6708926	C1821	SUPPLY/IMPLANTS	"$30,954.00"	Outpatient	"$15,477.00"	Not Applicable	"$16,931.84"	"$20,646.32"	"$12,381.60"	Not Applicable	"$10,833.90"	"$21,667.80"	"$10,833.90"	"$21,667.80"
GFT SFT TIS 10X6CM EPIXL XL-5610	C1713	SUPPLY/IMPLANTS	"$30,931.00"	Outpatient	"$15,465.50"	"$1,365.15"	"$16,919.26"	"$20,630.98"	"$12,372.40"	Not Applicable	"$10,825.85"	"$21,651.70"	"$1,365.15"	"$21,651.70"
DEV TRGT TIB PROX PEEK-OPTM NCB NS RT PLT MIS 200024080	C1713	SUPPLY/IMPLANTS	"$30,928.00"	Outpatient	"$15,464.00"	"$1,365.15"	"$16,917.62"	"$20,628.98"	"$12,371.20"	Not Applicable	"$10,824.80"	"$21,649.60"	"$1,365.15"	"$21,649.60"
DEV TRGT TIB PROX PEEK-OPTM NCB NS LT PLT MIS 200024081	C1713	SUPPLY/IMPLANTS	"$30,928.00"	Outpatient	"$15,464.00"	"$1,365.15"	"$16,917.62"	"$20,628.98"	"$12,371.20"	Not Applicable	"$10,824.80"	"$21,649.60"	"$1,365.15"	"$21,649.60"
GFT BN VIABLE BN MTRX POR CANC 10CC MLD SCFLD BIO4 3102-2110		SUPPLY/IMPLANTS	"$30,916.00"	Outpatient	"$15,458.00"	Not Applicable	"$16,911.05"	"$20,620.97"	"$12,366.40"	Not Applicable	"$10,820.60"	"$21,641.20"	"$10,820.60"	"$21,641.20"
TNSNR SRG WRE PSTL GRP 21435		STERILE SUPPLY	"$30,911.00"	Outpatient	"$15,455.50"	Not Applicable	"$16,908.32"	"$20,617.64"	"$12,364.40"	Not Applicable	"$10,818.85"	"$21,637.70"	"$10,818.85"	"$21,637.70"
DRSG WND 5X4IN BVN CLGN GAG THN STRL DISP 54051T		SUPPLY/IMPLANTS	"$30,895.00"	Outpatient	"$15,447.50"	Not Applicable	"$16,899.57"	"$20,606.97"	"$12,358.00"	Not Applicable	"$10,813.25"	"$21,626.50"	"$10,813.25"	"$21,626.50"
202735 PLATES BSE \T\ 230004000	C1713	SUPPLY/IMPLANTS	"$30,869.00"	Outpatient	"$15,434.50"	"$1,365.15"	"$16,885.34"	"$20,589.62"	"$12,347.60"	Not Applicable	"$10,804.15"	"$21,608.30"	"$1,365.15"	"$21,608.30"
44206-0439-40 - immune globulin intravenous 10% Soln	J1459	PHARMACY	"$30,833.00"	Outpatient	"$15,416.50"	$45.34	"$16,865.65"	"$20,565.61"	"$12,333.20"	Not Applicable	"$10,791.55"	"$21,583.10"	$45.34	"$21,583.10"
STEM FEM 155MM 15MM 130D LATERALIZE OFST ECHO BMTRC TI POR 192115	C1776	SUPPLY/IMPLANTS	"$30,795.00"	Outpatient	"$15,397.50"	Not Applicable	"$16,844.87"	"$20,540.27"	"$12,318.00"	Not Applicable	"$10,778.25"	"$21,556.50"	"$10,778.25"	"$21,556.50"
STEM FEM 140MM 12MM 135D STD OFST ECHO BMTRC TI POR HIP 192012	C1776	SUPPLY/IMPLANTS	"$30,795.00"	Outpatient	"$15,397.50"	Not Applicable	"$16,844.87"	"$20,540.27"	"$12,318.00"	Not Applicable	"$10,778.25"	"$21,556.50"	"$10,778.25"	"$21,556.50"
TRAY TIB MBT 67.1X44.2X4.8MM 2.5MM KN CMNT REV ROT PLAT STRL 129435125	C1776	SUPPLY/IMPLANTS	"$30,788.00"	Outpatient	"$15,394.00"	Not Applicable	"$16,841.04"	"$20,535.60"	"$12,315.20"	Not Applicable	"$10,775.80"	"$21,551.60"	"$10,775.80"	"$21,551.60"
SPCR SPNL 30X11X10MM AVS UNILIF 0D WDG NOSE PEEK-OPTM HLW 48351100	C1821	SUPPLY/IMPLANTS	"$30,778.00"	Outpatient	"$15,389.00"	Not Applicable	"$16,835.57"	"$20,528.93"	"$12,311.20"	Not Applicable	"$10,772.30"	"$21,544.60"	"$10,772.30"	"$21,544.60"
TRAY TIB MBT 69.6X45.8X4.8MM 3MM KN CMNT REV ROT PLAT STRL 129435130		STERILE SUPPLY	"$30,770.00"	Outpatient	"$15,385.00"	Not Applicable	"$16,831.19"	"$20,523.59"	"$12,308.00"	Not Applicable	"$10,769.50"	"$21,539.00"	"$10,769.50"	"$21,539.00"
PLT 2MM 20 HL MATRIXMANDIBLE BN PSPC SD449.502	C1713	SUPPLY/IMPLANTS	"$30,768.00"	Outpatient	"$15,384.00"	"$1,365.15"	"$16,830.10"	"$20,522.26"	"$12,307.20"	Not Applicable	"$10,768.80"	"$21,537.60"	"$1,365.15"	"$21,537.60"
PCMKR THK7.5MM 5MM 6MM MVP ADAPTA DR 2 CHMBR UNPLR PARYLENE ADDR06	C1785	PACE MAKER	"$30,768.00"	Outpatient	"$15,384.00"	Not Applicable	"$16,830.10"	"$20,522.26"	"$12,307.20"	Not Applicable	"$10,768.80"	"$21,537.60"	"$10,768.80"	"$21,537.60"
HEAD RADL 12MM MED 6948-0-612	C1776	SUPPLY/IMPLANTS	"$30,759.00"	Outpatient	"$15,379.50"	Not Applicable	"$16,825.17"	"$20,516.25"	"$12,303.60"	Not Applicable	"$10,765.65"	"$21,531.30"	"$10,765.65"	"$21,531.30"
RCDR CRD RVL LINQ LOOP LNQ11	C1764	SUPPLY/IMPLANTS	"$30,740.00"	Outpatient	"$15,370.00"	Not Applicable	"$16,814.78"	"$20,503.58"	"$12,296.00"	Not Applicable	"$10,759.00"	"$21,518.00"	"$10,759.00"	"$21,518.00"
PCMKR .75CM 13.7CU CM ACLD EL LTD NXT PACESAFE EASYVIEW 2 L321	C1785	PACE MAKER	"$30,725.00"	Outpatient	"$15,362.50"	Not Applicable	"$16,806.58"	"$20,493.58"	"$12,290.00"	Not Applicable	"$10,753.75"	"$21,507.50"	"$10,753.75"	"$21,507.50"
00006-3026-02 - pembrolizumab 25 mg/mL Soln	J9271	PHARMACY	"$25,847.00"	Outpatient	"$12,923.50"	$55.02	"$16,800.55"	"$17,239.95"	"$10,338.80"	Not Applicable	"$9,046.45"	"$18,092.90"	$55.02	"$18,092.90"
DEV TRGT RECON PHNX STRL ANTGRD FEM NL SYS 14-442018	C1713	SUPPLY/IMPLANTS	"$30,697.00"	Outpatient	"$15,348.50"	"$1,365.15"	"$16,791.26"	"$20,474.90"	"$12,278.80"	Not Applicable	"$10,743.95"	"$21,487.90"	"$1,365.15"	"$21,487.90"
TRIAL SHOULDER ECLIPSE MEDIUM OD35 MM GLENOID CAGE SCREW STE AR-9301-02	C1776	SUPPLY/IMPLANTS	"$30,674.00"	Outpatient	"$15,337.00"	Not Applicable	"$16,778.68"	"$20,459.56"	"$12,269.60"	Not Applicable	"$10,735.90"	"$21,471.80"	"$10,735.90"	"$21,471.80"
OPTIROM PROXIMAL ASSEMBLY 9600	C1713	SUPPLY/IMPLANTS	"$30,662.00"	Outpatient	"$15,331.00"	"$1,365.15"	"$16,772.11"	"$20,451.55"	"$12,264.80"	Not Applicable	"$10,731.70"	"$21,463.40"	"$1,365.15"	"$21,463.40"
AUG TIB SMTR TRTHLN TRITANIUM A CONE STRL LF 5549-A-110	C1776	SUPPLY/IMPLANTS	"$30,602.00"	Outpatient	"$15,301.00"	Not Applicable	"$16,739.29"	"$20,411.53"	"$12,240.80"	Not Applicable	"$10,710.70"	"$21,421.40"	"$10,710.70"	"$21,421.40"
AUG TIB SMTR TRTHLN TRITANIUM B CONE STRL LF 5549-A-120	C1776	SUPPLY/IMPLANTS	"$30,602.00"	Outpatient	"$15,301.00"	Not Applicable	"$16,739.29"	"$20,411.53"	"$12,240.80"	Not Applicable	"$10,710.70"	"$21,421.40"	"$10,710.70"	"$21,421.40"
GFT STNT 100MM 34MM AFX VELA EVAS STRATA AOR XTN 20MM AAA A34-34/C100-O20V	C1874	SUPPLY/IMPLANTS	"$30,566.00"	Outpatient	"$15,283.00"	Not Applicable	"$16,719.60"	"$20,387.52"	"$12,226.40"	Not Applicable	"$10,698.10"	"$21,396.20"	"$10,698.10"	"$21,396.20"
ASSURITY MRI SR RF SYS MERLIN PKG PM1272 SYSCELL	C1786	PACE MAKER	"$30,501.00"	Outpatient	"$15,250.50"	Not Applicable	"$16,684.05"	"$20,344.17"	"$12,200.40"	Not Applicable	"$10,675.35"	"$21,350.70"	"$10,675.35"	"$21,350.70"
SYS CRD PCMKR LD 1 CHMBR IS-1 CNCT ASSURITY MRI THK6MM 50X47 PM1272 SYSTEM	C1786	PACE MAKER	"$30,493.00"	Outpatient	"$15,246.50"	Not Applicable	"$16,679.67"	"$20,338.83"	"$12,197.20"	Not Applicable	"$10,672.55"	"$21,345.10"	"$10,672.55"	"$21,345.10"
CAGE SPNL 39-65MM 14MM SM VBR ADD 0D THOR LMBR TI CNT XPD CS 2250-14-39	C1821	SUPPLY/IMPLANTS	"$30,493.00"	Outpatient	"$15,246.50"	Not Applicable	"$16,679.67"	"$20,338.83"	"$12,197.20"	Not Applicable	"$10,672.55"	"$21,345.10"	"$10,672.55"	"$21,345.10"
CAGE SPNL 24-40MM 14MM SM VBR ADD 0D THOR LMBR TI CNT XPD CS 2250-14-24		STERILE SUPPLY	"$30,493.00"	Outpatient	"$15,246.50"	Not Applicable	"$16,679.67"	"$20,338.83"	"$12,197.20"	Not Applicable	"$10,672.55"	"$21,345.10"	"$10,672.55"	"$21,345.10"
CATHETER DELIVERY SYSTEM OD20 FR ENVPRO-16-US	C1817	SUPPLY/IMPLANTS	"$30,487.00"	Outpatient	"$15,243.50"	Not Applicable	"$16,676.39"	"$20,334.83"	"$12,194.80"	Not Applicable	"$10,670.45"	"$21,340.90"	"$10,670.45"	"$21,340.90"
DEVICE FUSION RIALTO TITANIUM L50 MM X W12 MM THREAD 74200001250	C1713	SUPPLY/IMPLANTS	"$30,482.00"	Outpatient	"$15,241.00"	"$1,365.15"	"$16,673.65"	"$20,331.49"	"$12,192.80"	Not Applicable	"$10,668.70"	"$21,337.40"	"$1,365.15"	"$21,337.40"
DEVICE FUSION RIALTO TITANIUM L40 MM X W12 MM THREAD 74200001240	C1713	SUPPLY/IMPLANTS	"$30,482.00"	Outpatient	"$15,241.00"	"$1,365.15"	"$16,673.65"	"$20,331.49"	"$12,192.80"	Not Applicable	"$10,668.70"	"$21,337.40"	"$1,365.15"	"$21,337.40"
"CAGE GIZA DIAM 14MM, 33-54MM, 2-5 DEG 48291432S"	C1821	SUPPLY/IMPLANTS	"$30,482.00"	Outpatient	"$15,241.00"	Not Applicable	"$16,673.65"	"$20,331.49"	"$12,192.80"	Not Applicable	"$10,668.70"	"$21,337.40"	"$10,668.70"	"$21,337.40"
GFT EVAS 13.5CM 16MM 13.5-14.5MM XCLDR CNTRLT LG GRTX NTNL PLC161400	C1884	SUPPLY/IMPLANTS	"$30,480.00"	Outpatient	"$15,240.00"	Not Applicable	"$16,672.56"	"$20,330.16"	"$12,192.00"	Not Applicable	"$10,668.00"	"$21,336.00"	"$10,668.00"	"$21,336.00"
GFT EVAS 11.5CM 20MM 16.5-18.5MM GRTX XCLDR CNTRLT LG NTNL PLC201200	C1884	SUPPLY/IMPLANTS	"$30,480.00"	Outpatient	"$15,240.00"	Not Applicable	"$16,672.56"	"$20,330.16"	"$12,192.00"	Not Applicable	"$10,668.00"	"$21,336.00"	"$10,668.00"	"$21,336.00"
GFT EVAS 12CM 23MM 18.5-21.5MM XCLDR CNTRLT LG GRTX NTNL FEP PLC231200	C1884	SUPPLY/IMPLANTS	"$30,480.00"	Outpatient	"$15,240.00"	Not Applicable	"$16,672.56"	"$20,330.16"	"$12,192.00"	Not Applicable	"$10,668.00"	"$21,336.00"	"$10,668.00"	"$21,336.00"
CAGE SPNL 12X14.5X21MM VERTA 7D CORPECTOMY NS LF CD-001-014	C1821	SUPPLY/IMPLANTS	"$30,480.00"	Outpatient	"$15,240.00"	Not Applicable	"$16,672.56"	"$20,330.16"	"$12,192.00"	Not Applicable	"$10,668.00"	"$21,336.00"	"$10,668.00"	"$21,336.00"
MESH TISS 30X20CM BIO-A BABSR REINF SCFLD SRG FS2030		SUPPLY/IMPLANTS	"$30,480.00"	Outpatient	"$15,240.00"	Not Applicable	"$16,672.56"	"$20,330.16"	"$12,192.00"	Not Applicable	"$10,668.00"	"$21,336.00"	"$10,668.00"	"$21,336.00"
GFT EVAS 13.5CM 20MM 16.5-18.5MM GRTX XCLDR CNTRLT LG NTNL PLC201400	C1874	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
SCR BN SACROILIAC TI 60MM 12MM CNN 9000260	C1713	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	"$1,365.15"	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$1,365.15"	"$21,335.30"
GFT EVAS 12CM 27MM XCLDR C3 CNTRLT LG GRTX NTNL FEP STNT XTD PXC271200	C1884	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
GFT EVAS 10CM 27MM XCLDR C3 CNTRLT LG GRTX NTNL FEP STNT XTD PXC271000	C1884	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
GFT EVAS 14CM 27MM 21.5-25MM XCLDR CNTRLT LG GRTX NTNL FEP PLC271400	C1884	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
GFT EVAS 10CM 27MM 21.5-25MM GRTX XCLDR CNTRLT LG NTNL FEP PLC271000	C1884	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
GFT EVAS 11.5CM 16MM 13.5-14.5MM XCLDR CNTRLT LG GRTX NTNL PLC161200	C1884	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
GFT EVAS 14CM 23MM 18.5-21.5MM XCLDR CNTRLT LG GRTX NTNL FEP PLC231400	C1884	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
STNT HEP 6MM 6FR SPRFC FEM ART ILIUM 5CM DLV SYS VBHN EPRSTH VBJ060502	C1884	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
CAGE PEEK CORPECTOMY 22MM C64713-122	C1821	SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
CAGE SAMSON CARPECTOMY 20MM 13520		SUPPLY/IMPLANTS	"$30,479.00"	Outpatient	"$15,239.50"	Not Applicable	"$16,672.01"	"$20,329.49"	"$12,191.60"	Not Applicable	"$10,667.65"	"$21,335.30"	"$10,667.65"	"$21,335.30"
CAGE CORPECTOMY 17 X 14 X 36 104-2-1743610	C1821	SUPPLY/IMPLANTS	"$30,468.00"	Outpatient	"$15,234.00"	Not Applicable	"$16,666.00"	"$20,322.16"	"$12,187.20"	Not Applicable	"$10,663.80"	"$21,327.60"	"$10,663.80"	"$21,327.60"
CAGE EXPANDABLE VBR 12 X 14 250-1214-17-00	C1821	SUPPLY/IMPLANTS	"$30,468.00"	Outpatient	"$15,234.00"	Not Applicable	"$16,666.00"	"$20,322.16"	"$12,187.20"	Not Applicable	"$10,663.80"	"$21,327.60"	"$10,663.80"	"$21,327.60"
PLT 150X150X.8MM CRNFCL RPD RSRB CNTR MESH FX BN STRL 1.5MM 851.633.01S	C1713	SUPPLY/IMPLANTS	"$30,465.00"	Outpatient	"$15,232.50"	"$1,365.15"	"$16,664.36"	"$20,320.16"	"$12,186.00"	Not Applicable	"$10,662.75"	"$21,325.50"	"$1,365.15"	"$21,325.50"
CAGE SPNL 12-17MM 16MM SM VBR ADD 0D THOR LMBR TI CNT XPD CS 2250-16-12	C1821	SUPPLY/IMPLANTS	"$30,463.00"	Outpatient	"$15,231.50"	Not Applicable	"$16,663.26"	"$20,318.82"	"$12,185.20"	Not Applicable	"$10,662.05"	"$21,324.10"	"$10,662.05"	"$21,324.10"
CAGE SPNL 16-25MM 16MM SM VBR ADD 0D THOR LMBR TI CNT XPD CS 2250-16-16	C1821	SUPPLY/IMPLANTS	"$30,463.00"	Outpatient	"$15,231.50"	Not Applicable	"$16,663.26"	"$20,318.82"	"$12,185.20"	Not Applicable	"$10,662.05"	"$21,324.10"	"$10,662.05"	"$21,324.10"
SYSTEM URINARY CONTROL SYSTEM 3.5CM 720157-01		STERILE SUPPLY	"$30,458.00"	Outpatient	"$15,229.00"	Not Applicable	"$16,660.53"	"$20,315.49"	"$12,183.20"	Not Applicable	"$10,660.30"	"$21,320.60"	"$10,660.30"	"$21,320.60"
VLV MTRL 29MM ATS OP MECH STD HRT 500DM29		SUPPLY/IMPLANTS	"$30,457.00"	Outpatient	"$15,228.50"	Not Applicable	"$16,659.98"	"$20,314.82"	"$12,182.80"	Not Applicable	"$10,659.95"	"$21,319.90"	"$10,659.95"	"$21,319.90"
SPACER CEMENT INTERSPACE GENTAMICIN PMMA MEDIUM W70 MM W64 M  SPK0122	C1776	SUPPLY/IMPLANTS	"$30,447.00"	Outpatient	"$15,223.50"	Not Applicable	"$16,654.51"	"$20,308.15"	"$12,178.80"	Not Applicable	"$10,656.45"	"$21,312.90"	"$10,656.45"	"$21,312.90"
SPCR SPNL 12MM PRIMTR 8D LRDTC LG VERT BD REPL 3493312	C1821	SUPPLY/IMPLANTS	"$30,423.00"	Outpatient	"$15,211.50"	Not Applicable	"$16,641.38"	"$20,292.14"	"$12,169.20"	Not Applicable	"$10,648.05"	"$21,296.10"	"$10,648.05"	"$21,296.10"
SPCR SPNL 14MM PRIMTR 8D LRDTC LG VERT BD REPL 3493314	C1821	SUPPLY/IMPLANTS	"$30,423.00"	Outpatient	"$15,211.50"	Not Applicable	"$16,641.38"	"$20,292.14"	"$12,169.20"	Not Applicable	"$10,648.05"	"$21,296.10"	"$10,648.05"	"$21,296.10"
SPCR SPNL 10MM PRIMTR 8D LRDTC LG VERT BD REPL 3493310	C1821	SUPPLY/IMPLANTS	"$30,423.00"	Outpatient	"$15,211.50"	Not Applicable	"$16,641.38"	"$20,292.14"	"$12,169.20"	Not Applicable	"$10,648.05"	"$21,296.10"	"$10,648.05"	"$21,296.10"
2735 PERC INSTR BSE \T\ TRY 230003500		STERILE SUPPLY	"$30,412.00"	Outpatient	"$15,206.00"	Not Applicable	"$16,635.36"	"$20,284.80"	"$12,164.80"	Not Applicable	"$10,644.20"	"$21,288.40"	"$10,644.20"	"$21,288.40"
PLATE LARGER ADJUSTABLE OC 77552781	C1713	SUPPLY/IMPLANTS	"$30,407.00"	Outpatient	"$15,203.50"	"$1,365.15"	"$16,632.63"	"$20,281.47"	"$12,162.80"	Not Applicable	"$10,642.45"	"$21,284.90"	"$1,365.15"	"$21,284.90"
CMPNT FEM MED KN LT TL STAB 6632-8-820	C1776	SUPPLY/IMPLANTS	"$30,399.00"	Outpatient	"$15,199.50"	Not Applicable	"$16,628.25"	"$20,276.13"	"$12,159.60"	Not Applicable	"$10,639.65"	"$21,279.30"	"$10,639.65"	"$21,279.30"
PCMKR ADVISA DR MRI SURESCAN 1 CHMBR UNPLR BP IS-1 CNCT CRD A3SR01	C1786	PACE MAKER	"$30,389.00"	Outpatient	"$15,194.50"	Not Applicable	"$16,622.78"	"$20,269.46"	"$12,155.60"	Not Applicable	"$10,636.15"	"$21,272.30"	"$10,636.15"	"$21,272.30"
BODY FEMORAL RECLAIM ARTICUL/EZE TITANIUM 40 MM OFFSET 12/14 1975-20-085	C1776	SUPPLY/IMPLANTS	"$30,372.00"	Outpatient	"$15,186.00"	Not Applicable	"$16,613.48"	"$20,258.12"	"$12,148.80"	Not Applicable	"$10,630.20"	"$21,260.40"	"$10,630.20"	"$21,260.40"
BODY FEMORAL RECLAIM ARTICUL/EZE TITANIUM 40 MM 12/14 OFFSET 1975-20-075	C1776	SUPPLY/IMPLANTS	"$30,372.00"	Outpatient	"$15,186.00"	Not Applicable	"$16,613.48"	"$20,258.12"	"$12,148.80"	Not Applicable	"$10,630.20"	"$21,260.40"	"$10,630.20"	"$21,260.40"
STEM HUM 55MM 13MM CMPRH POR MIC SHLDR RVRS SYS 113613	C1776	SUPPLY/IMPLANTS	"$30,368.00"	Outpatient	"$15,184.00"	Not Applicable	"$16,611.30"	"$20,255.46"	"$12,147.20"	Not Applicable	"$10,628.80"	"$21,257.60"	"$10,628.80"	"$21,257.60"
STEM HUM 55MM 8MM CMPRH POR MIC SHLDR RVRS SYS 113608	C1776	SUPPLY/IMPLANTS	"$30,366.00"	Outpatient	"$15,183.00"	Not Applicable	"$16,610.20"	"$20,254.12"	"$12,146.40"	Not Applicable	"$10,628.10"	"$21,256.20"	"$10,628.10"	"$21,256.20"
STEM HUM 55MM 9MM CMPRH POR MIC SHLDR RVRS SYS 113609	C1776	SUPPLY/IMPLANTS	"$30,366.00"	Outpatient	"$15,183.00"	Not Applicable	"$16,610.20"	"$20,254.12"	"$12,146.40"	Not Applicable	"$10,628.10"	"$21,256.20"	"$10,628.10"	"$21,256.20"
STEM HUM 55MM 12MM CMPRH POR MIC SHLDR RVRS SYS 113612	C1776	SUPPLY/IMPLANTS	"$30,366.00"	Outpatient	"$15,183.00"	Not Applicable	"$16,610.20"	"$20,254.12"	"$12,146.40"	Not Applicable	"$10,628.10"	"$21,256.20"	"$10,628.10"	"$21,256.20"
TRAY INST HIPLOC CHS SYS US 35-000264		STERILE SUPPLY	"$30,365.00"	Outpatient	"$15,182.50"	Not Applicable	"$16,609.66"	"$20,253.46"	"$12,146.00"	Not Applicable	"$10,627.75"	"$21,255.50"	"$10,627.75"	"$21,255.50"
RESTORIS MCK BI ONLAY 180999	C1776	SUPPLY/IMPLANTS	"$30,334.00"	Outpatient	"$15,167.00"	Not Applicable	"$16,592.70"	"$20,232.78"	"$12,133.60"	Not Applicable	"$10,616.90"	"$21,233.80"	"$10,616.90"	"$21,233.80"
SHNT NS STRT2 REG 120CM 27864		STERILE SUPPLY	"$30,330.00"	Outpatient	"$15,165.00"	Not Applicable	"$16,590.51"	"$20,230.11"	"$12,132.00"	Not Applicable	"$10,615.50"	"$21,231.00"	"$10,615.50"	"$21,231.00"
VALVE MITRAL HANCOCK T510 CINCH 25MM T510XXH		SUPPLY/IMPLANTS	"$30,303.00"	Outpatient	"$15,151.50"	Not Applicable	"$16,575.74"	"$20,212.10"	"$12,121.20"	Not Applicable	"$10,606.05"	"$21,212.10"	"$10,606.05"	"$21,212.10"
VLV AOR 34MM 23MM FRSTL BPRTH PRCN 3MM ROOT STRL FR995-23		SUPPLY/IMPLANTS	"$30,295.00"	Outpatient	"$15,147.50"	Not Applicable	"$16,571.37"	"$20,206.77"	"$12,118.00"	Not Applicable	"$10,603.25"	"$21,206.50"	"$10,603.25"	"$21,206.50"
ANNEX ADJACENT LEVEL SYSTEM 11-5040	C1713	SUPPLY/IMPLANTS	"$30,285.00"	Outpatient	"$15,142.50"	"$1,365.15"	"$16,565.90"	"$20,200.10"	"$12,114.00"	Not Applicable	"$10,599.75"	"$21,199.50"	"$1,365.15"	"$21,199.50"
SPACER SPINAL ELEVATE PEEK TITANIUM XLORDOTIC L28 MM X H10 M 8881028	C1821	SUPPLY/IMPLANTS	"$30,285.00"	Outpatient	"$15,142.50"	Not Applicable	"$16,565.90"	"$20,200.10"	"$12,114.00"	Not Applicable	"$10,599.75"	"$21,199.50"	"$10,599.75"	"$21,199.50"
SPACER SPINAL ELEVATE PEEK TITANIUM XLORDOTIC L32 MM X H10 M 8881032	C1821	SUPPLY/IMPLANTS	"$30,285.00"	Outpatient	"$15,142.50"	Not Applicable	"$16,565.90"	"$20,200.10"	"$12,114.00"	Not Applicable	"$10,599.75"	"$21,199.50"	"$10,599.75"	"$21,199.50"
SPACER SPINAL ELEVATE PEEK TITANIUM XLORDOTIC L28 MM X H8 MM 8880828	C1821	SUPPLY/IMPLANTS	"$30,285.00"	Outpatient	"$15,142.50"	Not Applicable	"$16,565.90"	"$20,200.10"	"$12,114.00"	Not Applicable	"$10,599.75"	"$21,199.50"	"$10,599.75"	"$21,199.50"
LEAD NS 65CM VECTRIS 2 CLMN 16 ELTRD MRI 977C265	C1778	SUPPLY/IMPLANTS	"$30,275.00"	Outpatient	"$15,137.50"	Not Applicable	"$16,560.43"	"$20,193.43"	"$12,110.00"	Not Applicable	"$10,596.25"	"$21,192.50"	"$10,596.25"	"$21,192.50"
RESTORIS MCK BI INLAY 180998	C1776	SUPPLY/IMPLANTS	"$30,234.00"	Outpatient	"$15,117.00"	Not Applicable	"$16,538.00"	"$20,166.08"	"$12,093.60"	Not Applicable	"$10,581.90"	"$21,163.80"	"$10,581.90"	"$21,163.80"
INSERT TIBIAL LPS COCR POLYETHYLENE 2XS UNIVERSAL H16 MM KNE 1987-27-016	C1776	SUPPLY/IMPLANTS	"$30,212.00"	Outpatient	"$15,106.00"	Not Applicable	"$16,525.96"	"$20,151.40"	"$12,084.80"	Not Applicable	"$10,574.20"	"$21,148.40"	"$10,574.20"	"$21,148.40"
DISC ARTIFICIAL M6-C TITANIUM UHMWPE POLYMER D16 MM LARGE W1 CDL-627	C1713	SUPPLY/IMPLANTS	"$30,208.00"	Outpatient	"$15,104.00"	"$1,365.15"	"$16,523.78"	"$20,148.74"	"$12,083.20"	Not Applicable	"$10,572.80"	"$21,145.60"	"$1,365.15"	"$21,145.60"
DISC ARTIFICIAL M6-C TITANIUM UHMWPE POLYMER D16 MM LARGE LO CDL-637L	C1713	SUPPLY/IMPLANTS	"$30,208.00"	Outpatient	"$15,104.00"	"$1,365.15"	"$16,523.78"	"$20,148.74"	"$12,083.20"	Not Applicable	"$10,572.80"	"$21,145.60"	"$1,365.15"	"$21,145.60"
DISC ARTIFICIAL M7-C TITANIUM UHMWPE POLYMER D16 MM LARGE LO CDL-737L	C1713	SUPPLY/IMPLANTS	"$30,208.00"	Outpatient	"$15,104.00"	"$1,365.15"	"$16,523.78"	"$20,148.74"	"$12,083.20"	Not Applicable	"$10,572.80"	"$21,145.60"	"$1,365.15"	"$21,145.60"
MOBI-C CERVICAL DISC 17X19 H6 MB3796		SUPPLY/IMPLANTS	"$30,208.00"	Outpatient	"$15,104.00"	Not Applicable	"$16,523.78"	"$20,148.74"	"$12,083.20"	Not Applicable	"$10,572.80"	"$21,145.60"	"$10,572.80"	"$21,145.60"
MTRX TISS 16X10CM STRATTICE PRCN DERM RECON STRL 1016002	Q4130	PHARMACY	"$30,207.00"	Outpatient	"$15,103.50"	Not Applicable	"$16,523.23"	"$20,148.07"	"$12,082.80"	Not Applicable	"$10,572.45"	"$21,144.90"	"$10,572.45"	"$21,144.90"
DISC INTERVERTEBRAL MOBI-C D17 MM STANDARD W17 MM X H6 MM ST MB3776	C1713	SUPPLY/IMPLANTS	"$30,176.00"	Outpatient	"$15,088.00"	"$1,365.15"	"$16,506.27"	"$20,127.39"	"$12,070.40"	Not Applicable	"$10,561.60"	"$21,123.20"	"$1,365.15"	"$21,123.20"
SYSTEM INTERNAL FIXATION LAPIPLASTY BIPLANAR L14 MM X W3.9 M SK14	C1713	SUPPLY/IMPLANTS	"$30,176.00"	Outpatient	"$15,088.00"	"$1,365.15"	"$16,506.27"	"$20,127.39"	"$12,070.40"	Not Applicable	"$10,561.60"	"$21,123.20"	"$1,365.15"	"$21,123.20"
DISC INTERVERTEBRAL MOBI-C D17 MM STANDARD W17 MM X H7 MM ST MB3777		SUPPLY/IMPLANTS	"$30,176.00"	Outpatient	"$15,088.00"	Not Applicable	"$16,506.27"	"$20,127.39"	"$12,070.40"	Not Applicable	"$10,561.60"	"$21,123.20"	"$10,561.60"	"$21,123.20"
SYS IMPL LINX 13 BEAD 1.5 TESLA GI GERD LXMC13	L8699	SUPPLY/IMPLANTS	"$30,172.00"	Outpatient	"$15,086.00"	Not Applicable	"$16,504.08"	"$20,124.72"	"$12,068.80"	Not Applicable	"$10,560.20"	"$21,120.40"	"$10,560.20"	"$21,120.40"
SYS IMPL LINX 14 BEAD 1.5 TESLA GI GERD LXMC14		STERILE SUPPLY	"$30,172.00"	Outpatient	"$15,086.00"	Not Applicable	"$16,504.08"	"$20,124.72"	"$12,068.80"	Not Applicable	"$10,560.20"	"$21,120.40"	"$10,560.20"	"$21,120.40"
SYS IMPL LINX 16 BEAD 1.5 TESLA GI GERD LXMC16		STERILE SUPPLY	"$30,172.00"	Outpatient	"$15,086.00"	Not Applicable	"$16,504.08"	"$20,124.72"	"$12,068.80"	Not Applicable	"$10,560.20"	"$21,120.40"	"$10,560.20"	"$21,120.40"
SYS IMPL LINX 17 BEAD 1.5 TESLA GI GERD LXMC17		STERILE SUPPLY	"$30,172.00"	Outpatient	"$15,086.00"	Not Applicable	"$16,504.08"	"$20,124.72"	"$12,068.80"	Not Applicable	"$10,560.20"	"$21,120.40"	"$10,560.20"	"$21,120.40"
SYS IMPL LINX 15 BEAD 1.5 TESLA GI GERD LXMC15		SUPPLY/IMPLANTS	"$30,172.00"	Outpatient	"$15,086.00"	Not Applicable	"$16,504.08"	"$20,124.72"	"$12,068.80"	Not Applicable	"$10,560.20"	"$21,120.40"	"$10,560.20"	"$21,120.40"
PCMKR THK6MM ACT DR 2 CHMBR INDUCTIVE TELEM EGM IS-1 52X46MM PM2110	C1785	PACE MAKER	"$30,170.00"	Outpatient	"$15,085.00"	Not Applicable	"$16,502.99"	"$20,123.39"	"$12,068.00"	Not Applicable	"$10,559.50"	"$21,119.00"	"$10,559.50"	"$21,119.00"
MTRX TISS 16X8CM ALDRM THK RGNRT RTU 1520128	Q4116	SUPPLY/IMPLANTS	"$30,158.00"	Outpatient	"$15,079.00"	$34.22	"$16,496.43"	"$20,115.39"	"$12,063.20"	Not Applicable	"$10,555.30"	"$21,110.60"	$34.22	"$21,110.60"
STEM HUM 150MM 12MM GB FX STD SHLDR STRL 112812000	C1776	SUPPLY/IMPLANTS	"$30,147.00"	Outpatient	"$15,073.50"	Not Applicable	"$16,490.41"	"$20,108.05"	"$12,058.80"	Not Applicable	"$10,551.45"	"$21,102.90"	"$10,551.45"	"$21,102.90"
BONE CELLULAR VIVIGEN 15CC BL-1500-004		SUPPLY/IMPLANTS	"$30,147.00"	Outpatient	"$15,073.50"	Not Applicable	"$16,490.41"	"$20,108.05"	"$12,058.80"	Not Applicable	"$10,551.45"	"$21,102.90"	"$10,551.45"	"$21,102.90"
PLT 2.5MM MNDB TI WO ANG BN NS PTSPC SD480.102	C1713	SUPPLY/IMPLANTS	"$30,133.00"	Outpatient	"$15,066.50"	"$1,365.15"	"$16,482.75"	"$20,098.71"	"$12,053.20"	Not Applicable	"$10,546.55"	"$21,093.10"	"$1,365.15"	"$21,093.10"
BODY BROACHED RSTR 5 HIP PROX MDLR 6276-3-005	C1776	SUPPLY/IMPLANTS	"$30,044.00"	Outpatient	"$15,022.00"	Not Applicable	"$16,434.07"	"$20,039.35"	"$12,017.60"	Not Applicable	"$10,515.40"	"$21,030.80"	"$10,515.40"	"$21,030.80"
BODY CONE HIP +20MM RSTR TI 21MM MDLR STRL REV SYS 6276-1-221	C1776	SUPPLY/IMPLANTS	"$30,039.00"	Outpatient	"$15,019.50"	Not Applicable	"$16,431.33"	"$20,036.01"	"$12,015.60"	Not Applicable	"$10,513.65"	"$21,027.30"	"$10,513.65"	"$21,027.30"
BODY CONE HIP +10MM RSTR TI 25MM MDLR STRL REV SYS 6276-1-125	C1776	SUPPLY/IMPLANTS	"$30,039.00"	Outpatient	"$15,019.50"	Not Applicable	"$16,431.33"	"$20,036.01"	"$12,015.60"	Not Applicable	"$10,513.65"	"$21,027.30"	"$10,513.65"	"$21,027.30"
VLV MTRL 27MM 22.5MM MSTR SER LFLT ORFC CNTRL TRQ ROT MECH 27MJ-501		SUPPLY/IMPLANTS	"$30,029.00"	Outpatient	"$15,014.50"	Not Applicable	"$16,425.86"	"$20,029.34"	"$12,011.60"	Not Applicable	"$10,510.15"	"$21,020.30"	"$10,510.15"	"$21,020.30"
VLV MTRL 29MM 24.2MM MSTR SER LFLT ORFC CNTRL TRQ ROT MECH 29MJ-501		SUPPLY/IMPLANTS	"$30,029.00"	Outpatient	"$15,014.50"	Not Applicable	"$16,425.86"	"$20,029.34"	"$12,011.60"	Not Applicable	"$10,510.15"	"$21,020.30"	"$10,510.15"	"$21,020.30"
VLV MTRL 31MM 26.1MM MSTR-SER CUF LFLT OPN CNTRL TRQ ROT 31MJ-501		SUPPLY/IMPLANTS	"$30,029.00"	Outpatient	"$15,014.50"	Not Applicable	"$16,425.86"	"$20,029.34"	"$12,011.60"	Not Applicable	"$10,510.15"	"$21,020.30"	"$10,510.15"	"$21,020.30"
GFT STNT 124MM 25-16MM 18FR ENDURANT II 2 BRCH EVAS NTNL ETBF2516C124E	C1884	SUPPLY/IMPLANTS	"$30,013.00"	Outpatient	"$15,006.50"	Not Applicable	"$16,417.11"	"$20,018.67"	"$12,005.20"	Not Applicable	"$10,504.55"	"$21,009.10"	"$10,504.55"	"$21,009.10"
GFT STNT 82MM 16-20MM 16FR ENDURANT II EVAS NTNL PLSTR HDRPH ETLW1620C82E	C1874	SUPPLY/IMPLANTS	"$29,998.00"	Outpatient	"$14,999.00"	Not Applicable	"$16,408.91"	"$20,008.67"	"$11,999.20"	Not Applicable	"$10,499.30"	"$20,998.60"	"$10,499.30"	"$20,998.60"
DSTRCT MNDB MTVCTR BD SRG TI NS 487.931	C1713	SUPPLY/IMPLANTS	"$29,998.00"	Outpatient	"$14,999.00"	"$1,365.15"	"$16,408.91"	"$20,008.67"	"$11,999.20"	Not Applicable	"$10,499.30"	"$20,998.60"	"$1,365.15"	"$20,998.60"
LEAD ATRIAL INGEVITY MRI MODEL 7740 45CM SN-608674	C1898	SUPPLY/IMPLANTS	"$29,998.00"	Outpatient	"$14,999.00"	Not Applicable	"$16,408.91"	"$20,008.67"	"$11,999.20"	Not Applicable	"$10,499.30"	"$20,998.60"	"$10,499.30"	"$20,998.60"
GFT STNT 124MM 16-10MM 14FR ENDURANT II EVAS NTNL PLSTR ETLW1610C124E	C1784	SUPPLY/IMPLANTS	"$29,991.00"	Outpatient	"$14,995.50"	Not Applicable	"$16,405.08"	"$20,004.00"	"$11,996.40"	Not Applicable	"$10,496.85"	"$20,993.70"	"$10,496.85"	"$20,993.70"
GFT STNT 82MM 16-10MM 14FR ENDURANT II EVAS NTNL PLSTR HDRPH ETLW1610C82E	C1876	SUPPLY/IMPLANTS	"$29,980.00"	Outpatient	"$14,990.00"	Not Applicable	"$16,399.06"	"$19,996.66"	"$11,992.00"	Not Applicable	"$10,493.00"	"$20,986.00"	"$10,493.00"	"$20,986.00"
GRAFT STENT ENDURANT IIS NITINOL PLATINUM POLYESTER 2 BRANCH L103 MM OD14-23 MM ODSEC18 FR INFRAREN		SUPPLY/IMPLANTS	"$29,980.00"	Outpatient	"$14,990.00"	Not Applicable	"$16,399.06"	"$19,996.66"	"$11,992.00"	Not Applicable	"$10,493.00"	"$20,986.00"	"$10,493.00"	"$20,986.00"
PLT 150X150X.5MM CNTR MESH RPD RSRB BN STRL 1.5MM SCR 851.623.01S	C1713	SUPPLY/IMPLANTS	"$29,966.00"	Outpatient	"$14,983.00"	"$1,365.15"	"$16,391.40"	"$19,987.32"	"$11,986.40"	Not Applicable	"$10,488.10"	"$20,976.20"	"$1,365.15"	"$20,976.20"
GFT STNT 82MM 13MM 14FR ENDURANT II EVAS PLSTR NTNL ILC XTN ETEW1313C82E	C1874	SUPPLY/IMPLANTS	"$29,956.00"	Outpatient	"$14,978.00"	Not Applicable	"$16,385.93"	"$19,980.65"	"$11,982.40"	Not Applicable	"$10,484.60"	"$20,969.20"	"$10,484.60"	"$20,969.20"
GFT BN RHBMP-2 BVN CLGN 2X1IN 5.6CC VL ABS SYR NDL INFS MED 7510400		SUPPLY/IMPLANTS	"$29,954.00"	Outpatient	"$14,977.00"	Not Applicable	"$16,384.84"	"$19,979.32"	"$11,981.60"	Not Applicable	"$10,483.90"	"$20,967.80"	"$10,483.90"	"$20,967.80"
CMPNT FEM STD NTRL HIP GMRS COCR 64951001	C1776	SUPPLY/IMPLANTS	"$29,876.00"	Outpatient	"$14,938.00"	Not Applicable	"$16,342.17"	"$19,927.29"	"$11,950.40"	Not Applicable	"$10,456.60"	"$20,913.20"	"$10,456.60"	"$20,913.20"
PLT 12 SPNE 2 HL DECADE BN NS XLIF 7140212	C1713	SUPPLY/IMPLANTS	"$29,875.00"	Outpatient	"$14,937.50"	"$1,365.15"	"$16,341.63"	"$19,926.63"	"$11,950.00"	Not Applicable	"$10,456.25"	"$20,912.50"	"$1,365.15"	"$20,912.50"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 2 KNEE RIGHT PATEL 00592601202	C1776	SUPPLY/IMPLANTS	"$29,874.00"	Outpatient	"$14,937.00"	Not Applicable	"$16,341.08"	"$19,925.96"	"$11,949.60"	Not Applicable	"$10,455.90"	"$20,911.80"	"$10,455.90"	"$20,911.80"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 2 KNEE LEFT PATELL 00592601201	C1776	SUPPLY/IMPLANTS	"$29,874.00"	Outpatient	"$14,937.00"	Not Applicable	"$16,341.08"	"$19,925.96"	"$11,949.60"	Not Applicable	"$10,455.90"	"$20,911.80"	"$10,455.90"	"$20,911.80"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 3 KNEE LEFT PATELL 0592601301	C1776	SUPPLY/IMPLANTS	"$29,874.00"	Outpatient	"$14,937.00"	Not Applicable	"$16,341.08"	"$19,925.96"	"$11,949.60"	Not Applicable	"$10,455.90"	"$20,911.80"	"$10,455.90"	"$20,911.80"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 3 KNEE RIGHT PATEL 0592601302	C1776	SUPPLY/IMPLANTS	"$29,874.00"	Outpatient	"$14,937.00"	Not Applicable	"$16,341.08"	"$19,925.96"	"$11,949.60"	Not Applicable	"$10,455.90"	"$20,911.80"	"$10,455.90"	"$20,911.80"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 5 KNEE LEFT PATELL 00592601501	C1776	SUPPLY/IMPLANTS	"$29,874.00"	Outpatient	"$14,937.00"	Not Applicable	"$16,341.08"	"$19,925.96"	"$11,949.60"	Not Applicable	"$10,455.90"	"$20,911.80"	"$10,455.90"	"$20,911.80"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 5 KNEE RIGHT PATEL 00592601502	C1776	SUPPLY/IMPLANTS	"$29,874.00"	Outpatient	"$14,937.00"	Not Applicable	"$16,341.08"	"$19,925.96"	"$11,949.60"	Not Applicable	"$10,455.90"	"$20,911.80"	"$10,455.90"	"$20,911.80"
ASMB XTRNFX HEADFRAME ADJ DSTRCT NS 390.1	C1713	SUPPLY/IMPLANTS	"$29,858.00"	Outpatient	"$14,929.00"	"$1,365.15"	"$16,332.33"	"$19,915.29"	"$11,943.20"	Not Applicable	"$10,450.30"	"$20,900.60"	"$1,365.15"	"$20,900.60"
MNTR PT MYCARELINK NS LF REUSE SVC 24950LLQ		STERILE SUPPLY	"$29,845.00"	Outpatient	"$14,922.50"	Not Applicable	"$16,325.22"	"$19,906.62"	"$11,938.00"	Not Applicable	"$10,445.75"	"$20,891.50"	"$10,445.75"	"$20,891.50"
DRSG WND FLW MTRX BVN CLGN GAG POLYSILOXANE 3ML STRL LF DISP FWD301	C9363	SUPPLY/IMPLANTS	"$29,832.00"	Outpatient	"$14,916.00"	$38.51	"$16,318.10"	"$19,897.94"	"$11,932.80"	Not Applicable	"$10,441.20"	"$20,882.40"	$38.51	"$20,882.40"
STNT NTNL SS/PL EPTFE 10MM 6CM SLF XPD RADOPQ 2 LUM CATH ACC PTB106275	C1874	SUPPLY/IMPLANTS	"$29,823.00"	Outpatient	"$14,911.50"	Not Applicable	"$16,313.18"	"$19,891.94"	"$11,929.20"	Not Applicable	"$10,438.05"	"$20,876.10"	"$10,438.05"	"$20,876.10"
STENT VIATORR 10MM X 8CM X 2CM PTB8107275	C1874	SUPPLY/IMPLANTS	"$29,821.00"	Outpatient	"$14,910.50"	Not Applicable	"$16,312.09"	"$19,890.61"	"$11,928.40"	Not Applicable	"$10,437.35"	"$20,874.70"	"$10,437.35"	"$20,874.70"
STNT NTNL SS/PL EPTFE 10MM 7CM SLF XPD RADOPQ 2 LUM CATH ACC PTB107275	C1874	SUPPLY/IMPLANTS	"$29,821.00"	Outpatient	"$14,910.50"	Not Applicable	"$16,312.09"	"$19,890.61"	"$11,928.40"	Not Applicable	"$10,437.35"	"$20,874.70"	"$10,437.35"	"$20,874.70"
AUGMENT TIBIAL TRIATHLON TRITANIUM C CONE KNEE LEFT MEDIAL R 5549-A-231	C1776	SUPPLY/IMPLANTS	"$29,821.00"	Outpatient	"$14,910.50"	Not Applicable	"$16,312.09"	"$19,890.61"	"$11,928.40"	Not Applicable	"$10,437.35"	"$20,874.70"	"$10,437.35"	"$20,874.70"
AUGMENT TIBIAL TRIATHLON TRITANIUM C CONE KNEE RIGHT MEDIAL 5549-A-232	C1776	SUPPLY/IMPLANTS	"$29,821.00"	Outpatient	"$14,910.50"	Not Applicable	"$16,312.09"	"$19,890.61"	"$11,928.40"	Not Applicable	"$10,437.35"	"$20,874.70"	"$10,437.35"	"$20,874.70"
PLT 56X8X2.5MM ANG MNDB CNDYL HD RT TI 4X18 HL LCK RECON BN 449.646	C1713	SUPPLY/IMPLANTS	"$29,815.00"	Outpatient	"$14,907.50"	"$1,365.15"	"$16,308.81"	"$19,886.61"	"$11,926.00"	Not Applicable	"$10,435.25"	"$20,870.50"	"$1,365.15"	"$20,870.50"
PLT 56X8X2.5MM ANG MNDB CNDYL HD LT TI 4X18 HL LCK RECON BN 449.647	C1713	SUPPLY/IMPLANTS	"$29,815.00"	Outpatient	"$14,907.50"	"$1,365.15"	"$16,308.81"	"$19,886.61"	"$11,926.00"	Not Applicable	"$10,435.25"	"$20,870.50"	"$1,365.15"	"$20,870.50"
DEV CRD BIOMONITOR IMPL STRL LF 398493	C1764	SUPPLY/IMPLANTS	"$29,787.00"	Outpatient	"$14,893.50"	Not Applicable	"$16,293.49"	"$19,867.93"	"$11,914.80"	Not Applicable	"$10,425.45"	"$20,850.90"	"$10,425.45"	"$20,850.90"
PCMKR THK7.5MM ADVANTIO 1 CHMBR RR IS-1 44.5X45.7MM CRD 11.5 K062	C1786	PACE MAKER	"$29,784.00"	Outpatient	"$14,892.00"	Not Applicable	"$16,291.85"	"$19,865.93"	"$11,913.60"	Not Applicable	"$10,424.40"	"$20,848.80"	"$10,424.40"	"$20,848.80"
CAGE 13MM 8841-2813	C1821	SUPPLY/IMPLANTS	"$29,766.00"	Outpatient	"$14,883.00"	Not Applicable	"$16,282.00"	"$19,853.92"	"$11,906.40"	Not Applicable	"$10,418.10"	"$20,836.20"	"$10,418.10"	"$20,836.20"
CMPNT FEM 3 KN RT POST STAB GNS2 LEGION SPC OXNM 71421203	C1776	SUPPLY/IMPLANTS	"$29,721.00"	Outpatient	"$14,860.50"	Not Applicable	"$16,257.39"	"$19,823.91"	"$11,888.40"	Not Applicable	"$10,402.35"	"$20,804.70"	"$10,402.35"	"$20,804.70"
PLT 2.5MM ANG MNDB LT TI 7X23 HL RECON MATRIXMANDIBLE BN SD449.510B	C1713	SUPPLY/IMPLANTS	"$29,715.00"	Outpatient	"$14,857.50"	"$1,365.15"	"$16,254.11"	"$19,819.91"	"$11,886.00"	Not Applicable	"$10,400.25"	"$20,800.50"	"$1,365.15"	"$20,800.50"
PLT 2.5MM ANG RT MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS SD449.511B	C1713	SUPPLY/IMPLANTS	"$29,715.00"	Outpatient	"$14,857.50"	"$1,365.15"	"$16,254.11"	"$19,819.91"	"$11,886.00"	Not Applicable	"$10,400.25"	"$20,800.50"	"$1,365.15"	"$20,800.50"
50242-0053-06 - riTUXimab 10 mg/mL Soln	J9312	PHARMACY	"$24,973.00"	Outpatient	"$12,486.50"	$94.18	"$16,232.45"	"$16,656.99"	"$9,989.20"	Not Applicable	"$8,740.55"	"$17,481.10"	$94.18	"$17,481.10"
50242-0051-21 - rituximab inj (per 100mg)	J9310	PHARMACY	"$24,973.00"	Outpatient	"$12,486.50"	Not Applicable	"$16,232.45"	"$16,656.99"	"$9,989.20"	Not Applicable	"$8,740.55"	"$17,481.10"	"$8,740.55"	"$17,481.10"
PCMKR ALTRUA 20 SR CRD S201/04	C1786	PACE MAKER	"$29,674.00"	Outpatient	"$14,837.00"	Not Applicable	"$16,231.68"	"$19,792.56"	"$11,869.60"	Not Applicable	"$10,385.90"	"$20,771.80"	"$10,385.90"	"$20,771.80"
Revasc Tib/Peron Art Bil Vsl W Trans	37228	CARDIAC CATH LAB	"$29,670.00"	Outpatient	"$14,835.00"	"$18,911.20"	"$16,229.49"	"$1,592.00"	"$11,868.00"	"$7,310.00"	"$10,384.50"	"$20,769.00"	"$1,592.00"	"$20,769.00"
Revasc Iliac Artery Initial Vessel Bilateral	37220	CARDIAC CATH LAB	"$29,670.00"	Outpatient	"$14,835.00"	"$18,911.20"	"$16,229.49"	"$1,592.00"	"$11,868.00"	"$7,310.00"	"$10,384.50"	"$20,769.00"	"$1,592.00"	"$20,769.00"
PM SYSTEM EDORA DR-T PROMRI W/HM 431748	C1786	PACE MAKER	"$29,668.00"	Outpatient	"$14,834.00"	Not Applicable	"$16,228.40"	"$19,788.56"	"$11,867.20"	Not Applicable	"$10,383.80"	"$20,767.60"	"$10,383.80"	"$20,767.60"
ACCOLADE MRI DR EL 1 LD 9H53	C1785	PACE MAKER	"$29,668.00"	Outpatient	"$14,834.00"	Not Applicable	"$16,228.40"	"$19,788.56"	"$11,867.20"	Not Applicable	"$10,383.80"	"$20,767.60"	"$10,383.80"	"$20,767.60"
STEM HUM 83MM 13MM CMPRH POR MN SHLDR RVRS SYS 113633	C1776	SUPPLY/IMPLANTS	"$29,644.00"	Outpatient	"$14,822.00"	Not Applicable	"$16,215.27"	"$19,772.55"	"$11,857.60"	Not Applicable	"$10,375.40"	"$20,750.80"	"$10,375.40"	"$20,750.80"
OXFORD UNI KNEE CONTSTRUCT W/SAW BLAKE KIT OUKC	C1713	SUPPLY/IMPLANTS	"$29,644.00"	Outpatient	"$14,822.00"	"$1,365.15"	"$16,215.27"	"$19,772.55"	"$11,857.60"	Not Applicable	"$10,375.40"	"$20,750.80"	"$1,365.15"	"$20,750.80"
BODY CONE HIP PROX +10MM RSTR 21MM MDLR 6276-1-121	C1776	SUPPLY/IMPLANTS	"$29,643.00"	Outpatient	"$14,821.50"	Not Applicable	"$16,214.72"	"$19,771.88"	"$11,857.20"	Not Applicable	"$10,375.05"	"$20,750.10"	"$10,375.05"	"$20,750.10"
DUAL CHAMBER ACCOLADE MRI DR IS-1 EL 9H52	C1785	PACE MAKER	"$29,637.00"	Outpatient	"$14,818.50"	Not Applicable	"$16,211.44"	"$19,767.88"	"$11,854.80"	Not Applicable	"$10,372.95"	"$20,745.90"	"$10,372.95"	"$20,745.90"
PACEMAKER CARDIAC ACCOLADE MRI 2 DR 9H32	C1785	PACE MAKER	"$29,637.00"	Outpatient	"$14,818.50"	Not Applicable	"$16,211.44"	"$19,767.88"	"$11,854.80"	Not Applicable	"$10,372.95"	"$20,745.90"	"$10,372.95"	"$20,745.90"
PACEMAKER MRI SYSTEM AZURE XT DR MEEM AZUREXTDRM RIMEEM		PACE MAKER	"$29,634.00"	Outpatient	"$14,817.00"	Not Applicable	"$16,209.80"	"$19,765.88"	"$11,853.60"	Not Applicable	"$10,371.90"	"$20,743.80"	"$10,371.90"	"$20,743.80"
STEM FEM 109MM 133D 12 STD OFST TPR TPRLK MICROPLASTY PPS 51-106120	C1776	SUPPLY/IMPLANTS	"$29,622.00"	Outpatient	"$14,811.00"	Not Applicable	"$16,203.23"	"$19,757.87"	"$11,848.80"	Not Applicable	"$10,367.70"	"$20,735.40"	"$10,367.70"	"$20,735.40"
GFT STNT 45MM 22MM 14FR 12FR TRIVASCULAR OV PRM OV IX 14FR TV-EX222245-J	C1874	SUPPLY/IMPLANTS	"$29,620.00"	Outpatient	"$14,810.00"	Not Applicable	"$16,202.14"	"$19,756.54"	"$11,848.00"	Not Applicable	"$10,367.00"	"$20,734.00"	"$10,367.00"	"$20,734.00"
FXTR XTRNFX DFS ANG STD ANT 6150	C1713	SUPPLY/IMPLANTS	"$29,615.00"	Outpatient	"$14,807.50"	"$1,365.15"	"$16,199.41"	"$19,753.21"	"$11,846.00"	Not Applicable	"$10,365.25"	"$20,730.50"	"$1,365.15"	"$20,730.50"
PCMKR .75CM ESSENTIO 2 CHMBR IS1 CNCT 4.45X5.02CM CRD 13.7CC L111	C1785	PACE MAKER	"$29,609.00"	Outpatient	"$14,804.50"	Not Applicable	"$16,196.12"	"$19,749.20"	"$11,843.60"	Not Applicable	"$10,363.15"	"$20,726.30"	"$10,363.15"	"$20,726.30"
HNDPC DRVR MATRIXPRO 05.000.020		STERILE SUPPLY	"$29,608.00"	Outpatient	"$14,804.00"	Not Applicable	"$16,195.58"	"$19,748.54"	"$11,843.20"	Not Applicable	"$10,362.80"	"$20,725.60"	"$10,362.80"	"$20,725.60"
Revasc Iliac Art Bil Init Vsl W/Transa Stent same Vsl	37221	CARDIAC CATH LAB	"$29,600.00"	Outpatient	"$14,800.00"	"$18,911.20"	"$16,191.20"	"$1,592.00"	"$11,840.00"	"$8,681.00"	"$10,360.00"	"$20,720.00"	"$1,592.00"	"$20,720.00"
Femoral Poplitial Revasc W/Transluminal Angioplasty Bilat	37224	CARDIAC CATH LAB	"$29,600.00"	Outpatient	"$14,800.00"	"$18,911.20"	"$16,191.20"	"$1,592.00"	"$11,840.00"	"$7,310.00"	"$10,360.00"	"$20,720.00"	"$1,592.00"	"$20,720.00"
CEMENT BONE HYDROSET XT HA 15 CC INJECTABLE STERILE LATEX FR 897015	C1713	SUPPLY/IMPLANTS	"$29,587.00"	Outpatient	"$14,793.50"	"$1,365.15"	"$16,184.09"	"$19,734.53"	"$11,834.80"	Not Applicable	"$10,355.45"	"$20,710.90"	"$1,365.15"	"$20,710.90"
STEM HUM 77MM LTD EV COCR STD MED RT STRL ARTHPL 30402	C1776	SUPPLY/IMPLANTS	"$29,567.00"	Outpatient	"$14,783.50"	Not Applicable	"$16,173.15"	"$19,721.19"	"$11,826.80"	Not Applicable	"$10,348.45"	"$20,696.90"	"$10,348.45"	"$20,696.90"
CMPNT FEM 5 73X69MM KN RT CMNT CRCTE STAB PFC S TC3 STRL 960090	C1776	SUPPLY/IMPLANTS	"$29,534.00"	Outpatient	"$14,767.00"	Not Applicable	"$16,155.10"	"$19,699.18"	"$11,813.60"	Not Applicable	"$10,336.90"	"$20,673.80"	"$10,336.90"	"$20,673.80"
SHL ACTB 68MM HIP RT ANTM RSTR 504-02-68F-R		STERILE SUPPLY	"$29,514.00"	Outpatient	"$14,757.00"	Not Applicable	"$16,144.16"	"$19,685.84"	"$11,805.60"	Not Applicable	"$10,329.90"	"$20,659.80"	"$10,329.90"	"$20,659.80"
FEMORAL ANTEGRADE KNEE FUSIJON NAIL 11.5MM X 60CM LEFT 71931599	C1776	SUPPLY/IMPLANTS	"$29,511.00"	Outpatient	"$14,755.50"	Not Applicable	"$16,142.52"	"$19,683.84"	"$11,804.40"	Not Applicable	"$10,328.85"	"$20,657.70"	"$10,328.85"	"$20,657.70"
CMPNT FEM 5 KN RT CRCTE RTN GNS2 LEGION SPC OXNM 71421225	C1776	SUPPLY/IMPLANTS	"$29,497.00"	Outpatient	"$14,748.50"	Not Applicable	"$16,134.86"	"$19,674.50"	"$11,798.80"	Not Applicable	"$10,323.95"	"$20,647.90"	"$10,323.95"	"$20,647.90"
DRSG BIO INTGR 5X4IN BVN CLGN GAG POLYSILOXANE BL MX MESH MWM4051	C9363	SUPPLY/IMPLANTS	"$29,479.00"	Outpatient	"$14,739.50"	$38.51	"$16,125.01"	"$19,662.49"	"$11,791.60"	Not Applicable	"$10,317.65"	"$20,635.30"	$38.51	"$20,635.30"
LEAD PCNG 86CM 4.7FR QRTT 4 ELTRD IS4 CNCT STRBL TIP LOPRFL 1458Q/86	C1900	PACE MAKER	"$29,479.00"	Outpatient	"$14,739.50"	Not Applicable	"$16,125.01"	"$19,662.49"	"$11,791.60"	Not Applicable	"$10,317.65"	"$20,635.30"	"$10,317.65"	"$20,635.30"
LEAD PCNG 92CMX16MM 5FR LH QRTT QUICKFLEX OPTIM 4 NAR ELTRD 1458Q/92	C1899	PACE MAKER	"$29,479.00"	Outpatient	"$14,739.50"	Not Applicable	"$16,125.01"	"$19,662.49"	"$11,791.60"	Not Applicable	"$10,317.65"	"$20,635.30"	"$10,317.65"	"$20,635.30"
INS ARTC 1-2 11MM TIB KN CNSTRN UHMWPE GNS2 71420960	C1776	SUPPLY/IMPLANTS	"$29,477.00"	Outpatient	"$14,738.50"	Not Applicable	"$16,123.92"	"$19,661.16"	"$11,790.80"	Not Applicable	"$10,316.95"	"$20,633.90"	"$10,316.95"	"$20,633.90"
STEM FEM 136MM 133D 8 STD OFST TPR TPRLK PPS HIP TY 1 PRFT 51-100080	C1776	SUPPLY/IMPLANTS	"$29,455.00"	Outpatient	"$14,727.50"	Not Applicable	"$16,111.89"	"$19,646.49"	"$11,782.00"	Not Applicable	"$10,309.25"	"$20,618.50"	"$10,309.25"	"$20,618.50"
STEM FEM 140MM 133D 10 STD OFST TPR TPRLK PPS 34.3MM HIP 51-103100	C1776	SUPPLY/IMPLANTS	"$29,455.00"	Outpatient	"$14,727.50"	Not Applicable	"$16,111.89"	"$19,646.49"	"$11,782.00"	Not Applicable	"$10,309.25"	"$20,618.50"	"$10,309.25"	"$20,618.50"
STEM FEM 142MM 133D 11 STD OFST TPR TPRLK PPS HIP TY 1 PRFT 51-103110	C1776	SUPPLY/IMPLANTS	"$29,455.00"	Outpatient	"$14,727.50"	Not Applicable	"$16,111.89"	"$19,646.49"	"$11,782.00"	Not Applicable	"$10,309.25"	"$20,618.50"	"$10,309.25"	"$20,618.50"
STEM PRIMARY FEMORAL POROUS COATED 9 X 137MM TYPE 1 TAPER 51-103090	C1776	SUPPLY/IMPLANTS	"$29,455.00"	Outpatient	"$14,727.50"	Not Applicable	"$16,111.89"	"$19,646.49"	"$11,782.00"	Not Applicable	"$10,309.25"	"$20,618.50"	"$10,309.25"	"$20,618.50"
STEM PRIMARY FEMORAL POROUS COATED 13 X 146MM TYPE 1 TAPER 51-104130	C1776	SUPPLY/IMPLANTS	"$29,455.00"	Outpatient	"$14,727.50"	Not Applicable	"$16,111.89"	"$19,646.49"	"$11,782.00"	Not Applicable	"$10,309.25"	"$20,618.50"	"$10,309.25"	"$20,618.50"
HEAD HUMERAL SIDUS H15 MM OD42 MM SHOULDER STEM FREE 104555420	C1776	SUPPLY/IMPLANTS	"$29,422.00"	Outpatient	"$14,711.00"	Not Applicable	"$16,093.83"	"$19,624.47"	"$11,768.80"	Not Applicable	"$10,297.70"	"$20,595.40"	"$10,297.70"	"$20,595.40"
ANCHOR SIDUS STEM SHOULDER HUMERAL 01.04555.120	C1713	SUPPLY/IMPLANTS	"$29,422.00"	Outpatient	"$14,711.00"	"$1,365.15"	"$16,093.83"	"$19,624.47"	"$11,768.80"	Not Applicable	"$10,297.70"	"$20,595.40"	"$1,365.15"	"$20,595.40"
GFT STNT 95MM 28MM AFX VELA STRATA AOR XTN 20MM AAA STRL LF A28-28/C95-O20V	C1883	SUPPLY/IMPLANTS	"$29,368.00"	Outpatient	"$14,684.00"	Not Applicable	"$16,064.30"	"$19,588.46"	"$11,747.20"	Not Applicable	"$10,278.80"	"$20,557.60"	"$10,278.80"	"$20,557.60"
DISC INTVRTB 17X5MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3575	C1713	SUPPLY/IMPLANTS	"$29,328.00"	Outpatient	"$14,664.00"	"$1,365.15"	"$16,042.42"	"$19,561.78"	"$11,731.20"	Not Applicable	"$10,264.80"	"$20,529.60"	"$1,365.15"	"$20,529.60"
 DISC INTERVERTEBRAL MOBI-C TITANIUM HA D17 MM STANDARD W19 MB3795		SUPPLY/IMPLANTS	"$29,328.00"	Outpatient	"$14,664.00"	Not Applicable	"$16,042.42"	"$19,561.78"	"$11,731.20"	Not Applicable	"$10,264.80"	"$20,529.60"	"$10,264.80"	"$20,529.60"
STEM FEM 217MM 19MM BW RSTR DIST HIP MDLR PLSM SPRAYED 6276-5-419	C1776	SUPPLY/IMPLANTS	"$29,296.00"	Outpatient	"$14,648.00"	Not Applicable	"$16,024.91"	"$19,540.43"	"$11,718.40"	Not Applicable	"$10,253.60"	"$20,507.20"	"$10,253.60"	"$20,507.20"
DRVR PHNX ANTGRD SRG FEM NL SYS 14-442017	C1713	SUPPLY/IMPLANTS	"$29,296.00"	Outpatient	"$14,648.00"	"$1,365.15"	"$16,024.91"	"$19,540.43"	"$11,718.40"	Not Applicable	"$10,253.60"	"$20,507.20"	"$1,365.15"	"$20,507.20"
SET TRMA FX CNN SCR INST CA 3.5-4 MM 114703501		STERILE SUPPLY	"$29,283.00"	Outpatient	"$14,641.50"	Not Applicable	"$16,017.80"	"$19,531.76"	"$11,713.20"	Not Applicable	"$10,249.05"	"$20,498.10"	"$10,249.05"	"$20,498.10"
STEM HUM 120MM 8MM REUNION HA SHLDR R5351-4508	C1776	SUPPLY/IMPLANTS	"$29,281.00"	Outpatient	"$14,640.50"	Not Applicable	"$16,016.71"	"$19,530.43"	"$11,712.40"	Not Applicable	"$10,248.35"	"$20,496.70"	"$10,248.35"	"$20,496.70"
STEM HUM 130MM 15MM REUNION HA SHLDR R5351-4515	C1776	SUPPLY/IMPLANTS	"$29,281.00"	Outpatient	"$14,640.50"	Not Applicable	"$16,016.71"	"$19,530.43"	"$11,712.40"	Not Applicable	"$10,248.35"	"$20,496.70"	"$10,248.35"	"$20,496.70"
STEM FEM 120MM 6.9MM 127D 6 37.2MM OFST SCRFT ADV PUREFIX TI 1601-06127	C1776	SUPPLY/IMPLANTS	"$29,271.00"	Outpatient	"$14,635.50"	Not Applicable	"$16,011.24"	"$19,523.76"	"$11,708.40"	Not Applicable	"$10,244.85"	"$20,489.70"	"$10,244.85"	"$20,489.70"
PFC SIGMA TIBIAL TRAY FIXED BEARING MODULAR COCR CEMENTED	C1776	SUPPLY/IMPLANTS	"$29,243.00"	Outpatient	"$14,621.50"	Not Applicable	"$15,995.92"	"$19,505.08"	"$11,697.20"	Not Applicable	"$10,235.05"	"$20,470.10"	"$10,235.05"	"$20,470.10"
IPG ADSR03 ADAPTA 3.2 ASDR03	C1786	PACE MAKER	"$29,236.00"	Outpatient	"$14,618.00"	Not Applicable	"$15,992.09"	"$19,500.41"	"$11,694.40"	Not Applicable	"$10,232.60"	"$20,465.20"	"$10,232.60"	"$20,465.20"
PLT 2.8MM ANG TI 20 HL RECON MATRIXMANDIBLE BN SD449.516B	C1713	SUPPLY/IMPLANTS	"$29,232.00"	Outpatient	"$14,616.00"	"$1,365.15"	"$15,989.90"	"$19,497.74"	"$11,692.80"	Not Applicable	"$10,231.20"	"$20,462.40"	"$1,365.15"	"$20,462.40"
SCR BN BIODRIVE TRY CNN 14-450400	C1713	SUPPLY/IMPLANTS	"$29,226.00"	Outpatient	"$14,613.00"	"$1,365.15"	"$15,986.62"	"$19,493.74"	"$11,690.40"	Not Applicable	"$10,229.10"	"$20,458.20"	"$1,365.15"	"$20,458.20"
LINR ACTB 66MM 36MM LNGVT CNSTRN 11.4MM TRLG HIP 633406636	C1776	SUPPLY/IMPLANTS	"$29,139.00"	Outpatient	"$14,569.50"	Not Applicable	"$15,939.03"	"$19,435.71"	"$11,655.60"	Not Applicable	"$10,198.65"	"$20,397.30"	"$10,198.65"	"$20,397.30"
GRAFT STENT ENDURANT II POLYESTER NITINOL L156 MM OD16-20 MM ETLW1620C156E	C2625	SUPPLY/IMPLANTS	"$29,136.00"	Outpatient	"$14,568.00"	Not Applicable	"$15,937.39"	"$19,433.71"	"$11,654.40"	Not Applicable	"$10,197.60"	"$20,395.20"	"$10,197.60"	"$20,395.20"
STEM FEMORAL OMNIFIT 9 LONG L200 MM OD14 MM HIP RIGHT REVISI 6088-0935-200R	C1776	SUPPLY/IMPLANTS	"$29,118.00"	Outpatient	"$14,559.00"	Not Applicable	"$15,927.55"	"$19,421.71"	"$11,647.20"	Not Applicable	"$10,191.30"	"$20,382.60"	"$10,191.30"	"$20,382.60"
STEM FEMORAL OMNIFIT 7 LONG L200 MM OD12.4 MM HIP LEFT REVIS 6088-0730-200L	C1776	SUPPLY/IMPLANTS	"$29,118.00"	Outpatient	"$14,559.00"	Not Applicable	"$15,927.55"	"$19,421.71"	"$11,647.20"	Not Applicable	"$10,191.30"	"$20,382.60"	"$10,191.30"	"$20,382.60"
MONITOR CARDIAC BIOMONITOR III SILICONE IRIDIUM 4.0 G INSERT 436066	C1764	SUPPLY/IMPLANTS	"$29,114.00"	Outpatient	"$14,557.00"	Not Applicable	"$15,925.36"	"$19,419.04"	"$11,645.60"	Not Applicable	"$10,189.90"	"$20,379.80"	"$10,189.90"	"$20,379.80"
VLV SHNT CERTAS INLN SPHGRD 828804PL		STERILE SUPPLY	"$29,104.00"	Outpatient	"$14,552.00"	Not Applicable	"$15,919.89"	"$19,412.37"	"$11,641.60"	Not Applicable	"$10,186.40"	"$20,372.80"	"$10,186.40"	"$20,372.80"
CORNEAL TISSUE V0090000	V2785	UNKNOWN/DONOR	"$29,097.00"	Outpatient	"$14,548.50"	Not Applicable	"$15,916.06"	"$19,407.70"	"$11,638.80"	Not Applicable	"$10,183.95"	"$20,367.90"	"$10,183.95"	"$20,367.90"
CORNEA DSAEK OR ALK RIGHT EYE V0091000	V2785	UNKNOWN/DONOR	"$29,097.00"	Outpatient	"$14,548.50"	Not Applicable	"$15,916.06"	"$19,407.70"	"$11,638.80"	Not Applicable	"$10,183.95"	"$20,367.90"	"$10,183.95"	"$20,367.90"
GFT EVAS 12CM 27MM 21.5-25MM XCLDR CNTRLT LG GRTX NTNL FEP PLC271200	C1874	SUPPLY/IMPLANTS	"$29,073.00"	Outpatient	"$14,536.50"	Not Applicable	"$15,902.93"	"$19,391.69"	"$11,629.20"	Not Applicable	"$10,175.55"	"$20,351.10"	"$10,175.55"	"$20,351.10"
BODY CALCAR RESTORATION +20 MM OFFSET OD19 MM HIP MODULAR 6276-4-219	C1776	SUPPLY/IMPLANTS	"$29,067.00"	Outpatient	"$14,533.50"	Not Applicable	"$15,899.65"	"$19,387.69"	"$11,626.80"	Not Applicable	"$10,173.45"	"$20,346.90"	"$10,173.45"	"$20,346.90"
MTRX TISS 19.3X9.6CM ALDRM SLCT THK.4-1.6MM MED CNTR ALGRF CM1518P	Q4116	SUPPLY/IMPLANTS	"$29,054.00"	Outpatient	"$14,527.00"	$34.22	"$15,892.54"	"$19,379.02"	"$11,621.60"	Not Applicable	"$10,168.90"	"$20,337.80"	$34.22	"$20,337.80"
PCMKR THK6MM ACT SR RF 1 CHMBR UNPLR BP IS-1 52X52MM CRD PM1210	C1786	PACE MAKER	"$28,976.00"	Outpatient	"$14,488.00"	Not Applicable	"$15,849.87"	"$19,326.99"	"$11,590.40"	Not Applicable	"$10,141.60"	"$20,283.20"	"$10,141.60"	"$20,283.20"
CNTNR STRL 5.5MMX4.5MM NS LF REUSE 230002000		STERILE SUPPLY	"$28,953.00"	Outpatient	"$14,476.50"	Not Applicable	"$15,837.29"	"$19,311.65"	"$11,581.20"	Not Applicable	"$10,133.55"	"$20,267.10"	"$10,133.55"	"$20,267.10"
PCMKR THK7.5MM 3.2MM MVP ADAPTA DR 2 CHMBR UNPLR BP IS-1 ADDR03	C1785	PACE MAKER	"$28,942.00"	Outpatient	"$14,471.00"	Not Applicable	"$15,831.27"	"$19,304.31"	"$11,576.80"	Not Applicable	"$10,129.70"	"$20,259.40"	"$10,129.70"	"$20,259.40"
STEM HUMERAL UNIVERS APEX RECTANGLE L60 MM OD6 MM SHOULDER P AR-9100-06S	C1776	SUPPLY/IMPLANTS	"$28,941.00"	Outpatient	"$14,470.50"	Not Applicable	"$15,830.73"	"$19,303.65"	"$11,576.40"	Not Applicable	"$10,129.35"	"$20,258.70"	"$10,129.35"	"$20,258.70"
SPACER SPINAL LEVA L25 MM X W10 MM X H10 MM EXPAND STERILE L 11-7010	C1821	SUPPLY/IMPLANTS	"$28,939.00"	Outpatient	"$14,469.50"	Not Applicable	"$15,829.63"	"$19,302.31"	"$11,575.60"	Not Applicable	"$10,128.65"	"$20,257.30"	"$10,128.65"	"$20,257.30"
CMPNT HUM 4IN CNRD MRY SM ELB ZML TIV UHMWPE 3281052504	C1776	SUPPLY/IMPLANTS	"$28,931.00"	Outpatient	"$14,465.50"	Not Applicable	"$15,825.26"	"$19,296.98"	"$11,572.40"	Not Applicable	"$10,125.85"	"$20,251.70"	"$10,125.85"	"$20,251.70"
STEM HUMERAL UNIVERS APEX RECTANGLE L60 MM OD9 MM SHOULDER P AR-9100-09S	C1776	SUPPLY/IMPLANTS	"$28,927.00"	Outpatient	"$14,463.50"	Not Applicable	"$15,823.07"	"$19,294.31"	"$11,570.80"	Not Applicable	"$10,124.45"	"$20,248.90"	"$10,124.45"	"$20,248.90"
LINER ACETABULAR PINNACLE ESC GVF TITANIUM POLYETHYLENE +4 MM NEUTRAL OD58 MM ID36 MM HIP CONSTRAIN	C1776	SUPPLY/IMPLANTS	"$28,849.00"	Outpatient	"$14,424.50"	Not Applicable	"$15,780.40"	"$19,242.28"	"$11,539.60"	Not Applicable	"$10,097.15"	"$20,194.30"	"$10,097.15"	"$20,194.30"
STEM HUM 82MM PRFT AQLS ASCND FLX PTC 132.5D 5B STD SHLDR DWF605B	C1776	SUPPLY/IMPLANTS	"$28,790.00"	Outpatient	"$14,395.00"	Not Applicable	"$15,748.13"	"$19,202.93"	"$11,516.00"	Not Applicable	"$10,076.50"	"$20,153.00"	"$10,076.50"	"$20,153.00"
STEM FEM 195MM 14MM STRG CONE RSTR HA HIP MDLR 6276-7-114	C1776	SUPPLY/IMPLANTS	"$28,784.00"	Outpatient	"$14,392.00"	Not Applicable	"$15,744.85"	"$19,198.93"	"$11,513.60"	Not Applicable	"$10,074.40"	"$20,148.80"	"$10,074.40"	"$20,148.80"
NUCLEUS SIZE 1 SIMPLICITI SHOULDER SYSTEM DWG401	C1776	SUPPLY/IMPLANTS	"$28,783.00"	Outpatient	"$14,391.50"	Not Applicable	"$15,744.30"	"$19,198.26"	"$11,513.20"	Not Applicable	"$10,074.05"	"$20,148.10"	"$10,074.05"	"$20,148.10"
STEM FEM 195MM 16MM STRG CNCL RSTR HA HIP MDLR SYS 6276-7-116	C1776	SUPPLY/IMPLANTS	"$28,780.00"	Outpatient	"$14,390.00"	Not Applicable	"$15,742.66"	"$19,196.26"	"$11,512.00"	Not Applicable	"$10,073.00"	"$20,146.00"	"$10,073.00"	"$20,146.00"
HEAD FEM 36MM +5MM OFST TPR V40 LFIT COCR HIP 6260-9-236	C1776	SUPPLY/IMPLANTS	"$28,765.00"	Outpatient	"$14,382.50"	Not Applicable	"$15,734.46"	"$19,186.26"	"$11,506.00"	Not Applicable	"$10,067.75"	"$20,135.50"	"$10,067.75"	"$20,135.50"
SYS SPNL FX 50MM 7MM SACROILIAC IFUSE IMPL SYS TI PLSM SPRY 7050-90	C1713	SUPPLY/IMPLANTS	"$28,760.00"	Outpatient	"$14,380.00"	"$1,365.15"	"$15,731.72"	"$19,182.92"	"$11,504.00"	Not Applicable	"$10,066.00"	"$20,132.00"	"$1,365.15"	"$20,132.00"
"IMPLANT SYS. 7.0MM X 45MM IMPLANT, IFUSE-3D 7045M-90"	C1713	SUPPLY/IMPLANTS	"$28,751.00"	Outpatient	"$14,375.50"	"$1,365.15"	"$15,726.80"	"$19,176.92"	"$11,500.40"	Not Applicable	"$10,062.85"	"$20,125.70"	"$1,365.15"	"$20,125.70"
SYSTEM SPINAL FIXATION IFUSE IMPLANT SYSTEM L60 MM OD7 MM SACROILIAC STERILE LATEX FREE 7060M-90	C1713	SUPPLY/IMPLANTS	"$28,751.00"	Outpatient	"$14,375.50"	"$1,365.15"	"$15,726.80"	"$19,176.92"	"$11,500.40"	Not Applicable	"$10,062.85"	"$20,125.70"	"$1,365.15"	"$20,125.70"
SYSTEM SPINAL FIXATION IFUSE IMPLANT SYSTEM L35 MM OD7 MM SACROILIAC STERILE LATEX FREE 7035M-90	C1713	SUPPLY/IMPLANTS	"$28,751.00"	Outpatient	"$14,375.50"	"$1,365.15"	"$15,726.80"	"$19,176.92"	"$11,500.40"	Not Applicable	"$10,062.85"	"$20,125.70"	"$1,365.15"	"$20,125.70"
SYS SPNL FX 45MM 7MM SACROILIAC IFUSE IMPL SYS TI PLSM SPRY 7045-90	C1713	SUPPLY/IMPLANTS	"$28,749.00"	Outpatient	"$14,374.50"	"$1,365.15"	"$15,725.70"	"$19,175.58"	"$11,499.60"	Not Applicable	"$10,062.15"	"$20,124.30"	"$1,365.15"	"$20,124.30"
SYS SPNL FX 40MM 7MM SACROILIAC IFUSE IMPL SYS FSN TI PLSM 7040-90	C1713	SUPPLY/IMPLANTS	"$28,749.00"	Outpatient	"$14,374.50"	"$1,365.15"	"$15,725.70"	"$19,175.58"	"$11,499.60"	Not Applicable	"$10,062.15"	"$20,124.30"	"$1,365.15"	"$20,124.30"
PCMKR EVIA SR-T CLS LANDLINE HOME MNTR CRD 377849	C1900	PACE MAKER	"$28,746.00"	Outpatient	"$14,373.00"	Not Applicable	"$15,724.06"	"$19,173.58"	"$11,498.40"	Not Applicable	"$10,061.10"	"$20,122.20"	"$10,061.10"	"$20,122.20"
GFT BN RHBMP-2 BVN CLGN 26MM 8CC ABS SPNG STRL H2O SYR NDL 7510800		SUPPLY/IMPLANTS	"$28,745.00"	Outpatient	"$14,372.50"	Not Applicable	"$15,723.52"	"$19,172.92"	"$11,498.00"	Not Applicable	"$10,060.75"	"$20,121.50"	"$10,060.75"	"$20,121.50"
FXTR XTRNFX DFS XS CMPLT NS LF DISP 2500	C1713	SUPPLY/IMPLANTS	"$28,735.00"	Outpatient	"$14,367.50"	"$1,365.15"	"$15,718.05"	"$19,166.25"	"$11,494.00"	Not Applicable	"$10,057.25"	"$20,114.50"	"$1,365.15"	"$20,114.50"
RMR SHFT NTNL TI 80CM SRG 27941	C1713	SUPPLY/IMPLANTS	"$28,714.00"	Outpatient	"$14,357.00"	"$1,365.15"	"$15,706.56"	"$19,152.24"	"$11,485.60"	Not Applicable	"$10,049.90"	"$20,099.80"	"$1,365.15"	"$20,099.80"
BODY CONE RESTORATION TITANIUM +10 MM OD19 MM HIP MODULAR ST 6276-1-119	C1776	SUPPLY/IMPLANTS	"$28,713.00"	Outpatient	"$14,356.50"	Not Applicable	"$15,706.01"	"$19,151.57"	"$11,485.20"	Not Applicable	"$10,049.55"	"$20,099.10"	"$10,049.55"	"$20,099.10"
BODY CONE RESTORATION PUREFIX TITANIUM +30 MM OD19 MM HIP MO 6276-1-319	C1776	SUPPLY/IMPLANTS	"$28,713.00"	Outpatient	"$14,356.50"	Not Applicable	"$15,706.01"	"$19,151.57"	"$11,485.20"	Not Applicable	"$10,049.55"	"$20,099.10"	"$10,049.55"	"$20,099.10"
VLV MTRL 33MM 26.1MM MSTR-SER MECH STD CUF STY PYROLYTIC C 33MJ-501		SUPPLY/IMPLANTS	"$28,674.00"	Outpatient	"$14,337.00"	Not Applicable	"$15,684.68"	"$19,125.56"	"$11,469.60"	Not Applicable	"$10,035.90"	"$20,071.80"	"$10,035.90"	"$20,071.80"
GRAFT STENT ENDURANT II NITINOL POLYESTER L49 MM OD32 MM INF ETCF3232C49E	C2625	SUPPLY/IMPLANTS	"$28,634.00"	Outpatient	"$14,317.00"	Not Applicable	"$15,662.80"	"$19,098.88"	"$11,453.60"	Not Applicable	"$10,021.90"	"$20,043.80"	"$10,021.90"	"$20,043.80"
PROS PENL AMS 700 MS PMP 18CM INFL PRECNCT INHBZN 72404232	C1813	SUPPLY/IMPLANTS	"$28,632.00"	Outpatient	"$14,316.00"	Not Applicable	"$15,661.70"	"$19,097.54"	"$11,452.80"	Not Applicable	"$10,021.20"	"$20,042.40"	"$10,021.20"	"$20,042.40"
AMNIOTIC MEMBRANE 4.0 X 4.0 CM ART0404	Q4151	PHARMACY	"$28,577.00"	Outpatient	"$14,288.50"	$141.19	"$15,631.62"	"$19,060.86"	"$11,430.80"	Not Applicable	"$10,001.95"	"$20,003.90"	$141.19	"$20,003.90"
CADDY SCR 3.5MM 231218105		STERILE SUPPLY	"$28,554.00"	Outpatient	"$14,277.00"	Not Applicable	"$15,619.04"	"$19,045.52"	"$11,421.60"	Not Applicable	"$9,993.90"	"$19,987.80"	"$9,993.90"	"$19,987.80"
COMPONENT FEMORAL LEGION COCR POROUS 5 KNEE LEFT CEMENTLESS 71423245	C1776	SUPPLY/IMPLANTS	"$28,543.00"	Outpatient	"$14,271.50"	Not Applicable	"$15,613.02"	"$19,038.18"	"$11,417.20"	Not Applicable	"$9,990.05"	"$19,980.10"	"$9,990.05"	"$19,980.10"
DSTRCT BD SRG SS 10MM NS 288.025	C1713	SUPPLY/IMPLANTS	"$28,524.00"	Outpatient	"$14,262.00"	"$1,365.15"	"$15,602.63"	"$19,025.51"	"$11,409.60"	Not Applicable	"$9,983.40"	"$19,966.80"	"$1,365.15"	"$19,966.80"
DSTRCT BD SRG SS 15MM NS 288.026	C1713	SUPPLY/IMPLANTS	"$28,524.00"	Outpatient	"$14,262.00"	"$1,365.15"	"$15,602.63"	"$19,025.51"	"$11,409.60"	Not Applicable	"$9,983.40"	"$19,966.80"	"$1,365.15"	"$19,966.80"
DSTRCT 20MM BD SRG SS NS 288.027	C1713	SUPPLY/IMPLANTS	"$28,524.00"	Outpatient	"$14,262.00"	"$1,365.15"	"$15,602.63"	"$19,025.51"	"$11,409.60"	Not Applicable	"$9,983.40"	"$19,966.80"	"$1,365.15"	"$19,966.80"
DSTRCT BD SRG SS 25MM NS 288.028	C1713	SUPPLY/IMPLANTS	"$28,524.00"	Outpatient	"$14,262.00"	"$1,365.15"	"$15,602.63"	"$19,025.51"	"$11,409.60"	Not Applicable	"$9,983.40"	"$19,966.80"	"$1,365.15"	"$19,966.80"
MESH 8X6IN RECT POLY-4-HB PHASIX MFL SCFLD FULL RSRB SRG HRN 1190300	C1781	SUPPLY/IMPLANTS	"$28,482.00"	Outpatient	"$14,241.00"	Not Applicable	"$15,579.65"	"$18,997.49"	"$11,392.80"	Not Applicable	"$9,968.70"	"$19,937.40"	"$9,968.70"	"$19,937.40"
NAIL IM 700MM 11.5MM T2 TI RT STRL ARTHDS 1829-1170S	C1713	SUPPLY/IMPLANTS	"$28,452.00"	Outpatient	"$14,226.00"	"$1,365.15"	"$15,563.24"	"$18,977.48"	"$11,380.80"	Not Applicable	"$9,958.20"	"$19,916.40"	"$1,365.15"	"$19,916.40"
GRAFT/SPACER SOFAMOR DANEK 12X26MM 399612	C1713	SUPPLY/IMPLANTS	"$28,413.00"	Outpatient	"$14,206.50"	"$1,365.15"	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$1,365.15"	"$19,889.10"
PCMKR THK6MM ASSURITY MRI 1 CHMBR IS-1 CNCT 50X47MM CRD 10.4 PM1272	C1786	PACE MAKER	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
SYS CRD PCMKR LD 2 CHMBR IS-1 CNCT ASSURITY MRI THK6MM 50X47 PM2272 SYSTEM	C1785	PACE MAKER	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
CAGE SPNL 24MMX13MM FUSE 4D PLIF FP-13.24.4	C1821	SUPPLY/IMPLANTS	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
CAGE SPNL 25X10X10MM CRNT 4D OBLQ TLIF NS LF 5300254	C1821	SUPPLY/IMPLANTS	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
CAGE SPNL 25X14X10MM CRNT 4D OBLQ TLIF NS LF 5340254	C1821	SUPPLY/IMPLANTS	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
CAGE SPNL 50X18X8MM CRNT XL PEEK LMBR INTRBD FS NS LF 6908850	C1821	SUPPLY/IMPLANTS	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
SPCR SPNL 26X14MM CPSTN PTC PEEK LMBR INTRBD FS STRL LF 3992614	C1821	SUPPLY/IMPLANTS	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
SPCR SPNL 26MMX12MM CPSTN PTC PEEK LMBR INTRBD FS STRL LF 3992612		STERILE SUPPLY	"$28,413.00"	Outpatient	"$14,206.50"	Not Applicable	"$15,541.91"	"$18,951.47"	"$11,365.20"	Not Applicable	"$9,944.55"	"$19,889.10"	"$9,944.55"	"$19,889.10"
STEM FEM 195MM 21MM STRG CONE RSTR HIP MDLR 6276-7-121	C1776	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
STEM FEM 235MM 21MM BW CNCL RSTR DIST HIP MDLR 6276-7-321	C1776	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE NANAMH 11 X 32 X13MM 133-6313	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 25X9X11MM SHURFIT CNVX BLT NOSE PEEK LG GFT AREA PLIF25-11P	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 23X9X10MM CNCRD PRLL BLT NOSE CFRP RADOPQ PLIF 187823110	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 45X18X12MM CRNT 10D XL PEEK LMBR INTRBD FS NS LF 6981245	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 25X12X10MM CRNT 4D OBLQ TLIF NS LF 5320254	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 30X12X10MM CRNT 12D OBLQ TLIF NS LF 5320302	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 30X12X10MM CRNT 4D OBLQ TLIF NS LF 5320304	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 25X10X10MM CRNT 12D OBLQ TLIF NS LF 5300252	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 30X10X10MM CRNT 12D OBLQ TLIF NS LF 5300302	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 25X8X10MM CRNT 12D OBLQ TLIF NS LF 5380252	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 25X8X10MM CRNT 4D OBLQ TLIF NS LF 5380254	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 26X11X13MM CRNT 4D LG IMPCT PEEK-OPTM NS LF 6713126	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 30X8X10MM CRNT 4D OBLQ TLIF NS LF 5380304	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 30X8X10MM CRNT 12D OBLQ TLIF NS LF 5380302	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE TLIF 26 X 12MM PM2612	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE TLIF 13 X 26MM PM2613	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE TLIF 9MM X 26MM PM2609	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
SCREW COROENT XLF 10 X18 X50MM 10 DEG 7871050	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
SPACER PLATEAU 13 X 28MM 52-1028-12	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
SPCR SPNL 45X20X9MM TRANSCONTINENTAL MPEEK 6D LRDTC LAT LMBR 375.279	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
SPCR SPNL 24X10X12MM PLTU 0D STRG BLT TIP TI INTRBD FS NS LF 52-1024-12T	C1821	SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE SPNL 30X10X10MM CRNT 4D OBLQ TLIF NS LF 5300304		STERILE SUPPLY	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
SYS ANLPLS HLDR SW C-E PH II MTRL COCR SIL PLSTR STRL HRT 5200		SUPPLY/IMPLANTS	"$28,403.00"	Outpatient	"$14,201.50"	Not Applicable	"$15,536.44"	"$18,944.80"	"$11,361.20"	Not Applicable	"$9,941.05"	"$19,882.10"	"$9,941.05"	"$19,882.10"
CAGE PEEK PLIF 12MM X 25MM 315488-6-1	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE PEEK 12 X 28 X 11MM 68-281112	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE SPNL 50X22X10MM CRNT XL W PEEK NS LF 6910250	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE SPNL 50X18X10MM CRNT 10D XL NS LF 6981050	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE SPNL 55X18X12MM CRNT 10D XL NS LF 6981255	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE SPNL 25X9X12MM SHURFIT CNVX BLT NOSE PEEK LG GFT AREA PLIF25-12P	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE SPNL 55X18X10MM CRNT 10D XL NS LF 6981055	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE TPLIF 15 X 28 X 9 0 DEGREE DP3015	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE TPLIF 12 X 28 X 9 DSP3012	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE TPLIF 10MM DP3010	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE TPLIF 12X28MM DP3102	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
PLATEU SPACE 14MM 52-1030-14	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SPACER PLATEAU 13 X28MM 52-1028-13	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SPACER PLATEAU 12 X24MM 52-1024-12	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SPCR SPNL 55X18X14MM ALEUTIAN 8D LRDTC PEEK NS LF 3203-21455SL	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SPCR SPNL 45X18X12MM ALEUTIAN PRLL PEEK NS LF 3203-21245SP	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SPCR SPNL 45X18X10MM ALEUTIAN PRLL PEEK NS LF 3203-21045SP	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SPCR SPNL 30X11X9MM AVS UNILIF 0D WDG NOSE PEEK-OPTM HLW 48351090	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SPCR SPNL 50X18X8MM TIMBERLINE 0D STD PEEK-OPTM LOPRFL 2.5CC 8601-5008	C1821	SUPPLY/IMPLANTS	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
SUB BNGF 15CC INJ OSTCNDC RADOPQ HYDROSET HA 397015		STERILE SUPPLY	"$28,402.00"	Outpatient	"$14,201.00"	Not Applicable	"$15,535.89"	"$18,944.13"	"$11,360.80"	Not Applicable	"$9,940.70"	"$19,881.40"	"$9,940.70"	"$19,881.40"
CAGE TPLIF 13 X 28 X 9 DP3013	C1821	SUPPLY/IMPLANTS	"$28,400.00"	Outpatient	"$14,200.00"	Not Applicable	"$15,534.80"	"$18,942.80"	"$11,360.00"	Not Applicable	"$9,940.00"	"$19,880.00"	"$9,940.00"	"$19,880.00"
CAGE TPLIF 12 X 24 X 9 DP2012	C1821	SUPPLY/IMPLANTS	"$28,400.00"	Outpatient	"$14,200.00"	Not Applicable	"$15,534.80"	"$18,942.80"	"$11,360.00"	Not Applicable	"$9,940.00"	"$19,880.00"	"$9,940.00"	"$19,880.00"
CAGE TPLIF 13 X 24 X 9 DP2013	C1821	SUPPLY/IMPLANTS	"$28,400.00"	Outpatient	"$14,200.00"	Not Applicable	"$15,534.80"	"$18,942.80"	"$11,360.00"	Not Applicable	"$9,940.00"	"$19,880.00"	"$9,940.00"	"$19,880.00"
CAGE TPLIF 14 X 28 X 9 DP3014	C1821	SUPPLY/IMPLANTS	"$28,400.00"	Outpatient	"$14,200.00"	Not Applicable	"$15,534.80"	"$18,942.80"	"$11,360.00"	Not Applicable	"$9,940.00"	"$19,880.00"	"$9,940.00"	"$19,880.00"
SPCR SPNL 60X18X12MM ALEUTIAN 8D LRDTC PEEK NS LF 3203-21260SL	C1821	SUPPLY/IMPLANTS	"$28,400.00"	Outpatient	"$14,200.00"	Not Applicable	"$15,534.80"	"$18,942.80"	"$11,360.00"	Not Applicable	"$9,940.00"	"$19,880.00"	"$9,940.00"	"$19,880.00"
SPCR SPNL 60X18X14MM ALEUTIAN 8D LRDTC PEEK NS LF 3203-21460SL	C1821	SUPPLY/IMPLANTS	"$28,400.00"	Outpatient	"$14,200.00"	Not Applicable	"$15,534.80"	"$18,942.80"	"$11,360.00"	Not Applicable	"$9,940.00"	"$19,880.00"	"$9,940.00"	"$19,880.00"
SPCR SPNL 27MMX15MM CPSTN CNTRL 6D PEEK INTRBD FS STRL LF 4001527		STERILE SUPPLY	"$28,400.00"	Outpatient	"$14,200.00"	Not Applicable	"$15,534.80"	"$18,942.80"	"$11,360.00"	Not Applicable	"$9,940.00"	"$19,880.00"	"$9,940.00"	"$19,880.00"
TRAY TIB MBT 74.9X49.3X4.8MM 4MM KN CMNT REV ROT PLAT STRL 129435140	C1776	SUPPLY/IMPLANTS	"$28,364.00"	Outpatient	"$14,182.00"	Not Applicable	"$15,515.11"	"$18,918.79"	"$11,345.60"	Not Applicable	"$9,927.40"	"$19,854.80"	"$9,927.40"	"$19,854.80"
MESH XL SRG CHIARI SP-2412	C1781	SUPPLY/IMPLANTS	"$28,354.00"	Outpatient	"$14,177.00"	Not Applicable	"$15,509.64"	"$18,912.12"	"$11,341.60"	Not Applicable	"$9,923.90"	"$19,847.80"	"$9,923.90"	"$19,847.80"
PTA Open Percutaneous Image Initial Vein	37248	CARDIAC CATH LAB	"$28,303.00"	Outpatient	"$14,151.50"	"$10,228.46"	"$15,481.74"	"$18,878.10"	"$11,321.20"	"$7,310.00"	"$9,906.05"	"$19,812.10"	"$7,310.00"	"$19,812.10"
PTA Open Percutaneous Image Initial Artery	37246	CARDIAC CATH LAB	"$28,303.00"	Outpatient	"$14,151.50"	"$10,228.46"	"$15,481.74"	"$18,878.10"	"$11,321.20"	"$7,310.00"	"$9,906.05"	"$19,812.10"	"$7,310.00"	"$19,812.10"
NAIL IM 320MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.152S	C1713	SUPPLY/IMPLANTS	"$28,298.00"	Outpatient	"$14,149.00"	"$1,365.15"	"$15,479.01"	"$18,874.77"	"$11,319.20"	Not Applicable	"$9,904.30"	"$19,808.60"	"$1,365.15"	"$19,808.60"
BASKET SPECIMEN RETRIEVAL 3FR DIA 11MMW OPENING 115CML WORKI FG-51D		STERILE SUPPLY	"$28,275.00"	Outpatient	"$14,137.50"	Not Applicable	"$15,466.43"	"$18,859.43"	"$11,310.00"	Not Applicable	"$9,896.25"	"$19,792.50"	"$9,896.25"	"$19,792.50"
STAXX XD EXPANDABLE DEVICE 11-1550	C1821	SUPPLY/IMPLANTS	"$28,266.00"	Outpatient	"$14,133.00"	Not Applicable	"$15,461.50"	"$18,853.42"	"$11,306.40"	Not Applicable	"$9,893.10"	"$19,786.20"	"$9,893.10"	"$19,786.20"
MESH MATRIXNEURO 150X150X.6MM TI CRNL RECON RGD STRL AU 04.503.146S	C1713	SUPPLY/IMPLANTS	"$28,255.00"	Outpatient	"$14,127.50"	"$1,365.15"	"$15,455.49"	"$18,846.09"	"$11,302.00"	Not Applicable	"$9,889.25"	"$19,778.50"	"$1,365.15"	"$19,778.50"
PLT 48X8X2.5MM ANG MNDB CNDYL HD RT TI 3X16 HL LCK RECON BN 449.644	C1713	SUPPLY/IMPLANTS	"$28,237.00"	Outpatient	"$14,118.50"	"$1,365.15"	"$15,445.64"	"$18,834.08"	"$11,294.80"	Not Applicable	"$9,882.95"	"$19,765.90"	"$1,365.15"	"$19,765.90"
PLT 48X8X2.5MM ANG MNDB CNDYL HD LT TI 3X16 HL LCK RECON BN 449.645	C1713	SUPPLY/IMPLANTS	"$28,237.00"	Outpatient	"$14,118.50"	"$1,365.15"	"$15,445.64"	"$18,834.08"	"$11,294.80"	Not Applicable	"$9,882.95"	"$19,765.90"	"$1,365.15"	"$19,765.90"
MTRX TISS ALDRM THK MED 132SQ CM ALGRF CM1520P	Q4116	PHARMACY	"$28,221.00"	Outpatient	"$14,110.50"	$34.22	"$15,436.89"	"$18,823.41"	"$11,288.40"	Not Applicable	"$9,877.35"	"$19,754.70"	$34.22	"$19,754.70"
MTRX TISS 19.3X9.6CM ALDRM SLCT THK.2-1MM THN MED CNTR ALGRF CM1516P	Q4116	SUPPLY/IMPLANTS	"$28,210.00"	Outpatient	"$14,105.00"	$34.22	"$15,430.87"	"$18,816.07"	"$11,284.00"	Not Applicable	"$9,873.50"	"$19,747.00"	$34.22	"$19,747.00"
MTRX TISS 19.3X9.6CM ALDRM SLCT THK.4-2.4MM THK MED CNTR CM1519P	C1762	SUPPLY/IMPLANTS	"$28,210.00"	Outpatient	"$14,105.00"	Not Applicable	"$15,430.87"	"$18,816.07"	"$11,284.00"	Not Applicable	"$9,873.50"	"$19,747.00"	"$9,873.50"	"$19,747.00"
Vertebral Angiogram Bilateral	36226	CARDIAC CATH LAB	"$28,186.00"	Outpatient	"$14,093.00"	"$18,161.90"	"$15,417.74"	"$18,800.06"	"$11,274.40"	"$7,310.00"	"$9,865.10"	"$19,730.20"	"$7,310.00"	"$19,730.20"
Subclavian or Innominate Angiogram Bilateral	36224	CARDIAC CATH LAB	"$28,186.00"	Outpatient	"$14,093.00"	"$18,161.90"	"$15,417.74"	"$18,800.06"	"$11,274.40"	"$7,310.00"	"$9,865.10"	"$19,730.20"	"$7,310.00"	"$19,730.20"
Av Fistula Central Segment PTA Stent	36908	CARDIAC CATH LAB	"$28,186.00"	Outpatient	"$14,093.00"	"$24,034.50"	"$15,417.74"	"$18,800.06"	"$11,274.40"	$819.00	"$9,865.10"	"$19,730.20"	$819.00	"$24,034.50"
STEM HUM 110MM 7MM REUNION HA SHLDR R5351-4507	C1776	SUPPLY/IMPLANTS	"$28,172.00"	Outpatient	"$14,086.00"	Not Applicable	"$15,410.08"	"$18,790.72"	"$11,268.80"	Not Applicable	"$9,860.20"	"$19,720.40"	"$9,860.20"	"$19,720.40"
PCMKR 2.8V 1.3AH 7.5MM VERSA DR IMPL 2 CHMBR UNPLR BP 44.9 VEDR01	C1785	PACE MAKER	"$28,169.00"	Outpatient	"$14,084.50"	Not Applicable	"$15,408.44"	"$18,788.72"	"$11,267.60"	Not Applicable	"$9,859.15"	"$19,718.30"	"$9,859.15"	"$19,718.30"
LEAD ICD RV SVC 62CM 8.6FR TENSI-LCK SQ ISOGLIDE STRD ELUT 6947M62	C1895	PACE MAKER	"$28,114.00"	Outpatient	"$14,057.00"	Not Applicable	"$15,378.36"	"$18,752.04"	"$11,245.60"	Not Applicable	"$9,839.90"	"$19,679.80"	"$9,839.90"	"$19,679.80"
70020-1911-01 - ixabepilone 45 mg Powd	J9207	PHARMACY	"$23,635.00"	Outpatient	"$11,817.50"	$98.87	"$15,362.75"	"$15,764.55"	"$9,454.00"	Not Applicable	"$8,272.25"	"$16,544.50"	$98.87	"$16,544.50"
SPHR EMBL WHT ONCOZENE 15-75UM MIC NRDCT CLBRT 3ML 10730-US1		STERILE SUPPLY	"$28,056.00"	Outpatient	"$14,028.00"	Not Applicable	"$15,346.63"	"$18,713.35"	"$11,222.40"	Not Applicable	"$9,819.60"	"$19,639.20"	"$9,819.60"	"$19,639.20"
SPHR EMBL WHT ONCOZENE 25-100UM MIC NRDCT CLBRT 3ML 11030-US1		STERILE SUPPLY	"$28,056.00"	Outpatient	"$14,028.00"	Not Applicable	"$15,346.63"	"$18,713.35"	"$11,222.40"	Not Applicable	"$9,819.60"	"$19,639.20"	"$9,819.60"	"$19,639.20"
SUCTION RETRACTOR 703953		STERILE SUPPLY	"$28,055.00"	Outpatient	"$14,027.50"	Not Applicable	"$15,346.09"	"$18,712.69"	"$11,222.00"	Not Applicable	"$9,819.25"	"$19,638.50"	"$9,819.25"	"$19,638.50"
CNDT VLV 21MM ATS OP AOR MECH CNDT 502AG21		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV AOR 23MM ATS OP MECH GFT CNDT STRL 502AG23		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV AOR 9.3MM 16MM 14.8MM ATS OP AP360 MECH SW CUF RADOPQ AP 505DA16		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV AOR 10.3MM 18MM 16.8MM ATS OP AP360 MECH SW CUF RADOPQ 505DA18		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV AOR 20.2MM 18.8MM OPN PVT AP360 MECH CUF 20MM 505DA20		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV AOR 16MM ATS OP MECH AP SER 505DA22		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV AOR 24.2MM 22.8MM OPN PVT AP360 MECH CUF 24MM 505DA24		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV AOR 26.2MM 24.8MM OPN PVT AP360 MECH CUF 26MM 505DA26		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV MTRL STD 500DM27		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
VLV MTRL 33MM ATS OP MECH STD SER 500DM33		SUPPLY/IMPLANTS	"$28,037.00"	Outpatient	"$14,018.50"	Not Applicable	"$15,336.24"	"$18,700.68"	"$11,214.80"	Not Applicable	"$9,812.95"	"$19,625.90"	"$9,812.95"	"$19,625.90"
PLT 254MM TROCH LAT SS 6 HL 7 CRMP BN BMP CBL SYS 350837	C1713	SUPPLY/IMPLANTS	"$28,028.00"	Outpatient	"$14,014.00"	"$1,365.15"	"$15,331.32"	"$18,694.68"	"$11,211.20"	Not Applicable	"$9,809.80"	"$19,619.60"	"$1,365.15"	"$19,619.60"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 4 KNEE RIGHT PATEL 00592601402	C1776	SUPPLY/IMPLANTS	"$28,002.00"	Outpatient	"$14,001.00"	Not Applicable	"$15,317.09"	"$18,677.33"	"$11,200.80"	Not Applicable	"$9,800.70"	"$19,601.40"	"$9,800.70"	"$19,601.40"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 1 KNEE LEFT PATELL 00592601101	C1776	SUPPLY/IMPLANTS	"$28,002.00"	Outpatient	"$14,001.00"	Not Applicable	"$15,317.09"	"$18,677.33"	"$11,200.80"	Not Applicable	"$9,800.70"	"$19,601.40"	"$9,800.70"	"$19,601.40"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 1 KNEE RIGHT PATEL 00592601102	C1776	SUPPLY/IMPLANTS	"$28,002.00"	Outpatient	"$14,001.00"	Not Applicable	"$15,317.09"	"$18,677.33"	"$11,200.80"	Not Applicable	"$9,800.70"	"$19,601.40"	"$9,800.70"	"$19,601.40"
COMPONENT FEMORAL GENDER SOLUTIONS NEXGEN 4 KNEE LEFT PATELL 00592601401	C1776	SUPPLY/IMPLANTS	"$28,002.00"	Outpatient	"$14,001.00"	Not Applicable	"$15,317.09"	"$18,677.33"	"$11,200.80"	Not Applicable	"$9,800.70"	"$19,601.40"	"$9,800.70"	"$19,601.40"
CK SRS - Fractionated	G0340	RADIATION RX	"$27,984.00"	Outpatient	"$13,992.00"	"$11,464.98"	"$15,307.25"	"$1,592.00"	"$11,193.60"	"$12,619.00"	"$9,794.40"	"$19,588.80"	"$1,592.00"	"$19,588.80"
PACEMAKER CARDIAC EDORA PROMRI TITANIUM SILICONE RUBBER EPOX 407157	C1786	PACE MAKER	"$27,977.00"	Outpatient	"$13,988.50"	Not Applicable	"$15,303.42"	"$18,660.66"	"$11,190.80"	Not Applicable	"$9,791.95"	"$19,583.90"	"$9,791.95"	"$19,583.90"
SET TRMA FX CNN SCR CA 7.5 MM SCR 114707501	C1713	SUPPLY/IMPLANTS	"$27,975.00"	Outpatient	"$13,987.50"	"$1,365.15"	"$15,302.33"	"$18,659.33"	"$11,190.00"	Not Applicable	"$9,791.25"	"$19,582.50"	"$1,365.15"	"$19,582.50"
INS TIB 3-4 15MM KN XLPE PS HI FLXN LEGION 71453214	C1776	SUPPLY/IMPLANTS	"$27,964.00"	Outpatient	"$13,982.00"	Not Applicable	"$15,296.31"	"$18,651.99"	"$11,185.60"	Not Applicable	"$9,787.40"	"$19,574.80"	"$9,787.40"	"$19,574.80"
SET ORTH JIG CMPLT ASMB PROX HUM VERSANAIL 2810-18-007	C1713	SUPPLY/IMPLANTS	"$27,951.00"	Outpatient	"$13,975.50"	"$1,365.15"	"$15,289.20"	"$18,643.32"	"$11,180.40"	Not Applicable	"$9,782.85"	"$19,565.70"	"$1,365.15"	"$19,565.70"
GFT STNT 95MM 28MM AFX VELA STRATA AOR XTN AAA STRL LF A28-28/C95V	C1883	SUPPLY/IMPLANTS	"$27,947.00"	Outpatient	"$13,973.50"	Not Applicable	"$15,287.01"	"$18,640.65"	"$11,178.80"	Not Applicable	"$9,781.45"	"$19,562.90"	"$9,781.45"	"$19,562.90"
NAIL IM UNV ARTHDS UNIFLEX FEM 344060	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 65CM 10MM ARTHDS KN 344065	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 70CM 10MM UNV ARTHDS KN 344070	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 75CM 10MM UNV ARTHDS KN 344075	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 80CM 10MM UNV ARTHDS KN 344080	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 60CM 11MM UNV ARTHDS KN 344160	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 65CM 11MM UNV ARTHDS KN 344165	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 70CM 11MM UNV ARTHDS KN 344170	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 75CM 11MM UNV ARTHDS KN 344175	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 80CM 11MM UNV ARTHDS KN 344180	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 65CM 12MM UNV ARTHDS KN 344265	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM UNIFLEX TI ANKL 344270	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 75CM 12MM UNV ARTHDS KN 344275	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 80CM 12MM UNV ARTHDS KN 344280	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM UNV UNIFLEX TI HUM 344365	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 70CM 13MM UNV ARTHDS KN 344370	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 75CM 13MM UNV ARTHDS KN 344375	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 80CM 13MM UNV ARTHDS KN 344380	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 65CM 14MM UNV ARTHDS KN 344465	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 70CM 14MM UNV ARTHDS KN 344470	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 75CM 14MM UNV ARTHDS KN 344475	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
NAIL IM 80CM 14MM UNV ARTHDS KN 344480	C1713	SUPPLY/IMPLANTS	"$27,897.00"	Outpatient	"$13,948.50"	"$1,365.15"	"$15,259.66"	"$18,607.30"	"$11,158.80"	Not Applicable	"$9,763.95"	"$19,527.90"	"$1,365.15"	"$19,527.90"
AUGMENT TIBIAL TRIATHLON TRITANIUM E CONE KNEE SYMMETRIC REV 5549-A-150	C1776	SUPPLY/IMPLANTS	"$27,884.00"	Outpatient	"$13,942.00"	Not Applicable	"$15,252.55"	"$18,598.63"	"$11,153.60"	Not Applicable	"$9,759.40"	"$19,518.80"	"$9,759.40"	"$19,518.80"
INST FX RDC ALGN GD CRNL FLP TUBE CLP 329.323		STERILE SUPPLY	"$27,882.00"	Outpatient	"$13,941.00"	Not Applicable	"$15,251.45"	"$18,597.29"	"$11,152.80"	Not Applicable	"$9,758.70"	"$19,517.40"	"$9,758.70"	"$19,517.40"
BODY CONE RESTORATION +30 MM OD21 MM HIP PROXIMAL MODULAR 6276-1-321	C1776	SUPPLY/IMPLANTS	"$27,876.00"	Outpatient	"$13,938.00"	Not Applicable	"$15,248.17"	"$18,593.29"	"$11,150.40"	Not Applicable	"$9,756.60"	"$19,513.20"	"$9,756.60"	"$19,513.20"
BODY CONE RESTORATION TITANIUM +30 MM OD23 MM HIP MODULAR ST 6276-1-323	C1776	SUPPLY/IMPLANTS	"$27,876.00"	Outpatient	"$13,938.00"	Not Applicable	"$15,248.17"	"$18,593.29"	"$11,150.40"	Not Applicable	"$9,756.60"	"$19,513.20"	"$9,756.60"	"$19,513.20"
JNT TOE 3 THN OFST LOPRFL COCR TI METATARSUS STRL LMH-0003	C1776	SUPPLY/IMPLANTS	"$27,868.00"	Outpatient	"$13,934.00"	Not Applicable	"$15,243.80"	"$18,587.96"	"$11,147.20"	Not Applicable	"$9,753.80"	"$19,507.60"	"$9,753.80"	"$19,507.60"
LEAD ICD 58CM 7FR DURATA OPTIM DF4 CNCT 2 COIL BP 7120Q/58	C1895	PACE MAKER	"$27,802.00"	Outpatient	"$13,901.00"	Not Applicable	"$15,207.69"	"$18,543.93"	"$11,120.80"	Not Applicable	"$9,730.70"	"$19,461.40"	"$9,730.70"	"$19,461.40"
LEAD PCNG 65CM 7FR ECRDM DURATA 2 COIL DF-4 TRUE BP ACTFX 7120Q/65	C1895	PACE MAKER	"$27,802.00"	Outpatient	"$13,901.00"	Not Applicable	"$15,207.69"	"$18,543.93"	"$11,120.80"	Not Applicable	"$9,730.70"	"$19,461.40"	"$9,730.70"	"$19,461.40"
LEAD PCNG 65CM 7FR ECRDM DURATA SJ4 2 COIL TRUE BP CARDVRT 7121Q/65	C1895	PACE MAKER	"$27,802.00"	Outpatient	"$13,901.00"	Not Applicable	"$15,207.69"	"$18,543.93"	"$11,120.80"	Not Applicable	"$9,730.70"	"$19,461.40"	"$9,730.70"	"$19,461.40"
LEAD PCNG 58CM 6.8FR ECRDM DURATA 1 COIL TRUE BP ACTFX XTD 7122Q/58	C1777	PACE MAKER	"$27,802.00"	Outpatient	"$13,901.00"	Not Applicable	"$15,207.69"	"$18,543.93"	"$11,120.80"	Not Applicable	"$9,730.70"	"$19,461.40"	"$9,730.70"	"$19,461.40"
LEAD PCNG 65CM 6.8FR ECRDM DURATA TRUE BP ACTFX XTD 1 COIL 7122Q/65	C1777	SUPPLY/IMPLANTS	"$27,802.00"	Outpatient	"$13,901.00"	Not Applicable	"$15,207.69"	"$18,543.93"	"$11,120.80"	Not Applicable	"$9,730.70"	"$19,461.40"	"$9,730.70"	"$19,461.40"
SYSTEM EMBOLIC PROTECTION SENTINEL L95 CM L4 CM OD6 FR ODSEC CMS15-10C-US	C1884	SUPPLY/IMPLANTS	"$27,728.00"	Outpatient	"$13,864.00"	Not Applicable	"$15,167.22"	"$18,494.58"	"$11,091.20"	Not Applicable	"$9,704.80"	"$19,409.60"	"$9,704.80"	"$19,409.60"
CAGE SPINAL COROENT PEEK 10 D XL L45 MM X W18 MM X H10 MM NO 6981045	C1821	SUPPLY/IMPLANTS	"$27,728.00"	Outpatient	"$13,864.00"	Not Applicable	"$15,167.22"	"$18,494.58"	"$11,091.20"	Not Applicable	"$9,704.80"	"$19,409.60"	"$9,704.80"	"$19,409.60"
GRAFT STENT LIMB EDNDURANT ETW1628C124E ETLW1628C124E	C2625	SUPPLY/IMPLANTS	"$27,721.00"	Outpatient	"$13,860.50"	Not Applicable	"$15,163.39"	"$18,489.91"	"$11,088.40"	Not Applicable	"$9,702.35"	"$19,404.70"	"$9,702.35"	"$19,404.70"
CAGE PEEK 14MM A2014	C1821	SUPPLY/IMPLANTS	"$27,721.00"	Outpatient	"$13,860.50"	Not Applicable	"$15,163.39"	"$18,489.91"	"$11,088.40"	Not Applicable	"$9,702.35"	"$19,404.70"	"$9,702.35"	"$19,404.70"
SPACER ALIF ROI-A 30 X39X16H 10DEG IR5336P	C1821	SUPPLY/IMPLANTS	"$27,721.00"	Outpatient	"$13,860.50"	Not Applicable	"$15,163.39"	"$18,489.91"	"$11,088.40"	Not Applicable	"$9,702.35"	"$19,404.70"	"$9,702.35"	"$19,404.70"
CAGE SPNL 34X24X14MM BRIGADE 8D TI NS LF 6941434		SUPPLY/IMPLANTS	"$27,721.00"	Outpatient	"$13,860.50"	Not Applicable	"$15,163.39"	"$18,489.91"	"$11,088.40"	Not Applicable	"$9,702.35"	"$19,404.70"	"$9,702.35"	"$19,404.70"
CAGE SPNL 34X24X12MM BRIGADE 8D TI NS LF 6941234		SUPPLY/IMPLANTS	"$27,721.00"	Outpatient	"$13,860.50"	Not Applicable	"$15,163.39"	"$18,489.91"	"$11,088.40"	Not Applicable	"$9,702.35"	"$19,404.70"	"$9,702.35"	"$19,404.70"
KNEE LGN GII PS VERILAST NP TIB 71704575	C1776	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
ELTRD DFBR SBQ 9FR 7FR 45CM EBLM S-ICD MP35N PU 3 PLR COIL 3401	C1896	PACE MAKER	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
CAGE SPNL 55X22X10MM CRNT ALPHA XL W TI NS LF 6410255	C1821	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
CAGE SPNL 50X18X8MM CRNT XL TI NS LF 6808850	C1821	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
CAGE SPNL 50X18X10MM CRNT XL TI NS LF 6810850	C1821	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
CAGE SPNL 25X16X8MM CRNT XL THOR PEEK NS LF 6990825	C1821	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
CAGE SPNL 40X16X8MM CRNT XL THOR PEEK NS LF 6990840	C1821	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
CAGE SPNL 45X18X12MM CRNT XL TI NS LF 6812845	C1821	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
LEAD NRSTM 50CM ARTSN MRI SC-8416-50	C1778	SUPPLY/IMPLANTS	"$27,713.00"	Outpatient	"$13,856.50"	Not Applicable	"$15,159.01"	"$18,484.57"	"$11,085.20"	Not Applicable	"$9,699.55"	"$19,399.10"	"$9,699.55"	"$19,399.10"
ELTRD DFBR SBQ 11.5FR 45CM EBLM TRPLR 3501	C1898	PACE MAKER	"$27,712.00"	Outpatient	"$13,856.00"	Not Applicable	"$15,158.46"	"$18,483.90"	"$11,084.80"	Not Applicable	"$9,699.20"	"$19,398.40"	"$9,699.20"	"$19,398.40"
CAGE SPINAL RENOVIS TESERA 12 D LORDOTIC D30 MM W34 MM X H15 MM STERILE LATEX FREE ALIF 1033-342-815	C1821	SUPPLY/IMPLANTS	"$27,712.00"	Outpatient	"$13,856.00"	Not Applicable	"$15,158.46"	"$18,483.90"	"$11,084.80"	Not Applicable	"$9,699.20"	"$19,398.40"	"$9,699.20"	"$19,398.40"
CAGE SPINAL COROENT TITANIUM 10 D XL L40 MM X W18 MM X H10 MM NONSTERILE LATEX FREE 6481040	C1821	SUPPLY/IMPLANTS	"$27,712.00"	Outpatient	"$13,856.00"	Not Applicable	"$15,158.46"	"$18,483.90"	"$11,084.80"	Not Applicable	"$9,699.20"	"$19,398.40"	"$9,699.20"	"$19,398.40"
CAGE SPINAL RENOVIS TESERA 12 D D28 MM W34 MM X H13 MM STERI 1033-342-813	C1821	SUPPLY/IMPLANTS	"$27,712.00"	Outpatient	"$13,856.00"	Not Applicable	"$15,158.46"	"$18,483.90"	"$11,084.80"	Not Applicable	"$9,699.20"	"$19,398.40"	"$9,699.20"	"$19,398.40"
KIT INST CNTRL 360 STRL SK12		STERILE SUPPLY	"$27,712.00"	Outpatient	"$13,856.00"	Not Applicable	"$15,158.46"	"$18,483.90"	"$11,084.80"	Not Applicable	"$9,699.20"	"$19,398.40"	"$9,699.20"	"$19,398.40"
SPCR SPNL 14X9MM COALITION MIS 7D LRDTC 12MM STRL LF 3136.1109	C1821	SUPPLY/IMPLANTS	"$27,711.00"	Outpatient	"$13,855.50"	Not Applicable	"$15,157.92"	"$18,483.24"	"$11,084.40"	Not Applicable	"$9,698.85"	"$19,397.70"	"$9,698.85"	"$19,397.70"
SPCR SPNL 14X10MM COALITION MIS 7D LRDTC 12MM STRL LF 3136.111	C1821	SUPPLY/IMPLANTS	"$27,711.00"	Outpatient	"$13,855.50"	Not Applicable	"$15,157.92"	"$18,483.24"	"$11,084.40"	Not Applicable	"$9,698.85"	"$19,397.70"	"$9,698.85"	"$19,397.70"
SPCR SPNL 14X8MM COALITION MIS 7D LRDTC 12MM STRL LF 3136.1108	C1821	SUPPLY/IMPLANTS	"$27,711.00"	Outpatient	"$13,855.50"	Not Applicable	"$15,157.92"	"$18,483.24"	"$11,084.40"	Not Applicable	"$9,698.85"	"$19,397.70"	"$9,698.85"	"$19,397.70"
KIT NRSTM 50CM INTSTM W 32 CNTCT PDL LD M365SC8352500		STERILE SUPPLY	"$27,711.00"	Outpatient	"$13,855.50"	Not Applicable	"$15,157.92"	"$18,483.24"	"$11,084.40"	Not Applicable	"$9,698.85"	"$19,397.70"	"$9,698.85"	"$19,397.70"
KIT NRSTM 70CM 32 CNTCT PDL TIGHT LD M365SC8336700		STERILE SUPPLY	"$27,711.00"	Outpatient	"$13,855.50"	Not Applicable	"$15,157.92"	"$18,483.24"	"$11,084.40"	Not Applicable	"$9,698.85"	"$19,397.70"	"$9,698.85"	"$19,397.70"
KIT NRSTM 70CM 32 CNTCT PDL LD M365SC8352700	C1778	SUPPLY/IMPLANTS	"$27,709.00"	Outpatient	"$13,854.50"	Not Applicable	"$15,156.82"	"$18,481.90"	"$11,083.60"	Not Applicable	"$9,698.15"	"$19,396.30"	"$9,698.15"	"$19,396.30"
KIT NRSTM 50CM INTSTM LD 32 CNTCT PDL TIGHT M365SC8336500	C1778	SUPPLY/IMPLANTS	"$27,709.00"	Outpatient	"$13,854.50"	Not Applicable	"$15,156.82"	"$18,481.90"	"$11,083.60"	Not Applicable	"$9,698.15"	"$19,396.30"	"$9,698.15"	"$19,396.30"
PLT 14MM LVL 1 BN ALAT LMBR FSN 4508-41F14	C1713	SUPPLY/IMPLANTS	"$27,705.00"	Outpatient	"$13,852.50"	"$1,365.15"	"$15,154.64"	"$18,479.24"	"$11,082.00"	Not Applicable	"$9,696.75"	"$19,393.50"	"$1,365.15"	"$19,393.50"
SYS CRD PCMKR LD 1 CHMBR IS-1 CNCT ASSURITY THK6MM SM 50X47 PM1240 SYSTEM	C1786	PACE MAKER	"$27,705.00"	Outpatient	"$13,852.50"	Not Applicable	"$15,154.64"	"$18,479.24"	"$11,082.00"	Not Applicable	"$9,696.75"	"$19,393.50"	"$9,696.75"	"$19,393.50"
GFT SFT TIS 10X4CM EPIXL XL-5410	C1765	SUPPLY/IMPLANTS	"$27,676.00"	Outpatient	"$13,838.00"	Not Applicable	"$15,138.77"	"$18,459.89"	"$11,070.40"	Not Applicable	"$9,686.60"	"$19,373.20"	"$9,686.60"	"$19,373.20"
OCCLUDER SEPTAL AMPLATZER 6MM 9-ASD-017	C1817	SUPPLY/IMPLANTS	"$27,671.00"	Outpatient	"$13,835.50"	Not Applicable	"$15,136.04"	"$18,456.56"	"$11,068.40"	Not Applicable	"$9,684.85"	"$19,369.70"	"$9,684.85"	"$19,369.70"
OCLR CV 3MM 10MM 18-22MM SPT 2 DISK SLF XPD SLFCNTR AMPLZR 9-ASD-010	C1817	SUPPLY/IMPLANTS	"$27,671.00"	Outpatient	"$13,835.50"	Not Applicable	"$15,136.04"	"$18,456.56"	"$11,068.40"	Not Applicable	"$9,684.85"	"$19,369.70"	"$9,684.85"	"$19,369.70"
OCLR CV 4MM 14MM 24-28MM SPT 2 DISK SLFCNTR WST AMPLZR NTNL 9-ASD-014	C1817	SUPPLY/IMPLANTS	"$27,671.00"	Outpatient	"$13,835.50"	Not Applicable	"$15,136.04"	"$18,456.56"	"$11,068.40"	Not Applicable	"$9,684.85"	"$19,369.70"	"$9,684.85"	"$19,369.70"
PCMKR .75CM ACLD 1 CHMBR RA RV IS1 CNCT 4.45X4.81CM CRD 13.2 L310	C1786	PACE MAKER	"$27,656.00"	Outpatient	"$13,828.00"	Not Applicable	"$15,127.83"	"$18,446.55"	"$11,062.40"	Not Applicable	"$9,679.60"	"$19,359.20"	"$9,679.60"	"$19,359.20"
PCMKR AZURE CRD W1SR01	C1786	PACE MAKER	"$27,656.00"	Outpatient	"$13,828.00"	Not Applicable	"$15,127.83"	"$18,446.55"	"$11,062.40"	Not Applicable	"$9,679.60"	"$19,359.20"	"$9,679.60"	"$19,359.20"
SPHR GLND 36MM AQLS SHLDR COCR RVRS CNTR 25MM BSPLT DWD180	C1776	SUPPLY/IMPLANTS	"$27,629.00"	Outpatient	"$13,814.50"	Not Applicable	"$15,113.06"	"$18,428.54"	"$11,051.60"	Not Applicable	"$9,670.15"	"$19,340.30"	"$9,670.15"	"$19,340.30"
PLATE 2-LEVEL TRESTLE LUXE 54MM 71003-054	C1713	SUPPLY/IMPLANTS	"$27,621.00"	Outpatient	"$13,810.50"	"$1,365.15"	"$15,108.69"	"$18,423.21"	"$11,048.40"	Not Applicable	"$9,667.35"	"$19,334.70"	"$1,365.15"	"$19,334.70"
PLATE 3-LEVEL TRESTLE LUXE 51MM 71003-051	C1713	SUPPLY/IMPLANTS	"$27,621.00"	Outpatient	"$13,810.50"	"$1,365.15"	"$15,108.69"	"$18,423.21"	"$11,048.40"	Not Applicable	"$9,667.35"	"$19,334.70"	"$1,365.15"	"$19,334.70"
PLATE TRESTLE LUXE 3-LEVEL 42MM 71003-042	C1713	SUPPLY/IMPLANTS	"$27,621.00"	Outpatient	"$13,810.50"	"$1,365.15"	"$15,108.69"	"$18,423.21"	"$11,048.40"	Not Applicable	"$9,667.35"	"$19,334.70"	"$1,365.15"	"$19,334.70"
CAGE 16 X 27 X 36MM X 6 IR5227P	C1821	SUPPLY/IMPLANTS	"$27,602.00"	Outpatient	"$13,801.00"	Not Applicable	"$15,098.29"	"$18,410.53"	"$11,040.80"	Not Applicable	"$9,660.70"	"$19,321.40"	"$9,660.70"	"$19,321.40"
BODY CONE HIP +10MM RSTR TI 23MM MDLR REV 6276-1-123	C1776	SUPPLY/IMPLANTS	"$27,590.00"	Outpatient	"$13,795.00"	Not Applicable	"$15,091.73"	"$18,402.53"	"$11,036.00"	Not Applicable	"$9,656.50"	"$19,313.00"	"$9,656.50"	"$19,313.00"
BODY CONE HIP +20MM RSTR TI 23MM MDLR STRL REV SYS 6276-1-223	C1776	SUPPLY/IMPLANTS	"$27,590.00"	Outpatient	"$13,795.00"	Not Applicable	"$15,091.73"	"$18,402.53"	"$11,036.00"	Not Applicable	"$9,656.50"	"$19,313.00"	"$9,656.50"	"$19,313.00"
BODY CONE HIP +30MM RSTR TI 25MM MDLR STRL REV SYS 6276-1-325	C1776	SUPPLY/IMPLANTS	"$27,590.00"	Outpatient	"$13,795.00"	Not Applicable	"$15,091.73"	"$18,402.53"	"$11,036.00"	Not Applicable	"$9,656.50"	"$19,313.00"	"$9,656.50"	"$19,313.00"
BODY CONE HIP PROX +0MM STD RSTR 21MM MDLR 6276-1-021	C1776	SUPPLY/IMPLANTS	"$27,590.00"	Outpatient	"$13,795.00"	Not Applicable	"$15,091.73"	"$18,402.53"	"$11,036.00"	Not Applicable	"$9,656.50"	"$19,313.00"	"$9,656.50"	"$19,313.00"
BODY CALCAR RESTORATION +20 MM OFFSET OD25 MM HIP MODULAR 6276-1-225	C1776	SUPPLY/IMPLANTS	"$27,590.00"	Outpatient	"$13,795.00"	Not Applicable	"$15,091.73"	"$18,402.53"	"$11,036.00"	Not Applicable	"$9,656.50"	"$19,313.00"	"$9,656.50"	"$19,313.00"
BODY CONE HIP PROX +0MM STD RSTR 25MM MDLR 6276-1-025	C1776	SUPPLY/IMPLANTS	"$27,577.00"	Outpatient	"$13,788.50"	Not Applicable	"$15,084.62"	"$18,393.86"	"$11,030.80"	Not Applicable	"$9,651.95"	"$19,303.90"	"$9,651.95"	"$19,303.90"
TI HUMERAL STEM PRESS FIT 8120MM 1328612	C1713	SUPPLY/IMPLANTS	"$27,564.00"	Outpatient	"$13,782.00"	"$1,365.15"	"$15,077.51"	"$18,385.19"	"$11,025.60"	Not Applicable	"$9,647.40"	"$19,294.80"	"$1,365.15"	"$19,294.80"
STEM HUM 120MM PRFT ANTM SLFCNTR EPOCA TI PLSM SPRAYED 8 1328612		STERILE SUPPLY	"$27,564.00"	Outpatient	"$13,782.00"	Not Applicable	"$15,077.51"	"$18,385.19"	"$11,025.60"	Not Applicable	"$9,647.40"	"$19,294.80"	"$9,647.40"	"$19,294.80"
CAGE CERIVAL PEEK 11 X 12 X 14MM X 5 A1001111L	C1821	SUPPLY/IMPLANTS	"$27,550.00"	Outpatient	"$13,775.00"	Not Applicable	"$15,069.85"	"$18,375.85"	"$11,020.00"	Not Applicable	"$9,642.50"	"$19,285.00"	"$9,642.50"	"$19,285.00"
CMPNT FEM 5 RMLL PRT KN RSRFC TRTHLN 5610-F-502	C1776	SUPPLY/IMPLANTS	"$27,546.00"	Outpatient	"$13,773.00"	Not Applicable	"$15,067.66"	"$18,373.18"	"$11,018.40"	Not Applicable	"$9,641.10"	"$19,282.20"	"$9,641.10"	"$19,282.20"
SPCR SPNL 14X10MM COALITION 7D LRDTC 12MM PEEK ACDF NS LF 384.11		STERILE SUPPLY	"$27,537.00"	Outpatient	"$13,768.50"	Not Applicable	"$15,062.74"	"$18,367.18"	"$11,014.80"	Not Applicable	"$9,637.95"	"$19,275.90"	"$9,637.95"	"$19,275.90"
STEM FEM 127MM 11MM STD STRG MRS POR KN CMNT BD SECT 6485-3-011	C1776	SUPPLY/IMPLANTS	"$27,475.00"	Outpatient	"$13,737.50"	Not Applicable	"$15,028.83"	"$18,325.83"	"$10,990.00"	Not Applicable	"$9,616.25"	"$19,232.50"	"$9,616.25"	"$19,232.50"
SI Transl Peripheral Atherectomy Open or Perc		CARDIAC CATH LAB	"$27,445.00"	Outpatient	"$13,722.50"	Not Applicable	"$15,012.42"	"$18,305.82"	"$10,978.00"	Not Applicable	"$9,605.75"	"$19,211.50"	"$9,605.75"	"$19,211.50"
PCMKR 7.5MM ADAPTA DR MVP 2 CHMBR LNGVT BP PLS GNTR 52.3 ADDRL1	C1785	PACE MAKER	"$27,360.00"	Outpatient	"$13,680.00"	Not Applicable	"$14,965.92"	"$18,249.12"	"$10,944.00"	Not Applicable	"$9,576.00"	"$19,152.00"	"$9,576.00"	"$19,152.00"
GFT SFT TIS 70X40MM ARTHROFLEX THK2.5-3.5MM DECELLULARIZED AFLEX301	C1763	SUPPLY/IMPLANTS	"$27,345.00"	Outpatient	"$13,672.50"	Not Applicable	"$14,957.72"	"$18,239.12"	"$10,938.00"	Not Applicable	"$9,570.75"	"$19,141.50"	"$9,570.75"	"$19,141.50"
PLT 35MM SPNE LMBR AFFIX II BN NS 7577035	C1713	SUPPLY/IMPLANTS	"$27,336.00"	Outpatient	"$13,668.00"	"$1,365.15"	"$14,952.79"	"$18,233.11"	"$10,934.40"	Not Applicable	"$9,567.60"	"$19,135.20"	"$1,365.15"	"$19,135.20"
CMNT BN HYDROSET BN SUB VOID FIL CA PHOS 15CC INJ OSTCNDC 7943915		SUPPLY/IMPLANTS	"$27,331.00"	Outpatient	"$13,665.50"	Not Applicable	"$14,950.06"	"$18,229.78"	"$10,932.40"	Not Applicable	"$9,565.85"	"$19,131.70"	"$9,565.85"	"$19,131.70"
CMPNT ULN 75MM 4MM DSCVR ELB LT BRNG 114822	C1776	SUPPLY/IMPLANTS	"$27,299.00"	Outpatient	"$13,649.50"	Not Applicable	"$14,932.55"	"$18,208.43"	"$10,919.60"	Not Applicable	"$9,554.65"	"$19,109.30"	"$9,554.65"	"$19,109.30"
CARTIVA MTP IMPLANT 10MM CAR-10	C1776	SUPPLY/IMPLANTS	"$27,279.00"	Outpatient	"$13,639.50"	Not Applicable	"$14,921.61"	"$18,195.09"	"$10,911.60"	Not Applicable	"$9,547.65"	"$19,095.30"	"$9,547.65"	"$19,095.30"
IMPL TOE JNT 8MM CARTIVA MTP CRTLG STRL CAR-8-US	C1776	SUPPLY/IMPLANTS	"$27,279.00"	Outpatient	"$13,639.50"	Not Applicable	"$14,921.61"	"$18,195.09"	"$10,911.60"	Not Applicable	"$9,547.65"	"$19,095.30"	"$9,547.65"	"$19,095.30"
MTRX TISS 16X8CM ALDRM XTHICK ACLR DERM ALGRF RGNRT FRZDR 982128	C1762	SUPPLY/IMPLANTS	"$27,278.00"	Outpatient	"$13,639.00"	Not Applicable	"$14,921.07"	"$18,194.43"	"$10,911.20"	Not Applicable	"$9,547.30"	"$19,094.60"	"$9,547.30"	"$19,094.60"
Place radiothrpy brachy catheter breast bilat 19298	19298	OR SERVICES	"$27,270.00"	Outpatient	"$13,635.00"	"$16,258.87"	"$14,916.69"	"$4,649.00"	"$10,908.00"	"$7,310.00"	"$9,544.50"	"$19,089.00"	"$4,649.00"	"$19,089.00"
Transcatheter Angioplasty Stent Placement	61635	CARDIAC CATH LAB	"$27,263.00"	Outpatient	"$13,631.50"	Not Applicable	"$14,912.86"	"$1,771.00"	"$10,905.20"	"$1,563.00"	"$9,542.05"	"$19,084.10"	"$1,563.00"	"$19,084.10"
MTRX TISS 16X8CM STRATTICE PRCN DERM RECON PLBL STRL 816001	Q4130	PHARMACY	"$27,240.00"	Outpatient	"$13,620.00"	Not Applicable	"$14,900.28"	"$18,169.08"	"$10,896.00"	Not Applicable	"$9,534.00"	"$19,068.00"	"$9,534.00"	"$19,068.00"
GFT STNT 75MM 25MM AFX VELA STRATA AOR XTN AAA STRL LF A25-25/C75V	C1722	SUPPLY/IMPLANTS	"$27,223.00"	Outpatient	"$13,611.50"	Not Applicable	"$14,890.98"	"$18,157.74"	"$10,889.20"	Not Applicable	"$9,528.05"	"$19,056.10"	"$9,528.05"	"$19,056.10"
STEM FEM 155MM 19MM CNCL RSTR HA DIST HIP MDLR 6276-7-019	C1776	SUPPLY/IMPLANTS	"$27,188.00"	Outpatient	"$13,594.00"	Not Applicable	"$14,871.84"	"$18,134.40"	"$10,875.20"	Not Applicable	"$9,515.80"	"$19,031.60"	"$9,515.80"	"$19,031.60"
MODULAR HIP SYSTEM RESTORATION 155MM  22MM 6276-7-002	C1713	SUPPLY/IMPLANTS	"$27,188.00"	Outpatient	"$13,594.00"	"$1,365.15"	"$14,871.84"	"$18,134.40"	"$10,875.20"	Not Applicable	"$9,515.80"	"$19,031.60"	"$1,365.15"	"$19,031.60"
STEM FEM 195MM 17MM STRG CONE RSTR HA HIP MDLR 6276-7-117	C1776	SUPPLY/IMPLANTS	"$27,183.00"	Outpatient	"$13,591.50"	Not Applicable	"$14,869.10"	"$18,131.06"	"$10,873.20"	Not Applicable	"$9,514.05"	"$19,028.10"	"$9,514.05"	"$19,028.10"
TRAY STRL OPTILOCK DIST TIB PERIART PLT SYS 26553	C1713	SUPPLY/IMPLANTS	"$27,163.00"	Outpatient	"$13,581.50"	"$1,365.15"	"$14,858.16"	"$18,117.72"	"$10,865.20"	Not Applicable	"$9,507.05"	"$19,014.10"	"$1,365.15"	"$19,014.10"
VALVE AORTIC ON-X CONFORM-X TITANIUM CARBON PTFE OD34 MM CYLINDRICAL H14.2 MM H17.8 MM OD25 MM ODSEC		SUPPLY/IMPLANTS	"$27,115.00"	Outpatient	"$13,557.50"	Not Applicable	"$14,831.91"	"$18,085.71"	"$10,846.00"	Not Applicable	"$9,490.25"	"$18,980.50"	"$9,490.25"	"$18,980.50"
FXTR XTRNFX CONSTRUX 1800	C1713	SUPPLY/IMPLANTS	"$27,016.00"	Outpatient	"$13,508.00"	"$1,365.15"	"$14,777.75"	"$18,019.67"	"$10,806.40"	Not Applicable	"$9,455.60"	"$18,911.20"	"$1,365.15"	"$18,911.20"
LEAD PCNG 55CM RV SQ SCR S DF-4 TRPLR SCR DFBR 6935M55	C1898	PACE MAKER	"$27,016.00"	Outpatient	"$13,508.00"	Not Applicable	"$14,777.75"	"$18,019.67"	"$10,806.40"	Not Applicable	"$9,455.60"	"$18,911.20"	"$9,455.60"	"$18,911.20"
GENERATOR ADVANTIO K062SR	C1786	PACE MAKER	"$27,015.00"	Outpatient	"$13,507.50"	Not Applicable	"$14,777.21"	"$18,019.01"	"$10,806.00"	Not Applicable	"$9,455.25"	"$18,910.50"	"$9,455.25"	"$18,910.50"
PROS PENL TTN CLPLST LCK-OUT 24CM SET INFL FLD FIL SFT MLD E17924	C1813	SUPPLY/IMPLANTS	"$27,015.00"	Outpatient	"$13,507.50"	Not Applicable	"$14,777.21"	"$18,019.01"	"$10,806.00"	Not Applicable	"$9,455.25"	"$18,910.50"	"$9,455.25"	"$18,910.50"
INS TIB 5-6 9MM KN XLPE PS HI FLXN LEGION 71453221	C1776	SUPPLY/IMPLANTS	"$26,947.00"	Outpatient	"$13,473.50"	Not Applicable	"$14,740.01"	"$17,973.65"	"$10,778.80"	Not Applicable	"$9,431.45"	"$18,862.90"	"$9,431.45"	"$18,862.90"
GFT STNT 115MM 28MM 17FR AFX ACTIVESEAL STRATA STRG EVAS ABD A28-28/C95-020	C1722	SUPPLY/IMPLANTS	"$26,943.00"	Outpatient	"$13,471.50"	Not Applicable	"$14,737.82"	"$17,970.98"	"$10,777.20"	Not Applicable	"$9,430.05"	"$18,860.10"	"$9,430.05"	"$18,860.10"
GFT EVAS 14CM 14.5MM 12-13.5MM GORE XCLDR CNTRLT LG AAA ACPT PLC141400	C1874	SUPPLY/IMPLANTS	"$26,938.00"	Outpatient	"$13,469.00"	Not Applicable	"$14,735.09"	"$17,967.65"	"$10,775.20"	Not Applicable	"$9,428.30"	"$18,856.60"	"$9,428.30"	"$18,856.60"
CAGE SPINAL ENDOSKELETON TAS TITANIUM 12 D D24 MM LARGE W36 2312-0213	C1821	SUPPLY/IMPLANTS	"$26,920.00"	Outpatient	"$13,460.00"	Not Applicable	"$14,725.24"	"$17,955.64"	"$10,768.00"	Not Applicable	"$9,422.00"	"$18,844.00"	"$9,422.00"	"$18,844.00"
CAGE SPINAL ENDOSKELETON TAS TITANIUM 12 D D24 MM LARGE W36 2312-0214	C1821	SUPPLY/IMPLANTS	"$26,920.00"	Outpatient	"$13,460.00"	Not Applicable	"$14,725.24"	"$17,955.64"	"$10,768.00"	Not Applicable	"$9,422.00"	"$18,844.00"	"$9,422.00"	"$18,844.00"
HNDPC DRL DRVR 05.000.008		STERILE SUPPLY	"$26,914.00"	Outpatient	"$13,457.00"	Not Applicable	"$14,721.96"	"$17,951.64"	"$10,765.60"	Not Applicable	"$9,419.90"	"$18,839.80"	"$9,419.90"	"$18,839.80"
GFT STNT 49MM 23MM 18FR ENDURANT II EVAS PLSTR NTNL AOR XTN ETCF2323C49E	C1874	SUPPLY/IMPLANTS	"$26,897.00"	Outpatient	"$13,448.50"	Not Applicable	"$14,712.66"	"$17,940.30"	"$10,758.80"	Not Applicable	"$9,413.95"	"$18,827.90"	"$9,413.95"	"$18,827.90"
GFT STNT 49MM 25MM 18FR ENDURANT II EVAS PLSTR NTNL AOR XTN ETCF2525C49E		SUPPLY/IMPLANTS	"$26,897.00"	Outpatient	"$13,448.50"	Not Applicable	"$14,712.66"	"$17,940.30"	"$10,758.80"	Not Applicable	"$9,413.95"	"$18,827.90"	"$9,413.95"	"$18,827.90"
"Open/Perc Place Stent each Add'l Artery, except leg"	37237	CARDIAC CATH LAB	"$26,883.00"	Outpatient	"$13,441.50"	"$12,069.84"	"$14,705.00"	"$1,592.00"	"$10,753.20"	"$7,310.00"	"$9,409.05"	"$18,818.10"	"$1,592.00"	"$18,818.10"
Open/Perc Place Stent each Add'l vein	37239	CARDIAC CATH LAB	"$26,883.00"	Outpatient	"$13,441.50"	"$22,064.09"	"$14,705.00"	"$1,592.00"	"$10,753.20"	"$7,310.00"	"$9,409.05"	"$18,818.10"	"$1,592.00"	"$22,064.09"
Open/Percutaneous Placement Stent each Additional Vein	37239	CARDIAC CATH LAB	"$26,883.00"	Outpatient	"$13,441.50"	"$22,064.09"	"$14,705.00"	"$1,592.00"	"$10,753.20"	"$7,310.00"	"$9,409.05"	"$18,818.10"	"$1,592.00"	"$22,064.09"
INS TIB 4 12.5MM KN AOX ROT PLAT STAB SGM STRL 196192142	C1776	SUPPLY/IMPLANTS	"$26,880.00"	Outpatient	"$13,440.00"	Not Applicable	"$14,703.36"	"$17,928.96"	"$10,752.00"	Not Applicable	"$9,408.00"	"$18,816.00"	"$9,408.00"	"$18,816.00"
GFT STENT 93MM 16X24MM ENDURANT II ETLW1624C93E	C1874	SUPPLY/IMPLANTS	"$26,862.00"	Outpatient	"$13,431.00"	Not Applicable	"$14,693.51"	"$17,916.95"	"$10,744.80"	Not Applicable	"$9,401.70"	"$18,803.40"	"$9,401.70"	"$18,803.40"
GFT STNT 103MM 14-25MM 18FR ENDURANT IIS 2 BRCH EVAS NTNL ESBF2514C103E	C1884	SUPPLY/IMPLANTS	"$26,862.00"	Outpatient	"$13,431.00"	Not Applicable	"$14,693.51"	"$17,916.95"	"$10,744.80"	Not Applicable	"$9,401.70"	"$18,803.40"	"$9,401.70"	"$18,803.40"
TRAY INST OPTILOCK SPHERELOCK TCH PROX HUM PLT SYS 36010	C1713	SUPPLY/IMPLANTS	"$26,857.00"	Outpatient	"$13,428.50"	"$1,365.15"	"$14,690.78"	"$17,913.62"	"$10,742.80"	Not Applicable	"$9,399.95"	"$18,799.90"	"$1,365.15"	"$18,799.90"
TISSUE CORNEA 16-0991-PC	V2785	UNKNOWN/DONOR	"$26,854.00"	Outpatient	"$13,427.00"	Not Applicable	"$14,689.14"	"$17,911.62"	"$10,741.60"	Not Applicable	"$9,398.90"	"$18,797.80"	"$9,398.90"	"$18,797.80"
PCMKR 2.8V .97AH 7.5MM SENSIA SR 1 CHMBR RR IS-1 42.9MMX40.2 SESR01	C1786	PACE MAKER	"$26,846.00"	Outpatient	"$13,423.00"	Not Applicable	"$14,684.76"	"$17,906.28"	"$10,738.40"	Not Applicable	"$9,396.10"	"$18,792.20"	"$9,396.10"	"$18,792.20"
GFT STNT 199MM 16-13MM 16FR ENDURANT II EVAS NTNL PLSTR ETLW1613C199E	C1884	SUPPLY/IMPLANTS	"$26,846.00"	Outpatient	"$13,423.00"	Not Applicable	"$14,684.76"	"$17,906.28"	"$10,738.40"	Not Applicable	"$9,396.10"	"$18,792.20"	"$9,396.10"	"$18,792.20"
SHELL ACETABULAR TRIDENT 64MM CODE H 541-11-64H	C1776	SUPPLY/IMPLANTS	"$26,845.00"	Outpatient	"$13,422.50"	Not Applicable	"$14,684.22"	"$17,905.62"	"$10,738.00"	Not Applicable	"$9,395.75"	"$18,791.50"	"$9,395.75"	"$18,791.50"
VLV SHNT PS MDCL STRATA NSC CSF ADJ WO BGL REG 32X16X8MM 42365	C1765	SUPPLY/IMPLANTS	"$26,828.00"	Outpatient	"$13,414.00"	Not Applicable	"$14,674.92"	"$17,894.28"	"$10,731.20"	Not Applicable	"$9,389.80"	"$18,779.60"	"$9,389.80"	"$18,779.60"
GFT BN CORT 14MM FRZDR RING MACH 26MM 439014	C1713	SUPPLY/IMPLANTS	"$26,814.00"	Outpatient	"$13,407.00"	"$1,365.15"	"$14,667.26"	"$17,884.94"	"$10,725.60"	Not Applicable	"$9,384.90"	"$18,769.80"	"$1,365.15"	"$18,769.80"
00310-1730-30 - benralizumab 30 mg/mL Soln	J0517	PHARMACY	"$26,813.00"	Outpatient	"$13,406.50"	$170.10	"$14,666.71"	"$17,884.27"	"$10,725.20"	Not Applicable	"$9,384.55"	"$18,769.10"	$170.10	"$18,769.10"
CONSTRUX FIXR MALEFEMALE ENDS 1801	C1713	SUPPLY/IMPLANTS	"$26,802.00"	Outpatient	"$13,401.00"	"$1,365.15"	"$14,660.69"	"$17,876.93"	"$10,720.80"	Not Applicable	"$9,380.70"	"$18,761.40"	"$1,365.15"	"$18,761.40"
FXTR XTRNFX CONSTRUX CNTR BD 14450500	C1713	SUPPLY/IMPLANTS	"$26,802.00"	Outpatient	"$13,401.00"	"$1,365.15"	"$14,660.69"	"$17,876.93"	"$10,720.80"	Not Applicable	"$9,380.70"	"$18,761.40"	"$1,365.15"	"$18,761.40"
STNT HEP 6MM 6FR SPRFC FEM ART ILC 15CM GORE VBHN EPRSTH 120 VBJ061502	C1874	SUPPLY/IMPLANTS	"$26,764.00"	Outpatient	"$13,382.00"	Not Applicable	"$14,639.91"	"$17,851.59"	"$10,705.60"	Not Applicable	"$9,367.40"	"$18,734.80"	"$9,367.40"	"$18,734.80"
STNT HEP 7MM 7FR SPRFC FEM ART ILC 15CM DLV SYS VBHN EPRSTH VBJ071502	C1884	SUPPLY/IMPLANTS	"$26,747.00"	Outpatient	"$13,373.50"	Not Applicable	"$14,630.61"	"$17,840.25"	"$10,698.80"	Not Applicable	"$9,361.45"	"$18,722.90"	"$9,361.45"	"$18,722.90"
TRAY STRL OPTILOCK SCR INST PERIART PLT SYS 26550	C1713	SUPPLY/IMPLANTS	"$26,739.00"	Outpatient	"$13,369.50"	"$1,365.15"	"$14,626.23"	"$17,834.91"	"$10,695.60"	Not Applicable	"$9,358.65"	"$18,717.30"	"$1,365.15"	"$18,717.30"
63459-0104-50 - riTUXimab abbs 10 mg/mL Soln	Q5115	PHARMACY	"$22,475.00"	Outpatient	"$11,237.50"	$94.18	"$14,608.75"	"$14,990.83"	"$8,990.00"	Not Applicable	"$7,866.25"	"$15,732.50"	$94.18	"$15,732.50"
(BC2) M-SPEC METAL FEMORAL HEAD	C1776	SUPPLY/IMPLANTS	"$26,705.00"	Outpatient	"$13,352.50"	Not Applicable	"$14,607.64"	"$17,812.24"	"$10,682.00"	Not Applicable	"$9,346.75"	"$18,693.50"	"$9,346.75"	"$18,693.50"
STEM FEM 8IN 15MM 12/14 SM STAT STRG TPR SOL POR 43MM HIP 157201150	C1776	SUPPLY/IMPLANTS	"$26,705.00"	Outpatient	"$13,352.50"	Not Applicable	"$14,607.64"	"$17,812.24"	"$10,682.00"	Not Applicable	"$9,346.75"	"$18,693.50"	"$9,346.75"	"$18,693.50"
STNT INTRCRAN 3MM 2.8-3FR .05IN 15MM 131CM RADOPQ SLF XPD M003SNF330150		SUPPLY/IMPLANTS	"$26,691.00"	Outpatient	"$13,345.50"	Not Applicable	"$14,599.98"	"$17,802.90"	"$10,676.40"	Not Applicable	"$9,341.85"	"$18,683.70"	"$9,341.85"	"$18,683.70"
PLT 2MM MNDB TI PTSPC BN SD480.112	C1713	SUPPLY/IMPLANTS	"$26,690.00"	Outpatient	"$13,345.00"	"$1,365.15"	"$14,599.43"	"$17,802.23"	"$10,676.00"	Not Applicable	"$9,341.50"	"$18,683.00"	"$1,365.15"	"$18,683.00"
STEM FEM 127MM 12MM STRG RSTR HA POR PLSM SPRY HIP MDLR 6276-5-012	C1776	SUPPLY/IMPLANTS	"$26,687.00"	Outpatient	"$13,343.50"	Not Applicable	"$14,597.79"	"$17,800.23"	"$10,674.80"	Not Applicable	"$9,340.45"	"$18,680.90"	"$9,340.45"	"$18,680.90"
STEM FEM 127MM 14MM STRG RSTR HA POR PLSM SPRY HIP MDLR 6276-5-014	C1776	SUPPLY/IMPLANTS	"$26,685.00"	Outpatient	"$13,342.50"	Not Applicable	"$14,596.70"	"$17,798.90"	"$10,674.00"	Not Applicable	"$9,339.75"	"$18,679.50"	"$9,339.75"	"$18,679.50"
APR IN CLP 40MM PRELD ATRICLIP PRO2 GILLINOV-CSGRV STRL LF PRO240		STERILE SUPPLY	"$26,683.00"	Outpatient	"$13,341.50"	Not Applicable	"$14,595.60"	"$17,797.56"	"$10,673.20"	Not Applicable	"$9,339.05"	"$18,678.10"	"$9,339.05"	"$18,678.10"
DEV CLSR 50MM ATRICLIP PRO2 GILLINOV-CSGRV STRL LF DISP LT PRO250		STERILE SUPPLY	"$26,683.00"	Outpatient	"$13,341.50"	Not Applicable	"$14,595.60"	"$17,797.56"	"$10,673.20"	Not Applicable	"$9,339.05"	"$18,678.10"	"$9,339.05"	"$18,678.10"
STNT HEP 7MM 7FR SPRFC FEM ART ILC 5CM DLV CATH GORE VBHN VBJR070502A	C1884	SUPPLY/IMPLANTS	"$26,672.00"	Outpatient	"$13,336.00"	Not Applicable	"$14,589.58"	"$17,790.22"	"$10,668.80"	Not Applicable	"$9,335.20"	"$18,670.40"	"$9,335.20"	"$18,670.40"
STNT HEP 7MM 7FR SPRFC FEM ART ILIUM 15CM DLV SYS VBHN VBJR071502A	C1884	SUPPLY/IMPLANTS	"$26,672.00"	Outpatient	"$13,336.00"	Not Applicable	"$14,589.58"	"$17,790.22"	"$10,668.80"	Not Applicable	"$9,335.20"	"$18,670.40"	"$9,335.20"	"$18,670.40"
STNT HEP 7MM 7FR SPRFC FEM ART ILIUM 10CM DLV SYS VBHN VBJR071002A	C1874	SUPPLY/IMPLANTS	"$26,670.00"	Outpatient	"$13,335.00"	Not Applicable	"$14,588.49"	"$17,788.89"	"$10,668.00"	Not Applicable	"$9,334.50"	"$18,669.00"	"$9,334.50"	"$18,669.00"
PCMKR ADAPTA SR IMPL 1 CHMBR RR UNPLR BP CRD ATR VNTRC ADAPTASRK2	C1786	PACE MAKER	"$26,669.00"	Outpatient	"$13,334.50"	Not Applicable	"$14,587.94"	"$17,788.22"	"$10,667.60"	Not Applicable	"$9,334.15"	"$18,668.30"	"$9,334.15"	"$18,668.30"
INS TIB 1-2 13MM KN XLPE PS HI FLXN LEGION 71453203	C1776	SUPPLY/IMPLANTS	"$26,635.00"	Outpatient	"$13,317.50"	Not Applicable	"$14,569.35"	"$17,765.55"	"$10,654.00"	Not Applicable	"$9,322.25"	"$18,644.50"	"$9,322.25"	"$18,644.50"
PLT 258MM TROCH LAT SS 9 HL 3 CRMP BN BMP CBL SYS 350836	C1713	SUPPLY/IMPLANTS	"$26,581.00"	Outpatient	"$13,290.50"	"$1,365.15"	"$14,539.81"	"$17,729.53"	"$10,632.40"	Not Applicable	"$9,303.35"	"$18,606.70"	"$1,365.15"	"$18,606.70"
NAIL IM 32CM 12MM 130D LNG IMHS CP SS LT HIP 71683132L	C1713	SUPPLY/IMPLANTS	"$26,562.00"	Outpatient	"$13,281.00"	"$1,365.15"	"$14,529.41"	"$17,716.85"	"$10,624.80"	Not Applicable	"$9,296.70"	"$18,593.40"	"$1,365.15"	"$18,593.40"
NAIL IM 42CM 12MM 130D LNG IMHS CP SS RT HIP 71683142R	C1713	SUPPLY/IMPLANTS	"$26,562.00"	Outpatient	"$13,281.00"	"$1,365.15"	"$14,529.41"	"$17,716.85"	"$10,624.80"	Not Applicable	"$9,296.70"	"$18,593.40"	"$1,365.15"	"$18,593.40"
GRAFT STENT AFX VELA STRATA L75 MM L20 MM OD28 MM SUPRARENAL AORTIC EXTENSION STERILE LATEX FREE AAA	C1874	SUPPLY/IMPLANTS	"$26,533.00"	Outpatient	"$13,266.50"	Not Applicable	"$14,513.55"	"$17,697.51"	"$10,613.20"	Not Applicable	"$9,286.55"	"$18,573.10"	"$9,286.55"	"$18,573.10"
BONE CERAMENT VOID FILLER SIZE 18 A0210-11	C1713	SUPPLY/IMPLANTS	"$26,515.00"	Outpatient	"$13,257.50"	"$1,365.15"	"$14,503.71"	"$17,685.51"	"$10,606.00"	Not Applicable	"$9,280.25"	"$18,560.50"	"$1,365.15"	"$18,560.50"
STEM FEM 127MM 13MM STRG RSTR HA POR PLSM SPRY HIP MDLR 6276-5-013	C1776	SUPPLY/IMPLANTS	"$26,490.00"	Outpatient	"$13,245.00"	Not Applicable	"$14,490.03"	"$17,668.83"	"$10,596.00"	Not Applicable	"$9,271.50"	"$18,543.00"	"$9,271.50"	"$18,543.00"
STEM FEM 167MM 13MM BW RSTR DIST HIP MDLR PLSM SPRAYED 6276-5-213	C1776	SUPPLY/IMPLANTS	"$26,486.00"	Outpatient	"$13,243.00"	Not Applicable	"$14,487.84"	"$17,666.16"	"$10,594.40"	Not Applicable	"$9,270.10"	"$18,540.20"	"$9,270.10"	"$18,540.20"
VISION UNILATERAL STD FIXATOR 20150	C1713	SUPPLY/IMPLANTS	"$26,471.00"	Outpatient	"$13,235.50"	"$1,365.15"	"$14,479.64"	"$17,656.16"	"$10,588.40"	Not Applicable	"$9,264.85"	"$18,529.70"	"$1,365.15"	"$18,529.70"
STEM FEM 102MM 10MM SM MRS HIP WO BD 6485-3-010	C1776	SUPPLY/IMPLANTS	"$26,417.00"	Outpatient	"$13,208.50"	Not Applicable	"$14,450.10"	"$17,620.14"	"$10,566.80"	Not Applicable	"$9,245.95"	"$18,491.90"	"$9,245.95"	"$18,491.90"
STEM FEM 127MM 13MM STD STRG MRS POR KN CMNT BD SECT 6485-3-013	C1776	SUPPLY/IMPLANTS	"$26,409.00"	Outpatient	"$13,204.50"	Not Applicable	"$14,445.72"	"$17,614.80"	"$10,563.60"	Not Applicable	"$9,243.15"	"$18,486.30"	"$9,243.15"	"$18,486.30"
STEM FEM 203MM 13MM LNG BW GMRS POR PROX CMNT BD SECT 64853313	C1776	SUPPLY/IMPLANTS	"$26,409.00"	Outpatient	"$13,204.50"	Not Applicable	"$14,445.72"	"$17,614.80"	"$10,563.60"	Not Applicable	"$9,243.15"	"$18,486.30"	"$9,243.15"	"$18,486.30"
SPCR SPNL 14X23MM NIKO 0D 12MM SM PEEK-OPTM CORPECTOMY NS LF 342.723	C1821	SUPPLY/IMPLANTS	"$26,407.00"	Outpatient	"$13,203.50"	Not Applicable	"$14,444.63"	"$17,613.47"	"$10,562.80"	Not Applicable	"$9,242.45"	"$18,484.90"	"$9,242.45"	"$18,484.90"
SPCR SPNL 14X21MM NIKO 0D 12MM SM PEEK-OPTM CORPECTOMY NS LF 342.721	C1821	SUPPLY/IMPLANTS	"$26,407.00"	Outpatient	"$13,203.50"	Not Applicable	"$14,444.63"	"$17,613.47"	"$10,562.80"	Not Applicable	"$9,242.45"	"$18,484.90"	"$9,242.45"	"$18,484.90"
CMPNT ULN CNRD MRY SM RT ELB ZML TIV UHMWPE 3281055302	C1776	SUPPLY/IMPLANTS	"$26,395.00"	Outpatient	"$13,197.50"	Not Applicable	"$14,438.07"	"$17,605.47"	"$10,558.00"	Not Applicable	"$9,238.25"	"$18,476.50"	"$9,238.25"	"$18,476.50"
MODL ANTM CLR ADLT ACRL MNDB ATCH FULL SD900.209	C1713	SUPPLY/IMPLANTS	"$26,384.00"	Outpatient	"$13,192.00"	"$1,365.15"	"$14,432.05"	"$17,598.13"	"$10,553.60"	Not Applicable	"$9,234.40"	"$18,468.80"	"$1,365.15"	"$18,468.80"
MTRX TISS 16X8CM ALDRM THN ACLR DERM ALGRF RGNRT FRZDR 1516128	Q4116	SUPPLY/IMPLANTS	"$26,344.00"	Outpatient	"$13,172.00"	$34.22	"$14,410.17"	"$17,571.45"	"$10,537.60"	Not Applicable	"$9,220.40"	"$18,440.80"	$34.22	"$18,440.80"
MTRX TISS 16X8CM ALDRM XTHICK ACLR DERM ALGRF RTU RGNRT 1522128	Q4116	SUPPLY/IMPLANTS	"$26,344.00"	Outpatient	"$13,172.00"	$34.22	"$14,410.17"	"$17,571.45"	"$10,537.60"	Not Applicable	"$9,220.40"	"$18,440.80"	$34.22	"$18,440.80"
PCMKR ETRINSA 8 1 CHMBR IMPL RR CRD SR-T 394936	C1786	SUPPLY/IMPLANTS	"$26,324.00"	Outpatient	"$13,162.00"	Not Applicable	"$14,399.23"	"$17,558.11"	"$10,529.60"	Not Applicable	"$9,213.40"	"$18,426.80"	"$9,213.40"	"$18,426.80"
LEAD ICD 65CM PROTEGO S 1 COIL 379969	C1777	SUPPLY/IMPLANTS	"$26,322.00"	Outpatient	"$13,161.00"	Not Applicable	"$14,398.13"	"$17,556.77"	"$10,528.80"	Not Applicable	"$9,212.70"	"$18,425.40"	"$9,212.70"	"$18,425.40"
SHL ACTB 54MM HIP MLHL OSSEOTI G7 F HMSPHR OFST 110010265	C1776	SUPPLY/IMPLANTS	"$26,321.00"	Outpatient	"$13,160.50"	Not Applicable	"$14,397.59"	"$17,556.11"	"$10,528.40"	Not Applicable	"$9,212.35"	"$18,424.70"	"$9,212.35"	"$18,424.70"
RENTAL OF CERTUS 140 INCLUDING ON-SITE SPRT RENTAL FEES		NON-STER SUPPLY	"$26,291.00"	Outpatient	"$13,145.50"	Not Applicable	"$14,381.18"	"$17,536.10"	"$10,516.40"	Not Applicable	"$9,201.85"	"$18,403.70"	"$9,201.85"	"$18,403.70"
STNT HEP 5MM 7FR SPRFC FEM ART ILIUM 15CM DLV SYS VBHN VBH051502	C1884	SUPPLY/IMPLANTS	"$26,289.00"	Outpatient	"$13,144.50"	Not Applicable	"$14,380.08"	"$17,534.76"	"$10,515.60"	Not Applicable	"$9,201.15"	"$18,402.30"	"$9,201.15"	"$18,402.30"
STNT HEP 9MM 9FR ILC ART 15CM VBHN EPRSTH 120CM ACPT .035IN VBH091502A	C1884	SUPPLY/IMPLANTS	"$26,289.00"	Outpatient	"$13,144.50"	Not Applicable	"$14,380.08"	"$17,534.76"	"$10,515.60"	Not Applicable	"$9,201.15"	"$18,402.30"	"$9,201.15"	"$18,402.30"
CATH ATHRCM 60CM 1.25MM DIAMONDBACK 360 PERI SLD CRWN 10MM DBP-125SOLID60	C1724	SUPPLY/IMPLANTS	"$26,289.00"	Outpatient	"$13,144.50"	Not Applicable	"$14,380.08"	"$17,534.76"	"$10,515.60"	Not Applicable	"$9,201.15"	"$18,402.30"	"$9,201.15"	"$18,402.30"
CATH ATHRCM 60CM 1.25MM DIAMONDBACK 360 PERI MIC CRWN 7MM DBP-125MICRO60	C1724	SUPPLY/IMPLANTS	"$26,285.00"	Outpatient	"$13,142.50"	Not Applicable	"$14,377.90"	"$17,532.10"	"$10,514.00"	Not Applicable	"$9,199.75"	"$18,399.50"	"$9,199.75"	"$18,399.50"
CATH ATHRCM 135CM 6FR 1.45MM DIAMONDBACK 360 1.25MM COR CLS DBEC-125		STERILE SUPPLY	"$26,285.00"	Outpatient	"$13,142.50"	Not Applicable	"$14,377.90"	"$17,532.10"	"$10,514.00"	Not Applicable	"$9,199.75"	"$18,399.50"	"$9,199.75"	"$18,399.50"
AUG TIB SMTR TRTHLN TRITANIUM C CONE STRL LF 5549-A-130	C1776	SUPPLY/IMPLANTS	"$26,271.00"	Outpatient	"$13,135.50"	Not Applicable	"$14,370.24"	"$17,522.76"	"$10,508.40"	Not Applicable	"$9,194.85"	"$18,389.70"	"$9,194.85"	"$18,389.70"
PCMKR .75CM 13.2CU CM ESSENTIO PACESAFE RIGHTRATE RYTHMIQ 1 L100	C1785	PACE MAKER	"$26,267.00"	Outpatient	"$13,133.50"	Not Applicable	"$14,368.05"	"$17,520.09"	"$10,506.80"	Not Applicable	"$9,193.45"	"$18,386.90"	"$9,193.45"	"$18,386.90"
VLV AOR 27MM CRP-ED PRIMNT MAGNA BIOPROSTHESES PRICRD 300027MM		SUPPLY/IMPLANTS	"$26,256.00"	Outpatient	"$13,128.00"	Not Applicable	"$14,362.03"	"$17,512.75"	"$10,502.40"	Not Applicable	"$9,189.60"	"$18,379.20"	"$9,189.60"	"$18,379.20"
Percut Transluminal Coronary Angioplasty 1st	92920	CARDIAC CATH LAB	"$24,157.00"	Outpatient	"$12,078.50"	"$20,126.23"	"$14,349.26"	"$8,056.00"	"$9,662.80"	"$7,310.00"	"$8,454.95"	"$16,909.90"	"$7,310.00"	"$20,126.23"
PLT 16MM MED SPNE ANCH LCK ROI-APEEK-OPTM BN IR 2008 T	C1713	SUPPLY/IMPLANTS	"$26,182.00"	Outpatient	"$13,091.00"	"$1,365.15"	"$14,321.55"	"$17,463.39"	"$10,472.80"	Not Applicable	"$9,163.70"	"$18,327.40"	"$1,365.15"	"$18,327.40"
PLT MED SPNE LCK ROI-APEEK-OPTM BN IR2009T	C1713	SUPPLY/IMPLANTS	"$26,182.00"	Outpatient	"$13,091.00"	"$1,365.15"	"$14,321.55"	"$17,463.39"	"$10,472.80"	Not Applicable	"$9,163.70"	"$18,327.40"	"$1,365.15"	"$18,327.40"
DEV SUT FSTNR DLV SEROSAFUSE STRL LF DISP R2007		STERILE SUPPLY	"$26,154.00"	Outpatient	"$13,077.00"	Not Applicable	"$14,306.24"	"$17,444.72"	"$10,461.60"	Not Applicable	"$9,153.90"	"$18,307.80"	"$9,153.90"	"$18,307.80"
SCR BN MNDB TI 8MM 2.9MM MATRIXMANDIBLE ST LCK NS AU 20 PK 04.503.668.20	C1713	SUPPLY/IMPLANTS	"$26,121.00"	Outpatient	"$13,060.50"	"$1,365.15"	"$14,288.19"	"$17,422.71"	"$10,448.40"	Not Applicable	"$9,142.35"	"$18,284.70"	"$1,365.15"	"$18,284.70"
SCR BN MNDB TI 10MM 2.9MM MATRIXMANDIBLE ST LCK NS AU 20 PK 04.503.670.20	C1713	SUPPLY/IMPLANTS	"$26,121.00"	Outpatient	"$13,060.50"	"$1,365.15"	"$14,288.19"	"$17,422.71"	"$10,448.40"	Not Applicable	"$9,142.35"	"$18,284.70"	"$1,365.15"	"$18,284.70"
SCR BN MNDB TI 12MM 2.9MM MATRIXMANDIBLE ST LCK NS AU 20 PK 04.503.672.20	C1713	SUPPLY/IMPLANTS	"$26,121.00"	Outpatient	"$13,060.50"	"$1,365.15"	"$14,288.19"	"$17,422.71"	"$10,448.40"	Not Applicable	"$9,142.35"	"$18,284.70"	"$1,365.15"	"$18,284.70"
SCR BN MNDB TI 14MM 2.9MM MATRIXMANDIBLE ST LCK NS AU 20 PK 04.503.674.20	C1713	SUPPLY/IMPLANTS	"$26,121.00"	Outpatient	"$13,060.50"	"$1,365.15"	"$14,288.19"	"$17,422.71"	"$10,448.40"	Not Applicable	"$9,142.35"	"$18,284.70"	"$1,365.15"	"$18,284.70"
SCR BN MNDB TI 16MM 2.9MM MATRIXMANDIBLE ST LCK NS AU 20 PK 04.503.676.20	C1713	SUPPLY/IMPLANTS	"$26,121.00"	Outpatient	"$13,060.50"	"$1,365.15"	"$14,288.19"	"$17,422.71"	"$10,448.40"	Not Applicable	"$9,142.35"	"$18,284.70"	"$1,365.15"	"$18,284.70"
SCR BN MNDB TI 18MM 2.9MM MATRIXMANDIBLE ST LCK NS AU 20 PK 04.503.678.20	C1713	SUPPLY/IMPLANTS	"$26,121.00"	Outpatient	"$13,060.50"	"$1,365.15"	"$14,288.19"	"$17,422.71"	"$10,448.40"	Not Applicable	"$9,142.35"	"$18,284.70"	"$1,365.15"	"$18,284.70"
STNT HEP 5MM 6FR SPRFC FEM ART ILIUM 15CM DLV SYS VBHN VBJ051502		SUPPLY/IMPLANTS	"$26,097.00"	Outpatient	"$13,048.50"	Not Applicable	"$14,275.06"	"$17,406.70"	"$10,438.80"	Not Applicable	"$9,133.95"	"$18,267.90"	"$9,133.95"	"$18,267.90"
CASE INST 5.5MM CNN SCR 114705501	C1713	SUPPLY/IMPLANTS	"$26,091.00"	Outpatient	"$13,045.50"	"$1,365.15"	"$14,271.78"	"$17,402.70"	"$10,436.40"	Not Applicable	"$9,131.85"	"$18,263.70"	"$1,365.15"	"$18,263.70"
INS ACTB 40MM 36MM 22MM 0D D HIP CNSTRN RING LCK OUTR BRNG 690-00-22D		STERILE SUPPLY	"$26,086.00"	Outpatient	"$13,043.00"	Not Applicable	"$14,269.04"	"$17,399.36"	"$10,434.40"	Not Applicable	"$9,130.10"	"$18,260.20"	"$9,130.10"	"$18,260.20"
STEM FEM 132D 4 SCRFT HIP PRFT ADV 1601-04132	C1776	SUPPLY/IMPLANTS	"$26,082.00"	Outpatient	"$13,041.00"	Not Applicable	"$14,266.85"	"$17,396.69"	"$10,432.80"	Not Applicable	"$9,128.70"	"$18,257.40"	"$9,128.70"	"$18,257.40"
TRAY INST EMP TIB NL 595400	C1713	SUPPLY/IMPLANTS	"$26,082.00"	Outpatient	"$13,041.00"	"$1,365.15"	"$14,266.85"	"$17,396.69"	"$10,432.80"	Not Applicable	"$9,128.70"	"$18,257.40"	"$1,365.15"	"$18,257.40"
TITAN PUMP 90-9000KC	C1813	SUPPLY/IMPLANTS	"$26,044.00"	Outpatient	"$13,022.00"	Not Applicable	"$14,246.07"	"$17,371.35"	"$10,417.60"	Not Applicable	"$9,115.40"	"$18,230.80"	"$9,115.40"	"$18,230.80"
VIAGRAFTM-MOLDABLE 10CC VCAM-100000		STERILE SUPPLY	"$26,037.00"	Outpatient	"$13,018.50"	Not Applicable	"$14,242.24"	"$17,366.68"	"$10,414.80"	Not Applicable	"$9,112.95"	"$18,225.90"	"$9,112.95"	"$18,225.90"
GFT BN 10CC MTRX OSTINDC PTNT NONIMMUNOGENIC ORIOS BORS010		SUPPLY/IMPLANTS	"$26,037.00"	Outpatient	"$13,018.50"	Not Applicable	"$14,242.24"	"$17,366.68"	"$10,414.80"	Not Applicable	"$9,112.95"	"$18,225.90"	"$9,112.95"	"$18,225.90"
STENT ENDOPROSTHESIS GORE VIABAHN HEPARIN L7.5 CM L120 CM OD VBH090702A	C1874	SUPPLY/IMPLANTS	"$26,009.00"	Outpatient	"$13,004.50"	Not Applicable	"$14,226.92"	"$17,348.00"	"$10,403.60"	Not Applicable	"$9,103.15"	"$18,206.30"	"$9,103.15"	"$18,206.30"
SHTH INTRO 28CM 12FR SENTRANT .035IN HDRPH RADOPQ REINF COIL SENSH1228W	C1894	SUPPLY/IMPLANTS	"$25,988.00"	Outpatient	"$12,994.00"	Not Applicable	"$14,215.44"	"$17,334.00"	"$10,395.20"	Not Applicable	"$9,095.80"	"$18,191.60"	"$9,095.80"	"$18,191.60"
GFT STNT 124MM 16-24MM 16FR ENDURANT II EVAS NTNL PLSTR ETLW1624C124E	C1884	SUPPLY/IMPLANTS	"$25,988.00"	Outpatient	"$12,994.00"	Not Applicable	"$14,215.44"	"$17,334.00"	"$10,395.20"	Not Applicable	"$9,095.80"	"$18,191.60"	"$9,095.80"	"$18,191.60"
DEV CLSR 35MM ATRICLIP PRO2 GILLINOV-CSGRV STRL LF DISP LT PRO235		STERILE SUPPLY	"$25,988.00"	Outpatient	"$12,994.00"	Not Applicable	"$14,215.44"	"$17,334.00"	"$10,395.20"	Not Applicable	"$9,095.80"	"$18,191.60"	"$9,095.80"	"$18,191.60"
IMPLANT CUSTOM MALAR JANITA 16-0269 4353		SUPPLY/IMPLANTS	"$25,988.00"	Outpatient	"$12,994.00"	Not Applicable	"$14,215.44"	"$17,334.00"	"$10,395.20"	Not Applicable	"$9,095.80"	"$18,191.60"	"$9,095.80"	"$18,191.60"
13533-0800-40 - immune globulin intravenous and subcutaneous 10% Soln	J1561	PHARMACY	"$25,981.00"	Outpatient	"$12,990.50"	$44.90	"$14,211.61"	"$17,329.33"	"$10,392.40"	Not Applicable	"$9,093.35"	"$18,186.70"	$44.90	"$18,186.70"
MAJOR JOINT REPLACEMENT OR REATTACHMENT WITHOUT MCC KNEES DR DRG 470D	C1776	SUPPLY/IMPLANTS	"$25,980.00"	Outpatient	"$12,990.00"	Not Applicable	"$14,211.06"	"$17,328.66"	"$10,392.00"	Not Applicable	"$9,093.00"	"$18,186.00"	"$9,093.00"	"$18,186.00"
PCMKR THK6MM SM ENDURITY 1 CHMBR IS-1 CNCT 50X41MM CRD 9.7CC PM1160	C1786	PACE MAKER	"$25,974.00"	Outpatient	"$12,987.00"	Not Applicable	"$14,207.78"	"$17,324.66"	"$10,389.60"	Not Applicable	"$9,090.90"	"$18,181.80"	"$9,090.90"	"$18,181.80"
NAIL IM 420MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.162S	C1713	SUPPLY/IMPLANTS	"$25,971.00"	Outpatient	"$12,985.50"	"$1,365.15"	"$14,206.14"	"$17,322.66"	"$10,388.40"	Not Applicable	"$9,089.85"	"$18,179.70"	"$1,365.15"	"$18,179.70"
TISSUE CORNEAL ALLOGRAFT PENETRATING KERATOPLASTY XXXXX2	V2785	UNKNOWN/DONOR	"$25,951.00"	Outpatient	"$12,975.50"	Not Applicable	"$14,195.20"	"$17,309.32"	"$10,380.40"	Not Applicable	"$9,082.85"	"$18,165.70"	"$9,082.85"	"$18,165.70"
00023-5906-23 - triptorelin 22.5 mg/6 months Powd	J3315	PHARMACY	"$25,940.00"	Outpatient	"$12,970.00"	$295.27	"$14,189.18"	"$17,301.98"	"$10,376.00"	Not Applicable	"$9,079.00"	"$18,158.00"	$295.27	"$18,158.00"
52544-0092-76 - triptorelin 22.5 mg/6 months Powd	J3315	PHARMACY	"$25,940.00"	Outpatient	"$12,970.00"	$295.27	"$14,189.18"	"$17,301.98"	"$10,376.00"	Not Applicable	"$9,079.00"	"$18,158.00"	$295.27	"$18,158.00"
00235-0902-05 - triptorelin 22.5mg/6 months Powder-Inj	C9016	PHARMACY	"$25,940.00"	Outpatient	"$12,970.00"	Not Applicable	"$14,189.18"	"$17,301.98"	"$10,376.00"	Not Applicable	"$9,079.00"	"$18,158.00"	"$9,079.00"	"$18,158.00"
STEM FEMORAL RECLAIM TITANIUM STRAIGHT TAPER L190 MM OD19 MM 1976-19-190	C1776	SUPPLY/IMPLANTS	"$25,864.00"	Outpatient	"$12,932.00"	Not Applicable	"$14,147.61"	"$17,251.29"	"$10,345.60"	Not Applicable	"$9,052.40"	"$18,104.80"	"$9,052.40"	"$18,104.80"
BSPLT TIB 6 KN RT CMNT M TPR LEGION TI NPOR 71420188	C1776	SUPPLY/IMPLANTS	"$25,839.00"	Outpatient	"$12,919.50"	Not Applicable	"$14,133.93"	"$17,234.61"	"$10,335.60"	Not Applicable	"$9,043.65"	"$18,087.30"	"$9,043.65"	"$18,087.30"
FXTR XTRNFX SHRT 3 CMPNT 2000		STERILE SUPPLY	"$25,839.00"	Outpatient	"$12,919.50"	Not Applicable	"$14,133.93"	"$17,234.61"	"$10,335.60"	Not Applicable	"$9,043.65"	"$18,087.30"	"$9,043.65"	"$18,087.30"
Drug Eluting Coronary Stent Add'l Vessel		CARDIAC CATH LAB	"$25,830.00"	Outpatient	"$12,915.00"	Not Applicable	"$14,129.01"	"$17,228.61"	"$10,332.00"	Not Applicable	"$9,040.50"	"$18,081.00"	"$9,040.50"	"$18,081.00"
CMPNT FEM 80MM HIP RT CNCT PC GMRS TI 64956018	C1776	SUPPLY/IMPLANTS	"$25,824.00"	Outpatient	"$12,912.00"	Not Applicable	"$14,125.73"	"$17,224.61"	"$10,329.60"	Not Applicable	"$9,038.40"	"$18,076.80"	"$9,038.40"	"$18,076.80"
COMPONENT FEMORAL JOURNEY OXINIUM 3 KNEE RIGHT MEDIAL LEFT L 71422353	C1776	SUPPLY/IMPLANTS	"$25,824.00"	Outpatient	"$12,912.00"	Not Applicable	"$14,125.73"	"$17,224.61"	"$10,329.60"	Not Applicable	"$9,038.40"	"$18,076.80"	"$9,038.40"	"$18,076.80"
STEM FEM 127MM 15MM STRG RSTR HA POR PLSM SPRY HIP MDLR 6276-5-015	C1776	SUPPLY/IMPLANTS	"$25,809.00"	Outpatient	"$12,904.50"	Not Applicable	"$14,117.52"	"$17,214.60"	"$10,323.60"	Not Applicable	"$9,033.15"	"$18,066.30"	"$9,033.15"	"$18,066.30"
66887-0003-01 - collagenase clostridium histolyticum 0.9 mg Powd	J0775	PHARMACY	"$25,774.00"	Outpatient	"$12,887.00"	$55.44	"$14,098.38"	"$17,191.26"	"$10,309.60"	Not Applicable	"$9,020.90"	"$18,041.80"	$55.44	"$18,041.80"
SHL ACTB 54MM HIP 3 HL POR R3 STD 71335554	C1776	SUPPLY/IMPLANTS	"$25,735.00"	Outpatient	"$12,867.50"	Not Applicable	"$14,077.05"	"$17,165.25"	"$10,294.00"	Not Applicable	"$9,007.25"	"$18,014.50"	"$9,007.25"	"$18,014.50"
VALVE SHUNT PROSA DIFFERENTIAL PRESSURE UNIT FV701T		SUPPLY/IMPLANTS	"$25,666.00"	Outpatient	"$12,833.00"	Not Applicable	"$14,039.30"	"$17,119.22"	"$10,266.40"	Not Applicable	"$8,983.10"	"$17,966.20"	"$8,983.10"	"$17,966.20"
MODL ANTM WHT PROPLAN CMF ADLT PLAMD SKL MNDB ATCH STRL SD900.309	C1713	SUPPLY/IMPLANTS	"$25,665.00"	Outpatient	"$12,832.50"	"$1,365.15"	"$14,038.76"	"$17,118.56"	"$10,266.00"	Not Applicable	"$8,982.75"	"$17,965.50"	"$1,365.15"	"$17,965.50"
GA MSR RTRGD PHNX FEM NL SYS 98CM 14-440067	C1713	SUPPLY/IMPLANTS	"$25,632.00"	Outpatient	"$12,816.00"	"$1,365.15"	"$14,020.70"	"$17,096.54"	"$10,252.80"	Not Applicable	"$8,971.20"	"$17,942.40"	"$1,365.15"	"$17,942.40"
GA MSR TLSCP NL 14-440047		STERILE SUPPLY	"$25,632.00"	Outpatient	"$12,816.00"	Not Applicable	"$14,020.70"	"$17,096.54"	"$10,252.80"	Not Applicable	"$8,971.20"	"$17,942.40"	"$8,971.20"	"$17,942.40"
CASE INST 6.5 MM CNN SCR 114706501	C1713	SUPPLY/IMPLANTS	"$25,627.00"	Outpatient	"$12,813.50"	"$1,365.15"	"$14,017.97"	"$17,093.21"	"$10,250.80"	Not Applicable	"$8,969.45"	"$17,938.90"	"$1,365.15"	"$17,938.90"
00078-0648-81 - octreotide 30 mg Powd	J2353	PHARMACY	"$25,586.00"	Outpatient	"$12,793.00"	$216.22	"$13,995.54"	"$17,065.86"	"$10,234.40"	Not Applicable	"$8,955.10"	"$17,910.20"	$216.22	"$17,910.20"
INSRTR SRG NL REM WINSERTER 46-6110		STERILE SUPPLY	"$25,557.00"	Outpatient	"$12,778.50"	Not Applicable	"$13,979.68"	"$17,046.52"	"$10,222.80"	Not Applicable	"$8,944.95"	"$17,889.90"	"$8,944.95"	"$17,889.90"
GFT STNT 75MM 28MM AFX STRATA AOR XTN 20MM AAA STRL LF A28-28/C75-O20	C1874	SUPPLY/IMPLANTS	"$25,509.00"	Outpatient	"$12,754.50"	Not Applicable	"$13,953.42"	"$17,014.50"	"$10,203.60"	Not Applicable	"$8,928.15"	"$17,856.30"	"$8,928.15"	"$17,856.30"
FXTR XTRNFX DFS XS BS LVL 2505		STERILE SUPPLY	"$25,499.00"	Outpatient	"$12,749.50"	Not Applicable	"$13,947.95"	"$17,007.83"	"$10,199.60"	Not Applicable	"$8,924.65"	"$17,849.30"	"$8,924.65"	"$17,849.30"
PLATE TRESTLE LUXE 2-LEVEL 28MM 71002-028L	C1713	SUPPLY/IMPLANTS	"$25,468.00"	Outpatient	"$12,734.00"	"$1,365.15"	"$13,931.00"	"$16,987.16"	"$10,187.20"	Not Applicable	"$8,913.80"	"$17,827.60"	"$1,365.15"	"$17,827.60"
"PLATE, 2-LEVEL, TRESTLE LUXE 30MM 71002-030L"	C1713	SUPPLY/IMPLANTS	"$25,468.00"	Outpatient	"$12,734.00"	"$1,365.15"	"$13,931.00"	"$16,987.16"	"$10,187.20"	Not Applicable	"$8,913.80"	"$17,827.60"	"$1,365.15"	"$17,827.60"
PLATE TRESTLE LUXE 2 LEVEL 37MM 71002-037L	C1713	SUPPLY/IMPLANTS	"$25,453.00"	Outpatient	"$12,726.50"	"$1,365.15"	"$13,922.79"	"$16,977.15"	"$10,181.20"	Not Applicable	"$8,908.55"	"$17,817.10"	"$1,365.15"	"$17,817.10"
PLATE 2-LEVEL TRESTLE LUXE 34MM 71002-034L	C1713	SUPPLY/IMPLANTS	"$25,453.00"	Outpatient	"$12,726.50"	"$1,365.15"	"$13,922.79"	"$16,977.15"	"$10,181.20"	Not Applicable	"$8,908.55"	"$17,817.10"	"$1,365.15"	"$17,817.10"
PLATE TRESTLE LUKE 2 LEVEL 32MM 71002-032	C1713	SUPPLY/IMPLANTS	"$25,453.00"	Outpatient	"$12,726.50"	"$1,365.15"	"$13,922.79"	"$16,977.15"	"$10,181.20"	Not Applicable	"$8,908.55"	"$17,817.10"	"$1,365.15"	"$17,817.10"
PLATE TRESTLE LUXE 2-LEVEL 43MM 71002-043L	C1713	SUPPLY/IMPLANTS	"$25,453.00"	Outpatient	"$12,726.50"	"$1,365.15"	"$13,922.79"	"$16,977.15"	"$10,181.20"	Not Applicable	"$8,908.55"	"$17,817.10"	"$1,365.15"	"$17,817.10"
PLATE TRESTLE LUXE 37MM 2-LEVEL 71002-37L	C1713	SUPPLY/IMPLANTS	"$25,453.00"	Outpatient	"$12,726.50"	"$1,365.15"	"$13,922.79"	"$16,977.15"	"$10,181.20"	Not Applicable	"$8,908.55"	"$17,817.10"	"$1,365.15"	"$17,817.10"
STENT ENDOPROSTHESIS VIABAHN HEPARIN L7.5CM L120CM VBJR060702A	C1874	SUPPLY/IMPLANTS	"$25,440.00"	Outpatient	"$12,720.00"	Not Applicable	"$13,915.68"	"$16,968.48"	"$10,176.00"	Not Applicable	"$8,904.00"	"$17,808.00"	"$8,904.00"	"$17,808.00"
STNT HEP NTNL EPTFE 5MM 10CM FLXB SLF XPD RADOPQ VBHN EPRSTH VBJR051002A	C1884	SUPPLY/IMPLANTS	"$25,433.00"	Outpatient	"$12,716.50"	Not Applicable	"$13,911.85"	"$16,963.81"	"$10,173.20"	Not Applicable	"$8,901.55"	"$17,803.10"	"$8,901.55"	"$17,803.10"
STENT ENDOPROSTHESIS VIABAHN HEPARIN L10 CM L120 CM OD6 MM O VBJR061002A	C1874	SUPPLY/IMPLANTS	"$25,425.00"	Outpatient	"$12,712.50"	Not Applicable	"$13,907.48"	"$16,958.48"	"$10,170.00"	Not Applicable	"$8,898.75"	"$17,797.50"	"$8,898.75"	"$17,797.50"
STENT ENDOPROSTHESIS GORE VIABAHN HEPARIN L15 CM L120 CM OD6 MM ODSEC6 FR SUPERFICIAL FEMORAL ARTERY	C1874	SUPPLY/IMPLANTS	"$25,425.00"	Outpatient	"$12,712.50"	Not Applicable	"$13,907.48"	"$16,958.48"	"$10,170.00"	Not Applicable	"$8,898.75"	"$17,797.50"	"$8,898.75"	"$17,797.50"
CASE INST RDS DIST PERIART LCK PLT JIG 235802505	C1713	SUPPLY/IMPLANTS	"$25,366.00"	Outpatient	"$12,683.00"	"$1,365.15"	"$13,875.20"	"$16,919.12"	"$10,146.40"	Not Applicable	"$8,878.10"	"$17,756.20"	"$1,365.15"	"$17,756.20"
STENT ENDOPROSTHESIS GORE VIABAHN .035 IN L79 MM L80 CM OD8 BXAL087901A	C1874	SUPPLY/IMPLANTS	"$25,364.00"	Outpatient	"$12,682.00"	Not Applicable	"$13,874.11"	"$16,917.79"	"$10,145.60"	Not Applicable	"$8,877.40"	"$17,754.80"	"$8,877.40"	"$17,754.80"
CASE INST TI 2.7 MM SCR UNV LCK SYS 483809500	C1713	SUPPLY/IMPLANTS	"$25,321.00"	Outpatient	"$12,660.50"	"$1,365.15"	"$13,850.59"	"$16,889.11"	"$10,128.40"	Not Applicable	"$8,862.35"	"$17,724.70"	"$1,365.15"	"$17,724.70"
GFT BN DBM 20X1CM MAGNIFUSE SPNE 7509212	C9362	SUPPLY/IMPLANTS	"$25,315.00"	Outpatient	"$12,657.50"	$110.85	"$13,847.31"	"$16,885.11"	"$10,126.00"	Not Applicable	"$8,860.25"	"$17,720.50"	$110.85	"$17,720.50"
PLT SPNE ADJ KEEL VUEPOINT II BN 8975000	C1713	SUPPLY/IMPLANTS	"$25,203.00"	Outpatient	"$12,601.50"	"$1,365.15"	"$13,786.04"	"$16,810.40"	"$10,081.20"	Not Applicable	"$8,821.05"	"$17,642.10"	"$1,365.15"	"$17,642.10"
"COMPREHENSIVE SHOULDER SYSTEM, 17 x 55mm 113617"	C1776	SUPPLY/IMPLANTS	"$25,183.00"	Outpatient	"$12,591.50"	Not Applicable	"$13,775.10"	"$16,797.06"	"$10,073.20"	Not Applicable	"$8,814.05"	"$17,628.10"	"$8,814.05"	"$17,628.10"
PLT 159MM TROCH LAT SS 3 HL 3 CRMP BN BMP CBL SYS 350838	C1713	SUPPLY/IMPLANTS	"$25,169.00"	Outpatient	"$12,584.50"	"$1,365.15"	"$13,767.44"	"$16,787.72"	"$10,067.60"	Not Applicable	"$8,809.15"	"$17,618.30"	"$1,365.15"	"$17,618.30"
SYS CBL 5 HL 4 XTD CBL RD 261X23MM LF GT REATT 223200207	C1713	SUPPLY/IMPLANTS	"$25,160.00"	Outpatient	"$12,580.00"	"$1,365.15"	"$13,762.52"	"$16,781.72"	"$10,064.00"	Not Applicable	"$8,806.00"	"$17,612.00"	"$1,365.15"	"$17,612.00"
MODL ANTM CHLD ACRL FULL SD900.269	C1713	SUPPLY/IMPLANTS	"$25,128.00"	Outpatient	"$12,564.00"	"$1,365.15"	"$13,745.02"	"$16,760.38"	"$10,051.20"	Not Applicable	"$8,794.80"	"$17,589.60"	"$1,365.15"	"$17,589.60"
MESH TMPR LT MATRIXNEURO 99X66X.6MM TI CNTR DYNMC STRL AU 04.503.151S	C1713	SUPPLY/IMPLANTS	"$25,114.00"	Outpatient	"$12,557.00"	"$1,365.15"	"$13,737.36"	"$16,751.04"	"$10,045.60"	Not Applicable	"$8,789.90"	"$17,579.80"	"$1,365.15"	"$17,579.80"
MESH TMPR RT MATRIXNEURO 99X66X.6MM TI CNTR DYNMC STRL AU 04.503.152S	C1713	SUPPLY/IMPLANTS	"$25,114.00"	Outpatient	"$12,557.00"	"$1,365.15"	"$13,737.36"	"$16,751.04"	"$10,045.60"	Not Applicable	"$8,789.90"	"$17,579.80"	"$1,365.15"	"$17,579.80"
STEM FEM 150MM 23MM TPR ARCOS STS TI DIST PRFT SPLINE STRL 11-300823	C1776	SUPPLY/IMPLANTS	"$25,107.00"	Outpatient	"$12,553.50"	Not Applicable	"$13,733.53"	"$16,746.37"	"$10,042.80"	Not Applicable	"$8,787.45"	"$17,574.90"	"$8,787.45"	"$17,574.90"
STNT BIL 8MM 8.5FR 60MM 75CM .035IN GW CATH FULL CVR M00574750	C1874	SUPPLY/IMPLANTS	"$25,099.00"	Outpatient	"$12,549.50"	Not Applicable	"$13,729.15"	"$16,741.03"	"$10,039.60"	Not Applicable	"$8,784.65"	"$17,569.30"	"$8,784.65"	"$17,569.30"
STNT BIL 8MM 80MM 75CM FULL CVR WALLFLEX RMLM 9FR SHTH M00574760	C1874	SUPPLY/IMPLANTS	"$25,099.00"	Outpatient	"$12,549.50"	Not Applicable	"$13,729.15"	"$16,741.03"	"$10,039.60"	Not Applicable	"$8,784.65"	"$17,569.30"	"$8,784.65"	"$17,569.30"
STNT BIL 10MM 8.5FR 40MM 75CM .035IN GW CATH FULL CVR M00574770	C1874	SUPPLY/IMPLANTS	"$25,099.00"	Outpatient	"$12,549.50"	Not Applicable	"$13,729.15"	"$16,741.03"	"$10,039.60"	Not Applicable	"$8,784.65"	"$17,569.30"	"$8,784.65"	"$17,569.30"
STNT BIL 10MM 8.5FR 60MM 75CM .035IN CATH FULL CVR SLF XPD M00574780	C1874	SUPPLY/IMPLANTS	"$25,099.00"	Outpatient	"$12,549.50"	Not Applicable	"$13,729.15"	"$16,741.03"	"$10,039.60"	Not Applicable	"$8,784.65"	"$17,569.30"	"$8,784.65"	"$17,569.30"
STNT BIL 10MM 8.5FR 80MM 75CM .035IN CATH FULL CVR SLF XPD M00574790	C1874	SUPPLY/IMPLANTS	"$25,099.00"	Outpatient	"$12,549.50"	Not Applicable	"$13,729.15"	"$16,741.03"	"$10,039.60"	Not Applicable	"$8,784.65"	"$17,569.30"	"$8,784.65"	"$17,569.30"
VLV SHNT HKM CSF UNITIZE DIST CATH PRGM INLN 120CM 14CM STRL 823844		SUPPLY/IMPLANTS	"$25,079.00"	Outpatient	"$12,539.50"	Not Applicable	"$13,718.21"	"$16,727.69"	"$10,031.60"	Not Applicable	"$8,777.65"	"$17,555.30"	"$8,777.65"	"$17,555.30"
CASE STRL 3.5 MM TI ULS 484608000	C1713	SUPPLY/IMPLANTS	"$25,069.00"	Outpatient	"$12,534.50"	"$1,365.15"	"$13,712.74"	"$16,721.02"	"$10,027.60"	Not Applicable	"$8,774.15"	"$17,548.30"	"$1,365.15"	"$17,548.30"
STEM RADL RHEAD 2 ELB PLSM COAT 310-2011	C1776	SUPPLY/IMPLANTS	"$25,027.00"	Outpatient	"$12,513.50"	Not Applicable	"$13,689.77"	"$16,693.01"	"$10,010.80"	Not Applicable	"$8,759.45"	"$17,518.90"	"$8,759.45"	"$17,518.90"
CASE INST TI 3.5 MM UNV LCK SYS 484609000	C1713	SUPPLY/IMPLANTS	"$25,025.00"	Outpatient	"$12,512.50"	"$1,365.15"	"$13,688.68"	"$16,691.68"	"$10,010.00"	Not Applicable	"$8,758.75"	"$17,517.50"	"$1,365.15"	"$17,517.50"
GFT BN DBM 10X1.75CM MAGNIFUSE 7509141	C1713	SUPPLY/IMPLANTS	"$24,965.00"	Outpatient	"$12,482.50"	"$1,365.15"	"$13,655.86"	"$16,651.66"	"$9,986.00"	Not Applicable	"$8,737.75"	"$17,475.50"	"$1,365.15"	"$17,475.50"
PCMKR EVIA 1 CHMBR PLS GNTR CRD SRT 359533	C1786	PACE MAKER	"$24,965.00"	Outpatient	"$12,482.50"	Not Applicable	"$13,655.86"	"$16,651.66"	"$9,986.00"	Not Applicable	"$8,737.75"	"$17,475.50"	"$8,737.75"	"$17,475.50"
LEAD PCNG 65CM 7.8FR LINOX SMRT S SILGLIDE TRPLR ACTFX 1IS-1 369 818	C1777	SUPPLY/IMPLANTS	"$24,965.00"	Outpatient	"$12,482.50"	Not Applicable	"$13,655.86"	"$16,651.66"	"$9,986.00"	Not Applicable	"$8,737.75"	"$17,475.50"	"$8,737.75"	"$17,475.50"
CORNEAL TRANSPLANT TISSUE XXXXX1	V2785	UNKNOWN/DONOR	"$24,965.00"	Outpatient	"$12,482.50"	Not Applicable	"$13,655.86"	"$16,651.66"	"$9,986.00"	Not Applicable	"$8,737.75"	"$17,475.50"	"$8,737.75"	"$17,475.50"
CAGE STANDARD LAT ONE LEVEL 8027097	C1821	SUPPLY/IMPLANTS	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
CAGE SPNL 30X10X12MM CRNT 4D OBLQ TI TLIF NS LF 5420304	C1821	SUPPLY/IMPLANTS	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
CAGE SPNL 60X22X10MM CLYDESDALE PTC 6D PEEK TI RADOPQ LMBR 4926060	C1821	SUPPLY/IMPLANTS	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
CAGE SPNL 22X10X12MM CASCADIA CNVX TI POR ANTM NAR INTBDY 6101-2102212NC-G2	C1821	SUPPLY/IMPLANTS	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
CAGE SPNL 22X10X13MM CASCADIA CNVX TI POR ANTM NAR INTBDY 6101-2102213NC-G2	C1821	SUPPLY/IMPLANTS	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
CORNEAL TISSUE 17-0839-PC	V2785	UNKNOWN/DONOR	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
TISSUE CORNEA 16-1085-PC	V2785	UNKNOWN/DONOR	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
TISSUE CORNEA 16-1352-PC	V2785	UNKNOWN/DONOR	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
IMPLANT SYSTEM STERNALOCK 360 SYSTEM MLTI 74-0004		SUPPLY/IMPLANTS	"$24,948.00"	Outpatient	"$12,474.00"	Not Applicable	"$13,646.56"	"$16,640.32"	"$9,979.20"	Not Applicable	"$8,731.80"	"$17,463.60"	"$8,731.80"	"$17,463.60"
AV FISTULA ANGIOGRAM ANGIOPLASTY STENT	36903	CARDIAC CATH LAB	"$24,945.00"	Outpatient	"$12,472.50"	"$20,673.20"	"$13,644.92"	"$16,638.32"	"$9,978.00"	"$8,681.00"	"$8,730.75"	"$17,461.50"	"$8,681.00"	"$20,673.20"
DEV PSTN HIP 2 CLP LCK 740004		STERILE SUPPLY	"$24,942.00"	Outpatient	"$12,471.00"	Not Applicable	"$13,643.27"	"$16,636.31"	"$9,976.80"	Not Applicable	"$8,729.70"	"$17,459.40"	"$8,729.70"	"$17,459.40"
CAGE SPNL 30X10X10MM CRNT 4D OBLQ TI TLIF NS LF 5400304	C1821	SUPPLY/IMPLANTS	"$24,941.00"	Outpatient	"$12,470.50"	Not Applicable	"$13,642.73"	"$16,635.65"	"$9,976.40"	Not Applicable	"$8,729.35"	"$17,458.70"	"$8,729.35"	"$17,458.70"
CAGE SPNL 25X10X12MM CRNT 4D OBLQ TI TLIF NS LF 5420254	C1821	SUPPLY/IMPLANTS	"$24,941.00"	Outpatient	"$12,470.50"	Not Applicable	"$13,642.73"	"$16,635.65"	"$9,976.40"	Not Applicable	"$8,729.35"	"$17,458.70"	"$8,729.35"	"$17,458.70"
"CAGE TLIF TI LI COROENT, 12 X 11X 26MM 4 DEG. 1661785"	C1821	SUPPLY/IMPLANTS	"$24,941.00"	Outpatient	"$12,470.50"	Not Applicable	"$13,642.73"	"$16,635.65"	"$9,976.40"	Not Applicable	"$8,729.35"	"$17,458.70"	"$8,729.35"	"$17,458.70"
CAGE ZEUS LLIF 18W X 12H 16-121855-L	C1821	SUPPLY/IMPLANTS	"$24,941.00"	Outpatient	"$12,470.50"	Not Applicable	"$13,642.73"	"$16,635.65"	"$9,976.40"	Not Applicable	"$8,729.35"	"$17,458.70"	"$8,729.35"	"$17,458.70"
PACEMAKER CARD IMPLANTABLE 50MMW X 47MMH 6MM THK 10.4ML 20GM PM2240 CELL	C1785	PACE MAKER	"$24,940.00"	Outpatient	"$12,470.00"	Not Applicable	"$13,642.18"	"$16,634.98"	"$9,976.00"	Not Applicable	"$8,729.00"	"$17,458.00"	"$8,729.00"	"$17,458.00"
TISSUE DSAEK PRECUT 15-0044-PC		SUPPLY/IMPLANTS	"$24,938.00"	Outpatient	"$12,469.00"	Not Applicable	"$13,641.09"	"$16,633.65"	"$9,975.20"	Not Applicable	"$8,728.30"	"$17,456.60"	"$8,728.30"	"$17,456.60"
LEAD NRSTM 70X8X2CM PRCS ARTSN PLATNALOCK PDL LIM SPNL CORD M365SC8216700	C1899	PACE MAKER	"$24,921.00"	Outpatient	"$12,460.50"	Not Applicable	"$13,631.79"	"$16,622.31"	"$9,968.40"	Not Applicable	"$8,722.35"	"$17,444.70"	"$8,722.35"	"$17,444.70"
RESERVOIR PRO SA PRO GAV2 39672040		NON-STER SUPPLY	"$24,919.00"	Outpatient	"$12,459.50"	Not Applicable	"$13,630.69"	"$16,620.97"	"$9,967.60"	Not Applicable	"$8,721.65"	"$17,443.30"	"$8,721.65"	"$17,443.30"
STENT DIAMONDBACK 360 PERIPHERAL SOILD CROWN 1.75 X 200 DBP-175SOILD 200	C1874	SUPPLY/IMPLANTS	"$24,906.00"	Outpatient	"$12,453.00"	Not Applicable	"$13,623.58"	"$16,612.30"	"$9,962.40"	Not Applicable	"$8,717.10"	"$17,434.20"	"$8,717.10"	"$17,434.20"
SYS ATHRCM GW DIAMONDBACK .014IN .063 PERI 200CM 1.25MM 5FR DBP-125SOLID200	C1874	SUPPLY/IMPLANTS	"$24,906.00"	Outpatient	"$12,453.00"	Not Applicable	"$13,623.58"	"$16,612.30"	"$9,962.40"	Not Applicable	"$8,717.10"	"$17,434.20"	"$8,717.10"	"$17,434.20"
SYS ATHRCM GW DIAMONDBACK .014IN .063 PERI 200CM 1.25MM 5FR DBP-150SOLID200	C1874	SUPPLY/IMPLANTS	"$24,906.00"	Outpatient	"$12,453.00"	Not Applicable	"$13,623.58"	"$16,612.30"	"$9,962.40"	Not Applicable	"$8,717.10"	"$17,434.20"	"$8,717.10"	"$17,434.20"
CATH ATHRCM 180CM 1.75MM DIAMONDBACK PERI RADL ACC 30MM STRL DBP-175SOLID180	C1724	SUPPLY/IMPLANTS	"$24,906.00"	Outpatient	"$12,453.00"	Not Applicable	"$13,623.58"	"$16,612.30"	"$9,962.40"	Not Applicable	"$8,717.10"	"$17,434.20"	"$8,717.10"	"$17,434.20"
GFT BN AMNIO TISS 4X4CM 2 LYR REPST DSGN AMNIOHEAL + TAH1404	C9362	SUPPLY/IMPLANTS	"$24,901.00"	Outpatient	"$12,450.50"	$110.85	"$13,620.85"	"$16,608.97"	"$9,960.40"	Not Applicable	"$8,715.35"	"$17,430.70"	$110.85	"$17,430.70"
SHNT NS DNVR ASCT 2 VLV PK STRL 42-2050		STERILE SUPPLY	"$24,855.00"	Outpatient	"$12,427.50"	Not Applicable	"$13,595.69"	"$16,578.29"	"$9,942.00"	Not Applicable	"$8,699.25"	"$17,398.50"	"$8,699.25"	"$17,398.50"
SHELL ACETABULAR RESTORATION OD62 MM HIP LEFT ANATOMIC 504-02-62E-L	C1776	SUPPLY/IMPLANTS	"$24,839.00"	Outpatient	"$12,419.50"	Not Applicable	"$13,586.93"	"$16,567.61"	"$9,935.60"	Not Applicable	"$8,693.65"	"$17,387.30"	"$8,693.65"	"$17,387.30"
SHELL ACETABULAR RESTORATION OD62 MM HIP RIGHT ANATOMIC 504-02-62E-R	C1776	SUPPLY/IMPLANTS	"$24,839.00"	Outpatient	"$12,419.50"	Not Applicable	"$13,586.93"	"$16,567.61"	"$9,935.60"	Not Applicable	"$8,693.65"	"$17,387.30"	"$8,693.65"	"$17,387.30"
GD BRL ITST SRG SS NS MIS IM NL 225805204		STERILE SUPPLY	"$24,819.00"	Outpatient	"$12,409.50"	Not Applicable	"$13,575.99"	"$16,554.27"	"$9,927.60"	Not Applicable	"$8,686.65"	"$17,373.30"	"$8,686.65"	"$17,373.30"
(BC2) GLOBAL ADVANTAGE HUMERAL HEAD SZ 44MM X 18MM	C1776	SUPPLY/IMPLANTS	"$24,815.00"	Outpatient	"$12,407.50"	Not Applicable	"$13,573.81"	"$16,551.61"	"$9,926.00"	Not Applicable	"$8,685.25"	"$17,370.50"	"$8,685.25"	"$17,370.50"
HEAD HUM 18MM 48MM SHLDR GB ADV STD STRL 112848010	C1776	SUPPLY/IMPLANTS	"$24,804.00"	Outpatient	"$12,402.00"	Not Applicable	"$13,567.79"	"$16,544.27"	"$9,921.60"	Not Applicable	"$8,681.40"	"$17,362.80"	"$8,681.40"	"$17,362.80"
TRAY TIB OXFD C LT MDL UNCMP 154722	C1776	SUPPLY/IMPLANTS	"$24,800.00"	Outpatient	"$12,400.00"	Not Applicable	"$13,565.60"	"$16,541.60"	"$9,920.00"	Not Applicable	"$8,680.00"	"$17,360.00"	"$8,680.00"	"$17,360.00"
DEV TRGT 24CM RTRGD MOD FEM NTR NL 249000424	C1713	SUPPLY/IMPLANTS	"$24,797.00"	Outpatient	"$12,398.50"	"$1,365.15"	"$13,563.96"	"$16,539.60"	"$9,918.80"	Not Applicable	"$8,678.95"	"$17,357.90"	"$1,365.15"	"$17,357.90"
GFT STNT 75MM 28MM 17FR AFX ACTIVESEAL STRATA STRG EVAS ABD A28-28/C75	C1883	SUPPLY/IMPLANTS	"$24,797.00"	Outpatient	"$12,398.50"	Not Applicable	"$13,563.96"	"$16,539.60"	"$9,918.80"	Not Applicable	"$8,678.95"	"$17,357.90"	"$8,678.95"	"$17,357.90"
CMPNT HUM 100MM 5MM DSCVR ELB LT FLNG 114906		SUPPLY/IMPLANTS	"$24,770.00"	Outpatient	"$12,385.00"	Not Applicable	"$13,549.19"	"$16,521.59"	"$9,908.00"	Not Applicable	"$8,669.50"	"$17,339.00"	"$8,669.50"	"$17,339.00"
STEM FEM 132D 5 SCRFT HIP PRFT ADV 1601-05132	C1776	SUPPLY/IMPLANTS	"$24,765.00"	Outpatient	"$12,382.50"	Not Applicable	"$13,546.46"	"$16,518.26"	"$9,906.00"	Not Applicable	"$8,667.75"	"$17,335.50"	"$8,667.75"	"$17,335.50"
STENT ENDOPROSTHESIS VIABAHN HEPARIN L10 CM L120 CM OD9 MM O VBH091002A	C1874	SUPPLY/IMPLANTS	"$24,747.00"	Outpatient	"$12,373.50"	Not Applicable	"$13,536.61"	"$16,506.25"	"$9,898.80"	Not Applicable	"$8,661.45"	"$17,322.90"	"$8,661.45"	"$17,322.90"
STNT HEP 11MM 11FR ILC ART 10CM DLV SYS TIP TO HUB DPL VBHN VBH111002A	C1884	SUPPLY/IMPLANTS	"$24,741.00"	Outpatient	"$12,370.50"	Not Applicable	"$13,533.33"	"$16,502.25"	"$9,896.40"	Not Applicable	"$8,659.35"	"$17,318.70"	"$8,659.35"	"$17,318.70"
PCMKR .75CM ACLD LTD NXT PACESAFE EASYVIEW 1 CHMBR IS1 CNCT L300		STERILE SUPPLY	"$24,741.00"	Outpatient	"$12,370.50"	Not Applicable	"$13,533.33"	"$16,502.25"	"$9,896.40"	Not Applicable	"$8,659.35"	"$17,318.70"	"$8,659.35"	"$17,318.70"
TIP CAUT DVNC XI EWRST CAUT MNPLR VSL SLR 480322		STERILE SUPPLY	"$24,730.00"	Outpatient	"$12,365.00"	Not Applicable	"$13,527.31"	"$16,494.91"	"$9,892.00"	Not Applicable	"$8,655.50"	"$17,311.00"	"$8,655.50"	"$17,311.00"
STEM FEMORAL RECLAIM TITANIUM STRAIGHT TAPER L140 MM OD18 MM 1976-18-140	C1776	SUPPLY/IMPLANTS	"$24,692.00"	Outpatient	"$12,346.00"	Not Applicable	"$13,506.52"	"$16,469.56"	"$9,876.80"	Not Applicable	"$8,642.20"	"$17,284.40"	"$8,642.20"	"$17,284.40"
JIG PSTN VERSANAIL LOPRFL TIB SET 2810-12-007	C1713	SUPPLY/IMPLANTS	"$24,675.00"	Outpatient	"$12,337.50"	"$1,365.15"	"$13,497.23"	"$16,458.23"	"$9,870.00"	Not Applicable	"$8,636.25"	"$17,272.50"	"$1,365.15"	"$17,272.50"
PCMKR THK6MM ACT SR 1 CHMBR UNPLR BP IS-1 52X42MM CRD 9.5ML PM1110	C1786	PACE MAKER	"$24,633.00"	Outpatient	"$12,316.50"	Not Applicable	"$13,474.25"	"$16,430.21"	"$9,853.20"	Not Applicable	"$8,621.55"	"$17,243.10"	"$8,621.55"	"$17,243.10"
GD MXL RECONSTUCTION FIB GFT HRVT SRG SD900.004	C1713	SUPPLY/IMPLANTS	"$24,622.00"	Outpatient	"$12,311.00"	"$1,365.15"	"$13,468.23"	"$16,422.87"	"$9,848.80"	Not Applicable	"$8,617.70"	"$17,235.40"	"$1,365.15"	"$17,235.40"
GFT BN FIB RECON MNDB NS SD900.001	C1713	SUPPLY/IMPLANTS	"$24,622.00"	Outpatient	"$12,311.00"	"$1,365.15"	"$13,468.23"	"$16,422.87"	"$9,848.80"	Not Applicable	"$8,617.70"	"$17,235.40"	"$1,365.15"	"$17,235.40"
KIT INST MNDB PTSPC MNDB RECON NONFIBULA GFT SD900.002	C1713	SUPPLY/IMPLANTS	"$24,622.00"	Outpatient	"$12,311.00"	"$1,365.15"	"$13,468.23"	"$16,422.87"	"$9,848.80"	Not Applicable	"$8,617.70"	"$17,235.40"	"$1,365.15"	"$17,235.40"
KIT INST PTSPC MXL RECON NONFIBULA GFT SD900.005	C1713	SUPPLY/IMPLANTS	"$24,622.00"	Outpatient	"$12,311.00"	"$1,365.15"	"$13,468.23"	"$16,422.87"	"$9,848.80"	Not Applicable	"$8,617.70"	"$17,235.40"	"$1,365.15"	"$17,235.40"
KIT INST PTSPC PLN DSTRCT SD900.006	C1713	SUPPLY/IMPLANTS	"$24,622.00"	Outpatient	"$12,311.00"	"$1,365.15"	"$13,468.23"	"$16,422.87"	"$9,848.80"	Not Applicable	"$8,617.70"	"$17,235.40"	"$1,365.15"	"$17,235.40"
KIT INST PTSPC CRNFCL RECON MODL SD900.010	C1713	SUPPLY/IMPLANTS	"$24,622.00"	Outpatient	"$12,311.00"	"$1,365.15"	"$13,468.23"	"$16,422.87"	"$9,848.80"	Not Applicable	"$8,617.70"	"$17,235.40"	"$1,365.15"	"$17,235.40"
50474-0700-62 - certolizumab 200 mg Kit	J0717	PHARMACY	"$24,615.00"	Outpatient	"$12,307.50"	$8.79	"$13,464.41"	"$16,418.21"	"$9,846.00"	Not Applicable	"$8,615.25"	"$17,230.50"	$8.79	"$17,230.50"
50474-0710-79 - certolizumab 200 mg/mL Kit	J0717	PHARMACY	"$24,615.00"	Outpatient	"$12,307.50"	$8.79	"$13,464.41"	"$16,418.21"	"$9,846.00"	Not Applicable	"$8,615.25"	"$17,230.50"	$8.79	"$17,230.50"
Percutaneous Int/Ext Biliary Drain	47533	DX X-RAY	"$24,604.00"	Outpatient	"$12,302.00"	"$10,891.49"	"$13,458.39"	"$16,410.87"	"$9,841.60"	"$4,680.00"	"$8,611.40"	"$17,222.80"	"$4,680.00"	"$17,222.80"
TRAY INTRO KPHPK XPNDR 20/3 SPNE 1ST FX KPHX 1STP OSTEO KPT2005		STERILE SUPPLY	"$24,597.00"	Outpatient	"$12,298.50"	Not Applicable	"$13,454.56"	"$16,406.20"	"$9,838.80"	Not Applicable	"$8,608.95"	"$17,217.90"	"$8,608.95"	"$17,217.90"
GFT SFT TIS 6X6CM NUSHIELD NO-1660	Q4160	SUPPLY/IMPLANTS	"$24,594.00"	Outpatient	"$12,297.00"	$98.34	"$13,452.92"	"$16,404.20"	"$9,837.60"	Not Applicable	"$8,607.90"	"$17,215.80"	$98.34	"$17,215.80"
PELVIC RETRACTOR 3 703952		STERILE SUPPLY	"$24,519.00"	Outpatient	"$12,259.50"	Not Applicable	"$13,411.89"	"$16,354.17"	"$9,807.60"	Not Applicable	"$8,581.65"	"$17,163.30"	"$8,581.65"	"$17,163.30"
GENERATOR PACEMAKER ASSURITY MRI THK6 MM W50 MM X H47 MM 10. PM1272 CELL	C1786	PACE MAKER	"$24,488.00"	Outpatient	"$12,244.00"	Not Applicable	"$13,394.94"	"$16,333.50"	"$9,795.20"	Not Applicable	"$8,570.80"	"$17,141.60"	"$8,570.80"	"$17,141.60"
LEAD PCNG 65CM 7.8FR VNTRC LNX SD QDPL ACTFX XTD-RETRAC HLX LINOX SD 65/16	C1895	SUPPLY/IMPLANTS	"$24,487.00"	Outpatient	"$12,243.50"	Not Applicable	"$13,394.39"	"$16,332.83"	"$9,794.80"	Not Applicable	"$8,570.45"	"$17,140.90"	"$8,570.45"	"$17,140.90"
STEM FEMORAL GMRS COCR LONG CURVE L203 MM OD13 MM HIP CEMENT 6485-3-613	C1776	SUPPLY/IMPLANTS	"$24,473.00"	Outpatient	"$12,236.50"	Not Applicable	"$13,386.73"	"$16,323.49"	"$9,789.20"	Not Applicable	"$8,565.55"	"$17,131.10"	"$8,565.55"	"$17,131.10"
NAIL IM 180MM 10MM LCK PHNX TI ANKL ARTHDS 14-440118	C1713	SUPPLY/IMPLANTS	"$24,451.00"	Outpatient	"$12,225.50"	"$1,365.15"	"$13,374.70"	"$16,308.82"	"$9,780.40"	Not Applicable	"$8,557.85"	"$17,115.70"	"$1,365.15"	"$17,115.70"
55513-0032-01 - darbepoetin alfa 500 mcg/mL Soln	J0881	PHARMACY	"$20,573.00"	Outpatient	"$10,286.50"	$4.04	"$13,372.45"	"$13,722.19"	"$8,229.20"	Not Applicable	"$7,200.55"	"$14,401.10"	$4.04	"$14,401.10"
MODL ANTM WHT PROPLAN CMF CHLD PLAMD SKL MNDB DEATTACH STRL SD900.369	C1713	SUPPLY/IMPLANTS	"$24,433.00"	Outpatient	"$12,216.50"	"$1,365.15"	"$13,364.85"	"$16,296.81"	"$9,773.20"	Not Applicable	"$8,551.55"	"$17,103.10"	"$1,365.15"	"$17,103.10"
HNDL GD NTR NL ANTGRD SM FEM TRGT 249009810		STERILE SUPPLY	"$24,432.00"	Outpatient	"$12,216.00"	Not Applicable	"$13,364.30"	"$16,296.14"	"$9,772.80"	Not Applicable	"$8,551.20"	"$17,102.40"	"$8,551.20"	"$17,102.40"
63459-0396-02 - bendamustine 90 mg/mL Soln	J9033	PHARMACY	"$20,533.00"	Outpatient	"$10,266.50"	$28.83	"$13,346.45"	"$13,695.51"	"$8,213.20"	Not Applicable	"$7,186.55"	"$14,373.10"	$28.83	"$14,373.10"
Carotid Angiography Cerebral Unilateral	36223	CARDIAC CATH LAB	"$24,398.00"	Outpatient	"$12,199.00"	"$11,105.17"	"$13,345.71"	"$16,273.47"	"$9,759.20"	"$7,310.00"	"$8,539.30"	"$17,078.60"	"$7,310.00"	"$17,078.60"
Angiography Carotid Internal Unilateral	36224	CARDIAC CATH LAB	"$24,398.00"	Outpatient	"$12,199.00"	"$18,161.90"	"$13,345.71"	"$16,273.47"	"$9,759.20"	"$7,310.00"	"$8,539.30"	"$17,078.60"	"$7,310.00"	"$18,161.90"
Carotid Cerebral Bilateral Angiogram	36224	CARDIAC CATH LAB	"$24,398.00"	Outpatient	"$12,199.00"	"$18,161.90"	"$13,345.71"	"$16,273.47"	"$9,759.20"	"$7,310.00"	"$8,539.30"	"$17,078.60"	"$7,310.00"	"$18,161.90"
CAGE SPNL 15.5X6-8MM ROI-C VERTEBRIDGE 12MM TI CRV SUP SRFC CMC 1354 P	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
CAGE SPNL 14X5-7MM ROI-C VERTEBRIDGE 12MM TI CRV SUP SRFC CMC 1343 P	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
CAGE SPNL 15.5X4.2-7MM ROI-C VERTEBRIDGE 7D LRDTC 14MM TPR CMC 1423 P	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
CAGE SPNL 15.5X6.2-9MM ROI-C VERTEBRIDGE 7D LRDTC 14MM TPR CMC 1425 P	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
CAGE SPNL 14X6.1-9MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR TI CMC 1445 P	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
CAGE SPNL 14X3.1-6MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR TI CMC 1442 P	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
CAGE SPNL 14X5.1-8MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR TI CMC 1444 P	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
ROI-C PEEK OPTIMA TITANIUN 12X15.5X8 CMC1454T	C1821	SUPPLY/IMPLANTS	"$24,395.00"	Outpatient	"$12,197.50"	Not Applicable	"$13,344.07"	"$16,271.47"	"$9,758.00"	Not Applicable	"$8,538.25"	"$17,076.50"	"$8,538.25"	"$17,076.50"
CAGE CERVICAL STND ALONE 16MM X 13.5MM X 7MM HT. 1055-161-307	C1821	SUPPLY/IMPLANTS	"$24,388.00"	Outpatient	"$12,194.00"	Not Applicable	"$13,340.24"	"$16,266.80"	"$9,755.20"	Not Applicable	"$8,535.80"	"$17,071.60"	"$8,535.80"	"$17,071.60"
CAGE SPNL 17X8MM DIVERGENCE 14MM PRLL NCL PULPOSUS PEEK G6620748	C1821	SUPPLY/IMPLANTS	"$24,388.00"	Outpatient	"$12,194.00"	Not Applicable	"$13,340.24"	"$16,266.80"	"$9,755.20"	Not Applicable	"$8,535.80"	"$17,071.60"	"$8,535.80"	"$17,071.60"
CAGE SPINAL LORDOSIS 16MM X13.5MM X8MM HEIGHT 7 DEGREE 1055-161-308	C1821	SUPPLY/IMPLANTS	"$24,388.00"	Outpatient	"$12,194.00"	Not Applicable	"$13,340.24"	"$16,266.80"	"$9,755.20"	Not Applicable	"$8,535.80"	"$17,071.60"	"$8,535.80"	"$17,071.60"
SPCR SPNL 9MM ZERO-PPEEK-OPTM TI STD LRDTC PREASSEMBLE 04.617.129S	C1821	SUPPLY/IMPLANTS	"$24,388.00"	Outpatient	"$12,194.00"	Not Applicable	"$13,340.24"	"$16,266.80"	"$9,755.20"	Not Applicable	"$8,535.80"	"$17,071.60"	"$8,535.80"	"$17,071.60"
KIT SPINAL AERO PEEK-OPTIMA TITANIUM ALUMINUM VANADIUM 0 D D 48892090	C1713	SUPPLY/IMPLANTS	"$24,387.00"	Outpatient	"$12,193.50"	"$1,365.15"	"$13,339.69"	"$16,266.13"	"$9,754.80"	Not Applicable	"$8,535.45"	"$17,070.90"	"$1,365.15"	"$17,070.90"
KIT SPINAL AERO PEEK-OPTIMA TITANIUM ALUMINUM VANADIUM 6 D L 48892096	C1713	SUPPLY/IMPLANTS	"$24,387.00"	Outpatient	"$12,193.50"	"$1,365.15"	"$13,339.69"	"$16,266.13"	"$9,754.80"	Not Applicable	"$8,535.45"	"$17,070.90"	"$1,365.15"	"$17,070.90"
PLASMA COATED SPACER X003-0011PC	C1821	SUPPLY/IMPLANTS	"$24,387.00"	Outpatient	"$12,193.50"	Not Applicable	"$13,339.69"	"$16,266.13"	"$9,754.80"	Not Applicable	"$8,535.45"	"$17,070.90"	"$8,535.45"	"$17,070.90"
TIBIAL BASE 71934164 71634164	C1776	SUPPLY/IMPLANTS	"$24,366.00"	Outpatient	"$12,183.00"	Not Applicable	"$13,328.20"	"$16,252.12"	"$9,746.40"	Not Applicable	"$8,528.10"	"$17,056.20"	"$8,528.10"	"$17,056.20"
GFT EVAS 12CM 14.5MM GORE XCLDR CNTRLT LG PLC141200	C1874	SUPPLY/IMPLANTS	"$24,365.00"	Outpatient	"$12,182.50"	Not Applicable	"$13,327.66"	"$16,251.46"	"$9,746.00"	Not Applicable	"$8,527.75"	"$17,055.50"	"$8,527.75"	"$17,055.50"
GFT EVAS 9.5CM 16MM 13.5-14.5MM XCLDR CNTRLT LG GRTX NTNL PLC161000	C1874	SUPPLY/IMPLANTS	"$24,365.00"	Outpatient	"$12,182.50"	Not Applicable	"$13,327.66"	"$16,251.46"	"$9,746.00"	Not Applicable	"$8,527.75"	"$17,055.50"	"$8,527.75"	"$17,055.50"
GFT EVAS 9.5CM 20MM 16.5-18.5MM XCLDR CNTRLT LG GRTX NTNL PLC201000	C1874	SUPPLY/IMPLANTS	"$24,365.00"	Outpatient	"$12,182.50"	Not Applicable	"$13,327.66"	"$16,251.46"	"$9,746.00"	Not Applicable	"$8,527.75"	"$17,055.50"	"$8,527.75"	"$17,055.50"
SHL ACTB 64MM HIP RT ANTM RSTR 504-02-64E-R	C1776	SUPPLY/IMPLANTS	"$24,353.00"	Outpatient	"$12,176.50"	Not Applicable	"$13,321.09"	"$16,243.45"	"$9,741.20"	Not Applicable	"$8,523.55"	"$17,047.10"	"$8,523.55"	"$17,047.10"
SHL ACTB 58MM HIP LT ANTM RSTR 504-02-58D-L	C1776	SUPPLY/IMPLANTS	"$24,353.00"	Outpatient	"$12,176.50"	Not Applicable	"$13,321.09"	"$16,243.45"	"$9,741.20"	Not Applicable	"$8,523.55"	"$17,047.10"	"$8,523.55"	"$17,047.10"
SHL ACTB 70MM HIP LT ANTM RSTR 504-02-70G-L	C1776	SUPPLY/IMPLANTS	"$24,353.00"	Outpatient	"$12,176.50"	Not Applicable	"$13,321.09"	"$16,243.45"	"$9,741.20"	Not Applicable	"$8,523.55"	"$17,047.10"	"$8,523.55"	"$17,047.10"
SHL ACTB 72MM HIP LT ANTM RSTR 504-02-72G-L	C1776	SUPPLY/IMPLANTS	"$24,353.00"	Outpatient	"$12,176.50"	Not Applicable	"$13,321.09"	"$16,243.45"	"$9,741.20"	Not Applicable	"$8,523.55"	"$17,047.10"	"$8,523.55"	"$17,047.10"
PELVIC RETRACTOR 1 703950		STERILE SUPPLY	"$24,275.00"	Outpatient	"$12,137.50"	Not Applicable	"$13,278.43"	"$16,191.43"	"$9,710.00"	Not Applicable	"$8,496.25"	"$16,992.50"	"$8,496.25"	"$16,992.50"
SYSTEM SPINAL FIXATION IFUSE IMPLANT SYSTEM L40 MM OD7 MM SA 7040M-90	C1713	SUPPLY/IMPLANTS	"$24,262.00"	Outpatient	"$12,131.00"	"$1,365.15"	"$13,271.31"	"$16,182.75"	"$9,704.80"	Not Applicable	"$8,491.70"	"$16,983.40"	"$1,365.15"	"$16,983.40"
TRIFECTA VIABLE CELL ALLOGRAFT 8137.0110S	C1713	SUPPLY/IMPLANTS	"$24,262.00"	Outpatient	"$12,131.00"	"$1,365.15"	"$13,271.31"	"$16,182.75"	"$9,704.80"	Not Applicable	"$8,491.70"	"$16,983.40"	"$1,365.15"	"$16,983.40"
SYSTEM SPINAL FIXATION IFUSE-3D IMPLANT TITANIUM PLASMA SPRA 7050M-90	C1821	SUPPLY/IMPLANTS	"$24,262.00"	Outpatient	"$12,131.00"	Not Applicable	"$13,271.31"	"$16,182.75"	"$9,704.80"	Not Applicable	"$8,491.70"	"$16,983.40"	"$8,491.70"	"$16,983.40"
QUICKCLEAR 10FR ASPIRATION CATHETER 10FR X 85CM SHAPED STERI AC10SH085		STERILE SUPPLY	"$24,262.00"	Outpatient	"$12,131.00"	Not Applicable	"$13,271.31"	"$16,182.75"	"$9,704.80"	Not Applicable	"$8,491.70"	"$16,983.40"	"$8,491.70"	"$16,983.40"
STEM HUM 83MM 7MM CMPRH POR MN SHLDR RVRS SYS 113627	C1776	SUPPLY/IMPLANTS	"$24,256.00"	Outpatient	"$12,128.00"	Not Applicable	"$13,268.03"	"$16,178.75"	"$9,702.40"	Not Applicable	"$8,489.60"	"$16,979.20"	"$8,489.60"	"$16,979.20"
STEM HUM 90MM PRFT AQLS ASCND FLX PTC 127.5D 7A STD SHLDR DWF607A	C1776	SUPPLY/IMPLANTS	"$24,256.00"	Outpatient	"$12,128.00"	Not Applicable	"$13,268.03"	"$16,178.75"	"$9,702.40"	Not Applicable	"$8,489.60"	"$16,979.20"	"$8,489.60"	"$16,979.20"
STEM HUM 55MM 16MM CMPRH POR MIC SHLDR RVRS SYS 113616	C1776	SUPPLY/IMPLANTS	"$24,256.00"	Outpatient	"$12,128.00"	Not Applicable	"$13,268.03"	"$16,178.75"	"$9,702.40"	Not Applicable	"$8,489.60"	"$16,979.20"	"$8,489.60"	"$16,979.20"
STEM HUM 55MM 15MM CMPRH POR MIC SHLDR RVRS SYS 113615	C1776	SUPPLY/IMPLANTS	"$24,256.00"	Outpatient	"$12,128.00"	Not Applicable	"$13,268.03"	"$16,178.75"	"$9,702.40"	Not Applicable	"$8,489.60"	"$16,979.20"	"$8,489.60"	"$16,979.20"
STEM HUM 122MM 4MM CMPRH POR STD SHLDR RVRS SYS 113644	C1776	SUPPLY/IMPLANTS	"$24,256.00"	Outpatient	"$12,128.00"	Not Applicable	"$13,268.03"	"$16,178.75"	"$9,702.40"	Not Applicable	"$8,489.60"	"$16,979.20"	"$8,489.60"	"$16,979.20"
TENDON ALLOGRAFT PRESHAPED PATELLA PS293FF	C1762	SUPPLY/IMPLANTS	"$24,256.00"	Outpatient	"$12,128.00"	Not Applicable	"$13,268.03"	"$16,178.75"	"$9,702.40"	Not Applicable	"$8,489.60"	"$16,979.20"	"$8,489.60"	"$16,979.20"
GFT BN DMNR CORT FBR 10CC ALGRF CHSV PTTY HI AVG CELL CNT 8137.0010S	C1713	SUPPLY/IMPLANTS	"$24,249.00"	Outpatient	"$12,124.50"	"$1,365.15"	"$13,264.20"	"$16,174.08"	"$9,699.60"	Not Applicable	"$8,487.15"	"$16,974.30"	"$1,365.15"	"$16,974.30"
GFT BN VIABLE BN MTRX 10CC ALGRF BIO4 PS51010	C1765	SUPPLY/IMPLANTS	"$24,249.00"	Outpatient	"$12,124.50"	Not Applicable	"$13,264.20"	"$16,174.08"	"$9,699.60"	Not Applicable	"$8,487.15"	"$16,974.30"	"$8,487.15"	"$16,974.30"
SYS ANLPLS 1 SEAM 2 WRP ANTM ED MC3 TRCSD TI SIL RBR PLSTR 4900		SUPPLY/IMPLANTS	"$24,247.00"	Outpatient	"$12,123.50"	Not Applicable	"$13,263.11"	"$16,172.75"	"$9,698.80"	Not Applicable	"$8,486.45"	"$16,972.90"	"$8,486.45"	"$16,972.90"
00024-5151-75 - rasburicase 7.5 mg Powd	J2783	PHARMACY	"$24,238.00"	Outpatient	"$12,119.00"	$321.98	"$13,258.19"	"$16,166.75"	"$9,695.20"	Not Applicable	"$8,483.30"	"$16,966.60"	$321.98	"$16,966.60"
CAGE CERVICAL PEEK 9 X 12 X 14 X 5 A1001109L	C1821	SUPPLY/IMPLANTS	"$24,229.00"	Outpatient	"$12,114.50"	Not Applicable	"$13,253.26"	"$16,160.74"	"$9,691.60"	Not Applicable	"$8,480.15"	"$16,960.30"	"$8,480.15"	"$16,960.30"
CAGE CERVICAL PEEK 7 X 12 X 14-5 A1001107L	C1821	SUPPLY/IMPLANTS	"$24,229.00"	Outpatient	"$12,114.50"	Not Applicable	"$13,253.26"	"$16,160.74"	"$9,691.60"	Not Applicable	"$8,480.15"	"$16,960.30"	"$8,480.15"	"$16,960.30"
CAGE EMERALD CERVICAL PEEK 10 X 13 X 14MM C-L-035	C1821	SUPPLY/IMPLANTS	"$24,229.00"	Outpatient	"$12,114.50"	Not Applicable	"$13,253.26"	"$16,160.74"	"$9,691.60"	Not Applicable	"$8,480.15"	"$16,960.30"	"$8,480.15"	"$16,960.30"
CAGE EMERALD CERVICAL PEEK 8 X 13 X 14 EC-L-033	C1821	SUPPLY/IMPLANTS	"$24,229.00"	Outpatient	"$12,114.50"	Not Applicable	"$13,253.26"	"$16,160.74"	"$9,691.60"	Not Applicable	"$8,480.15"	"$16,960.30"	"$8,480.15"	"$16,960.30"
CAGE LORDOTIC CERVICAL 7 X 13 X 14MM C-L-032	C1821	SUPPLY/IMPLANTS	"$24,229.00"	Outpatient	"$12,114.50"	Not Applicable	"$13,253.26"	"$16,160.74"	"$9,691.60"	Not Applicable	"$8,480.15"	"$16,960.30"	"$8,480.15"	"$16,960.30"
CAGE PEEK CERVICAL 8 X 2 X 14-5 A1001108L	C1821	SUPPLY/IMPLANTS	"$24,229.00"	Outpatient	"$12,114.50"	Not Applicable	"$13,253.26"	"$16,160.74"	"$9,691.60"	Not Applicable	"$8,480.15"	"$16,960.30"	"$8,480.15"	"$16,960.30"
SPCR SPNL 14X13X8MM EMRLD 6D LRDTC CRV PEEK NS LF C-L-033	C1821	SUPPLY/IMPLANTS	"$24,229.00"	Outpatient	"$12,114.50"	Not Applicable	"$13,253.26"	"$16,160.74"	"$9,691.60"	Not Applicable	"$8,480.15"	"$16,960.30"	"$8,480.15"	"$16,960.30"
GFT BN 3CC AUG K20003010		SUPPLY/IMPLANTS	"$24,214.00"	Outpatient	"$12,107.00"	Not Applicable	"$13,245.06"	"$16,150.74"	"$9,685.60"	Not Applicable	"$8,474.90"	"$16,949.80"	"$8,474.90"	"$16,949.80"
STNT HEP 6MM 7FR SPRFC FEM ART ILIUM 15CM DLV SYS VBHN VBH061502	C1874	SUPPLY/IMPLANTS	"$24,212.00"	Outpatient	"$12,106.00"	Not Applicable	"$13,243.96"	"$16,149.40"	"$9,684.80"	Not Applicable	"$8,474.20"	"$16,948.40"	"$8,474.20"	"$16,948.40"
STNT HEP 7MM 8FR SPRFC FEM ART ILIUM 10CM DLV SYS VBHN VBH071002	C1874	SUPPLY/IMPLANTS	"$24,212.00"	Outpatient	"$12,106.00"	Not Applicable	"$13,243.96"	"$16,149.40"	"$9,684.80"	Not Applicable	"$8,474.20"	"$16,948.40"	"$8,474.20"	"$16,948.40"
STNT HEP 8MM 7FR SPRFC FEM ART ILIUM 10CM DLV SYS VBHN VBJR081002A	C1874	SUPPLY/IMPLANTS	"$24,212.00"	Outpatient	"$12,106.00"	Not Applicable	"$13,243.96"	"$16,149.40"	"$9,684.80"	Not Applicable	"$8,474.20"	"$16,948.40"	"$8,474.20"	"$16,948.40"
TISSUE LANYARD 3X3 CM AGT-5330	C9363	SUPPLY/IMPLANTS	"$24,210.00"	Outpatient	"$12,105.00"	$38.51	"$13,242.87"	"$16,148.07"	"$9,684.00"	Not Applicable	"$8,473.50"	"$16,947.00"	$38.51	"$16,947.00"
NAIL IM 16CM 12-10MM FSN RND XSECT DC SLOT TRGN TI HINDFOOT 71701016L	C1713	SUPPLY/IMPLANTS	"$24,185.00"	Outpatient	"$12,092.50"	"$1,365.15"	"$13,229.20"	"$16,131.40"	"$9,674.00"	Not Applicable	"$8,464.75"	"$16,929.50"	"$1,365.15"	"$16,929.50"
MODL ANTM CLR PLN OUTCM SKL SD900.239	C1713	SUPPLY/IMPLANTS	"$24,184.00"	Outpatient	"$12,092.00"	"$1,365.15"	"$13,228.65"	"$16,130.73"	"$9,673.60"	Not Applicable	"$8,464.40"	"$16,928.80"	"$1,365.15"	"$16,928.80"
MODL ANTM WHT SKL SD900.339	C1713	SUPPLY/IMPLANTS	"$24,184.00"	Outpatient	"$12,092.00"	"$1,365.15"	"$13,228.65"	"$16,130.73"	"$9,673.60"	Not Applicable	"$8,464.40"	"$16,928.80"	"$1,365.15"	"$16,928.80"
GFT BN CORT CNC DMNR 10CC ALGRF VIVIGEN BL-1500-003		SUPPLY/IMPLANTS	"$24,169.00"	Outpatient	"$12,084.50"	Not Applicable	"$13,220.44"	"$16,120.72"	"$9,667.60"	Not Applicable	"$8,459.15"	"$16,918.30"	"$8,459.15"	"$16,918.30"
Percutaneous Transluminal Arterial Intracranial	61630	CARDIAC CATH LAB	"$24,156.00"	Outpatient	"$12,078.00"	Not Applicable	"$13,213.33"	"$1,771.00"	"$9,662.40"	"$1,563.00"	"$8,454.60"	"$16,909.20"	"$1,563.00"	"$16,909.20"
BSPLT TIB 4 KN RT CMNT M TPR LEGION TI NPOR 71420184	C1776	SUPPLY/IMPLANTS	"$24,140.00"	Outpatient	"$12,070.00"	Not Applicable	"$13,204.58"	"$16,101.38"	"$9,656.00"	Not Applicable	"$8,449.00"	"$16,898.00"	"$8,449.00"	"$16,898.00"
NAIL IM 40CM 12MM 125D LNG IMHS CP SS LT HIP 71682640L	C1713	SUPPLY/IMPLANTS	"$24,140.00"	Outpatient	"$12,070.00"	"$1,365.15"	"$13,204.58"	"$16,101.38"	"$9,656.00"	Not Applicable	"$8,449.00"	"$16,898.00"	"$1,365.15"	"$16,898.00"
NAIL IM 40CM 12MM 130D LNG IMHS CP SS RT HIP 71683140R	C1713	SUPPLY/IMPLANTS	"$24,140.00"	Outpatient	"$12,070.00"	"$1,365.15"	"$13,204.58"	"$16,101.38"	"$9,656.00"	Not Applicable	"$8,449.00"	"$16,898.00"	"$1,365.15"	"$16,898.00"
NAIL IM 34CM 12MM 130D LNG IMHS CP SS LT HIP 71683134L	C1713	SUPPLY/IMPLANTS	"$24,140.00"	Outpatient	"$12,070.00"	"$1,365.15"	"$13,204.58"	"$16,101.38"	"$9,656.00"	Not Applicable	"$8,449.00"	"$16,898.00"	"$1,365.15"	"$16,898.00"
NAIL IM 40CM 12MM 130D LNG IMHS CP SS LT HIP 71683140L	C1713	SUPPLY/IMPLANTS	"$24,140.00"	Outpatient	"$12,070.00"	"$1,365.15"	"$13,204.58"	"$16,101.38"	"$9,656.00"	Not Applicable	"$8,449.00"	"$16,898.00"	"$1,365.15"	"$16,898.00"
STNT HEP 8MM 8FR SPRFC FEM ART ILIUM 15CM DLV SYS VBHN VBH081501	C1874	SUPPLY/IMPLANTS	"$24,112.00"	Outpatient	"$12,056.00"	Not Applicable	"$13,189.26"	"$16,082.70"	"$9,644.80"	Not Applicable	"$8,439.20"	"$16,878.40"	"$8,439.20"	"$16,878.40"
ZPS STORAGE CABINET 480000000		STERILE SUPPLY	"$24,066.00"	Outpatient	"$12,033.00"	Not Applicable	"$13,164.10"	"$16,052.02"	"$9,626.40"	Not Applicable	"$8,423.10"	"$16,846.20"	"$8,423.10"	"$16,846.20"
"COMPREHENSIVE SHOULDER SYSTEM, 6 x 83MM 113626"	C1776	SUPPLY/IMPLANTS	"$24,040.00"	Outpatient	"$12,020.00"	Not Applicable	"$13,149.88"	"$16,034.68"	"$9,616.00"	Not Applicable	"$8,414.00"	"$16,828.00"	"$8,414.00"	"$16,828.00"
STEM HUMERAL COMPREHENSIVE POROUS MINI L83 MM OD9 MM SHOULDE 113629	C1776	SUPPLY/IMPLANTS	"$24,040.00"	Outpatient	"$12,020.00"	Not Applicable	"$13,149.88"	"$16,034.68"	"$9,616.00"	Not Applicable	"$8,414.00"	"$16,828.00"	"$8,414.00"	"$16,828.00"
SCR BN FT 2.5MM ALPS MOD 8299-60-040	C1713	SUPPLY/IMPLANTS	"$24,040.00"	Outpatient	"$12,020.00"	"$1,365.15"	"$13,149.88"	"$16,034.68"	"$9,616.00"	Not Applicable	"$8,414.00"	"$16,828.00"	"$1,365.15"	"$16,828.00"
TAMP 20/3 INTRO SRG BN KPHPK XPNDR II 1STP LF KPX203PB		STERILE SUPPLY	"$24,028.00"	Outpatient	"$12,014.00"	Not Applicable	"$13,143.32"	"$16,026.68"	"$9,611.20"	Not Applicable	"$8,409.80"	"$16,819.60"	"$8,409.80"	"$16,819.60"
TRAY INTRO XPR KPHPK 15/2 1ST FX KPE1003		SUPPLY/IMPLANTS	"$24,028.00"	Outpatient	"$12,014.00"	Not Applicable	"$13,143.32"	"$16,026.68"	"$9,611.20"	Not Applicable	"$8,409.80"	"$16,819.60"	"$8,409.80"	"$16,819.60"
STNT BIL 8MM 8.5FR 60MM 75CM .035IN PRT CVR GW CATH TRNSHEP M00574700	C1874	SUPPLY/IMPLANTS	"$24,004.00"	Outpatient	"$12,002.00"	Not Applicable	"$13,130.19"	"$16,010.67"	"$9,601.60"	Not Applicable	"$8,401.40"	"$16,802.80"	"$8,401.40"	"$16,802.80"
STNT BIL 8MM 8.5FR 80MM 70MM .035IN PRT CVR GW CATH WALLFLEX M00574710	C1874	SUPPLY/IMPLANTS	"$24,004.00"	Outpatient	"$12,002.00"	Not Applicable	"$13,130.19"	"$16,010.67"	"$9,601.60"	Not Applicable	"$8,401.40"	"$16,802.80"	"$8,401.40"	"$16,802.80"
STNT BIL 10MM 8.5FR 75MM 28MM .035IN PRT CVR GW CATH TRNSHEP M00574720	C1874	SUPPLY/IMPLANTS	"$24,004.00"	Outpatient	"$12,002.00"	Not Applicable	"$13,130.19"	"$16,010.67"	"$9,601.60"	Not Applicable	"$8,401.40"	"$16,802.80"	"$8,401.40"	"$16,802.80"
STNT BIL 10MM 8.5FR 60MM 48MM .035IN PRT COVERED GW CATH M00574730	C1874	SUPPLY/IMPLANTS	"$24,004.00"	Outpatient	"$12,002.00"	Not Applicable	"$13,130.19"	"$16,010.67"	"$9,601.60"	Not Applicable	"$8,401.40"	"$16,802.80"	"$8,401.40"	"$16,802.80"
STNT BIL 10MM 8.5FR 80MM 70MM .035IN PRT CVR GW CATH M00574740	C1874	SUPPLY/IMPLANTS	"$24,004.00"	Outpatient	"$12,002.00"	Not Applicable	"$13,130.19"	"$16,010.67"	"$9,601.60"	Not Applicable	"$8,401.40"	"$16,802.80"	"$8,401.40"	"$16,802.80"
LINR ACTB 36MM 15 H CONNEXION GXL HIP 132-36-28	C1776	SUPPLY/IMPLANTS	"$23,978.00"	Outpatient	"$11,989.00"	Not Applicable	"$13,115.97"	"$15,993.33"	"$9,591.20"	Not Applicable	"$8,392.30"	"$16,784.60"	"$8,392.30"	"$16,784.60"
KIT EXTERNAL FIXATION JET-X MINI RADIAL DISTAL STERILE 71064701		STERILE SUPPLY	"$23,958.00"	Outpatient	"$11,979.00"	Not Applicable	"$13,105.03"	"$15,979.99"	"$9,583.20"	Not Applicable	"$8,385.30"	"$16,770.60"	"$8,385.30"	"$16,770.60"
GFT SFT TIS 12X8CM PRIMATRIX THK.7MM FLT BVN NONDENATURED 607-005-812		STERILE SUPPLY	"$23,941.00"	Outpatient	"$11,970.50"	Not Applicable	"$13,095.73"	"$15,968.65"	"$9,576.40"	Not Applicable	"$8,379.35"	"$16,758.70"	"$8,379.35"	"$16,758.70"
SHNT NS STRATA PRGM 27888		STERILE SUPPLY	"$23,934.00"	Outpatient	"$11,967.00"	Not Applicable	"$13,091.90"	"$15,963.98"	"$9,573.60"	Not Applicable	"$8,376.90"	"$16,753.80"	"$8,376.90"	"$16,753.80"
Intro Percutaneous Transhepatic Biliary Stent	47539	CARDIAC CATH LAB	"$23,887.00"	Outpatient	"$11,943.50"	"$20,602.38"	"$13,066.19"	"$15,932.63"	"$9,554.80"	"$7,310.00"	"$8,360.45"	"$16,720.90"	"$7,310.00"	"$20,602.38"
MOD STRL CRRT MAC 15210	C1713	SUPPLY/IMPLANTS	"$23,872.00"	Outpatient	"$11,936.00"	"$1,365.15"	"$13,057.98"	"$15,922.62"	"$9,548.80"	Not Applicable	"$8,355.20"	"$16,710.40"	"$1,365.15"	"$16,710.40"
TRAY STRL DVR ANTM PLT DRT	C1713	SUPPLY/IMPLANTS	"$23,845.00"	Outpatient	"$11,922.50"	"$1,365.15"	"$13,043.22"	"$15,904.62"	"$9,538.00"	Not Applicable	"$8,345.75"	"$16,691.50"	"$1,365.15"	"$16,691.50"
STEM HUMERAL COMPREHENSIVE PPS L122 MM OD4 MM SHOULDER 12-113554	C1776	SUPPLY/IMPLANTS	"$23,798.00"	Outpatient	"$11,899.00"	Not Applicable	"$13,017.51"	"$15,873.27"	"$9,519.20"	Not Applicable	"$8,329.30"	"$16,658.60"	"$8,329.30"	"$16,658.60"
SHL ACTB 58MM 58MM HIP MLHL RIM TRITANIUM X3 MDM TRDNT F 509-02-58F	C1776	SUPPLY/IMPLANTS	"$23,791.00"	Outpatient	"$11,895.50"	Not Applicable	"$13,013.68"	"$15,868.60"	"$9,516.40"	Not Applicable	"$8,326.85"	"$16,653.70"	"$8,326.85"	"$16,653.70"
SHL ACTB 56MM 56MM HIP MLHL RIM TRITANIUM X3 MDM TRDNT E 509-02-56E	C1776	SUPPLY/IMPLANTS	"$23,791.00"	Outpatient	"$11,895.50"	Not Applicable	"$13,013.68"	"$15,868.60"	"$9,516.40"	Not Applicable	"$8,326.85"	"$16,653.70"	"$8,326.85"	"$16,653.70"
PELVIC RETRACTOR 2 703951		STERILE SUPPLY	"$23,787.00"	Outpatient	"$11,893.50"	Not Applicable	"$13,011.49"	"$15,865.93"	"$9,514.80"	Not Applicable	"$8,325.45"	"$16,650.90"	"$8,325.45"	"$16,650.90"
GFT SFT TIS 6X6CM AMNIOFIX APS-5616		STERILE SUPPLY	"$23,780.00"	Outpatient	"$11,890.00"	Not Applicable	"$13,007.66"	"$15,861.26"	"$9,512.00"	Not Applicable	"$8,323.00"	"$16,646.00"	"$8,323.00"	"$16,646.00"
STEM FEM 195MM 14MM CNCL RSTR DIST HIP MDLR 6276-7-214	C1776	SUPPLY/IMPLANTS	"$23,737.00"	Outpatient	"$11,868.50"	Not Applicable	"$12,984.14"	"$15,832.58"	"$9,494.80"	Not Applicable	"$8,307.95"	"$16,615.90"	"$8,307.95"	"$16,615.90"
61748-0400-02 - lindane topical 1% Sham	J3490	PHARMACY	"$23,728.00"	Outpatient	"$11,864.00"	Not Applicable	"$12,979.22"	"$15,826.58"	"$9,491.20"	Not Applicable	"$8,304.80"	"$16,609.60"	"$8,304.80"	"$16,609.60"
STENT ENDOPROSTHESIS GORE VIABAHN .035 IN L39 MM L80 CM OD10 BXA103901A	C1874	SUPPLY/IMPLANTS	"$23,701.00"	Outpatient	"$11,850.50"	Not Applicable	"$12,964.45"	"$15,808.57"	"$9,480.40"	Not Applicable	"$8,295.35"	"$16,590.70"	"$8,295.35"	"$16,590.70"
STENT ENDOPROSTHESIS GORE VIABAHN .035 IN L39 MM L135 CM OD1 BXA103902A	C1874	SUPPLY/IMPLANTS	"$23,701.00"	Outpatient	"$11,850.50"	Not Applicable	"$12,964.45"	"$15,808.57"	"$9,480.40"	Not Applicable	"$8,295.35"	"$16,590.70"	"$8,295.35"	"$16,590.70"
STENT ENDOPROSTHESIS GORE VIABAHN .035 IN L29 MM L135 CM OD9 BXA092902A	C1874	SUPPLY/IMPLANTS	"$23,701.00"	Outpatient	"$11,850.50"	Not Applicable	"$12,964.45"	"$15,808.57"	"$9,480.40"	Not Applicable	"$8,295.35"	"$16,590.70"	"$8,295.35"	"$16,590.70"
STENT ENDOPROSTHESIS VIABAHN .035 IN L29 MM L135 CM OD10 MM BXA102902A	C1874	SUPPLY/IMPLANTS	"$23,686.00"	Outpatient	"$11,843.00"	Not Applicable	"$12,956.24"	"$15,798.56"	"$9,474.40"	Not Applicable	"$8,290.10"	"$16,580.20"	"$8,290.10"	"$16,580.20"
Radiofrequency Ablation	47370	OR SERVICES	"$23,683.00"	Outpatient	"$11,841.50"	"$19,718.80"	"$12,954.60"	"$1,592.00"	"$9,473.20"	"$8,681.00"	"$8,289.05"	"$16,578.10"	"$1,592.00"	"$19,718.80"
CAGE PEEK STALIF C 14 X 6.5MM TAPERED C146551-3T	C1821	SUPPLY/IMPLANTS	"$23,667.00"	Outpatient	"$11,833.50"	Not Applicable	"$12,945.85"	"$15,785.89"	"$9,466.80"	Not Applicable	"$8,283.45"	"$16,566.90"	"$8,283.45"	"$16,566.90"
GFT EVAS 10CM 12MM GORE XCLDR CNTRLT LG PLC121000	C1874	SUPPLY/IMPLANTS	"$23,661.00"	Outpatient	"$11,830.50"	Not Applicable	"$12,942.57"	"$15,781.89"	"$9,464.40"	Not Applicable	"$8,281.35"	"$16,562.70"	"$8,281.35"	"$16,562.70"
GFT EVAS 10CM 14.5MM GORE XCLDR CNTRLT LG PLC141000	C1874	SUPPLY/IMPLANTS	"$23,661.00"	Outpatient	"$11,830.50"	Not Applicable	"$12,942.57"	"$15,781.89"	"$9,464.40"	Not Applicable	"$8,281.35"	"$16,562.70"	"$8,281.35"	"$16,562.70"
GFT EVAS 12CM 12MM GORE XCLDR CNTRLT LG PLC121200	C1874	SUPPLY/IMPLANTS	"$23,661.00"	Outpatient	"$11,830.50"	Not Applicable	"$12,942.57"	"$15,781.89"	"$9,464.40"	Not Applicable	"$8,281.35"	"$16,562.70"	"$8,281.35"	"$16,562.70"
LEAD NRSTM SPNL CORD 41CM INTSTM TN QDPL RX URO 3889-41	C1778	SUPPLY/IMPLANTS	"$23,657.00"	Outpatient	"$11,828.50"	Not Applicable	"$12,940.38"	"$15,779.22"	"$9,462.80"	Not Applicable	"$8,279.95"	"$16,559.90"	"$8,279.95"	"$16,559.90"
LEAD NRSTM 28CM INTSTM QDPL 3889-28	C1778	SUPPLY/IMPLANTS	"$23,657.00"	Outpatient	"$11,828.50"	Not Applicable	"$12,940.38"	"$15,779.22"	"$9,462.80"	Not Applicable	"$8,279.95"	"$16,559.90"	"$8,279.95"	"$16,559.90"
SUB BNGF 10ML VOID FIL FM PK BIOACTIVE VITOSS BTCP CLGN 2102-1610		STERILE SUPPLY	"$23,653.00"	Outpatient	"$11,826.50"	Not Applicable	"$12,938.19"	"$15,776.55"	"$9,461.20"	Not Applicable	"$8,278.55"	"$16,557.10"	"$8,278.55"	"$16,557.10"
BIT DRL HFMN A11523		STERILE SUPPLY	"$23,643.00"	Outpatient	"$11,821.50"	Not Applicable	"$12,932.72"	"$15,769.88"	"$9,457.20"	Not Applicable	"$8,275.05"	"$16,550.10"	"$8,275.05"	"$16,550.10"
LEAD NRSTM 50X8X2CM PRCS ARTSN PLATNALOCK PDL LIM SPNL CORD M365SC8216500		STERILE SUPPLY	"$23,638.00"	Outpatient	"$11,819.00"	Not Applicable	"$12,929.99"	"$15,766.55"	"$9,455.20"	Not Applicable	"$8,273.30"	"$16,546.60"	"$8,273.30"	"$16,546.60"
NAIL IM 320MM 10.5MM PHNX FEM TROCH LT 14-443332	C1713	SUPPLY/IMPLANTS	"$23,629.00"	Outpatient	"$11,814.50"	"$1,365.15"	"$12,925.06"	"$15,760.54"	"$9,451.60"	Not Applicable	"$8,270.15"	"$16,540.30"	"$1,365.15"	"$16,540.30"
NAIL IM 70MM 10MM TRB MTL NS 119707010	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 7.5CM 10MM TRB MTL NS 119707510	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 8CM 10MM TRB MTL NS 119708010	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 8.5CM 10MM TRB MTL NS 119708510	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 9CM 10MM TRB MTL NS 119709010	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 10CM 10MM TRB MTL NS 119710010	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 10.5CM 10MM TRB MTL NS 119710510	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 11CM 10MM TRB MTL NS 119711010	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 11.5CM 10MM TRB MTL NS 119711510	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 12CM 10MM TRB MTL NS 119712010	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 12.5CM 10MM TRB MTL NS 119712510	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
NAIL IM 13CM 10MM TRB MTL NS 119713010	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
ROD SPNL 9.5CM 10MM NS OSTEONECROSIS 119709510	C1713	SUPPLY/IMPLANTS	"$23,564.00"	Outpatient	"$11,782.00"	"$1,365.15"	"$12,889.51"	"$15,717.19"	"$9,425.60"	Not Applicable	"$8,247.40"	"$16,494.80"	"$1,365.15"	"$16,494.80"
PLT 10 SPNE 2 HL DECADE BN NS XLIF 7140210	C1713	SUPPLY/IMPLANTS	"$23,563.00"	Outpatient	"$11,781.50"	"$1,365.15"	"$12,888.96"	"$15,716.52"	"$9,425.20"	Not Applicable	"$8,247.05"	"$16,494.10"	"$1,365.15"	"$16,494.10"
PLT 14 SPNE 2 HL DECADE BN NS XLIF 7140214	C1713	SUPPLY/IMPLANTS	"$23,554.00"	Outpatient	"$11,777.00"	"$1,365.15"	"$12,884.04"	"$15,710.52"	"$9,421.60"	Not Applicable	"$8,243.90"	"$16,487.80"	"$1,365.15"	"$16,487.80"
PLT 14 SPNE 4 HL DECADE BN NS XLIF 7140414	C1713	SUPPLY/IMPLANTS	"$23,554.00"	Outpatient	"$11,777.00"	"$1,365.15"	"$12,884.04"	"$15,710.52"	"$9,421.60"	Not Applicable	"$8,243.90"	"$16,487.80"	"$1,365.15"	"$16,487.80"
PLT 28.5MM 8MM SPNE TI 4 HL LOPRFL TIMBERLINE BN LAT MDLR FX 8605-0408	C1713	SUPPLY/IMPLANTS	"$23,551.00"	Outpatient	"$11,775.50"	"$1,365.15"	"$12,882.40"	"$15,708.52"	"$9,420.40"	Not Applicable	"$8,242.85"	"$16,485.70"	"$1,365.15"	"$16,485.70"
PLT 2.5MM MNDB TI 20 HL RECON MATRIXMANDIBLE BN SD449.509B	C1713	SUPPLY/IMPLANTS	"$23,543.00"	Outpatient	"$11,771.50"	"$1,365.15"	"$12,878.02"	"$15,703.18"	"$9,417.20"	Not Applicable	"$8,240.05"	"$16,480.10"	"$1,365.15"	"$16,480.10"
MESH CRANIAL LORENZ L206 MM X W123 MM X H.3 MM NEURO PANEL 1 01-7250	C1713	SUPPLY/IMPLANTS	"$23,534.00"	Outpatient	"$11,767.00"	"$1,365.15"	"$12,873.10"	"$15,697.18"	"$9,413.60"	Not Applicable	"$8,236.90"	"$16,473.80"	"$1,365.15"	"$16,473.80"
PLATE BONE TITANIUM L206 MM X W123 MM X H.6 MM MIDFACE CONTO 01-7251	C1713	SUPPLY/IMPLANTS	"$23,520.00"	Outpatient	"$11,760.00"	"$1,365.15"	"$12,865.44"	"$15,687.84"	"$9,408.00"	Not Applicable	"$8,232.00"	"$16,464.00"	"$1,365.15"	"$16,464.00"
SYS ATHRCM SLD CRWN DIAMONDBACK 360 1.25MM PERI 145CM DMD DBP-125SOLID145	C1874	SUPPLY/IMPLANTS	"$23,518.00"	Outpatient	"$11,759.00"	Not Applicable	"$12,864.35"	"$15,686.51"	"$9,407.20"	Not Applicable	"$8,231.30"	"$16,462.60"	"$8,231.30"	"$16,462.60"
STNT HEP NTNL EPTFE 8MM 10CM FLXB SLF XPD RADOPQ VBHN EPRSTH VBHR081002A	C1884	SUPPLY/IMPLANTS	"$23,518.00"	Outpatient	"$11,759.00"	Not Applicable	"$12,864.35"	"$15,686.51"	"$9,407.20"	Not Applicable	"$8,231.30"	"$16,462.60"	"$8,231.30"	"$16,462.60"
STNT HEP 9MM 9FR ILC ART 10CM DLV SYS TIP TO HUB DPL VBHN VBH091002	C1884	SUPPLY/IMPLANTS	"$23,518.00"	Outpatient	"$11,759.00"	Not Applicable	"$12,864.35"	"$15,686.51"	"$9,407.20"	Not Applicable	"$8,231.30"	"$16,462.60"	"$8,231.30"	"$16,462.60"
CATH ATHRCM 145CM 2MM 6FR DIAMONDBACK 360 2MM PERI CLS CRWN DBP-200CLASS145	C1724	SUPPLY/IMPLANTS	"$23,518.00"	Outpatient	"$11,759.00"	Not Applicable	"$12,864.35"	"$15,686.51"	"$9,407.20"	Not Applicable	"$8,231.30"	"$16,462.60"	"$8,231.30"	"$16,462.60"
STEALTH 360 SOLID PRD-SC30-200		STERILE SUPPLY	"$23,518.00"	Outpatient	"$11,759.00"	Not Applicable	"$12,864.35"	"$15,686.51"	"$9,407.20"	Not Applicable	"$8,231.30"	"$16,462.60"	"$8,231.30"	"$16,462.60"
INS TIB 3-4 9MM KN XLPE PS HI FLXN LEGION 71453211	C1776	SUPPLY/IMPLANTS	"$23,516.00"	Outpatient	"$11,758.00"	Not Applicable	"$12,863.25"	"$15,685.17"	"$9,406.40"	Not Applicable	"$8,230.60"	"$16,461.20"	"$8,230.60"	"$16,461.20"
STEM FEMORAL GMRS LONG BOW L203 MM OD17 MM PROXIMAL CEMENTED 6485-3-617	C1776	SUPPLY/IMPLANTS	"$23,516.00"	Outpatient	"$11,758.00"	Not Applicable	"$12,863.25"	"$15,685.17"	"$9,406.40"	Not Applicable	"$8,230.60"	"$16,461.20"	"$8,230.60"	"$16,461.20"
TISSUE LANYARD WRAP 2X4 CM AWT-5240	C9363	SUPPLY/IMPLANTS	"$23,516.00"	Outpatient	"$11,758.00"	$38.51	"$12,863.25"	"$15,685.17"	"$9,406.40"	Not Applicable	"$8,230.60"	"$16,461.20"	$38.51	"$16,461.20"
SYS ATHRCM MIC CRWN DIAMONDBACK 360 PERI 145CM 1.25MM ACPT 4 DBP-125MICRO145		SUPPLY/IMPLANTS	"$23,516.00"	Outpatient	"$11,758.00"	Not Applicable	"$12,863.25"	"$15,685.17"	"$9,406.40"	Not Applicable	"$8,230.60"	"$16,461.20"	"$8,230.60"	"$16,461.20"
CATH ATHRCM 145CM 1.6MM 5FR DIAMONDBACK 360 1.5MM PERI CLS DBP-150CLASS145	C1724	SUPPLY/IMPLANTS	"$23,502.00"	Outpatient	"$11,751.00"	Not Applicable	"$12,855.59"	"$15,675.83"	"$9,400.80"	Not Applicable	"$8,225.70"	"$16,451.40"	"$8,225.70"	"$16,451.40"
00310-4611-50 - durvalumab 50 mg/mL Soln	J9173	PHARMACY	"$19,776.00"	Outpatient	"$9,888.00"	$73.23	"$12,854.40"	"$13,190.59"	"$7,910.40"	Not Applicable	"$6,921.60"	"$13,843.20"	$73.23	"$13,843.20"
STEM FEM 155MM 15MM STRG CNCL RSTR HA HIP MDLR SYS 6276-7-015	C1776	SUPPLY/IMPLANTS	"$23,490.00"	Outpatient	"$11,745.00"	Not Applicable	"$12,849.03"	"$15,667.83"	"$9,396.00"	Not Applicable	"$8,221.50"	"$16,443.00"	"$8,221.50"	"$16,443.00"
STEM FEM 155MM 22MM STRG CONE RSTR HA HIP MDLR 6276-7-022	C1776	SUPPLY/IMPLANTS	"$23,490.00"	Outpatient	"$11,745.00"	Not Applicable	"$12,849.03"	"$15,667.83"	"$9,396.00"	Not Applicable	"$8,221.50"	"$16,443.00"	"$8,221.50"	"$16,443.00"
STEM FEM 155MM 20MM STRG CNCL RSTR HA HIP MDLR SYS 6276-7-020	C1776	SUPPLY/IMPLANTS	"$23,490.00"	Outpatient	"$11,745.00"	Not Applicable	"$12,849.03"	"$15,667.83"	"$9,396.00"	Not Applicable	"$8,221.50"	"$16,443.00"	"$8,221.50"	"$16,443.00"
TRAY SRG DFS VSN BN SCR 3165	C1713	SUPPLY/IMPLANTS	"$23,484.00"	Outpatient	"$11,742.00"	"$1,365.15"	"$12,845.75"	"$15,663.83"	"$9,393.60"	Not Applicable	"$8,219.40"	"$16,438.80"	"$1,365.15"	"$16,438.80"
STEM HUMERAL ARTHREX ECLIPSE OD43 MM SHOULDER TRUNION AR-9301-43CPC	C1776	SUPPLY/IMPLANTS	"$23,430.00"	Outpatient	"$11,715.00"	Not Applicable	"$12,816.21"	"$15,627.81"	"$9,372.00"	Not Applicable	"$8,200.50"	"$16,401.00"	"$8,200.50"	"$16,401.00"
SURESCAN MRI LEAD 28CM 978B128	C1778	SUPPLY/IMPLANTS	"$23,420.00"	Outpatient	"$11,710.00"	Not Applicable	"$12,810.74"	"$15,621.14"	"$9,368.00"	Not Applicable	"$8,197.00"	"$16,394.00"	"$8,197.00"	"$16,394.00"
INTERSTIM SURESCAN MRI LEAD KIT (2.16MM SPACING - 33CM LENGT 978A133		STERILE SUPPLY	"$23,420.00"	Outpatient	"$11,710.00"	Not Applicable	"$12,810.74"	"$15,621.14"	"$9,368.00"	Not Applicable	"$8,197.00"	"$16,394.00"	"$8,197.00"	"$16,394.00"
INTERSTIM MICRO SURESCAN LEAD KIT 28CM 978A128		STERILE SUPPLY	"$23,420.00"	Outpatient	"$11,710.00"	Not Applicable	"$12,810.74"	"$15,621.14"	"$9,368.00"	Not Applicable	"$8,197.00"	"$16,394.00"	"$8,197.00"	"$16,394.00"
GRAFT AFX ILIAC EXTENTION 120-13/C88FSA	C1874	SUPPLY/IMPLANTS	"$23,413.00"	Outpatient	"$11,706.50"	Not Applicable	"$12,806.91"	"$15,616.47"	"$9,365.20"	Not Applicable	"$8,194.55"	"$16,389.10"	"$8,194.55"	"$16,389.10"
AFX ILIAC EXTENSION 120-13/C70FSA	C1766	SUPPLY/IMPLANTS	"$23,411.00"	Outpatient	"$11,705.50"	Not Applicable	"$12,805.82"	"$15,615.14"	"$9,364.40"	Not Applicable	"$8,193.85"	"$16,387.70"	"$8,193.85"	"$16,387.70"
50242-0044-13 - alteplase 1 mg Injection	J2997	PHARMACY	"$23,392.00"	Outpatient	"$11,696.00"	$96.47	"$12,795.42"	"$15,602.46"	"$9,356.80"	Not Applicable	"$8,187.20"	"$16,374.40"	$96.47	"$16,374.40"
STEM HUM 122MM 10MM CMPRH MACROBOND SHLDR RVRS SYS 11-113560	C1776	SUPPLY/IMPLANTS	"$23,383.00"	Outpatient	"$11,691.50"	Not Applicable	"$12,790.50"	"$15,596.46"	"$9,353.20"	Not Applicable	"$8,184.05"	"$16,368.10"	"$8,184.05"	"$16,368.10"
IMPL BRST 475ML P5.3CM FULL HT FULL PRJ STY FF HI CHSV GEL FF-410475	C1789	SUPPLY/IMPLANTS	"$23,377.00"	Outpatient	"$11,688.50"	Not Applicable	"$12,787.22"	"$15,592.46"	"$9,350.80"	Not Applicable	"$8,181.95"	"$16,363.90"	"$8,181.95"	"$16,363.90"
00002-7623-01 - pemetrexed 500 mg Inj	J9305	PHARMACY	"$19,664.00"	Outpatient	"$9,832.00"	$77.58	"$12,781.60"	"$13,115.89"	"$7,865.60"	Not Applicable	"$6,882.40"	"$13,764.80"	$77.58	"$13,764.80"
SYS SHNT PRGM VLV VNTRC CATH INFO MNL UNITIZE CDMN HKM ANG 823148		SUPPLY/IMPLANTS	"$23,366.00"	Outpatient	"$11,683.00"	Not Applicable	"$12,781.20"	"$15,585.12"	"$9,346.40"	Not Applicable	"$8,178.10"	"$16,356.20"	"$8,178.10"	"$16,356.20"
VLV SHNT CDMN HKM PRGM INLN ADPR STRL 823164		SUPPLY/IMPLANTS	"$23,366.00"	Outpatient	"$11,683.00"	Not Applicable	"$12,781.20"	"$15,585.12"	"$9,346.40"	Not Applicable	"$8,178.10"	"$16,356.20"	"$8,178.10"	"$16,356.20"
GFT SFT TIS 3X3IN DRGN + CRNL DURA CLGN RGNRT MTRX DRPLS DP5033	C9362	SUPPLY/IMPLANTS	"$23,365.00"	Outpatient	"$11,682.50"	$110.85	"$12,780.66"	"$15,584.46"	"$9,346.00"	Not Applicable	"$8,177.75"	"$16,355.50"	$110.85	"$16,355.50"
NAIL IM 15CM 10MM LCK PHNX TI ANKL ARTHDS 14-440115	C1713	SUPPLY/IMPLANTS	"$23,316.00"	Outpatient	"$11,658.00"	"$1,365.15"	"$12,753.85"	"$15,551.77"	"$9,326.40"	Not Applicable	"$8,160.60"	"$16,321.20"	"$1,365.15"	"$16,321.20"
SCR BN SS 95MM 6.5MM ASNS III CNN NS 326295	C1713	SUPPLY/IMPLANTS	"$23,281.00"	Outpatient	"$11,640.50"	"$1,365.15"	"$12,734.71"	"$15,528.43"	"$9,312.40"	Not Applicable	"$8,148.35"	"$16,296.70"	"$1,365.15"	"$16,296.70"
CMPNT HUM 18X7.2X2MM RHEAD UNI-ELB 2 STD RDS LAT COLR STM 310-0001	C1776	SUPPLY/IMPLANTS	"$23,274.00"	Outpatient	"$11,637.00"	Not Applicable	"$12,730.88"	"$15,523.76"	"$9,309.60"	Not Applicable	"$8,145.90"	"$16,291.80"	"$8,145.90"	"$16,291.80"
HEAD RADL 4 LAT ELB 310-0003	C1776	SUPPLY/IMPLANTS	"$23,274.00"	Outpatient	"$11,637.00"	Not Applicable	"$12,730.88"	"$15,523.76"	"$9,309.60"	Not Applicable	"$8,145.90"	"$16,291.80"	"$8,145.90"	"$16,291.80"
SYS FX 2 TGHTRP BB-TAK AR-8958TDS	C1713	SUPPLY/IMPLANTS	"$23,271.00"	Outpatient	"$11,635.50"	"$1,365.15"	"$12,729.24"	"$15,521.76"	"$9,308.40"	Not Applicable	"$8,144.85"	"$16,289.70"	"$1,365.15"	"$16,289.70"
LEAD DEFIBRILLATOR RELIANCE 4-FRONT MP35N IROX STEROID SILIC 0673	C1777	SUPPLY/IMPLANTS	"$23,271.00"	Outpatient	"$11,635.50"	Not Applicable	"$12,729.24"	"$15,521.76"	"$9,308.40"	Not Applicable	"$8,144.85"	"$16,289.70"	"$8,144.85"	"$16,289.70"
LEAD PCNG 65CM 8.6FR VNTRC SQ SCR 1 COIL ACTFX DFBR TRPLR 693565	C1777	SUPPLY/IMPLANTS	"$23,271.00"	Outpatient	"$11,635.50"	Not Applicable	"$12,729.24"	"$15,521.76"	"$9,308.40"	Not Applicable	"$8,144.85"	"$16,289.70"	"$8,144.85"	"$16,289.70"
PRC SND BLONDE COCLR BAHA 5 KT ABTMNT CVR BTRY SF LN 95201	L8691	PROSTH/ORTH DEVICE	"$23,260.00"	Outpatient	"$11,630.00"	Not Applicable	"$12,723.22"	"$15,514.42"	"$9,304.00"	Not Applicable	"$8,141.00"	"$16,282.00"	"$8,141.00"	"$16,282.00"
PRC SND BLK COCLR BAHA 5 KT ABTMNT CVR BTRY SF LN 95202	L8691	PROSTH/ORTH DEVICE	"$23,260.00"	Outpatient	"$11,630.00"	Not Applicable	"$12,723.22"	"$15,514.42"	"$9,304.00"	Not Applicable	"$8,141.00"	"$16,282.00"	"$8,141.00"	"$16,282.00"
PRC SND SLVR 26X19X12MM COCLR BAHA 5 BLUETOOTH BCDRIVE 1.4MA 95203	L8691	PROSTH/ORTH DEVICE	"$23,260.00"	Outpatient	"$11,630.00"	Not Applicable	"$12,723.22"	"$15,514.42"	"$9,304.00"	Not Applicable	"$8,141.00"	"$16,282.00"	"$8,141.00"	"$16,282.00"
PRC SND BRN 26X19X12MM COCLR BAHA 5 BLUETOOTH BCDRIVE 1.4MA 95204	L8691	PROSTH/ORTH DEVICE	"$23,260.00"	Outpatient	"$11,630.00"	Not Applicable	"$12,723.22"	"$15,514.42"	"$9,304.00"	Not Applicable	"$8,141.00"	"$16,282.00"	"$8,141.00"	"$16,282.00"
PRC SND CU 26X19X12MM COCLR BAHA 5 BLUETOOTH BCDRIVE 1.4MA 95205	L8691	PROSTH/ORTH DEVICE	"$23,260.00"	Outpatient	"$11,630.00"	Not Applicable	"$12,723.22"	"$15,514.42"	"$9,304.00"	Not Applicable	"$8,141.00"	"$16,282.00"	"$8,141.00"	"$16,282.00"
STEM FEMORAL RESTORATION BOW CONICAL L235 MM OD16 MM HIP MODULAR SYSTEM 6276-7-316	C1776	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
STEM FEMORAL HIP RESTORATION 235MM X 20MM 6276-7-320	C1776	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
LEAD DEFIBRILLATOR RELIANCE 4-FRONT MP35N IROX STEROID SILIC 0672	C1895	PACE MAKER	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
LEAD DEFIBRILLATOR PLEXA PROMRI L65 CM L180 MM DF-1 STERILE LATEX FREE DISPOSABLE SD 65/15 414001	C1895	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
LEAD ICD RV PLEXA PROMRI DF-1 S DX 65/17 414006	C1777	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
LEAD ICD RV PLEXA PROMRI DF-1 S DX 65/15 414005	C1777	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
LEAD ICD PLEXA PROMRI S 65 402266	C1777	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
LEAD PCNG 64CM ECRDM 4-ST ETAK RLNC 1 COIL ACT DF4 TRM CNCT 293	C1777	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
LEAD PLEXA PROMRI DF-1S 65 413997	C1777	SUPPLY/IMPLANTS	"$23,257.00"	Outpatient	"$11,628.50"	Not Applicable	"$12,721.58"	"$15,512.42"	"$9,302.80"	Not Applicable	"$8,139.95"	"$16,279.90"	"$8,139.95"	"$16,279.90"
DEV TRGT 20CM RTRGD MOD FEM NTR NL 249000420	C1713	SUPPLY/IMPLANTS	"$23,243.00"	Outpatient	"$11,621.50"	"$1,365.15"	"$12,713.92"	"$15,503.08"	"$9,297.20"	Not Applicable	"$8,135.05"	"$16,270.10"	"$1,365.15"	"$16,270.10"
LEAD NEUROSTIMULATOR INTERSTIM 3 MM SPACE STRAIGHT L33 CM OD 3889-33	C1897	SUPPLY/IMPLANTS	"$23,223.00"	Outpatient	"$11,611.50"	Not Applicable	"$12,702.98"	"$15,489.74"	"$9,289.20"	Not Applicable	"$8,128.05"	"$16,256.10"	"$8,128.05"	"$16,256.10"
CAGE SPNL 17X14X8MM CRNT SM INTLK 7D LRDTC CRV NS LF 6790228	C1821	SUPPLY/IMPLANTS	"$23,216.00"	Outpatient	"$11,608.00"	Not Applicable	"$12,699.15"	"$15,485.07"	"$9,286.40"	Not Applicable	"$8,125.60"	"$16,251.20"	"$8,125.60"	"$16,251.20"
CAGE SPNL 17X14X10MM CRNT SM INTLK 7D LRDTC CRV NS LF 6790230	C1821	SUPPLY/IMPLANTS	"$23,216.00"	Outpatient	"$11,608.00"	Not Applicable	"$12,699.15"	"$15,485.07"	"$9,286.40"	Not Applicable	"$8,125.60"	"$16,251.20"	"$8,125.60"	"$16,251.20"
PLATFORM KIT BILATERAL 4-LEGGED MP-KIT-02D	C1713	SUPPLY/IMPLANTS	"$23,190.00"	Outpatient	"$11,595.00"	"$1,365.15"	"$12,684.93"	"$15,467.73"	"$9,276.00"	Not Applicable	"$8,116.50"	"$16,233.00"	"$1,365.15"	"$16,233.00"
NAIL IM 380MM 10MM 125D LCK GAMMA3 TI FEM LT STRL 3525-0380S	C1713	SUPPLY/IMPLANTS	"$23,183.00"	Outpatient	"$11,591.50"	"$1,365.15"	"$12,681.10"	"$15,463.06"	"$9,273.20"	Not Applicable	"$8,114.05"	"$16,228.10"	"$1,365.15"	"$16,228.10"
NAIL IM 380MM 10MM 125D LCK GAMMA3 TI FEM LT STRL R1.5 3425-0380S	C1713	SUPPLY/IMPLANTS	"$23,183.00"	Outpatient	"$11,591.50"	"$1,365.15"	"$12,681.10"	"$15,463.06"	"$9,273.20"	Not Applicable	"$8,114.05"	"$16,228.10"	"$1,365.15"	"$16,228.10"
NAIL IM 420MM 10MM 125D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3425-0420S	C1713	SUPPLY/IMPLANTS	"$23,183.00"	Outpatient	"$11,591.50"	"$1,365.15"	"$12,681.10"	"$15,463.06"	"$9,273.20"	Not Applicable	"$8,114.05"	"$16,228.10"	"$1,365.15"	"$16,228.10"
NAIL IM 420MM 10MM 125D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3525-0420S	C1713	SUPPLY/IMPLANTS	"$23,183.00"	Outpatient	"$11,591.50"	"$1,365.15"	"$12,681.10"	"$15,463.06"	"$9,273.20"	Not Applicable	"$8,114.05"	"$16,228.10"	"$1,365.15"	"$16,228.10"
NAIL IM 360MM 10MM 125D LCK GAMMA3 TI FEM LT STRL R1.5 3425-0360S	C1713	SUPPLY/IMPLANTS	"$23,183.00"	Outpatient	"$11,591.50"	"$1,365.15"	"$12,681.10"	"$15,463.06"	"$9,273.20"	Not Applicable	"$8,114.05"	"$16,228.10"	"$1,365.15"	"$16,228.10"
PLT MN SPNE THOR OC TI OASYS BN 48551048	C1713	SUPPLY/IMPLANTS	"$23,152.00"	Outpatient	"$11,576.00"	"$1,365.15"	"$12,664.14"	"$15,442.38"	"$9,260.80"	Not Applicable	"$8,103.20"	"$16,206.40"	"$1,365.15"	"$16,206.40"
PLT SM SPNE THOR OC TI OASYS BN 48551044	C1713	SUPPLY/IMPLANTS	"$23,151.00"	Outpatient	"$11,575.50"	"$1,365.15"	"$12,663.60"	"$15,441.72"	"$9,260.40"	Not Applicable	"$8,102.85"	"$16,205.70"	"$1,365.15"	"$16,205.70"
RESTORIS MCK PFJ 180997	C1776	SUPPLY/IMPLANTS	"$23,134.00"	Outpatient	"$11,567.00"	Not Applicable	"$12,654.30"	"$15,430.38"	"$9,253.60"	Not Applicable	"$8,096.90"	"$16,193.80"	"$8,096.90"	"$16,193.80"
STENT ENDOPROSTHESIS GORE VIABAHN .035 IN L59 MM L80 CM OD8 BXA085901A	C1874	SUPPLY/IMPLANTS	"$23,125.00"	Outpatient	"$11,562.50"	Not Applicable	"$12,649.38"	"$15,424.38"	"$9,250.00"	Not Applicable	"$8,093.75"	"$16,187.50"	"$8,093.75"	"$16,187.50"
STNT 10MM 13MM 8FR 59MM BLN EXPANDABLE GW GORE VBHN EPRSTH BXA105902A	C1884	SUPPLY/IMPLANTS	"$23,113.00"	Outpatient	"$11,556.50"	Not Applicable	"$12,642.81"	"$15,416.37"	"$9,245.20"	Not Applicable	"$8,089.55"	"$16,179.10"	"$8,089.55"	"$16,179.10"
STNT 9MM 13MM 8FR 39MM BLN EXPANDABLE GW GORE VBHN EPRSTH BXA093902A	C1884	SUPPLY/IMPLANTS	"$23,113.00"	Outpatient	"$11,556.50"	Not Applicable	"$12,642.81"	"$15,416.37"	"$9,245.20"	Not Applicable	"$8,089.55"	"$16,179.10"	"$8,089.55"	"$16,179.10"
GFT EVAS 11.5CM 18MM 14.5-16.5MM XCLDR CNTRLT LG GRTX NTNL PLC181200	C1874	SUPPLY/IMPLANTS	"$23,082.00"	Outpatient	"$11,541.00"	Not Applicable	"$12,625.85"	"$15,395.69"	"$9,232.80"	Not Applicable	"$8,078.70"	"$16,157.40"	"$8,078.70"	"$16,157.40"
GFT EVAS 9.5CM 18MM 14.5-16.5MM XCLDR CNTRLT LG GRTX NTNL PLC181000	C1874	SUPPLY/IMPLANTS	"$23,082.00"	Outpatient	"$11,541.00"	Not Applicable	"$12,625.85"	"$15,395.69"	"$9,232.80"	Not Applicable	"$8,078.70"	"$16,157.40"	"$8,078.70"	"$16,157.40"
INDIGO CATHETER 8 + LARGE LUMEN ASPIRATION TUBING CAT8TORQ85KIT	C1758	SUPPLY/IMPLANTS	"$23,069.00"	Outpatient	"$11,534.50"	Not Applicable	"$12,618.74"	"$15,387.02"	"$9,227.60"	Not Applicable	"$8,074.15"	"$16,148.30"	"$8,074.15"	"$16,148.30"
CATHETER THROMBECTOMY INDIGO L115 CM OD8 FR ASPIRATION XTORQ CAT8XTORQ115KIT	C1757	SUPPLY/IMPLANTS	"$23,069.00"	Outpatient	"$11,534.50"	Not Applicable	"$12,618.74"	"$15,387.02"	"$9,227.60"	Not Applicable	"$8,074.15"	"$16,148.30"	"$8,074.15"	"$16,148.30"
CASE INST ITST AL RADEL NS 225808000		STERILE SUPPLY	"$23,016.00"	Outpatient	"$11,508.00"	Not Applicable	"$12,589.75"	"$15,351.67"	"$9,206.40"	Not Applicable	"$8,055.60"	"$16,111.20"	"$8,055.60"	"$16,111.20"
ECLIPSE CAGE SCREW S 30MM AR--9301-01	C1713	SUPPLY/IMPLANTS	"$23,015.00"	Outpatient	"$11,507.50"	"$1,365.15"	"$12,589.21"	"$15,351.01"	"$9,206.00"	Not Applicable	"$8,055.25"	"$16,110.50"	"$1,365.15"	"$16,110.50"
SUB BNGF 10ML FM PK BIOACTIVE OSTCNDC SCFLD BBTRAUMA VITOSS 2102-2210	C1713	SUPPLY/IMPLANTS	"$22,987.00"	Outpatient	"$11,493.50"	"$1,365.15"	"$12,573.89"	"$15,332.33"	"$9,194.80"	Not Applicable	"$8,045.45"	"$16,090.90"	"$1,365.15"	"$16,090.90"
SET SRG INST XS MAC CRRT MOD 15230	C1713	SUPPLY/IMPLANTS	"$22,916.00"	Outpatient	"$11,458.00"	"$1,365.15"	"$12,535.05"	"$15,284.97"	"$9,166.40"	Not Applicable	"$8,020.60"	"$16,041.20"	"$1,365.15"	"$16,041.20"
LINR ACTB 56MM 36MM 10D +4MM ALTRX PNCL HIP STRL LF 122136156	C1776	SUPPLY/IMPLANTS	"$22,905.00"	Outpatient	"$11,452.50"	Not Applicable	"$12,529.04"	"$15,277.64"	"$9,162.00"	Not Applicable	"$8,016.75"	"$16,033.50"	"$8,016.75"	"$16,033.50"
455565 INST BASE AND 230002500	C1713	SUPPLY/IMPLANTS	"$22,902.00"	Outpatient	"$11,451.00"	"$1,365.15"	"$12,527.39"	"$15,275.63"	"$9,160.80"	Not Applicable	"$8,015.70"	"$16,031.40"	"$1,365.15"	"$16,031.40"
JAW BUNDLE F/ORTHOGNATHIC IMPLANT VSPCUST6	C1713	SUPPLY/IMPLANTS	"$22,863.00"	Outpatient	"$11,431.50"	"$1,365.15"	"$12,506.06"	"$15,249.62"	"$9,145.20"	Not Applicable	"$8,002.05"	"$16,004.10"	"$1,365.15"	"$16,004.10"
SYS ATHRCM HAWKONE H1-S H1-S	C1714	SUPPLY/IMPLANTS	"$22,863.00"	Outpatient	"$11,431.50"	Not Applicable	"$12,506.06"	"$15,249.62"	"$9,145.20"	Not Applicable	"$8,002.05"	"$16,004.10"	"$8,002.05"	"$16,004.10"
CAGE SPINAL INCORPORATE PEEK 10 D LORDOTIC L12 MM X W14 MM X H26 MM THORACOLUMBAR RADIOPAQUE HOLLO 1	C1821	SUPPLY/IMPLANTS	"$22,861.00"	Outpatient	"$11,430.50"	Not Applicable	"$12,504.97"	"$15,248.29"	"$9,144.40"	Not Applicable	"$8,001.35"	"$16,002.70"	"$8,001.35"	"$16,002.70"
"PEEK CORPECTOMY CAGE, 14 X 12 X 24MM 104-1-14122410"	C1821	SUPPLY/IMPLANTS	"$22,861.00"	Outpatient	"$11,430.50"	Not Applicable	"$12,504.97"	"$15,248.29"	"$9,144.40"	Not Applicable	"$8,001.35"	"$16,002.70"	"$8,001.35"	"$16,002.70"
CBL ORTH BMP TY II TENSOR 498007	C1713	SUPPLY/IMPLANTS	"$22,852.00"	Outpatient	"$11,426.00"	"$1,365.15"	"$12,500.04"	"$15,242.28"	"$9,140.80"	Not Applicable	"$7,998.20"	"$15,996.40"	"$1,365.15"	"$15,996.40"
STNT GRTX NTNL 8MM SPRFC FEM ART 5CM DLV SYS VBHN EPRSTH 120 VBC080502	C1884	SUPPLY/IMPLANTS	"$22,836.00"	Outpatient	"$11,418.00"	Not Applicable	"$12,491.29"	"$15,231.61"	"$9,134.40"	Not Applicable	"$7,992.60"	"$15,985.20"	"$7,992.60"	"$15,985.20"
PLATE 10 HOLE LATERAL PL-SCB1012	C1713	SUPPLY/IMPLANTS	"$22,829.00"	Outpatient	"$11,414.50"	"$1,365.15"	"$12,487.46"	"$15,226.94"	"$9,131.60"	Not Applicable	"$7,990.15"	"$15,980.30"	"$1,365.15"	"$15,980.30"
STNT HEP 5MM 7FR SPRFC FEM ART ILIUM 10CM DLV SYS VBHN VBH051002	C1874	SUPPLY/IMPLANTS	"$22,825.00"	Outpatient	"$11,412.50"	Not Applicable	"$12,485.28"	"$15,224.28"	"$9,130.00"	Not Applicable	"$7,988.75"	"$15,977.50"	"$7,988.75"	"$15,977.50"
STNT HEP 6MM 7FR SPRFC FEM ART ILIUM 10CM DLV SYS VBHN VBH061002	C1884	SUPPLY/IMPLANTS	"$22,825.00"	Outpatient	"$11,412.50"	Not Applicable	"$12,485.28"	"$15,224.28"	"$9,130.00"	Not Applicable	"$7,988.75"	"$15,977.50"	"$7,988.75"	"$15,977.50"
STNT HEP 13MM 12FR ILC ART 10CM DLV SYS TIP TO HUB DPL VBHN VBH131002	C1884	SUPPLY/IMPLANTS	"$22,825.00"	Outpatient	"$11,412.50"	Not Applicable	"$12,485.28"	"$15,224.28"	"$9,130.00"	Not Applicable	"$7,988.75"	"$15,977.50"	"$7,988.75"	"$15,977.50"
CMNT BN CRANIOS 10ML REINF FST ST PTTY STRL 615.10.01S	C9359	SUPPLY/IMPLANTS	"$22,824.00"	Outpatient	"$11,412.00"	$130.50	"$12,484.73"	"$15,223.61"	"$9,129.60"	Not Applicable	"$7,988.40"	"$15,976.80"	$130.50	"$15,976.80"
CMNT BN 10ML REINF ROTATORY MX DLV SYR STRL 616.10.01S	C9359	SUPPLY/IMPLANTS	"$22,824.00"	Outpatient	"$11,412.00"	$130.50	"$12,484.73"	"$15,223.61"	"$9,129.60"	Not Applicable	"$7,988.40"	"$15,976.80"	$130.50	"$15,976.80"
FIL BN VOID 10CC CA PHOS FBR NRN DRILLABLE INJ REINF 07.704.010S		STERILE SUPPLY	"$22,823.00"	Outpatient	"$11,411.50"	Not Applicable	"$12,484.18"	"$15,222.94"	"$9,129.20"	Not Applicable	"$7,988.05"	"$15,976.10"	"$7,988.05"	"$15,976.10"
Coronary PTCA Add'l Vessel	92921	CARDIAC CATH LAB	"$21,001.00"	Outpatient	"$10,500.50"	"$20,126.23"	"$12,474.59"	"$8,056.00"	"$8,400.40"	"$7,310.00"	"$7,350.35"	"$14,700.70"	"$7,310.00"	"$20,126.23"
CORNEA TISSUE 0443-27 OS 0443-27 OS	V2785	UNKNOWN/DONOR	"$22,794.00"	Outpatient	"$11,397.00"	Not Applicable	"$12,468.32"	"$15,203.60"	"$9,117.60"	Not Applicable	"$7,977.90"	"$15,955.80"	"$7,977.90"	"$15,955.80"
CORNEA TISSUE V0105000 V0105000	V2785	UNKNOWN/DONOR	"$22,794.00"	Outpatient	"$11,397.00"	Not Applicable	"$12,468.32"	"$15,203.60"	"$9,117.60"	Not Applicable	"$7,977.90"	"$15,955.80"	"$7,977.90"	"$15,955.80"
CORNEA TISSUE 0445-17 OD 0445-17 OD	V2785	UNKNOWN/DONOR	"$22,794.00"	Outpatient	"$11,397.00"	Not Applicable	"$12,468.32"	"$15,203.60"	"$9,117.60"	Not Applicable	"$7,977.90"	"$15,955.80"	"$7,977.90"	"$15,955.80"
CATHETER ATHERECTOMY NAVITUS JETSTREAM 3 MM L135 CM OD7 FR O PV31300	C1724	SUPPLY/IMPLANTS	"$22,793.00"	Outpatient	"$11,396.50"	Not Applicable	"$12,467.77"	"$15,202.93"	"$9,117.20"	Not Applicable	"$7,977.55"	"$15,955.10"	"$7,977.55"	"$15,955.10"
CATH ATHRCM 1.6MM JETSTREAM 1 CTR 112260001		STERILE SUPPLY	"$22,791.00"	Outpatient	"$11,395.50"	Not Applicable	"$12,466.68"	"$15,201.60"	"$9,116.40"	Not Applicable	"$7,976.85"	"$15,953.70"	"$7,976.85"	"$15,953.70"
CATH ATHRCM 1.85MM JETSTREAM 1 CTR 112262-001		STERILE SUPPLY	"$22,791.00"	Outpatient	"$11,395.50"	Not Applicable	"$12,466.68"	"$15,201.60"	"$9,116.40"	Not Applicable	"$7,976.85"	"$15,953.70"	"$7,976.85"	"$15,953.70"
CATH ATHRCM 2.1MM JETSTREAM EXPANDABLE CTR 112264-001		STERILE SUPPLY	"$22,791.00"	Outpatient	"$11,395.50"	Not Applicable	"$12,466.68"	"$15,201.60"	"$9,116.40"	Not Applicable	"$7,976.85"	"$15,953.70"	"$7,976.85"	"$15,953.70"
CATH ATHRCM 2.4MM JETSTREAM EXPANDABLE CTR 112266-001		STERILE SUPPLY	"$22,791.00"	Outpatient	"$11,395.50"	Not Applicable	"$12,466.68"	"$15,201.60"	"$9,116.40"	Not Applicable	"$7,976.85"	"$15,953.70"	"$7,976.85"	"$15,953.70"
00944-2700-07 - immune globulin intravenous and subcutaneous 10% Soln	J1569	PHARMACY	"$22,771.00"	Outpatient	"$11,385.50"	$43.73	"$12,455.74"	"$15,188.26"	"$9,108.40"	Not Applicable	"$7,969.85"	"$15,939.70"	$43.73	"$15,939.70"
COMPONENT GLENOID ARTHREX ECLIPSE OD49 MM TRUNION AR-9301-49CPC	C1776	SUPPLY/IMPLANTS	"$22,747.00"	Outpatient	"$11,373.50"	Not Applicable	"$12,442.61"	"$15,172.25"	"$9,098.80"	Not Applicable	"$7,961.45"	"$15,922.90"	"$7,961.45"	"$15,922.90"
SCR BN MNDB TI 8MM 2.4MM MATRIXMANDIBLE ST LCK NS LGHT BLU 04.503.638.20	C1713	SUPPLY/IMPLANTS	"$22,733.00"	Outpatient	"$11,366.50"	"$1,365.15"	"$12,434.95"	"$15,162.91"	"$9,093.20"	Not Applicable	"$7,956.55"	"$15,913.10"	"$1,365.15"	"$15,913.10"
SCR BN MNDB TI 10MM 2.4MM MATRIXMANDIBLE ST LCK NS LGHT BLU 04.503.640.20	C1713	SUPPLY/IMPLANTS	"$22,733.00"	Outpatient	"$11,366.50"	"$1,365.15"	"$12,434.95"	"$15,162.91"	"$9,093.20"	Not Applicable	"$7,956.55"	"$15,913.10"	"$1,365.15"	"$15,913.10"
SCR BN MNDB TI 12MM 2.4MM MATRIXMANDIBLE ST LCK NS LGHT BLU 04.503.642.20	C1713	SUPPLY/IMPLANTS	"$22,733.00"	Outpatient	"$11,366.50"	"$1,365.15"	"$12,434.95"	"$15,162.91"	"$9,093.20"	Not Applicable	"$7,956.55"	"$15,913.10"	"$1,365.15"	"$15,913.10"
SCR BN MNDB TI 14MM 2.4MM MATRIXMANDIBLE ST LCK NS LGHT BLU 04.503.644.20	C1713	SUPPLY/IMPLANTS	"$22,733.00"	Outpatient	"$11,366.50"	"$1,365.15"	"$12,434.95"	"$15,162.91"	"$9,093.20"	Not Applicable	"$7,956.55"	"$15,913.10"	"$1,365.15"	"$15,913.10"
SCR BN MNDB TI 16MM 2.4MM MATRIXMANDIBLE ST LCK NS LGHT BLU 04.503.646.20	C1713	SUPPLY/IMPLANTS	"$22,733.00"	Outpatient	"$11,366.50"	"$1,365.15"	"$12,434.95"	"$15,162.91"	"$9,093.20"	Not Applicable	"$7,956.55"	"$15,913.10"	"$1,365.15"	"$15,913.10"
SCR BN MNDB TI 18MM 2.4MM MATRIXMANDIBLE ST LCK NS LGHT BLU 04.503.648.20	C1713	SUPPLY/IMPLANTS	"$22,733.00"	Outpatient	"$11,366.50"	"$1,365.15"	"$12,434.95"	"$15,162.91"	"$9,093.20"	Not Applicable	"$7,956.55"	"$15,913.10"	"$1,365.15"	"$15,913.10"
CAGE 12 X 26MM X 10 MM PLASMA COATED XO34-039PC	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE 12 X 26MM X 10MM PLASMA COATED X034-03PC	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE POST. LUMBAR 12MM X 28MM X 6DEG-11MM 48955126	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 28X11X14MM 0D TRITANIUM PLIF STRL LF 48953140	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 28X11X14MM 6D LRDTC TRITANIUM PLIF STRL LF 48955146	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 55X22X10MM CLYDESDALE PTC 6D PEEK TI RADOPQ LMBR 4926055	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 50X22X10MM CLYDESDALE PTC 6D PEEK TI RADOPQ LMBR 4926050	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 28X11X13MM 6D LRDTC TRITANIUM PLIF STRL LF 48955136	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 23X11X9MM 0D TRITANIUM PLIF STRL LF 48951090	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 28X11X11MM 6D LRDTC TRITANIUM PLIF STRL LF 48955116	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
SPCR SPNL 40X20X11MM TRANSCONTINENTAL MPEEK 6D LRDTC LAT 375.181	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
SPCR SPNL 28X8.5X13MM ALEUTIAN CNVX PEEK PLIF NS LF 603-21328C	C1821	SUPPLY/IMPLANTS	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
SPCR SPNL 50X20X8MM TRANSCONTINENTAL MPEEK 6D LRDTC LAT LMBR 375.378		STERILE SUPPLY	"$22,732.00"	Outpatient	"$11,366.00"	Not Applicable	"$12,434.40"	"$15,162.24"	"$9,092.80"	Not Applicable	"$7,956.20"	"$15,912.40"	"$7,956.20"	"$15,912.40"
CAGE SPNL 23X11X11MM 6D LRDTC TRITANIUM PLIF STRL LF 48951116	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
CAGE SPNL 23X11X13MM 6D LRDTC TRITANIUM PLIF STRL LF 48951136	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
CAGE SPNL 28X10X11MM CASCADIA CNVX TI POR ANTM NAR INTBDY 6101-2102811NC-G2	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
CAGE SPNL 45X18X12MM ZEUS-L LRDTC ANG NOSE PEEK RADOPQ LG 16-121845-L	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
CAGE SPNL 45X18X10MM ZEUS-L LRDTC ANG NOSE PEEK RADOPQ LG 16-101845-L	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
CAGE SPNL 50X18X14MM ZEUS-L LRDTC ANG NOSE PEEK RADOPQ LG 16-141850-L	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
"CAGE XLIF, ZEUS LLIF, 12 X 18 X 50 16-121850-L"	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
CG SPNL 22X10X11MM CASCADIA CNVX TI POR ANTM NAR INTBDY SYS 6101-2102211NC-G2	C1821	SUPPLY/IMPLANTS	"$22,724.00"	Outpatient	"$11,362.00"	Not Applicable	"$12,430.03"	"$15,156.91"	"$9,089.60"	Not Applicable	"$7,953.40"	"$15,906.80"	"$7,953.40"	"$15,906.80"
"CAGE CASCADE INTERBODY SYSTEM, 9X22X10MM 6101-2102209NC-G2"	C1821	SUPPLY/IMPLANTS	"$22,723.00"	Outpatient	"$11,361.50"	Not Applicable	"$12,429.48"	"$15,156.24"	"$9,089.20"	Not Applicable	"$7,953.05"	"$15,906.10"	"$7,953.05"	"$15,906.10"
CAGE SPINAL POROUS 6 D D45 MM W18 MM X H14 MM LATERAL LUMBAR P11845-614	C1821	SUPPLY/IMPLANTS	"$22,723.00"	Outpatient	"$11,361.50"	Not Applicable	"$12,429.48"	"$15,156.24"	"$9,089.20"	Not Applicable	"$7,953.05"	"$15,906.10"	"$7,953.05"	"$15,906.10"
CAGE SPINAL POROUS 6 D D45 MM W18 MM X H10 MM LATERAL LUMBAR P11845-610	C1821	SUPPLY/IMPLANTS	"$22,723.00"	Outpatient	"$11,361.50"	Not Applicable	"$12,429.48"	"$15,156.24"	"$9,089.20"	Not Applicable	"$7,953.05"	"$15,906.10"	"$7,953.05"	"$15,906.10"
CYLINDERS 700 CX IZ 72404174		STERILE SUPPLY	"$22,713.00"	Outpatient	"$11,356.50"	Not Applicable	"$12,424.01"	"$15,149.57"	"$9,085.20"	Not Applicable	"$7,949.55"	"$15,899.10"	"$7,949.55"	"$15,899.10"
AMS 700 CX 21 CM 72404272		STERILE SUPPLY	"$22,698.00"	Outpatient	"$11,349.00"	Not Applicable	"$12,415.81"	"$15,139.57"	"$9,079.20"	Not Applicable	"$7,944.30"	"$15,888.60"	"$7,944.30"	"$15,888.60"
STEM FEMORAL GMRS COCR POROUS STRAIGHT L127 MM OD15 MM HIP C 6485-3-015	C1776	SUPPLY/IMPLANTS	"$22,671.00"	Outpatient	"$11,335.50"	Not Applicable	"$12,401.04"	"$15,121.56"	"$9,068.40"	Not Applicable	"$7,934.85"	"$15,869.70"	"$7,934.85"	"$15,869.70"
STNT VASC 7MM 200MM 120CM SLF XPD DLV CATH SYS SPRL CELL PRB35-07-200-120	C1876	SUPPLY/IMPLANTS	"$22,653.00"	Outpatient	"$11,326.50"	Not Applicable	"$12,391.19"	"$15,109.55"	"$9,061.20"	Not Applicable	"$7,928.55"	"$15,857.10"	"$7,928.55"	"$15,857.10"
STNT HEP 7MM 7FR SPRFC FEM ART ILC 10CM DLV SYS VBHN EPRSTH VBJ071002	C1874	SUPPLY/IMPLANTS	"$22,639.00"	Outpatient	"$11,319.50"	Not Applicable	"$12,383.53"	"$15,100.21"	"$9,055.60"	Not Applicable	"$7,923.65"	"$15,847.30"	"$7,923.65"	"$15,847.30"
SHNT NS STRATA REG 120CM CSF CATH BA IMPRG ASMB STRL 46866		STERILE SUPPLY	"$22,587.00"	Outpatient	"$11,293.50"	Not Applicable	"$12,355.09"	"$15,065.53"	"$9,034.80"	Not Applicable	"$7,905.45"	"$15,810.90"	"$7,905.45"	"$15,810.90"
PLATE BONE ANTEGRA TITANIUM L79 MM L65 MM SPINE LUMBAR 2 LEV 04.102.279	C1713	SUPPLY/IMPLANTS	"$22,564.00"	Outpatient	"$11,282.00"	"$1,365.15"	"$12,342.51"	"$15,050.19"	"$9,025.60"	Not Applicable	"$7,897.40"	"$15,794.80"	"$1,365.15"	"$15,794.80"
VLV SHNT STRT2 CSF PRGM FLW CNTRL BALL SPRG MECH BGL REG 42866		SUPPLY/IMPLANTS	"$22,552.00"	Outpatient	"$11,276.00"	Not Applicable	"$12,335.94"	"$15,042.18"	"$9,020.80"	Not Applicable	"$7,893.20"	"$15,786.40"	"$7,893.20"	"$15,786.40"
BSPLT TIB 3 KN RT CMNT M TPR LEGION TI NPOR 71420182	C1776	SUPPLY/IMPLANTS	"$22,547.00"	Outpatient	"$11,273.50"	Not Applicable	"$12,333.21"	"$15,038.85"	"$9,018.80"	Not Applicable	"$7,891.45"	"$15,782.90"	"$7,891.45"	"$15,782.90"
RESTORIS MCK UNI INLAY 180995	C1776	SUPPLY/IMPLANTS	"$22,547.00"	Outpatient	"$11,273.50"	Not Applicable	"$12,333.21"	"$15,038.85"	"$9,018.80"	Not Applicable	"$7,891.45"	"$15,782.90"	"$7,891.45"	"$15,782.90"
SCR ORTH 21MM ACUMATCH SM HIP MTPHSL STRL LF 150-21-01	C1713	SUPPLY/IMPLANTS	"$22,547.00"	Outpatient	"$11,273.50"	"$1,365.15"	"$12,333.21"	"$15,038.85"	"$9,018.80"	Not Applicable	"$7,891.45"	"$15,782.90"	"$1,365.15"	"$15,782.90"
GFT BN DBM PLGLY 5X2.5CM ALGRF RSRB REMODEL REPL MESH BG 7509505	C1713	SUPPLY/IMPLANTS	"$22,543.00"	Outpatient	"$11,271.50"	"$1,365.15"	"$12,331.02"	"$15,036.18"	"$9,017.20"	Not Applicable	"$7,890.05"	"$15,780.10"	"$1,365.15"	"$15,780.10"
TIP ASP SONOPET 1.77MM 1.37MM 25KHZ MIC STRG SFT TIS 4.9IN 5450800309		STERILE SUPPLY	"$22,517.00"	Outpatient	"$11,258.50"	Not Applicable	"$12,316.80"	"$15,018.84"	"$9,006.80"	Not Applicable	"$7,880.95"	"$15,761.90"	"$7,880.95"	"$15,761.90"
CMPNT HUM SIMPLICITI 2 NCL STRL LF DWG402	C1776	SUPPLY/IMPLANTS	"$22,516.00"	Outpatient	"$11,258.00"	Not Applicable	"$12,316.25"	"$15,018.17"	"$9,006.40"	Not Applicable	"$7,880.60"	"$15,761.20"	"$7,880.60"	"$15,761.20"
CORNEA TISSUE V0108000	V2785	UNKNOWN/DONOR	"$22,516.00"	Outpatient	"$11,258.00"	Not Applicable	"$12,316.25"	"$15,018.17"	"$9,006.40"	Not Applicable	"$7,880.60"	"$15,761.20"	"$7,880.60"	"$15,761.20"
VALVE AORTIC MECHANICAL 22.8MM ID 27.5MM DIA ANNULUS 27MM PO 500FA27		SUPPLY/IMPLANTS	"$22,516.00"	Outpatient	"$11,258.00"	Not Applicable	"$12,316.25"	"$15,018.17"	"$9,006.40"	Not Applicable	"$7,880.60"	"$15,761.20"	"$7,880.60"	"$15,761.20"
BURR CATH 135CM 1.25MM RTBL RTL+ PERI DMD OTW PCTV SHTH ROT M0011401250		STERILE SUPPLY	"$22,451.00"	Outpatient	"$11,225.50"	Not Applicable	"$12,280.70"	"$14,974.82"	"$8,980.40"	Not Applicable	"$7,857.85"	"$15,715.70"	"$7,857.85"	"$15,715.70"
BURR CATH 135CM 1.5MM RTBL RTL+ PERI DMD OTW PCTV SHTH ROT M0011401500		STERILE SUPPLY	"$22,451.00"	Outpatient	"$11,225.50"	Not Applicable	"$12,280.70"	"$14,974.82"	"$8,980.40"	Not Applicable	"$7,857.85"	"$15,715.70"	"$7,857.85"	"$15,715.70"
BURR CATH 135CM 1.75MM RTBL RTL+ PERI DMD OTW PCTV SHTH ROT M0011401750		STERILE SUPPLY	"$22,451.00"	Outpatient	"$11,225.50"	Not Applicable	"$12,280.70"	"$14,974.82"	"$8,980.40"	Not Applicable	"$7,857.85"	"$15,715.70"	"$7,857.85"	"$15,715.70"
BURR CATH 135CM 2MM RTBL RTL+ PERI DMD OTW PCTV SHTH ROT M0011402000		STERILE SUPPLY	"$22,451.00"	Outpatient	"$11,225.50"	Not Applicable	"$12,280.70"	"$14,974.82"	"$8,980.40"	Not Applicable	"$7,857.85"	"$15,715.70"	"$7,857.85"	"$15,715.70"
BURR CATH 135CM 2.25MM RTBL RTL+ PERI DMD OTW PCTV SHTH ROT M0011402250		STERILE SUPPLY	"$22,451.00"	Outpatient	"$11,225.50"	Not Applicable	"$12,280.70"	"$14,974.82"	"$8,980.40"	Not Applicable	"$7,857.85"	"$15,715.70"	"$7,857.85"	"$15,715.70"
BURR CATH 135CM 2.5MM RTBL RTL+ PERI DMD OTW PCTV SHTH ROT M0011402500		STERILE SUPPLY	"$22,451.00"	Outpatient	"$11,225.50"	Not Applicable	"$12,280.70"	"$14,974.82"	"$8,980.40"	Not Applicable	"$7,857.85"	"$15,715.70"	"$7,857.85"	"$15,715.70"
GFT SFT TIS 3.9X3.9IN ALLOMAX SQ HMN DRML CLGN RGNRT HRN ABD 1180070	C1762	SUPPLY/IMPLANTS	"$22,448.00"	Outpatient	"$11,224.00"	Not Applicable	"$12,279.06"	"$14,972.82"	"$8,979.20"	Not Applicable	"$7,856.80"	"$15,713.60"	"$7,856.80"	"$15,713.60"
DISC INTVRTB 19X7MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3597	C1713	SUPPLY/IMPLANTS	"$22,445.00"	Outpatient	"$11,222.50"	"$1,365.15"	"$12,277.42"	"$14,970.82"	"$8,978.00"	Not Applicable	"$7,855.75"	"$15,711.50"	"$1,365.15"	"$15,711.50"
DISC INTVRTB 17X7MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3577	C1713	SUPPLY/IMPLANTS	"$22,445.00"	Outpatient	"$11,222.50"	"$1,365.15"	"$12,277.42"	"$14,970.82"	"$8,978.00"	Not Applicable	"$7,855.75"	"$15,711.50"	"$1,365.15"	"$15,711.50"
DISC INTVRTB 19X6MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3596	C1713	SUPPLY/IMPLANTS	"$22,443.00"	Outpatient	"$11,221.50"	"$1,365.15"	"$12,276.32"	"$14,969.48"	"$8,977.20"	Not Applicable	"$7,855.05"	"$15,710.10"	"$1,365.15"	"$15,710.10"
DISC INTVRTB 19X5MM MOBI-C 15MM SPNE CRV COCRMO TI UHMWPE HA MB 3595	C1713	SUPPLY/IMPLANTS	"$22,443.00"	Outpatient	"$11,221.50"	"$1,365.15"	"$12,276.32"	"$14,969.48"	"$8,977.20"	Not Applicable	"$7,855.05"	"$15,710.10"	"$1,365.15"	"$15,710.10"
DBS LEAD 3389S	C1778	SUPPLY/IMPLANTS	"$22,443.00"	Outpatient	"$11,221.50"	Not Applicable	"$12,276.32"	"$14,969.48"	"$8,977.20"	Not Applicable	"$7,855.05"	"$15,710.10"	"$7,855.05"	"$15,710.10"
TRAY INST CONSTRUX 14-450565	C1713	SUPPLY/IMPLANTS	"$22,425.00"	Outpatient	"$11,212.50"	"$1,365.15"	"$12,266.48"	"$14,957.48"	"$8,970.00"	Not Applicable	"$7,848.75"	"$15,697.50"	"$1,365.15"	"$15,697.50"
TRAY SRGPRP CONSTRUX 14-450555	C1713	SUPPLY/IMPLANTS	"$22,425.00"	Outpatient	"$11,212.50"	"$1,365.15"	"$12,266.48"	"$14,957.48"	"$8,970.00"	Not Applicable	"$7,848.75"	"$15,697.50"	"$1,365.15"	"$15,697.50"
TITAN CYLINDER SET 909224KC		STERILE SUPPLY	"$22,409.00"	Outpatient	"$11,204.50"	Not Applicable	"$12,257.72"	"$14,946.80"	"$8,963.60"	Not Applicable	"$7,843.15"	"$15,686.30"	"$7,843.15"	"$15,686.30"
TITAN CYLINDER SET 26CM NO PUMP 909226KC		STERILE SUPPLY	"$22,409.00"	Outpatient	"$11,204.50"	Not Applicable	"$12,257.72"	"$14,946.80"	"$8,963.60"	Not Applicable	"$7,843.15"	"$15,686.30"	"$7,843.15"	"$15,686.30"
TITAN CYLINDER SET 28CM NO PUMP 909228KC		STERILE SUPPLY	"$22,409.00"	Outpatient	"$11,204.50"	Not Applicable	"$12,257.72"	"$14,946.80"	"$8,963.60"	Not Applicable	"$7,843.15"	"$15,686.30"	"$7,843.15"	"$15,686.30"
TITAN TOUCH PUMP ASSEMBLY 517750		SUPPLY/IMPLANTS	"$22,409.00"	Outpatient	"$11,204.50"	Not Applicable	"$12,257.72"	"$14,946.80"	"$8,963.60"	Not Applicable	"$7,843.15"	"$15,686.30"	"$7,843.15"	"$15,686.30"
PLT 248MM SP CNDL SS CBL VHS BN 200325	C1713	SUPPLY/IMPLANTS	"$22,390.00"	Outpatient	"$11,195.00"	"$1,365.15"	"$12,247.33"	"$14,934.13"	"$8,956.00"	Not Applicable	"$7,836.50"	"$15,673.00"	"$1,365.15"	"$15,673.00"
SHL ACTB 72MM MLHL TRDNT 509-02-721		STERILE SUPPLY	"$22,371.00"	Outpatient	"$11,185.50"	Not Applicable	"$12,236.94"	"$14,921.46"	"$8,948.40"	Not Applicable	"$7,829.85"	"$15,659.70"	"$7,829.85"	"$15,659.70"
Implant Pt Activated Cardiac Event Recorder	33285	CARDIAC CATH LAB	"$22,364.00"	Outpatient	"$11,182.00"	"$15,695.23"	"$12,233.11"	"$14,916.79"	"$8,945.60"	"$8,681.00"	"$7,827.40"	"$15,654.80"	"$7,827.40"	"$15,695.23"
STNT HEP 11MM 11FR ILC ART 5CM DLV SYS TIP TO HUB DPL VBHN VBH110502A	C1884	SUPPLY/IMPLANTS	"$22,350.00"	Outpatient	"$11,175.00"	Not Applicable	"$12,225.45"	"$14,907.45"	"$8,940.00"	Not Applicable	"$7,822.50"	"$15,645.00"	"$7,822.50"	"$15,645.00"
TRIAL SHOULDER ECLIPSE LARGE OD40 MM GLENOID CAGE SCREW STER AR-9301-03	C1713	SUPPLY/IMPLANTS	"$22,344.00"	Outpatient	"$11,172.00"	"$1,365.15"	"$12,222.17"	"$14,903.45"	"$8,937.60"	Not Applicable	"$7,820.40"	"$15,640.80"	"$1,365.15"	"$15,640.80"
PLT 2.5MM LG MNDB RT TI PRFRM RECON MATRIXMANDIBLE BN NS 04.503.904	C1713	SUPPLY/IMPLANTS	"$22,342.00"	Outpatient	"$11,171.00"	"$1,365.15"	"$12,221.07"	"$14,902.11"	"$8,936.80"	Not Applicable	"$7,819.70"	"$15,639.40"	"$1,365.15"	"$15,639.40"
PLT 2.5MM LG MNDB LT TI PRFRM RECON MATRIXMANDIBLE BN NS 04.503.905	C1713	SUPPLY/IMPLANTS	"$22,342.00"	Outpatient	"$11,171.00"	"$1,365.15"	"$12,221.07"	"$14,902.11"	"$8,936.80"	Not Applicable	"$7,819.70"	"$15,639.40"	"$1,365.15"	"$15,639.40"
NOVABONE MACROPOR SI 15CC NB2515	C9362	SUPPLY/IMPLANTS	"$22,340.00"	Outpatient	"$11,170.00"	$110.85	"$12,219.98"	"$14,900.78"	"$8,936.00"	Not Applicable	"$7,819.00"	"$15,638.00"	$110.85	"$15,638.00"
SHELL ACETABULAR TRIDENT II TRITANIUM D OD50 MM HIP 9 HOLE S 709-04-50D	C1776	SUPPLY/IMPLANTS	"$22,338.00"	Outpatient	"$11,169.00"	Not Applicable	"$12,218.89"	"$14,899.45"	"$8,935.20"	Not Applicable	"$7,818.30"	"$15,636.60"	"$7,818.30"	"$15,636.60"
SHELL ACETABULAR TRIDENT II TRITANIUM F OD56 MM HIP 13 HOLE 709-04-56F	C1776	SUPPLY/IMPLANTS	"$22,338.00"	Outpatient	"$11,169.00"	Not Applicable	"$12,218.89"	"$14,899.45"	"$8,935.20"	Not Applicable	"$7,818.30"	"$15,636.60"	"$7,818.30"	"$15,636.60"
PLT .8MM CNTR CRNMXF MESH RAPIDSORB BN 100MM STRL 1.5MM SCR 851.662.01S	C1713	SUPPLY/IMPLANTS	"$22,336.00"	Outpatient	"$11,168.00"	"$1,365.15"	"$12,217.79"	"$14,898.11"	"$8,934.40"	Not Applicable	"$7,817.60"	"$15,635.20"	"$1,365.15"	"$15,635.20"
CATH ATHRCM 10MM DIAMONDBACK STLTH 360 1.25IN SLD CRWN PRD-SC30-125S	C1888	SUPPLY/IMPLANTS	"$22,305.00"	Outpatient	"$11,152.50"	Not Applicable	"$12,200.84"	"$14,877.44"	"$8,922.00"	Not Applicable	"$7,806.75"	"$15,613.50"	"$7,806.75"	"$15,613.50"
CATH ATHRCM 145CM 2MM DIAMONDBACK 360 PERI DMD ROT SLD CRWN DBP-200SOLID145	C1888	SUPPLY/IMPLANTS	"$22,305.00"	Outpatient	"$11,152.50"	Not Applicable	"$12,200.84"	"$14,877.44"	"$8,922.00"	Not Applicable	"$7,806.75"	"$15,613.50"	"$7,806.75"	"$15,613.50"
CATH ATHRCM 145CM 1.5MM DIAMONDBACK 360 PERI DMD SLD CRWN DBP-150SOLID145	C1724	SUPPLY/IMPLANTS	"$22,305.00"	Outpatient	"$11,152.50"	Not Applicable	"$12,200.84"	"$14,877.44"	"$8,922.00"	Not Applicable	"$7,806.75"	"$15,613.50"	"$7,806.75"	"$15,613.50"
Angiography Carotid Cervical Bilateral	36222	CARDIAC CATH LAB	"$22,304.00"	Outpatient	"$11,152.00"	"$11,105.17"	"$12,200.29"	"$14,876.77"	"$8,921.60"	"$4,680.00"	"$7,806.40"	"$15,612.80"	"$4,680.00"	"$15,612.80"
00074-3663-03 - leuprolide 11.25 mg/3 months PWDI	J1950	PHARMACY	"$22,274.00"	Outpatient	"$11,137.00"	"$1,349.12"	"$12,183.88"	"$14,856.76"	"$8,909.60"	Not Applicable	"$7,795.90"	"$15,591.80"	"$1,349.12"	"$15,591.80"
GFT STNT 55MM 20-25MM AFX ILC LMB STRATA AAA STRL LF IS20-25/C55 SA	C1884	SUPPLY/IMPLANTS	"$22,245.00"	Outpatient	"$11,122.50"	Not Applicable	"$12,168.02"	"$14,837.42"	"$8,898.00"	Not Applicable	"$7,785.75"	"$15,571.50"	"$7,785.75"	"$15,571.50"
GFT STNT 65MM 20-25MM AFX ILC LMB STRATA AAA STRL LF IS20-25/C65 SA		STERILE SUPPLY	"$22,245.00"	Outpatient	"$11,122.50"	Not Applicable	"$12,168.02"	"$14,837.42"	"$8,898.00"	Not Applicable	"$7,785.75"	"$15,571.50"	"$7,785.75"	"$15,571.50"
(BC3) PFC SIGMA TIBIAL TRAY FIXED BEARING MODULAR COCR	C1776	SUPPLY/IMPLANTS	"$22,196.00"	Outpatient	"$11,098.00"	Not Applicable	"$12,141.21"	"$14,804.73"	"$8,878.40"	Not Applicable	"$7,768.60"	"$15,537.20"	"$7,768.60"	"$15,537.20"
(BC3) UNIVERSAL STEM FLUTED 115MM X 16MM	C1776	SUPPLY/IMPLANTS	"$22,196.00"	Outpatient	"$11,098.00"	Not Applicable	"$12,141.21"	"$14,804.73"	"$8,878.40"	Not Applicable	"$7,768.60"	"$15,537.20"	"$7,768.60"	"$15,537.20"
INS TIB 3 22.5MM KN UHMWPE FX BRNG STAB + PFC S STRL 962735	C1776	SUPPLY/IMPLANTS	"$22,196.00"	Outpatient	"$11,098.00"	Not Applicable	"$12,141.21"	"$14,804.73"	"$8,878.40"	Not Applicable	"$7,768.60"	"$15,537.20"	"$7,768.60"	"$15,537.20"
HEAD HUM 18MM 48MM SHLDR SIMPLICITI STRL LF 7122872	C1776	SUPPLY/IMPLANTS	"$22,195.00"	Outpatient	"$11,097.50"	Not Applicable	"$12,140.67"	"$14,804.07"	"$8,878.00"	Not Applicable	"$7,768.25"	"$15,536.50"	"$7,768.25"	"$15,536.50"
67457-0833-06 - pegfilgrastim jmdb 6 mg/0.6 mL Soln	Q5108	PHARMACY	"$22,195.00"	Outpatient	"$11,097.50"	$338.27	"$12,140.67"	"$14,804.07"	"$8,878.00"	Not Applicable	"$7,768.25"	"$15,536.50"	$338.27	"$15,536.50"
70114-0101-01 - pegfilgrastim cbqv 6 mg/0.6 mL Soln	Q5111	PHARMACY	"$22,195.00"	Outpatient	"$11,097.50"	$354.04	"$12,140.67"	"$14,804.07"	"$8,878.00"	Not Applicable	"$7,768.25"	"$15,536.50"	$354.04	"$15,536.50"
CAGE SPINAL RENOVIS TESERA 12 D D30 MM W38 MM X H17 MM STERI 1033-383-017	C1821	SUPPLY/IMPLANTS	"$22,183.00"	Outpatient	"$11,091.50"	Not Applicable	"$12,134.10"	"$14,796.06"	"$8,873.20"	Not Applicable	"$7,764.05"	"$15,528.10"	"$7,764.05"	"$15,528.10"
CATH ATHRCM 150CM 2MM .081IN TRBO-PWR .08IN LSR VAPORIZE 420-050		STERILE SUPPLY	"$22,176.00"	Outpatient	"$11,088.00"	Not Applicable	"$12,130.27"	"$14,791.39"	"$8,870.40"	Not Applicable	"$7,761.60"	"$15,523.20"	"$7,761.60"	"$15,523.20"
CATH INFS 2.8-3.2F .021IN 120CM 3.5MM PRCS 021 EXPANDABLE SPS-21120-35		STERILE SUPPLY	"$22,176.00"	Outpatient	"$11,088.00"	Not Applicable	"$12,130.27"	"$14,791.39"	"$8,870.40"	Not Applicable	"$7,761.60"	"$15,523.20"	"$7,761.60"	"$15,523.20"
ALIF SYSTEM S128 RENOVIS 30MMX 26MMX15MM 12 DEG LORDOSIS 1033-302-615	C1821	SUPPLY/IMPLANTS	"$22,169.00"	Outpatient	"$11,084.50"	Not Applicable	"$12,126.44"	"$14,786.72"	"$8,867.60"	Not Applicable	"$7,759.15"	"$15,518.30"	"$7,759.15"	"$15,518.30"
CAGE SPINAL CASCADIA TITANIUM POROUS CONVEX L22 MM X W10 MM 6101-2102210NC-G2	C1821	SUPPLY/IMPLANTS	"$22,169.00"	Outpatient	"$11,084.50"	Not Applicable	"$12,126.44"	"$14,786.72"	"$8,867.60"	Not Applicable	"$7,759.15"	"$15,518.30"	"$7,759.15"	"$15,518.30"
CAGE SPINAL JULIET TITANIUM L50 MM X W17 MM X H8 IN STERILE JLT-S8 50 10-S	C1821	SUPPLY/IMPLANTS	"$22,169.00"	Outpatient	"$11,084.50"	Not Applicable	"$12,126.44"	"$14,786.72"	"$8,867.60"	Not Applicable	"$7,759.15"	"$15,518.30"	"$7,759.15"	"$15,518.30"
CAGE SPINAL  JULIET TITANIUM W17 MM LUMBAR LATERAL JLT-S8 50 12-S	C1821	SUPPLY/IMPLANTS	"$22,169.00"	Outpatient	"$11,084.50"	Not Applicable	"$12,126.44"	"$14,786.72"	"$8,867.60"	Not Applicable	"$7,759.15"	"$15,518.30"	"$7,759.15"	"$15,518.30"
CAGE SPINAL JULIET TITANIUM W17 MM LUMBAR LATERAL 3D STERILE JLT-S8 50 14-S	C1821	SUPPLY/IMPLANTS	"$22,169.00"	Outpatient	"$11,084.50"	Not Applicable	"$12,126.44"	"$14,786.72"	"$8,867.60"	Not Applicable	"$7,759.15"	"$15,518.30"	"$7,759.15"	"$15,518.30"
KIT KYPOPLASTY ACCESS INTVM-15-DDK		STERILE SUPPLY	"$22,169.00"	Outpatient	"$11,084.50"	Not Applicable	"$12,126.44"	"$14,786.72"	"$8,867.60"	Not Applicable	"$7,759.15"	"$15,518.30"	"$7,759.15"	"$15,518.30"
CATH ATHRCM 120CM 2.3MM .091IN TRBO-PWR LSR MAXIMAL LUMINAL 423-050	C1714	SUPPLY/IMPLANTS	"$22,168.00"	Outpatient	"$11,084.00"	Not Applicable	"$12,125.90"	"$14,786.06"	"$8,867.20"	Not Applicable	"$7,758.80"	"$15,517.60"	"$7,758.80"	"$15,517.60"
SPHR EMBL WHT ONCOZENE 40UM +- 10UM MIC NRDCT CLBRT 2ML 10420-US1		STERILE SUPPLY	"$22,168.00"	Outpatient	"$11,084.00"	Not Applicable	"$12,125.90"	"$14,786.06"	"$8,867.20"	Not Applicable	"$7,758.80"	"$15,517.60"	"$7,758.80"	"$15,517.60"
GFT SFT TIS AT 453042	C1713	SUPPLY/IMPLANTS	"$22,167.00"	Outpatient	"$11,083.50"	"$1,365.15"	"$12,125.35"	"$14,785.39"	"$8,866.80"	Not Applicable	"$7,758.45"	"$15,516.90"	"$1,365.15"	"$15,516.90"
CAGE PEEK STALIF C C149581-3T	C1821	SUPPLY/IMPLANTS	"$22,164.00"	Outpatient	"$11,082.00"	Not Applicable	"$12,123.71"	"$14,783.39"	"$8,865.60"	Not Applicable	"$7,757.40"	"$15,514.80"	"$7,757.40"	"$15,514.80"
STEM FEM LONG MODULAR MED REMEDY RHLSMD	C1776	SUPPLY/IMPLANTS	"$22,155.00"	Outpatient	"$11,077.50"	Not Applicable	"$12,118.79"	"$14,777.39"	"$8,862.00"	Not Applicable	"$7,754.25"	"$15,508.50"	"$7,754.25"	"$15,508.50"
MATRIX TISSUE CYTAL PORCINE BLADDER L15 CM X W10 CM 3 LAYER WSR1015	Q4166	SUPPLY/IMPLANTS	"$22,155.00"	Outpatient	"$11,077.50"	$12.76	"$12,118.79"	"$14,777.39"	"$8,862.00"	Not Applicable	"$7,754.25"	"$15,508.50"	$12.76	"$15,508.50"
HNDPC SRG PIEZOELECTRIC SYS NS 05.001.401.98		STERILE SUPPLY	"$22,152.00"	Outpatient	"$11,076.00"	Not Applicable	"$12,117.14"	"$14,775.38"	"$8,860.80"	Not Applicable	"$7,753.20"	"$15,506.40"	"$7,753.20"	"$15,506.40"
CATH CRYABL BLU 90CM 9FR FRZR MAX 3-5-2MM SPC 55MM MED QDPL 239F3	C1733	SUPPLY/IMPLANTS	"$22,142.00"	Outpatient	"$11,071.00"	Not Applicable	"$12,111.67"	"$14,768.71"	"$8,856.80"	Not Applicable	"$7,749.70"	"$15,499.40"	"$7,749.70"	"$15,499.40"
CATH CRYABL ORNG 90CM 9FR FRZR MAX 3-5-2MM SPC 66MM LNG QDPL 239F5	C1733	SUPPLY/IMPLANTS	"$22,142.00"	Outpatient	"$11,071.00"	Not Applicable	"$12,111.67"	"$14,768.71"	"$8,856.80"	Not Applicable	"$7,749.70"	"$15,499.40"	"$7,749.70"	"$15,499.40"
STNT HEP 8MM 7FR SPRFC FEM ART ILIUM 5CM DLV SYS VBHN EPRSTH VBJR080502A	C1884	SUPPLY/IMPLANTS	"$22,134.00"	Outpatient	"$11,067.00"	Not Applicable	"$12,107.30"	"$14,763.38"	"$8,853.60"	Not Applicable	"$7,746.90"	"$15,493.80"	"$7,746.90"	"$15,493.80"
SYS ABLT ANTNA EMPRINT THERMOSPHERE SHRT PERC 15CM FBGLS CA15L1		STERILE SUPPLY	"$22,134.00"	Outpatient	"$11,067.00"	Not Applicable	"$12,107.30"	"$14,763.38"	"$8,853.60"	Not Applicable	"$7,746.90"	"$15,493.80"	"$7,746.90"	"$15,493.80"
PRB LSR 25GA SYNERGETICS DRCT ILLUMINATE STRL LF DISP 55.47.25P		STERILE SUPPLY	"$22,129.00"	Outpatient	"$11,064.50"	Not Applicable	"$12,104.56"	"$14,760.04"	"$8,851.60"	Not Applicable	"$7,745.15"	"$15,490.30"	"$7,745.15"	"$15,490.30"
INS TIB MED UNV 12MM KN COCR PE BRNG HNG FLT ANT SRFC HPEXTN 198727312	C1776	SUPPLY/IMPLANTS	"$22,127.00"	Outpatient	"$11,063.50"	Not Applicable	"$12,103.47"	"$14,758.71"	"$8,850.80"	Not Applicable	"$7,744.45"	"$15,488.90"	"$7,744.45"	"$15,488.90"
SYS ATHRCM STD TIP RADOPQ PRELD DIST FLSH TL PREDICTABLE CUT H1-LS	C1714	SUPPLY/IMPLANTS	"$22,118.00"	Outpatient	"$11,059.00"	Not Applicable	"$12,098.55"	"$14,752.71"	"$8,847.20"	Not Applicable	"$7,741.30"	"$15,482.60"	"$7,741.30"	"$15,482.60"
SYS ATHRCM XTD TIP RADOPQ PRELD DIST FLSH TL PREDICTABLE CUT H1-LX	C1714	SUPPLY/IMPLANTS	"$22,118.00"	Outpatient	"$11,059.00"	Not Applicable	"$12,098.55"	"$14,752.71"	"$8,847.20"	Not Applicable	"$7,741.30"	"$15,482.60"	"$7,741.30"	"$15,482.60"
INS TIB 2.5 CRV 10MM KN XLK FX BRNG PFC S STRL 158112110	C1776	SUPPLY/IMPLANTS	"$22,115.00"	Outpatient	"$11,057.50"	Not Applicable	"$12,096.91"	"$14,750.71"	"$8,846.00"	Not Applicable	"$7,740.25"	"$15,480.50"	"$7,740.25"	"$15,480.50"
INS TIB 2.5 CRV + 10MM KN XLK FX BRNG SGM STRL 970441	C1776	SUPPLY/IMPLANTS	"$22,115.00"	Outpatient	"$11,057.50"	Not Applicable	"$12,096.91"	"$14,750.71"	"$8,846.00"	Not Applicable	"$7,740.25"	"$15,480.50"	"$7,740.25"	"$15,480.50"
PFC SIGMA TIBIAL INSERT FIXED BEARING STABILIZED 3.8MM	C1776	SUPPLY/IMPLANTS	"$22,115.00"	Outpatient	"$11,057.50"	Not Applicable	"$12,096.91"	"$14,750.71"	"$8,846.00"	Not Applicable	"$7,740.25"	"$15,480.50"	"$7,740.25"	"$15,480.50"
CMPNT FEM 60MM KN RT CR CMNT PRM VNGRD INTLK COCR 183004	C1776	SUPPLY/IMPLANTS	"$22,108.00"	Outpatient	"$11,054.00"	Not Applicable	"$12,093.08"	"$14,746.04"	"$8,843.20"	Not Applicable	"$7,737.80"	"$15,475.60"	"$7,737.80"	"$15,475.60"
CMPNT FEM 57.5MM KN RT CR CMNT PRM VNGRD INTLK COCR 183002	C1776	SUPPLY/IMPLANTS	"$22,108.00"	Outpatient	"$11,054.00"	Not Applicable	"$12,093.08"	"$14,746.04"	"$8,843.20"	Not Applicable	"$7,737.80"	"$15,475.60"	"$7,737.80"	"$15,475.60"
CMPNT FEM 57.5MM KN LT CR CMNT PRM VNGRD INTLK COCR 183022	C1776	SUPPLY/IMPLANTS	"$22,108.00"	Outpatient	"$11,054.00"	Not Applicable	"$12,093.08"	"$14,746.04"	"$8,843.20"	Not Applicable	"$7,737.80"	"$15,475.60"	"$7,737.80"	"$15,475.60"
CMPNT FEM 65MM KN RT CR CMNT PRM VNGRD INTLK COCR 183008	C1776	SUPPLY/IMPLANTS	"$22,108.00"	Outpatient	"$11,054.00"	Not Applicable	"$12,093.08"	"$14,746.04"	"$8,843.20"	Not Applicable	"$7,737.80"	"$15,475.60"	"$7,737.80"	"$15,475.60"
MATRIX COLLAGEN BIOACTIVE 20CC MCCBA2012		SUPPLY/IMPLANTS	"$22,074.00"	Outpatient	"$11,037.00"	Not Applicable	"$12,074.48"	"$14,723.36"	"$8,829.60"	Not Applicable	"$7,725.90"	"$15,451.80"	"$7,725.90"	"$15,451.80"
CADDY SCR LCK 2.7MM 8299-53-030	C1713	SUPPLY/IMPLANTS	"$22,071.00"	Outpatient	"$11,035.50"	"$1,365.15"	"$12,072.84"	"$14,721.36"	"$8,828.40"	Not Applicable	"$7,724.85"	"$15,449.70"	"$1,365.15"	"$15,449.70"
MATRIX TISSUE GENTRIX PORCINE BLADDER THIN L15 CM X W10 CM S PSM1015	C1763	SUPPLY/IMPLANTS	"$22,061.00"	Outpatient	"$11,030.50"	Not Applicable	"$12,067.37"	"$14,714.69"	"$8,824.40"	Not Applicable	"$7,721.35"	"$15,442.70"	"$7,721.35"	"$15,442.70"
GFT BN RHBMP-2 BVN CLGN 23MM 2.8ML ABS SPNG STRL H2O SYR NDL 7510200	C1762	SUPPLY/IMPLANTS	"$22,039.00"	Outpatient	"$11,019.50"	Not Applicable	"$12,055.33"	"$14,700.01"	"$8,815.60"	Not Applicable	"$7,713.65"	"$15,427.30"	"$7,713.65"	"$15,427.30"
Vascular Embolize/Occlude Artery	37242	OR/MINOR	"$22,029.00"	Outpatient	"$11,014.50"	"$11,009.75"	"$12,049.86"	"$1,592.00"	"$8,811.60"	"$8,681.00"	"$7,710.15"	"$15,420.30"	"$1,592.00"	"$15,420.30"
Vasc Embolize/Occlude Bleed	37244	CARDIAC CATH LAB	"$22,029.00"	Outpatient	"$11,014.50"	"$11,009.75"	"$12,049.86"	"$1,592.00"	"$8,811.60"	"$8,681.00"	"$7,710.15"	"$15,420.30"	"$1,592.00"	"$15,420.30"
Vasc Embolize/Occlude Artery	37242	CARDIAC CATH LAB	"$22,029.00"	Outpatient	"$11,014.50"	"$11,009.75"	"$12,049.86"	"$1,592.00"	"$8,811.60"	"$8,681.00"	"$7,710.15"	"$15,420.30"	"$1,592.00"	"$15,420.30"
Vascular Embolization/Occlude Venous	37241	CARDIAC CATH LAB	"$22,029.00"	Outpatient	"$11,014.50"	"$11,009.75"	"$12,049.86"	"$1,592.00"	"$8,811.60"	"$8,681.00"	"$7,710.15"	"$15,420.30"	"$1,592.00"	"$15,420.30"
Cerebral Balloon Occlusion	61623	CARDIAC CATH LAB	"$22,029.00"	Outpatient	"$11,014.50"	"$12,583.47"	"$12,049.86"	"$1,592.00"	"$8,811.60"	"$8,681.00"	"$7,710.15"	"$15,420.30"	"$1,592.00"	"$15,420.30"
Dialysis Circuit Emoblization	36909	CARDIAC CATH LAB	"$22,029.00"	Outpatient	"$11,014.50"	"$17,543.68"	"$12,049.86"	"$14,693.34"	"$8,811.60"	$819.00	"$7,710.15"	"$15,420.30"	$819.00	"$17,543.68"
NAIL IM 360MM 12MM LCK RTRGD T2 TI SP CNDL STRL 1826-1236S	C1713	SUPPLY/IMPLANTS	"$22,004.00"	Outpatient	"$11,002.00"	"$1,365.15"	"$12,036.19"	"$14,676.67"	"$8,801.60"	Not Applicable	"$7,701.40"	"$15,402.80"	"$1,365.15"	"$15,402.80"
STNT HEP 8FR 8MM 5CM RADOPQ VBHN EPRSTH 120CM STRL LF VBHR080502A	C1874	SUPPLY/IMPLANTS	"$22,003.00"	Outpatient	"$11,001.50"	Not Applicable	"$12,035.64"	"$14,676.00"	"$8,801.20"	Not Applicable	"$7,701.05"	"$15,402.10"	"$7,701.05"	"$15,402.10"
STNT HEP NTNL EPTFE 7MM 5CM FLXB SLF XPD RADOPQ VBHN EPRSTH VBHR070502A	C1876	SUPPLY/IMPLANTS	"$22,003.00"	Outpatient	"$11,001.50"	Not Applicable	"$12,035.64"	"$14,676.00"	"$8,801.20"	Not Applicable	"$7,701.05"	"$15,402.10"	"$7,701.05"	"$15,402.10"
NAIL IM 340MM 10MM 125D LCK GAMMA3 TI FEM LT STRL R1.5 3425-0340S	C1713	SUPPLY/IMPLANTS	"$22,002.00"	Outpatient	"$11,001.00"	"$1,365.15"	"$12,035.09"	"$14,675.33"	"$8,800.80"	Not Applicable	"$7,700.70"	"$15,401.40"	"$1,365.15"	"$15,401.40"
STNT HEP 9MM 9FR ILC ART 5CM DLV SYS TIP TO HUB DPL VBHN VBH090502A	C1876	SUPPLY/IMPLANTS	"$21,994.00"	Outpatient	"$10,997.00"	Not Applicable	"$12,030.72"	"$14,670.00"	"$8,797.60"	Not Applicable	"$7,697.90"	"$15,395.80"	"$7,697.90"	"$15,395.80"
Percutaneous Transcatheter Closure of Patent Ductus Arteriousus	93582	CARDIAC CATH LAB	"$21,991.00"	Outpatient	"$10,995.50"	"$15,735.19"	"$12,029.08"	"$8,056.00"	"$8,796.40"	"$12,306.00"	"$7,696.85"	"$15,393.70"	"$7,696.85"	"$15,735.19"
HEAD FEM 36MM -3MM BLX D HIP MDLR 12-115120	C1776	SUPPLY/IMPLANTS	"$21,973.00"	Outpatient	"$10,986.50"	Not Applicable	"$12,019.23"	"$14,655.99"	"$8,789.20"	Not Applicable	"$7,690.55"	"$15,381.10"	"$7,690.55"	"$15,381.10"
202735 SCREWS BASE 230004500	C1713	SUPPLY/IMPLANTS	"$21,965.00"	Outpatient	"$10,982.50"	"$1,365.15"	"$12,014.86"	"$14,650.66"	"$8,786.00"	Not Applicable	"$7,687.75"	"$15,375.50"	"$1,365.15"	"$15,375.50"
CT Ablation Liver Cryo	47383	OR SERVICES	"$21,953.00"	Outpatient	"$10,976.50"	"$20,490.62"	"$12,008.29"	"$14,642.65"	"$8,781.20"	"$7,310.00"	"$7,683.55"	"$15,367.10"	"$7,310.00"	"$20,490.62"
CT Ablation Liver Cryo	47383	OR SERVICES	"$21,953.00"	Outpatient	"$10,976.50"	"$20,490.62"	"$12,008.29"	"$14,642.65"	"$8,781.20"	"$7,310.00"	"$7,683.55"	"$15,367.10"	"$7,310.00"	"$20,490.62"
JNT TOE 20 HEMI MOV MTRSL MGT-890-20MT	C1776	SUPPLY/IMPLANTS	"$21,935.00"	Outpatient	"$10,967.50"	Not Applicable	"$11,998.45"	"$14,630.65"	"$8,774.00"	Not Applicable	"$7,677.25"	"$15,354.50"	"$7,677.25"	"$15,354.50"
JNT TOE 30 HMSPHR STM MOV MTRSL MGT-890-30MT	C1776	SUPPLY/IMPLANTS	"$21,935.00"	Outpatient	"$10,967.50"	Not Applicable	"$11,998.45"	"$14,630.65"	"$8,774.00"	Not Applicable	"$7,677.25"	"$15,354.50"	"$7,677.25"	"$15,354.50"
STEM FEM 120MM 9.6MM 132D 6 36MM OFST OMFT EON COCR 30MM HIP 6098-0630	C1776	SUPPLY/IMPLANTS	"$21,893.00"	Outpatient	"$10,946.50"	Not Applicable	"$11,975.47"	"$14,602.63"	"$8,757.20"	Not Applicable	"$7,662.55"	"$15,325.10"	"$7,662.55"	"$15,325.10"
SCR BN SPNE 45MM 7.5MM LNG BLDE LOPRFL ES2 LT XIA 3 15MM 6 482804745	C1713	SUPPLY/IMPLANTS	"$21,876.00"	Outpatient	"$10,938.00"	"$1,365.15"	"$11,966.17"	"$14,591.29"	"$8,750.40"	Not Applicable	"$7,656.60"	"$15,313.20"	"$1,365.15"	"$15,313.20"
SCR BN SPNE 50MM 6.5MM LNG BLDE LOPRFL ES2 LT XIA 3 15MM 6 482804650	C1713	SUPPLY/IMPLANTS	"$21,870.00"	Outpatient	"$10,935.00"	"$1,365.15"	"$11,962.89"	"$14,587.29"	"$8,748.00"	Not Applicable	"$7,654.50"	"$15,309.00"	"$1,365.15"	"$15,309.00"
SCR BN SPNE 50MM 7.5MM LNG BLDE LOPRFL ES2 LT XIA 3 15MM 6 482804750	C1713	SUPPLY/IMPLANTS	"$21,870.00"	Outpatient	"$10,935.00"	"$1,365.15"	"$11,962.89"	"$14,587.29"	"$8,748.00"	Not Applicable	"$7,654.50"	"$15,309.00"	"$1,365.15"	"$15,309.00"
SCR BN SPNE 40MM 5.5MM LNG BLDE LOPRFL ES2 LT XIA 3 15MM 6 482804540	C1713	SUPPLY/IMPLANTS	"$21,870.00"	Outpatient	"$10,935.00"	"$1,365.15"	"$11,962.89"	"$14,587.29"	"$8,748.00"	Not Applicable	"$7,654.50"	"$15,309.00"	"$1,365.15"	"$15,309.00"
SCR BN SPNE 45MM 6.5MM SHRT BLDE LOPRFL ES2 LT XIA 3 15MM 6 482802645	C1713	SUPPLY/IMPLANTS	"$21,870.00"	Outpatient	"$10,935.00"	"$1,365.15"	"$11,962.89"	"$14,587.29"	"$8,748.00"	Not Applicable	"$7,654.50"	"$15,309.00"	"$1,365.15"	"$15,309.00"
SCR BN SPNE 50MM 6.5MM SHRT BLDE LOPRFL ES2 LT XIA 3 15MM 6 482802650	C1713	SUPPLY/IMPLANTS	"$21,870.00"	Outpatient	"$10,935.00"	"$1,365.15"	"$11,962.89"	"$14,587.29"	"$8,748.00"	Not Applicable	"$7,654.50"	"$15,309.00"	"$1,365.15"	"$15,309.00"
SCR BN SPNE 40MM 6.5MM SHRT BLDE LOPRFL ES2 LT XIA 3 15MM 6 482802640	C1713	SUPPLY/IMPLANTS	"$21,859.00"	Outpatient	"$10,929.50"	"$1,365.15"	"$11,956.87"	"$14,579.95"	"$8,743.60"	Not Applicable	"$7,650.65"	"$15,301.30"	"$1,365.15"	"$15,301.30"
CADDY SCR LCK SM FRAG PLT SYS 3.5-4MM 829951020	C1713	SUPPLY/IMPLANTS	"$21,850.00"	Outpatient	"$10,925.00"	"$1,365.15"	"$11,951.95"	"$14,573.95"	"$8,740.00"	Not Applicable	"$7,647.50"	"$15,295.00"	"$1,365.15"	"$15,295.00"
STEM HUMERAL DELTA XTEND COCR 2 STANDARD LENGTH OD10 MM SHOU 130710200	C1776	SUPPLY/IMPLANTS	"$21,823.00"	Outpatient	"$10,911.50"	Not Applicable	"$11,937.18"	"$14,555.94"	"$8,729.20"	Not Applicable	"$7,638.05"	"$15,276.10"	"$7,638.05"	"$15,276.10"
STEM HUMERAL DELTA XTEND COCR 1 STANDARD LENGTH OD8 MM SHOUL 1307-08-100	C1776	SUPPLY/IMPLANTS	"$21,823.00"	Outpatient	"$10,911.50"	Not Applicable	"$11,937.18"	"$14,555.94"	"$8,729.20"	Not Applicable	"$7,638.05"	"$15,276.10"	"$7,638.05"	"$15,276.10"
NANO TLIF INTERDBODY 13 X 2 SSI-33-6913	C1713	SUPPLY/IMPLANTS	"$21,822.00"	Outpatient	"$10,911.00"	"$1,365.15"	"$11,936.63"	"$14,555.27"	"$8,728.80"	Not Applicable	"$7,637.70"	"$15,275.40"	"$1,365.15"	"$15,275.40"
CAGE SPNL 55X18X12MM AERO 0D LAT LMBR INTBDY FX SYS STRL LF 48940312	C1821	SUPPLY/IMPLANTS	"$21,822.00"	Outpatient	"$10,911.00"	Not Applicable	"$11,936.63"	"$14,555.27"	"$8,728.80"	Not Applicable	"$7,637.70"	"$15,275.40"	"$7,637.70"	"$15,275.40"
CAGE SPNL 26X9X13MM CRNT 4D LG IMPCT PEEK-OPTM NS LF 6713926	C1821	SUPPLY/IMPLANTS	"$21,822.00"	Outpatient	"$10,911.00"	Not Applicable	"$11,936.63"	"$14,555.27"	"$8,728.80"	Not Applicable	"$7,637.70"	"$15,275.40"	"$7,637.70"	"$15,275.40"
SPACE PALEAU 10X 7D 52-1028-10	C1821	SUPPLY/IMPLANTS	"$21,822.00"	Outpatient	"$10,911.00"	Not Applicable	"$11,936.63"	"$14,555.27"	"$8,728.80"	Not Applicable	"$7,637.70"	"$15,275.40"	"$7,637.70"	"$15,275.40"
SPACER PLATEUM 13 X 24MM 52-1024-13	C1821	SUPPLY/IMPLANTS	"$21,822.00"	Outpatient	"$10,911.00"	Not Applicable	"$11,936.63"	"$14,555.27"	"$8,728.80"	Not Applicable	"$7,637.70"	"$15,275.40"	"$7,637.70"	"$15,275.40"
SPACER PLATEAU 14MM 52-1028-14	C1821	SUPPLY/IMPLANTS	"$21,822.00"	Outpatient	"$10,911.00"	Not Applicable	"$11,936.63"	"$14,555.27"	"$8,728.80"	Not Applicable	"$7,637.70"	"$15,275.40"	"$7,637.70"	"$15,275.40"
SPCR SPNL 22MMX12MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991222	C1821	SUPPLY/IMPLANTS	"$21,822.00"	Outpatient	"$10,911.00"	Not Applicable	"$11,936.63"	"$14,555.27"	"$8,728.80"	Not Applicable	"$7,637.70"	"$15,275.40"	"$7,637.70"	"$15,275.40"
CAGE PLIF 12 X 24 X 9  0 DEGREE EP2012	C1821	SUPPLY/IMPLANTS	"$21,821.00"	Outpatient	"$10,910.50"	Not Applicable	"$11,936.09"	"$14,554.61"	"$8,728.40"	Not Applicable	"$7,637.35"	"$15,274.70"	"$7,637.35"	"$15,274.70"
CAGE SPNL 22X9X10MM SHURFIT CNVX BLT NOSE PEEK LG GFT AREA PLIF22-10P	C1821	SUPPLY/IMPLANTS	"$21,821.00"	Outpatient	"$10,910.50"	Not Applicable	"$11,936.09"	"$14,554.61"	"$8,728.40"	Not Applicable	"$7,637.35"	"$15,274.70"	"$7,637.35"	"$15,274.70"
CAGE TPLIF PEEK 12 X 24 X 9 DSP2012	C1821	SUPPLY/IMPLANTS	"$21,821.00"	Outpatient	"$10,910.50"	Not Applicable	"$11,936.09"	"$14,554.61"	"$8,728.40"	Not Applicable	"$7,637.35"	"$15,274.70"	"$7,637.35"	"$15,274.70"
SPCR SPNL 22MMX11MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991122	C1821	SUPPLY/IMPLANTS	"$21,821.00"	Outpatient	"$10,910.50"	Not Applicable	"$11,936.09"	"$14,554.61"	"$8,728.40"	Not Applicable	"$7,637.35"	"$15,274.70"	"$7,637.35"	"$15,274.70"
SPCR SPNL 26MMX10MM AVS NVGTR 0D PEEK RADOPQ HLW TLIF NS 48392100	C1821	SUPPLY/IMPLANTS	"$21,821.00"	Outpatient	"$10,910.50"	Not Applicable	"$11,936.09"	"$14,554.61"	"$8,728.40"	Not Applicable	"$7,637.35"	"$15,274.70"	"$7,637.35"	"$15,274.70"
SPCR SPNL 26MMX15MM CPSTN PEEK-OPTM SLF DSTRCT LMBR INTRBD 2991526		STERILE SUPPLY	"$21,821.00"	Outpatient	"$10,910.50"	Not Applicable	"$11,936.09"	"$14,554.61"	"$8,728.40"	Not Applicable	"$7,637.35"	"$15,274.70"	"$7,637.35"	"$15,274.70"
CAGE 14 X 24 X 9 DP2014	C1821	SUPPLY/IMPLANTS	"$21,819.00"	Outpatient	"$10,909.50"	Not Applicable	"$11,934.99"	"$14,553.27"	"$8,727.60"	Not Applicable	"$7,636.65"	"$15,273.30"	"$7,636.65"	"$15,273.30"
CAGE 10 X 24 X 9 DP2010	C1821	SUPPLY/IMPLANTS	"$21,819.00"	Outpatient	"$10,909.50"	Not Applicable	"$11,934.99"	"$14,553.27"	"$8,727.60"	Not Applicable	"$7,636.65"	"$15,273.30"	"$7,636.65"	"$15,273.30"
SLEEVE ADAPTER POROUS UNIVERSAL L40 MM KNEE FEMORAL STERILE 129453236	C1776	SUPPLY/IMPLANTS	"$21,788.00"	Outpatient	"$10,894.00"	Not Applicable	"$11,918.04"	"$14,532.60"	"$8,715.20"	Not Applicable	"$7,625.80"	"$15,251.60"	"$7,625.80"	"$15,251.60"
PLT STRNM TI 30 HL LCK BN STRL 460.024S	C1713	SUPPLY/IMPLANTS	"$21,786.00"	Outpatient	"$10,893.00"	"$1,365.15"	"$11,916.94"	"$14,531.26"	"$8,714.40"	Not Applicable	"$7,625.10"	"$15,250.20"	"$1,365.15"	"$15,250.20"
"Percutaneous Transluminal Angioplasty  Carotid, Additional Vessel"	0076T	CARDIAC CATH LAB	"$21,761.00"	Outpatient	"$10,880.50"	"$17,878.73"	"$11,903.27"	"$1,592.00"	"$8,704.40"	"$1,563.00"	"$7,616.35"	"$15,232.70"	"$1,563.00"	"$17,878.73"
Percutaneous Transluminal Angioplasty Carotid  Initial Vessel	0075T	CARDIAC CATH LAB	"$21,761.00"	Outpatient	"$10,880.50"	"$17,878.73"	"$11,903.27"	"$1,592.00"	"$8,704.40"	"$1,563.00"	"$7,616.35"	"$15,232.70"	"$1,563.00"	"$17,878.73"
NAIL IM 11MM LNG FEM TROCH LT 28228	C1713	SUPPLY/IMPLANTS	"$21,755.00"	Outpatient	"$10,877.50"	"$1,365.15"	"$11,899.99"	"$14,510.59"	"$8,702.00"	Not Applicable	"$7,614.25"	"$15,228.50"	"$1,365.15"	"$15,228.50"
"LEAD, DBS 40CM 3387-40"	C1820	PACE MAKER	"$21,750.00"	Outpatient	"$10,875.00"	Not Applicable	"$11,897.25"	"$14,507.25"	"$8,700.00"	Not Applicable	"$7,612.50"	"$15,225.00"	"$7,612.50"	"$15,225.00"
CMPNT FEM 65MM KN LT CMNT POST STAB OPN BX VNGRD INTLK COCR 183128	C1776	SUPPLY/IMPLANTS	"$21,747.00"	Outpatient	"$10,873.50"	Not Applicable	"$11,895.61"	"$14,505.25"	"$8,698.80"	Not Applicable	"$7,611.45"	"$15,222.90"	"$7,611.45"	"$15,222.90"
VLV AOR 25MM ATS OP MECH GFT CNDT STRL 502AG25		SUPPLY/IMPLANTS	"$21,732.00"	Outpatient	"$10,866.00"	Not Applicable	"$11,887.40"	"$14,495.24"	"$8,692.80"	Not Applicable	"$7,606.20"	"$15,212.40"	"$7,606.20"	"$15,212.40"
PLATE TRESTLE LUXE CERVICAL 16MM E71001-016	C1713	SUPPLY/IMPLANTS	"$21,707.00"	Outpatient	"$10,853.50"	"$1,365.15"	"$11,873.73"	"$14,478.57"	"$8,682.80"	Not Applicable	"$7,597.45"	"$15,194.90"	"$1,365.15"	"$15,194.90"
PLATE TRESTLE LUXE 1  LEVEL 12 MM 71001-012L	C1713	SUPPLY/IMPLANTS	"$21,707.00"	Outpatient	"$10,853.50"	"$1,365.15"	"$11,873.73"	"$14,478.57"	"$8,682.80"	Not Applicable	"$7,597.45"	"$15,194.90"	"$1,365.15"	"$15,194.90"
PLATE TRESLE LUXE 1-LEVEL 12 MM 71001-012	C1713	SUPPLY/IMPLANTS	"$21,707.00"	Outpatient	"$10,853.50"	"$1,365.15"	"$11,873.73"	"$14,478.57"	"$8,682.80"	Not Applicable	"$7,597.45"	"$15,194.90"	"$1,365.15"	"$15,194.90"
KIT IM NL 340MM 11MM 130D R1.5 LNG LT TI 3530-1340S	C1713	SUPPLY/IMPLANTS	"$21,701.00"	Outpatient	"$10,850.50"	"$1,365.15"	"$11,870.45"	"$14,474.57"	"$8,680.40"	Not Applicable	"$7,595.35"	"$15,190.70"	"$1,365.15"	"$15,190.70"
KIT IM NL 360MM 11MM 130D R1.5 LT TI 3530-1360S	C1713	SUPPLY/IMPLANTS	"$21,701.00"	Outpatient	"$10,850.50"	"$1,365.15"	"$11,870.45"	"$14,474.57"	"$8,680.40"	Not Applicable	"$7,595.35"	"$15,190.70"	"$1,365.15"	"$15,190.70"
KIT IM NL 380MM 11MM 130D R1.5 LNG RT TI 3430-1380S	C1713	SUPPLY/IMPLANTS	"$21,701.00"	Outpatient	"$10,850.50"	"$1,365.15"	"$11,870.45"	"$14,474.57"	"$8,680.40"	Not Applicable	"$7,595.35"	"$15,190.70"	"$1,365.15"	"$15,190.70"
NAIL IM 380MM 10MM 130D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3430-0380S	C1713	SUPPLY/IMPLANTS	"$21,701.00"	Outpatient	"$10,850.50"	"$1,365.15"	"$11,870.45"	"$14,474.57"	"$8,680.40"	Not Applicable	"$7,595.35"	"$15,190.70"	"$1,365.15"	"$15,190.70"
PLATE TRESTLE LUX 1-LEVER 16MM 71001-16L	C1713	SUPPLY/IMPLANTS	"$21,694.00"	Outpatient	"$10,847.00"	"$1,365.15"	"$11,866.62"	"$14,469.90"	"$8,677.60"	Not Applicable	"$7,592.90"	"$15,185.80"	"$1,365.15"	"$15,185.80"
PLATE 1-LEVEL TRESTLE LUXE 16MM 71001-016L	C1713	SUPPLY/IMPLANTS	"$21,694.00"	Outpatient	"$10,847.00"	"$1,365.15"	"$11,866.62"	"$14,469.90"	"$8,677.60"	Not Applicable	"$7,592.90"	"$15,185.80"	"$1,365.15"	"$15,185.80"
PLATE TRESTLE LUXE 1-LEVEL 18MM 71001-018L	C1713	SUPPLY/IMPLANTS	"$21,694.00"	Outpatient	"$10,847.00"	"$1,365.15"	"$11,866.62"	"$14,469.90"	"$8,677.60"	Not Applicable	"$7,592.90"	"$15,185.80"	"$1,365.15"	"$15,185.80"
PLATE TRESTLE LUX 14MM 71001-014	C1713	SUPPLY/IMPLANTS	"$21,694.00"	Outpatient	"$10,847.00"	"$1,365.15"	"$11,866.62"	"$14,469.90"	"$8,677.60"	Not Applicable	"$7,592.90"	"$15,185.80"	"$1,365.15"	"$15,185.80"
NAIL IM 360MM 10MM 130D LCK GAMMA3 TI HIP LT FEM STRL 3530-0360S		STERILE SUPPLY	"$21,693.00"	Outpatient	"$10,846.50"	Not Applicable	"$11,866.07"	"$14,469.23"	"$8,677.20"	Not Applicable	"$7,592.55"	"$15,185.10"	"$7,592.55"	"$15,185.10"
SYS CBL 4 HL 4 XTD CBL RD 232X23MM LF GT REATT 223200206	C1713	SUPPLY/IMPLANTS	"$21,689.00"	Outpatient	"$10,844.50"	"$1,365.15"	"$11,863.88"	"$14,466.56"	"$8,675.60"	Not Applicable	"$7,591.15"	"$15,182.30"	"$1,365.15"	"$15,182.30"
NAIL IM 420MM 11MM RECON T2 TI LT STRL 1846-1142S	C1713	SUPPLY/IMPLANTS	"$21,688.00"	Outpatient	"$10,844.00"	"$1,365.15"	"$11,863.34"	"$14,465.90"	"$8,675.20"	Not Applicable	"$7,590.80"	"$15,181.60"	"$1,365.15"	"$15,181.60"
NAIL IM 380MM 11MM RECON T2 TI RT STRL 1847-1138S	C1713	SUPPLY/IMPLANTS	"$21,688.00"	Outpatient	"$10,844.00"	"$1,365.15"	"$11,863.34"	"$14,465.90"	"$8,675.20"	Not Applicable	"$7,590.80"	"$15,181.60"	"$1,365.15"	"$15,181.60"
NAIL IM 440MM 11MM RECON T2 TI LT STRL 1846-1144S	C1713	SUPPLY/IMPLANTS	"$21,688.00"	Outpatient	"$10,844.00"	"$1,365.15"	"$11,863.34"	"$14,465.90"	"$8,675.20"	Not Applicable	"$7,590.80"	"$15,181.60"	"$1,365.15"	"$15,181.60"
NAIL IM 400MM 11MM RECON T2 TI LT STRL 1846-1140S	C1713	SUPPLY/IMPLANTS	"$21,688.00"	Outpatient	"$10,844.00"	"$1,365.15"	"$11,863.34"	"$14,465.90"	"$8,675.20"	Not Applicable	"$7,590.80"	"$15,181.60"	"$1,365.15"	"$15,181.60"
NAIL IM 460MM 13MM RECON T2 TI RT STRL 1847-1346S		STERILE SUPPLY	"$21,686.00"	Outpatient	"$10,843.00"	Not Applicable	"$11,862.24"	"$14,464.56"	"$8,674.40"	Not Applicable	"$7,590.10"	"$15,180.20"	"$7,590.10"	"$15,180.20"
PLT LT TROCH COCR ANTM ALLY BN MFL CRLGE SYS 350840	C1713	SUPPLY/IMPLANTS	"$21,683.00"	Outpatient	"$10,841.50"	"$1,365.15"	"$11,860.60"	"$14,462.56"	"$8,673.20"	Not Applicable	"$7,589.05"	"$15,178.10"	"$1,365.15"	"$15,178.10"
PLT RT TROCH COCR CNN ALLY BN MFL CRLGE SYS 350841	C1713	SUPPLY/IMPLANTS	"$21,683.00"	Outpatient	"$10,841.50"	"$1,365.15"	"$11,860.60"	"$14,462.56"	"$8,673.20"	Not Applicable	"$7,589.05"	"$15,178.10"	"$1,365.15"	"$15,178.10"
CASE STRL CMPLT SM LWR XTRMT 8299-53-003	C1713	SUPPLY/IMPLANTS	"$21,656.00"	Outpatient	"$10,828.00"	"$1,365.15"	"$11,845.83"	"$14,444.55"	"$8,662.40"	Not Applicable	"$7,579.60"	"$15,159.20"	"$1,365.15"	"$15,159.20"
00078-0342-61 - octreotide LAR 30 mg Inj   (per 1mg)	J2353	PHARMACY	"$21,647.00"	Outpatient	"$10,823.50"	$216.22	"$11,840.91"	"$14,438.55"	"$8,658.80"	Not Applicable	"$7,576.45"	"$15,152.90"	$216.22	"$15,152.90"
HEAD RADIAL ACUMED CONTOUR OD22 MM ELBOW LEFT DISH STERILE S 5001-0522L-S	C1776	SUPPLY/IMPLANTS	"$21,607.00"	Outpatient	"$10,803.50"	Not Applicable	"$11,819.03"	"$14,411.87"	"$8,642.80"	Not Applicable	"$7,562.45"	"$15,124.90"	"$7,562.45"	"$15,124.90"
TRAY STRL IMPL 14-401411	C1713	SUPPLY/IMPLANTS	"$21,593.00"	Outpatient	"$10,796.50"	"$1,365.15"	"$11,811.37"	"$14,402.53"	"$8,637.20"	Not Applicable	"$7,557.55"	"$15,115.10"	"$1,365.15"	"$15,115.10"
BONE 10CC MACROPOR SI NB2510	C9359	SUPPLY/IMPLANTS	"$21,584.00"	Outpatient	"$10,792.00"	$130.50	"$11,806.45"	"$14,396.53"	"$8,633.60"	Not Applicable	"$7,554.40"	"$15,108.80"	$130.50	"$15,108.80"
PLT 2.5MM MED MNDB RT TI PRFRM RECON MATRIXMANDIBLE BN NS 04.503.902	C1713	SUPPLY/IMPLANTS	"$21,568.00"	Outpatient	"$10,784.00"	"$1,365.15"	"$11,797.70"	"$14,385.86"	"$8,627.20"	Not Applicable	"$7,548.80"	"$15,097.60"	"$1,365.15"	"$15,097.60"
PLT 2.5MM MED MNDB LT TI PRFRM RECON MATRIXMANDIBLE BN NS 04.503.903	C1713	SUPPLY/IMPLANTS	"$21,568.00"	Outpatient	"$10,784.00"	"$1,365.15"	"$11,797.70"	"$14,385.86"	"$8,627.20"	Not Applicable	"$7,548.80"	"$15,097.60"	"$1,365.15"	"$15,097.60"
BSPLT TIB 6 KN TRTHLN TRITANIUM 5536-B-600	C1776	SUPPLY/IMPLANTS	"$21,566.00"	Outpatient	"$10,783.00"	Not Applicable	"$11,796.60"	"$14,384.52"	"$8,626.40"	Not Applicable	"$7,548.10"	"$15,096.20"	"$7,548.10"	"$15,096.20"
INSERT TRIATHLON TIBIAL BEARING CS SIZE 3 5531-G-313	C1776	SUPPLY/IMPLANTS	"$21,563.00"	Outpatient	"$10,781.50"	Not Applicable	"$11,794.96"	"$14,382.52"	"$8,625.20"	Not Applicable	"$7,547.05"	"$15,094.10"	"$7,547.05"	"$15,094.10"
OPTIROM CENTRAL COMP 9575	C1713	SUPPLY/IMPLANTS	"$21,544.00"	Outpatient	"$10,772.00"	"$1,365.15"	"$11,784.57"	"$14,369.85"	"$8,617.60"	Not Applicable	"$7,540.40"	"$15,080.80"	"$1,365.15"	"$15,080.80"
CAGE SPINAL COROENT TITANIUM XL L40 MM X W18 MM X H8 MM NONS 6808840	C1821	SUPPLY/IMPLANTS	"$21,536.00"	Outpatient	"$10,768.00"	Not Applicable	"$11,780.19"	"$14,364.51"	"$8,614.40"	Not Applicable	"$7,537.60"	"$15,075.20"	"$7,537.60"	"$15,075.20"
ROD XTRNFX VRT ASMB ANGULATING XTRN MDFC DSTRCT 390.104	C1713	SUPPLY/IMPLANTS	"$21,520.00"	Outpatient	"$10,760.00"	"$1,365.15"	"$11,771.44"	"$14,353.84"	"$8,608.00"	Not Applicable	"$7,532.00"	"$15,064.00"	"$1,365.15"	"$15,064.00"
CMPNT GLND 56MM KEEL REUNION SHLDR X3 TL ARTHPL SYS 5542-K-0056	C1776	SUPPLY/IMPLANTS	"$21,516.00"	Outpatient	"$10,758.00"	Not Applicable	"$11,769.25"	"$14,351.17"	"$8,606.40"	Not Applicable	"$7,530.60"	"$15,061.20"	"$7,530.60"	"$15,061.20"
CMPNT GLND 40MM KEEL REUNION SHLDR X3 TL ARTHPL SYS 5542-K-0040	C1776	SUPPLY/IMPLANTS	"$21,516.00"	Outpatient	"$10,758.00"	Not Applicable	"$11,769.25"	"$14,351.17"	"$8,606.40"	Not Applicable	"$7,530.60"	"$15,061.20"	"$7,530.60"	"$15,061.20"
STEM HUMERAL REUNION S L101 MM OD16 MM SHOULDER CEMENT 5567-P-3016	C1776	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
CAGE SPINAL RENOVIS T3 7 D CONVEX L27 MM X W9 MM X H10 MM SP 1043-279-010	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
CAGE SPINAL RENOVIS TESERA TITANIUM 5 D CONVEX L22 MM X W9 M 1043-229-007	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
CAGE SPINAL RENOVIS T3 CONVEX L30 MM X W12 MM X H11 MM NONST 1043-301-112	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
CAGE SPINAL RENOVIS TESERA TITANIUM 7 D CONVEX L25 MM X W9 M 1043-259-009	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
SPACER SPINAL TESERA CONVEX STARIGHT L30 MM X W11 MM X H16 M 1043-301-116	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
"TESERA-ST SPACER, 30MMX14MM, CONVEX 1043-301-114"	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
"TESERA-P SPACER, 25MMX9MMX10MM, CONVEX 7 1043-259-010"	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
"TESERA-P SPACER, 25MM X 9MM X 14MM, CONVEX 7 1043-259-014"	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
"TESERA ST, 25MM X 11MM X 9MM, CONVEX, T3 1045-251-109"	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
"TESERA-P SPACER, 22MMX9MMX11MM CONVEX 7 CAGE 1043-229-011"	C1821	SUPPLY/IMPLANTS	"$21,489.00"	Outpatient	"$10,744.50"	Not Applicable	"$11,754.48"	"$14,333.16"	"$8,595.60"	Not Applicable	"$7,521.15"	"$15,042.30"	"$7,521.15"	"$15,042.30"
PLATE ALIF 11MM 15 DEG 10-P3215-11P	C1713	SUPPLY/IMPLANTS	"$21,484.00"	Outpatient	"$10,742.00"	"$1,365.15"	"$11,751.75"	"$14,329.83"	"$8,593.60"	Not Applicable	"$7,519.40"	"$15,038.80"	"$1,365.15"	"$15,038.80"
PLT SPNL 32X13MM VAULT 8D LRDTC PEEK RADOPQ ALIF NS 10-P3208-13P	C1713	SUPPLY/IMPLANTS	"$21,484.00"	Outpatient	"$10,742.00"	"$1,365.15"	"$11,751.75"	"$14,329.83"	"$8,593.60"	Not Applicable	"$7,519.40"	"$15,038.80"	"$1,365.15"	"$15,038.80"
CAGE ALIF PREBENT 21MM L5-S1 1176448	C1821	SUPPLY/IMPLANTS	"$21,484.00"	Outpatient	"$10,742.00"	Not Applicable	"$11,751.75"	"$14,329.83"	"$8,593.60"	Not Applicable	"$7,519.40"	"$15,038.80"	"$7,519.40"	"$15,038.80"
SHELL ACETABULAR TRIDENT II TRITANIUM G OD62 MM HIP 13 HOLE 709-04-62G	C1776	SUPPLY/IMPLANTS	"$21,479.00"	Outpatient	"$10,739.50"	Not Applicable	"$11,749.01"	"$14,326.49"	"$8,591.60"	Not Applicable	"$7,517.65"	"$15,035.30"	"$7,517.65"	"$15,035.30"
SHELL ACETABULAR TRIDENT II TRITANIUM J OD72 MM HIP 13 HOLE 709-04-72J	C1776	SUPPLY/IMPLANTS	"$21,479.00"	Outpatient	"$10,739.50"	Not Applicable	"$11,749.01"	"$14,326.49"	"$8,591.60"	Not Applicable	"$7,517.65"	"$15,035.30"	"$7,517.65"	"$15,035.30"
SHELL ACETABULAR TRIDENT II TRITANIUM E OD54 MM HIP 11 HOLE 709-04-54E	C1776	SUPPLY/IMPLANTS	"$21,479.00"	Outpatient	"$10,739.50"	Not Applicable	"$11,749.01"	"$14,326.49"	"$8,591.60"	Not Applicable	"$7,517.65"	"$15,035.30"	"$7,517.65"	"$15,035.30"
"TENDON ACHILLES FROZEN, 9MM BONE SHAPED PRESHAPED ATP-091"	C1713	SUPPLY/IMPLANTS	"$21,477.00"	Outpatient	"$10,738.50"	"$1,365.15"	"$11,747.92"	"$14,325.16"	"$8,590.80"	Not Applicable	"$7,516.95"	"$15,033.90"	"$1,365.15"	"$15,033.90"
CAGE SPINAL CASCADIA TITANIUM POROUS CONVEX L28 MM X W10 MM 6101-2102815NC-G2	C1821	SUPPLY/IMPLANTS	"$21,476.00"	Outpatient	"$10,738.00"	Not Applicable	"$11,747.37"	"$14,324.49"	"$8,590.40"	Not Applicable	"$7,516.60"	"$15,033.20"	"$7,516.60"	"$15,033.20"
CAGE SPINAL CASCADIA TITANIUM POROUS CONVEX L28 MM X W10 MM 6101-2102809NC-G2	C1821	SUPPLY/IMPLANTS	"$21,476.00"	Outpatient	"$10,738.00"	Not Applicable	"$11,747.37"	"$14,324.49"	"$8,590.40"	Not Applicable	"$7,516.60"	"$15,033.20"	"$7,516.60"	"$15,033.20"
CAGE SPINAL CASCADIA TITANIUM POROUS CONVEX L22 MM X W10 MM 6101-2102208NC-G2	C1821	SUPPLY/IMPLANTS	"$21,476.00"	Outpatient	"$10,738.00"	Not Applicable	"$11,747.37"	"$14,324.49"	"$8,590.40"	Not Applicable	"$7,516.60"	"$15,033.20"	"$7,516.60"	"$15,033.20"
CAGE SPINAL TRITANIUM 6 D LORDOTIC L28 MM X W11 MM X H10 MM 48955106	C1821	SUPPLY/IMPLANTS	"$21,476.00"	Outpatient	"$10,738.00"	Not Applicable	"$11,747.37"	"$14,324.49"	"$8,590.40"	Not Applicable	"$7,516.60"	"$15,033.20"	"$7,516.60"	"$15,033.20"
GAGE LUMBER TI TESARA P 25MM X9MM X 11MM CONVEX 7 DEG 1043-259-011	C1821	SUPPLY/IMPLANTS	"$21,476.00"	Outpatient	"$10,738.00"	Not Applicable	"$11,747.37"	"$14,324.49"	"$8,590.40"	Not Applicable	"$7,516.60"	"$15,033.20"	"$7,516.60"	"$15,033.20"
SPACER TESERA P 27X9X14 CONVEX 7 DEGREES 1043-279-014	C1821	SUPPLY/IMPLANTS	"$21,476.00"	Outpatient	"$10,738.00"	Not Applicable	"$11,747.37"	"$14,324.49"	"$8,590.40"	Not Applicable	"$7,516.60"	"$15,033.20"	"$7,516.60"	"$15,033.20"
PLATE 13 X 32MM 10-P3208-13	C1713	SUPPLY/IMPLANTS	"$21,475.00"	Outpatient	"$10,737.50"	"$1,365.15"	"$11,746.83"	"$14,323.83"	"$8,590.00"	Not Applicable	"$7,516.25"	"$15,032.50"	"$1,365.15"	"$15,032.50"
PLT 23MM UNV SPNE ANT TI AL VNDM 1 LVL LT BN NS 49170123	C1713	SUPPLY/IMPLANTS	"$21,475.00"	Outpatient	"$10,737.50"	"$1,365.15"	"$11,746.83"	"$14,323.83"	"$8,590.00"	Not Applicable	"$7,516.25"	"$15,032.50"	"$1,365.15"	"$15,032.50"
PLT 25X21X4MM SPNE SCRL ANT TI AL VNDM 1 LVL LT BN NS 49171125	C1713	SUPPLY/IMPLANTS	"$21,475.00"	Outpatient	"$10,737.50"	"$1,365.15"	"$11,746.83"	"$14,323.83"	"$8,590.00"	Not Applicable	"$7,516.25"	"$15,032.50"	"$1,365.15"	"$15,032.50"
PLT SPNL 32X11MM VAULT 8D LRDTC PEEK RADOPQ ALIF NS 10-P3208-11P	C1713	SUPPLY/IMPLANTS	"$21,475.00"	Outpatient	"$10,737.50"	"$1,365.15"	"$11,746.83"	"$14,323.83"	"$8,590.00"	Not Applicable	"$7,516.25"	"$15,032.50"	"$1,365.15"	"$15,032.50"
GFT EVAS 4.5CM 36MM 30-32MM XCLDR GRTX NTNL FEP SINUSOIDAL PLA360400	C1884	SUPPLY/IMPLANTS	"$21,475.00"	Outpatient	"$10,737.50"	Not Applicable	"$11,746.83"	"$14,323.83"	"$8,590.00"	Not Applicable	"$7,516.25"	"$15,032.50"	"$7,516.25"	"$15,032.50"
CAGE SPNL 22X9X11MM SHURFIT CNVX BLT NOSE PEEK LG GFT AREA PLIF22-11P	C1821	SUPPLY/IMPLANTS	"$21,475.00"	Outpatient	"$10,737.50"	Not Applicable	"$11,746.83"	"$14,323.83"	"$8,590.00"	Not Applicable	"$7,516.25"	"$15,032.50"	"$7,516.25"	"$15,032.50"
SPACER PLATEAU 11 X 24MM 52-1024-11	C1821	SUPPLY/IMPLANTS	"$21,475.00"	Outpatient	"$10,737.50"	Not Applicable	"$11,746.83"	"$14,323.83"	"$8,590.00"	Not Applicable	"$7,516.25"	"$15,032.50"	"$7,516.25"	"$15,032.50"
SPCR SPNL 26MMX7MM AVS NVGTR 0D PEEK RADOPQ HLW TLIF NS 48392070	C1821	SUPPLY/IMPLANTS	"$21,474.00"	Outpatient	"$10,737.00"	Not Applicable	"$11,746.28"	"$14,323.16"	"$8,589.60"	Not Applicable	"$7,515.90"	"$15,031.80"	"$7,515.90"	"$15,031.80"
SHELL ACETABULAR MLTIHOLE TRIDENT IITRITANIUM 709-04-64H	C1776	SUPPLY/IMPLANTS	"$21,466.00"	Outpatient	"$10,733.00"	Not Applicable	"$11,741.90"	"$14,317.82"	"$8,586.40"	Not Applicable	"$7,513.10"	"$15,026.20"	"$7,513.10"	"$15,026.20"
SHELL MULTIHOLE ACETABULAR TRIDENT 66MM 709-04-66H	C1776	SUPPLY/IMPLANTS	"$21,466.00"	Outpatient	"$10,733.00"	Not Applicable	"$11,741.90"	"$14,317.82"	"$8,586.40"	Not Applicable	"$7,513.10"	"$15,026.20"	"$7,513.10"	"$15,026.20"
TRIDENT 2 TITANIUM MULTIHOLE ACETABULAR SHELL 52MM 709-04-52E	C1776	SUPPLY/IMPLANTS	"$21,466.00"	Outpatient	"$10,733.00"	Not Applicable	"$11,741.90"	"$14,317.82"	"$8,586.40"	Not Applicable	"$7,513.10"	"$15,026.20"	"$7,513.10"	"$15,026.20"
CATH CRYABL 108CM 7FR FRZR 2-5-2MM SPC 47MM CRV CRD 1 307F1	C1733	SUPPLY/IMPLANTS	"$21,450.00"	Outpatient	"$10,725.00"	Not Applicable	"$11,733.15"	"$14,307.15"	"$8,580.00"	Not Applicable	"$7,507.50"	"$15,015.00"	"$7,507.50"	"$15,015.00"
CATH CRYABL 4MM 7FR FRZR 53MM REACH CRD 307F3	C1733	SUPPLY/IMPLANTS	"$21,450.00"	Outpatient	"$10,725.00"	Not Applicable	"$11,733.15"	"$14,307.15"	"$8,580.00"	Not Applicable	"$7,507.50"	"$15,015.00"	"$7,507.50"	"$15,015.00"
CATH CRYABL 108CM 7FR FRZR 2-5-2MM SPC 58MM 4 TIP ELTRD 307F5	C1733	SUPPLY/IMPLANTS	"$21,450.00"	Outpatient	"$10,725.00"	Not Applicable	"$11,733.15"	"$14,307.15"	"$8,580.00"	Not Applicable	"$7,507.50"	"$15,015.00"	"$7,507.50"	"$15,015.00"
CATH CRYABL RD 108CM 7FR FRZRX1 2-5-2MM SPC 49MM REACH SHRT 227F1	C1733	SUPPLY/IMPLANTS	"$21,450.00"	Outpatient	"$10,725.00"	Not Applicable	"$11,733.15"	"$14,307.15"	"$8,580.00"	Not Applicable	"$7,507.50"	"$15,015.00"	"$7,507.50"	"$15,015.00"
CATH CRYABL BLU 108CM 7FR FRZRX3 2-5-2MM SPC 55MM REACH MED 227F3	C1733	SUPPLY/IMPLANTS	"$21,450.00"	Outpatient	"$10,725.00"	Not Applicable	"$11,733.15"	"$14,307.15"	"$8,580.00"	Not Applicable	"$7,507.50"	"$15,015.00"	"$7,507.50"	"$15,015.00"
CATH CRYABL ORNG 108CM 7FR FRZRX5 2-5-2MM SPC 60MM REACH LNG 227F5	C1733	SUPPLY/IMPLANTS	"$21,450.00"	Outpatient	"$10,725.00"	Not Applicable	"$11,733.15"	"$14,307.15"	"$8,580.00"	Not Applicable	"$7,507.50"	"$15,015.00"	"$7,507.50"	"$15,015.00"
SYS ATHRCM HAWKONE H1-M H1-M	C1714	SUPPLY/IMPLANTS	"$21,442.00"	Outpatient	"$10,721.00"	Not Applicable	"$11,728.77"	"$14,301.81"	"$8,576.80"	Not Applicable	"$7,504.70"	"$15,009.40"	"$7,504.70"	"$15,009.40"
GFT SFT TIS 8X3CM NEOX CRYOTEK 1MM THK 24SQ CM AMNIO MEMBR NX-10-8030		SUPPLY/IMPLANTS	"$21,442.00"	Outpatient	"$10,721.00"	Not Applicable	"$11,728.77"	"$14,301.81"	"$8,576.80"	Not Applicable	"$7,504.70"	"$15,009.40"	"$7,504.70"	"$15,009.40"
STNT HEP 7MM 8FR SPRFC FEM ART ILIUM 15CM DLV SYS VBHN VBH071502	C1874	SUPPLY/IMPLANTS	"$21,440.00"	Outpatient	"$10,720.00"	Not Applicable	"$11,727.68"	"$14,300.48"	"$8,576.00"	Not Applicable	"$7,504.00"	"$15,008.00"	"$7,504.00"	"$15,008.00"
STNT HEP 8MM 8FR SPRFC FEM ART ILIUM 10CM DLV SYS VBHN VBH081002	C1874	SUPPLY/IMPLANTS	"$21,440.00"	Outpatient	"$10,720.00"	Not Applicable	"$11,727.68"	"$14,300.48"	"$8,576.00"	Not Applicable	"$7,504.00"	"$15,008.00"	"$7,504.00"	"$15,008.00"
STNT HEP 5MM 7FR SPRFC FEM ART ILIUM 5CM DLV SYS VBHN EPRSTH VBH050502	C1874	SUPPLY/IMPLANTS	"$21,440.00"	Outpatient	"$10,720.00"	Not Applicable	"$11,727.68"	"$14,300.48"	"$8,576.00"	Not Applicable	"$7,504.00"	"$15,008.00"	"$7,504.00"	"$15,008.00"
STNT HEP 6MM 7FR SPRFC FEM ART ILIUM 5CM DLV SYS VBHN EPRSTH VBH060502	C1884	SUPPLY/IMPLANTS	"$21,440.00"	Outpatient	"$10,720.00"	Not Applicable	"$11,727.68"	"$14,300.48"	"$8,576.00"	Not Applicable	"$7,504.00"	"$15,008.00"	"$7,504.00"	"$15,008.00"
STNT HEP 7MM 8FR SPRFC FEM ART ILIUM 5CM DLV SYS VBHN EPRSTH VBH070502	C1884	SUPPLY/IMPLANTS	"$21,440.00"	Outpatient	"$10,720.00"	Not Applicable	"$11,727.68"	"$14,300.48"	"$8,576.00"	Not Applicable	"$7,504.00"	"$15,008.00"	"$7,504.00"	"$15,008.00"
Percutaneous Placement Bile Duct Stent	47538	CARDIAC CATH LAB	"$21,430.00"	Outpatient	"$10,715.00"	"$20,602.38"	"$11,722.21"	"$14,293.81"	"$8,572.00"	"$7,310.00"	"$7,500.50"	"$15,001.00"	"$7,310.00"	"$20,602.38"
CATH 49.2IN 9FR ENST ARR EP 64 ELTRD ATRM PGTL TIP 43.3IN EC1000	C1732	SUPPLY/IMPLANTS	"$21,428.00"	Outpatient	"$10,714.00"	Not Applicable	"$11,721.12"	"$14,292.48"	"$8,571.20"	Not Applicable	"$7,499.80"	"$14,999.60"	"$7,499.80"	"$14,999.60"
SET ORTH OSTM 3158		STERILE SUPPLY	"$21,427.00"	Outpatient	"$10,713.50"	Not Applicable	"$11,720.57"	"$14,291.81"	"$8,570.80"	Not Applicable	"$7,499.45"	"$14,998.90"	"$7,499.45"	"$14,998.90"
DISTAL RADIUS FIXATOR KIT 240MM ROD/SCHANZ SCREW - STERILE 03.390.054S	C1713	SUPPLY/IMPLANTS	"$21,409.00"	Outpatient	"$10,704.50"	"$1,365.15"	"$11,710.72"	"$14,279.80"	"$8,563.60"	Not Applicable	"$7,493.15"	"$14,986.30"	"$1,365.15"	"$14,986.30"
SYS CBL LNG TROCH TI COCR STRL REATT DEV 498.807S		STERILE SUPPLY	"$21,409.00"	Outpatient	"$10,704.50"	Not Applicable	"$11,710.72"	"$14,279.80"	"$8,563.60"	Not Applicable	"$7,493.15"	"$14,986.30"	"$7,493.15"	"$14,986.30"
VLV SHNT CHPV RT ANG VNTRC STRL 823184		SUPPLY/IMPLANTS	"$21,396.00"	Outpatient	"$10,698.00"	Not Applicable	"$11,703.61"	"$14,271.13"	"$8,558.40"	Not Applicable	"$7,488.60"	"$14,977.20"	"$7,488.60"	"$14,977.20"
PLT 100X100X.8MM CRNMXF MESH RPD RSRB BN STRL 1.5MM SCR 851.521.01S	C1713	SUPPLY/IMPLANTS	"$21,379.00"	Outpatient	"$10,689.50"	"$1,365.15"	"$11,694.31"	"$14,259.79"	"$8,551.60"	Not Applicable	"$7,482.65"	"$14,965.30"	"$1,365.15"	"$14,965.30"
SHL ACTB 62MM 62MM HIP MLHL RIM TRITANIUM X3 MDM TRDNT G 509-02-62G		STERILE SUPPLY	"$21,349.00"	Outpatient	"$10,674.50"	Not Applicable	"$11,677.90"	"$14,239.78"	"$8,539.60"	Not Applicable	"$7,472.15"	"$14,944.30"	"$7,472.15"	"$14,944.30"
Coronary Artery Graft Angiography	93455	CARDIAC CATH LAB	"$19,659.00"	Outpatient	"$9,829.50"	"$13,641.70"	"$11,677.45"	"$6,201.00"	"$7,863.60"	"$6,120.00"	"$6,880.65"	"$13,761.30"	"$6,120.00"	"$13,761.30"
Coronary Artery Angiography	93454	CARDIAC CATH LAB	"$19,659.00"	Outpatient	"$9,829.50"	"$13,641.70"	"$11,677.45"	"$6,201.00"	"$7,863.60"	"$6,120.00"	"$6,880.65"	"$13,761.30"	"$6,120.00"	"$13,761.30"
LEAD PCNG 86CM 4.3FR LV QUICKFLEX BP STRBL TIP OPTIM INSL 1258T/86		SUPPLY/IMPLANTS	"$21,348.00"	Outpatient	"$10,674.00"	Not Applicable	"$11,677.36"	"$14,239.12"	"$8,539.20"	Not Applicable	"$7,471.80"	"$14,943.60"	"$7,471.80"	"$14,943.60"
SHL ACTB 64MM HIP MLHL RIM TRITANIUM X3 MDM TRDNT G HMSPHR 509-02-64G	C1776	SUPPLY/IMPLANTS	"$21,338.00"	Outpatient	"$10,669.00"	Not Applicable	"$11,671.89"	"$14,232.45"	"$8,535.20"	Not Applicable	"$7,468.30"	"$14,936.60"	"$7,468.30"	"$14,936.60"
NAIL IM 30CM 10MM ARTHDS LCK T2 TI LT ANKL STRL 18181030S	C1713	SUPPLY/IMPLANTS	"$21,335.00"	Outpatient	"$10,667.50"	"$1,365.15"	"$11,670.25"	"$14,230.45"	"$8,534.00"	Not Applicable	"$7,467.25"	"$14,934.50"	"$1,365.15"	"$14,934.50"
NAIL IM 30CM 11MM ARTHDS LCK T2 TI RT ANKL STRL 18191130S	C1713	SUPPLY/IMPLANTS	"$21,335.00"	Outpatient	"$10,667.50"	"$1,365.15"	"$11,670.25"	"$14,230.45"	"$8,534.00"	Not Applicable	"$7,467.25"	"$14,934.50"	"$1,365.15"	"$14,934.50"
DEV TRGT 16CM RTRGD MOD FEM NTR NL 249000416	C1713	SUPPLY/IMPLANTS	"$21,325.00"	Outpatient	"$10,662.50"	"$1,365.15"	"$11,664.78"	"$14,223.78"	"$8,530.00"	Not Applicable	"$7,463.75"	"$14,927.50"	"$1,365.15"	"$14,927.50"
SHELL ACETABULAR MULTI-HOLE SIZE G 58MM DIA OSSEOTI G7 110010267	C1776	SUPPLY/IMPLANTS	"$21,300.00"	Outpatient	"$10,650.00"	Not Applicable	"$11,651.10"	"$14,207.10"	"$8,520.00"	Not Applicable	"$7,455.00"	"$14,910.00"	"$7,455.00"	"$14,910.00"
SHELL ACETABULAR MULTI-HOLE SIZE G 60MM DIA OSSEOTI G7 110010268	C1776	SUPPLY/IMPLANTS	"$21,300.00"	Outpatient	"$10,650.00"	Not Applicable	"$11,651.10"	"$14,207.10"	"$8,520.00"	Not Applicable	"$7,455.00"	"$14,910.00"	"$7,455.00"	"$14,910.00"
24338-0050-08 - carmustine 7.7 mg Devi	J3490	PHARMACY	"$21,284.00"	Outpatient	"$10,642.00"	Not Applicable	"$11,642.35"	"$14,196.43"	"$8,513.60"	Not Applicable	"$7,449.40"	"$14,898.80"	"$7,449.40"	"$14,898.80"
NAIL IM 400MM 10MM 125D LCK GAMMA3 TI FEM LT STRL R1.5 3425-0400S	C1713	SUPPLY/IMPLANTS	"$21,255.00"	Outpatient	"$10,627.50"	"$1,365.15"	"$11,626.49"	"$14,177.09"	"$8,502.00"	Not Applicable	"$7,439.25"	"$14,878.50"	"$1,365.15"	"$14,878.50"
NAIL IM 400MM 10MM 125D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3525-0400S	C1713	SUPPLY/IMPLANTS	"$21,255.00"	Outpatient	"$10,627.50"	"$1,365.15"	"$11,626.49"	"$14,177.09"	"$8,502.00"	Not Applicable	"$7,439.25"	"$14,878.50"	"$1,365.15"	"$14,878.50"
NAIL IM 320MM 10MM 125D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3425-0320S	C1713	SUPPLY/IMPLANTS	"$21,255.00"	Outpatient	"$10,627.50"	"$1,365.15"	"$11,626.49"	"$14,177.09"	"$8,502.00"	Not Applicable	"$7,439.25"	"$14,878.50"	"$1,365.15"	"$14,878.50"
NAIL IM 340MM 10MM 125D LCK GAMMA3 TI FEM LT STRL R1.5 3525-0340S	C1713	SUPPLY/IMPLANTS	"$21,255.00"	Outpatient	"$10,627.50"	"$1,365.15"	"$11,626.49"	"$14,177.09"	"$8,502.00"	Not Applicable	"$7,439.25"	"$14,878.50"	"$1,365.15"	"$14,878.50"
PUMP ASSEMBLY TITAN OTR 90-9000KCOTR		STERILE SUPPLY	"$21,251.00"	Outpatient	"$10,625.50"	Not Applicable	"$11,624.30"	"$14,174.42"	"$8,500.40"	Not Applicable	"$7,437.85"	"$14,875.70"	"$7,437.85"	"$14,875.70"
MESH RAPIDSORB 100X100X.25MM CRNL CNTR RSRB RPD STRL 1.5MM 851.612.01S	C1713	SUPPLY/IMPLANTS	"$21,213.00"	Outpatient	"$10,606.50"	"$1,365.15"	"$11,603.51"	"$14,149.07"	"$8,485.20"	Not Applicable	"$7,424.55"	"$14,849.10"	"$1,365.15"	"$14,849.10"
PLT .5MM CRNMXF CNTR MESH RPD RSRB BN 100MM STRL 1.5MM SCR 851.652.01S	C1713	SUPPLY/IMPLANTS	"$21,213.00"	Outpatient	"$10,606.50"	"$1,365.15"	"$11,603.51"	"$14,149.07"	"$8,485.20"	Not Applicable	"$7,424.55"	"$14,849.10"	"$1,365.15"	"$14,849.10"
PLT 100X100X.50MM CNTR MESH RPD RSRB BN STRL 1.5MM SCR 851.622.01S	C1713	SUPPLY/IMPLANTS	"$21,213.00"	Outpatient	"$10,606.50"	"$1,365.15"	"$11,603.51"	"$14,149.07"	"$8,485.20"	Not Applicable	"$7,424.55"	"$14,849.10"	"$1,365.15"	"$14,849.10"
PRC SND PIANO BLK COCLR BAHA 3 PWR KT ABTMNT CVR MPK BTRY 92845	L8691	PROSTH/ORTH DEVICE	"$21,198.00"	Outpatient	"$10,599.00"	Not Applicable	"$11,595.31"	"$14,139.07"	"$8,479.20"	Not Applicable	"$7,419.30"	"$14,838.60"	"$7,419.30"	"$14,838.60"
PRC SND GLACIER WHT COCLR BAHA 3 PWR KT ABTMNT CVR MPK BTRY 92844	L8691	PROSTH/ORTH DEVICE	"$21,198.00"	Outpatient	"$10,599.00"	Not Applicable	"$11,595.31"	"$14,139.07"	"$8,479.20"	Not Applicable	"$7,419.30"	"$14,838.60"	"$7,419.30"	"$14,838.60"
PRC SND CHESTNUT BRN COCLR BAHA 3 PWR KT ABTMNT CVR MPK BTRY 92843	L8691	PROSTH/ORTH DEVICE	"$21,198.00"	Outpatient	"$10,599.00"	Not Applicable	"$11,595.31"	"$14,139.07"	"$8,479.20"	Not Applicable	"$7,419.30"	"$14,838.60"	"$7,419.30"	"$14,838.60"
PRC SND SLT GRY COCLR BAHA 3 PWR KT ABTMNT CVR MPK BTRY BRSH 92842	L8691	PROSTH/ORTH DEVICE	"$21,198.00"	Outpatient	"$10,599.00"	Not Applicable	"$11,595.31"	"$14,139.07"	"$8,479.20"	Not Applicable	"$7,419.30"	"$14,838.60"	"$7,419.30"	"$14,838.60"
PRC SND BLK COCLR BAHA 3 PWR KT ABTMNT CVR MPK BTRY SF LN BP 92841	L8691	PROSTH/ORTH DEVICE	"$21,198.00"	Outpatient	"$10,599.00"	Not Applicable	"$11,595.31"	"$14,139.07"	"$8,479.20"	Not Applicable	"$7,419.30"	"$14,838.60"	"$7,419.30"	"$14,838.60"
PRC SND CHMPGN BLONDE COCLR BAHA 3 ABTMNT CVR MPK BTRY CLN 92840	L8691	PROSTH/ORTH DEVICE	"$21,198.00"	Outpatient	"$10,599.00"	Not Applicable	"$11,595.31"	"$14,139.07"	"$8,479.20"	Not Applicable	"$7,419.30"	"$14,838.60"	"$7,419.30"	"$14,838.60"
SET SRG INST NEW DFS ADLT 3155	C1713	SUPPLY/IMPLANTS	"$21,177.00"	Outpatient	"$10,588.50"	"$1,365.15"	"$11,583.82"	"$14,125.06"	"$8,470.80"	Not Applicable	"$7,411.95"	"$14,823.90"	"$1,365.15"	"$14,823.90"
PLT 100X100X.8MM CRNMXF STRG ROW MESH RPD RSRB BN STRL 1.5MM 851.722.01S	C1713	SUPPLY/IMPLANTS	"$21,154.00"	Outpatient	"$10,577.00"	"$1,365.15"	"$11,571.24"	"$14,109.72"	"$8,461.60"	Not Applicable	"$7,403.90"	"$14,807.80"	"$1,365.15"	"$14,807.80"
 STEM FEMORAL RESTORATION CONICAL L195 MM OD15 MM HIP DISTAL 6276-7-115	C1776	SUPPLY/IMPLANTS	"$21,152.00"	Outpatient	"$10,576.00"	Not Applicable	"$11,570.14"	"$14,108.38"	"$8,460.80"	Not Applicable	"$7,403.20"	"$14,806.40"	"$7,403.20"	"$14,806.40"
GD STD BRL ITST SRG SS NS IM NL 225805203		STERILE SUPPLY	"$21,143.00"	Outpatient	"$10,571.50"	Not Applicable	"$11,565.22"	"$14,102.38"	"$8,457.20"	Not Applicable	"$7,400.05"	"$14,800.10"	"$7,400.05"	"$14,800.10"
KIT NRSTM 40CM 1.27MM STIMLOC DBS STRG CYL FIRM TUNG 4 ELTRD 3387S-40		STERILE SUPPLY	"$21,129.00"	Outpatient	"$10,564.50"	Not Applicable	"$11,557.56"	"$14,093.04"	"$8,451.60"	Not Applicable	"$7,395.15"	"$14,790.30"	"$7,395.15"	"$14,790.30"
KIT INST PTSPC LNR DSTRCT SD900.007	C1713	SUPPLY/IMPLANTS	"$21,105.00"	Outpatient	"$10,552.50"	"$1,365.15"	"$11,544.44"	"$14,077.04"	"$8,442.00"	Not Applicable	"$7,386.75"	"$14,773.50"	"$1,365.15"	"$14,773.50"
XTRT SRG FRM IM NL NS SS 40901100		STERILE SUPPLY	"$21,098.00"	Outpatient	"$10,549.00"	Not Applicable	"$11,540.61"	"$14,072.37"	"$8,439.20"	Not Applicable	"$7,384.30"	"$14,768.60"	"$7,384.30"	"$14,768.60"
CUP ACETABULAR PINNACLE GRIPTION OD52 MM MULTIHOLE 1217-30-052	C1776	SUPPLY/IMPLANTS	"$21,070.00"	Outpatient	"$10,535.00"	Not Applicable	"$11,525.29"	"$14,053.69"	"$8,428.00"	Not Applicable	"$7,374.50"	"$14,749.00"	"$7,374.50"	"$14,749.00"
CUP ACETABULAR PINNACLE GRIPTION OD58 MM HIP 12 DOME SCREW M 1217-30-058	C1713	SUPPLY/IMPLANTS	"$21,070.00"	Outpatient	"$10,535.00"	"$1,365.15"	"$11,525.29"	"$14,053.69"	"$8,428.00"	Not Applicable	"$7,374.50"	"$14,749.00"	"$1,365.15"	"$14,749.00"
STEM FEMORAL REMEDY STAINLESS STEEL GENTAMICIN MEDIUM L112 M RHSTMD	C1776	SUPPLY/IMPLANTS	"$21,060.00"	Outpatient	"$10,530.00"	Not Applicable	"$11,519.82"	"$14,047.02"	"$8,424.00"	Not Applicable	"$7,371.00"	"$14,742.00"	"$7,371.00"	"$14,742.00"
CUP ACETABULAR PINNACLE GRIPTION OD50 MM HIP 10 DOME SCREW MULTIHOLE II STERILE LATEX FREE REVISION	C1776	SUPPLY/IMPLANTS	"$21,057.00"	Outpatient	"$10,528.50"	Not Applicable	"$11,518.18"	"$14,045.02"	"$8,422.80"	Not Applicable	"$7,369.95"	"$14,739.90"	"$7,369.95"	"$14,739.90"
SHELL ACETABULAR PINNACLE GRIPTION OD56 MM HIP 1 MULTIHOLE S 1217-30-056	C1776	SUPPLY/IMPLANTS	"$21,057.00"	Outpatient	"$10,528.50"	Not Applicable	"$11,518.18"	"$14,045.02"	"$8,422.80"	Not Applicable	"$7,369.95"	"$14,739.90"	"$7,369.95"	"$14,739.90"
CUP ACTB 54MM PNCL 12 HL GRIPTION 1217-30-054	C1713	SUPPLY/IMPLANTS	"$21,057.00"	Outpatient	"$10,528.50"	"$1,365.15"	"$11,518.18"	"$14,045.02"	"$8,422.80"	Not Applicable	"$7,369.95"	"$14,739.90"	"$1,365.15"	"$14,739.90"
Ablate Atroventricular Node	93650	CARDIAC CATH LAB	"$21,055.00"	Outpatient	"$10,527.50"	"$10,078.84"	"$11,517.09"	"$14,043.69"	"$8,422.00"	"$7,310.00"	"$7,369.25"	"$14,738.50"	"$7,310.00"	"$14,738.50"
KIT 32MM 4MM .018IN MCTH PSHR WRE FLEXCELL RTRV 80052		STERILE SUPPLY	"$20,991.00"	Outpatient	"$10,495.50"	Not Applicable	"$11,482.08"	"$14,001.00"	"$8,396.40"	Not Applicable	"$7,346.85"	"$14,693.70"	"$7,346.85"	"$14,693.70"
INS TIB 4 11MM KN X3 TL STAB+ TRTHLN 5537-G-411	C1776	SUPPLY/IMPLANTS	"$20,948.00"	Outpatient	"$10,474.00"	Not Applicable	"$11,458.56"	"$13,972.32"	"$8,379.20"	Not Applicable	"$7,331.80"	"$14,663.60"	"$7,331.80"	"$14,663.60"
INS TIB 7 9MM KN X3 TL STAB + TRTHLN 5537-G-709	C1776	SUPPLY/IMPLANTS	"$20,948.00"	Outpatient	"$10,474.00"	Not Applicable	"$11,458.56"	"$13,972.32"	"$8,379.20"	Not Applicable	"$7,331.80"	"$14,663.60"	"$7,331.80"	"$14,663.60"
INS TIB 8 11MM KN X3 TRTHLN TL STAB + 5537-G-811	C1776	SUPPLY/IMPLANTS	"$20,948.00"	Outpatient	"$10,474.00"	Not Applicable	"$11,458.56"	"$13,972.32"	"$8,379.20"	Not Applicable	"$7,331.80"	"$14,663.60"	"$7,331.80"	"$14,663.60"
INS TIB 6 9MM KN X3 TL STAB + TRTHLN 5537-G-609	C1776	SUPPLY/IMPLANTS	"$20,948.00"	Outpatient	"$10,474.00"	Not Applicable	"$11,458.56"	"$13,972.32"	"$8,379.20"	Not Applicable	"$7,331.80"	"$14,663.60"	"$7,331.80"	"$14,663.60"
INS TIB 4 9MM KN X3 TL STAB + TRTHLN 5537-G-409	C1776	SUPPLY/IMPLANTS	"$20,947.00"	Outpatient	"$10,473.50"	Not Applicable	"$11,458.01"	"$13,971.65"	"$8,378.80"	Not Applicable	"$7,331.45"	"$14,662.90"	"$7,331.45"	"$14,662.90"
INS TIB 2 19MM KN X3 TL STAB + TRTHLN 5537-G-219	C1776	SUPPLY/IMPLANTS	"$20,947.00"	Outpatient	"$10,473.50"	Not Applicable	"$11,458.01"	"$13,971.65"	"$8,378.80"	Not Applicable	"$7,331.45"	"$14,662.90"	"$7,331.45"	"$14,662.90"
INS TIB 2 9MM KN X3 TL STAB + TRTHLN 5537-G-209	C1776	SUPPLY/IMPLANTS	"$20,947.00"	Outpatient	"$10,473.50"	Not Applicable	"$11,458.01"	"$13,971.65"	"$8,378.80"	Not Applicable	"$7,331.45"	"$14,662.90"	"$7,331.45"	"$14,662.90"
INS TIB 2 16MM KN X3 TL STAB + TRTHLN 5537-G-216	C1776	SUPPLY/IMPLANTS	"$20,947.00"	Outpatient	"$10,473.50"	Not Applicable	"$11,458.01"	"$13,971.65"	"$8,378.80"	Not Applicable	"$7,331.45"	"$14,662.90"	"$7,331.45"	"$14,662.90"
INS TIB 1 16MM KN X3 TL STAB + TRTHLN 5537-G-116	C1776	SUPPLY/IMPLANTS	"$20,946.00"	Outpatient	"$10,473.00"	Not Applicable	"$11,457.46"	"$13,970.98"	"$8,378.40"	Not Applicable	"$7,331.10"	"$14,662.20"	"$7,331.10"	"$14,662.20"
CMPNT FEM 8 KN LT CRCTE RTN BEAD TRTHLN PA 5517F801	C1776	SUPPLY/IMPLANTS	"$20,941.00"	Outpatient	"$10,470.50"	Not Applicable	"$11,454.73"	"$13,967.65"	"$8,376.40"	Not Applicable	"$7,329.35"	"$14,658.70"	"$7,329.35"	"$14,658.70"
STEM FEMORAL RESTORATION STRAIGHT CONE L195 MM OD22 MM HIP MODULAR 6276-7-122	C1776	SUPPLY/IMPLANTS	"$20,936.00"	Outpatient	"$10,468.00"	Not Applicable	"$11,451.99"	"$13,964.31"	"$8,374.40"	Not Applicable	"$7,327.60"	"$14,655.20"	"$7,327.60"	"$14,655.20"
STEM FEMORAL HIP RESTORATION 195MM X 20MM 6276-7-120	C1776	SUPPLY/IMPLANTS	"$20,936.00"	Outpatient	"$10,468.00"	Not Applicable	"$11,451.99"	"$13,964.31"	"$8,374.40"	Not Applicable	"$7,327.60"	"$14,655.20"	"$7,327.60"	"$14,655.20"
INS TIB 2 13MM KN X3 TL STAB + TRTHLN 5537-G-213	C1776	SUPPLY/IMPLANTS	"$20,934.00"	Outpatient	"$10,467.00"	Not Applicable	"$11,450.90"	"$13,962.98"	"$8,373.60"	Not Applicable	"$7,326.90"	"$14,653.80"	"$7,326.90"	"$14,653.80"
INS TIB 7 16MM KN X3 TL STAB + TRTHLN 5537-G-716	C1776	SUPPLY/IMPLANTS	"$20,934.00"	Outpatient	"$10,467.00"	Not Applicable	"$11,450.90"	"$13,962.98"	"$8,373.60"	Not Applicable	"$7,326.90"	"$14,653.80"	"$7,326.90"	"$14,653.80"
INS TIB 4 13MM KN X3 TL STAB + TRTHLN 5537-G-413	C1776	SUPPLY/IMPLANTS	"$20,934.00"	Outpatient	"$10,467.00"	Not Applicable	"$11,450.90"	"$13,962.98"	"$8,373.60"	Not Applicable	"$7,326.90"	"$14,653.80"	"$7,326.90"	"$14,653.80"
INS TIB 3 9MM KN X3 TL STAB + TRTHLN 5537-G-309	C1776	SUPPLY/IMPLANTS	"$20,934.00"	Outpatient	"$10,467.00"	Not Applicable	"$11,450.90"	"$13,962.98"	"$8,373.60"	Not Applicable	"$7,326.90"	"$14,653.80"	"$7,326.90"	"$14,653.80"
STEM FEMORAL CEMENTLESS SPLINED 20MM DIA 150MML TITANIUM ALL 11-300820	C1776	SUPPLY/IMPLANTS	"$20,930.00"	Outpatient	"$10,465.00"	Not Applicable	"$11,448.71"	"$13,960.31"	"$8,372.00"	Not Applicable	"$7,325.50"	"$14,651.00"	"$7,325.50"	"$14,651.00"
BONE SCREW 00-6520-65-20 00-6520-65-20	C1713	SUPPLY/IMPLANTS	"$20,930.00"	Outpatient	"$10,465.00"	"$1,365.15"	"$11,448.71"	"$13,960.31"	"$8,372.00"	Not Applicable	"$7,325.50"	"$14,651.00"	"$1,365.15"	"$14,651.00"
HEAD RADIAL 22MM DIA TITANIUM RIGHT ELBOW 4DEG ANGLED TR-H220R-S	C1776	SUPPLY/IMPLANTS	"$20,923.00"	Outpatient	"$10,461.50"	Not Applicable	"$11,444.88"	"$13,955.64"	"$8,369.20"	Not Applicable	"$7,323.05"	"$14,646.10"	"$7,323.05"	"$14,646.10"
STEM RADIAL ANATOMIC 22.0MM HEAD RIGHT TR-H2204-S	C1776	SUPPLY/IMPLANTS	"$20,923.00"	Outpatient	"$10,461.50"	Not Applicable	"$11,444.88"	"$13,955.64"	"$8,369.20"	Not Applicable	"$7,323.05"	"$14,646.10"	"$7,323.05"	"$14,646.10"
DEV TRGT LOPRFL ARM TIB VERSANAIL 2810-12-009	C1713	SUPPLY/IMPLANTS	"$20,921.00"	Outpatient	"$10,460.50"	"$1,365.15"	"$11,443.79"	"$13,954.31"	"$8,368.40"	Not Applicable	"$7,322.35"	"$14,644.70"	"$1,365.15"	"$14,644.70"
00078-0331-84 - basiliximab 20 mg Powd	J0480	PHARMACY	"$20,907.00"	Outpatient	"$10,453.50"	"$4,186.09"	"$11,436.13"	"$13,944.97"	"$8,362.80"	Not Applicable	"$7,317.45"	"$14,634.90"	"$4,186.09"	"$14,634.90"
PLT 14MM XLORDOTIC SPNE CRV ANT TI 1 LVL PRV BN 150.134	C1713	SUPPLY/IMPLANTS	"$20,884.00"	Outpatient	"$10,442.00"	"$1,365.15"	"$11,423.55"	"$13,929.63"	"$8,353.60"	Not Applicable	"$7,309.40"	"$14,618.80"	"$1,365.15"	"$14,618.80"
PLT 34MM SPNE CRV ANT LVL 2 PRV BN NS 150.234	C1713	SUPPLY/IMPLANTS	"$20,884.00"	Outpatient	"$10,442.00"	"$1,365.15"	"$11,423.55"	"$13,929.63"	"$8,353.60"	Not Applicable	"$7,309.40"	"$14,618.80"	"$1,365.15"	"$14,618.80"
MOD IMPL RECON SCR NTR NL ANTGRD STD TLL FEM 249000108	C1713	SUPPLY/IMPLANTS	"$20,868.00"	Outpatient	"$10,434.00"	"$1,365.15"	"$11,414.80"	"$13,918.96"	"$8,347.20"	Not Applicable	"$7,303.80"	"$14,607.60"	"$1,365.15"	"$14,607.60"
CAGE SPINAL RENOVIS TESERA 7 D CONVEX L27 MM X W9 MM X H9 MM 1043-279-009	C1821	SUPPLY/IMPLANTS	"$20,863.00"	Outpatient	"$10,431.50"	Not Applicable	"$11,412.06"	"$13,915.62"	"$8,345.20"	Not Applicable	"$7,302.05"	"$14,604.10"	"$7,302.05"	"$14,604.10"
PIVOTING SPACER SYSTEM 11-6103	C1821	SUPPLY/IMPLANTS	"$20,863.00"	Outpatient	"$10,431.50"	Not Applicable	"$11,412.06"	"$13,915.62"	"$8,345.20"	Not Applicable	"$7,302.05"	"$14,604.10"	"$7,302.05"	"$14,604.10"
CAGE SPNL 28X10X12MM CASCADIA CNVX TI POR ANTM NAR INTBDY 6101-2102812NC-G2	C1821	SUPPLY/IMPLANTS	"$20,851.00"	Outpatient	"$10,425.50"	Not Applicable	"$11,405.50"	"$13,907.62"	"$8,340.40"	Not Applicable	"$7,297.85"	"$14,595.70"	"$7,297.85"	"$14,595.70"
LEAD NRSTM 90CM 5MM 8X1CM ELTRD CMPCT MRI 977A290	C1899	PACE MAKER	"$20,849.00"	Outpatient	"$10,424.50"	Not Applicable	"$11,404.40"	"$13,906.28"	"$8,339.60"	Not Applicable	"$7,297.15"	"$14,594.30"	"$7,297.15"	"$14,594.30"
LEAD NRSTM 60CM 5MM VECTRIS 1X8 ELTRD MRI 977A260		STERILE SUPPLY	"$20,836.00"	Outpatient	"$10,418.00"	Not Applicable	"$11,397.29"	"$13,897.61"	"$8,334.40"	Not Applicable	"$7,292.60"	"$14,585.20"	"$7,292.60"	"$14,585.20"
STEM HUMERAL COMPREHENSIVE PPS L122 MM OD14 MM SHOULDER 12-113564	C1776	SUPPLY/IMPLANTS	"$20,796.00"	Outpatient	"$10,398.00"	Not Applicable	"$11,375.41"	"$13,870.93"	"$8,318.40"	Not Applicable	"$7,278.60"	"$14,557.20"	"$7,278.60"	"$14,557.20"
STEM HUMERAL COMPREHENSIVE POROUS MICRO L55 MM OD14 MM SHOUL 113614	C1776	SUPPLY/IMPLANTS	"$20,796.00"	Outpatient	"$10,398.00"	Not Applicable	"$11,375.41"	"$13,870.93"	"$8,318.40"	Not Applicable	"$7,278.60"	"$14,557.20"	"$7,278.60"	"$14,557.20"
STEM HUMERAL REUNION L123 MM OD11 MM STERILE REVERSIBLE FRAC 5568-0011	C1776	SUPPLY/IMPLANTS	"$20,796.00"	Outpatient	"$10,398.00"	Not Applicable	"$11,375.41"	"$13,870.93"	"$8,318.40"	Not Applicable	"$7,278.60"	"$14,557.20"	"$7,278.60"	"$14,557.20"
GFT EVAS 7CM 14.5MM GORE XCLDR ILC INTNL CMPNT AAA HGB161407A	C1874	SUPPLY/IMPLANTS	"$20,791.00"	Outpatient	"$10,395.50"	Not Applicable	"$11,372.68"	"$13,867.60"	"$8,316.40"	Not Applicable	"$7,276.85"	"$14,553.70"	"$7,276.85"	"$14,553.70"
LEAD PCNG 86CM 4.7FR LH QRTT QDPL IS-4 LLLL CNCT 8 CRV 1456Q/86	C1900	PACE MAKER	"$20,791.00"	Outpatient	"$10,395.50"	Not Applicable	"$11,372.68"	"$13,867.60"	"$8,316.40"	Not Applicable	"$7,276.85"	"$14,553.70"	"$7,276.85"	"$14,553.70"
LEAD PCNG 86CM 4.7FR LH QRTT QDPL IS-4 LLLL CNCT 16 CRV 1458QL/86	C1900	SUPPLY/IMPLANTS	"$20,791.00"	Outpatient	"$10,395.50"	Not Applicable	"$11,372.68"	"$13,867.60"	"$8,316.40"	Not Applicable	"$7,276.85"	"$14,553.70"	"$7,276.85"	"$14,553.70"
GFT EVAS 7CM 12MM GORE XCLDR ILC INTNL CMPNT AAA HGB161207A	C1884	SUPPLY/IMPLANTS	"$20,791.00"	Outpatient	"$10,395.50"	Not Applicable	"$11,372.68"	"$13,867.60"	"$8,316.40"	Not Applicable	"$7,276.85"	"$14,553.70"	"$7,276.85"	"$14,553.70"
STEM HUM 7MM CMNT REUNION T/S ARTHPL 5569-C-2007	C1776	SUPPLY/IMPLANTS	"$20,785.00"	Outpatient	"$10,392.50"	Not Applicable	"$11,369.40"	"$13,863.60"	"$8,314.00"	Not Applicable	"$7,274.75"	"$14,549.50"	"$7,274.75"	"$14,549.50"
CATH GD MITRACLIP STRBL STRL SGC0301	C1887	SUPPLY/IMPLANTS	"$20,785.00"	Outpatient	"$10,392.50"	Not Applicable	"$11,369.40"	"$13,863.60"	"$8,314.00"	Not Applicable	"$7,274.75"	"$14,549.50"	"$7,274.75"	"$14,549.50"
GRAFT VIABAHN 7MM X 120CM VBRJR071502A	C1874	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
STEM HUM 122MM 6MM CMPRH PPS SHLDR 12-113556	C1776	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
STEM HUM 55MM 10MM CMPRH POR MIC SHLDR RVRS SYS 113610	C1776	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
STEM HUMERAL REUNION L123 MM OD11 MM SHOULDER PRESSFIT STERI 5569-P-2011	C1776	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
ELTRD ESURG 6MM 6.1CM ISLTR SNG X CRV V2 EML2	C1713	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	"$1,365.15"	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$1,365.15"	"$14,548.80"
PLT 2.5MM SM MNDB RT TI PRFRM RECON MATRIXMANDIBLE BN NS 04.503.900	C1713	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	"$1,365.15"	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$1,365.15"	"$14,548.80"
PLT 2.5MM SM MNDB LT TI PRFRM RECON MATRIXMANDIBLE BN NS 04.503.901	C1713	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	"$1,365.15"	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$1,365.15"	"$14,548.80"
PLT 37MM SPNE 3 HL PRMD BN 9873137	C1713	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	"$1,365.15"	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$1,365.15"	"$14,548.80"
GFT EVAS 7CM 10MM GORE XCLDR ILC INTNL CMPNT AAA HGB161007A	C1884	SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
CLP ESURG 6.1CM ISLTR SNG RT CRV MN INVSV ABLT SYS ELTRD EMR2		STERILE SUPPLY	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
FCP LAPSCP 1CM DVNC XI EWRST BLK DMD MIC RPSB 15 31.5CM 470033		STERILE SUPPLY	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
WATCHMAN TRUSEAL ACCESS SYSTEM SGL US M635TU70010		SUPPLY/IMPLANTS	"$20,784.00"	Outpatient	"$10,392.00"	Not Applicable	"$11,368.85"	"$13,862.93"	"$8,313.60"	Not Applicable	"$7,274.40"	"$14,548.80"	"$7,274.40"	"$14,548.80"
PLT 12MM LMBR ALAT LVL 1 BN 4508-41F12	C1713	SUPPLY/IMPLANTS	"$20,782.00"	Outpatient	"$10,391.00"	"$1,365.15"	"$11,367.75"	"$13,861.59"	"$8,312.80"	Not Applicable	"$7,273.70"	"$14,547.40"	"$1,365.15"	"$14,547.40"
MESH 122X122X.5MM CRNL DLT 1.7MM PLT 7005150	C1763	SUPPLY/IMPLANTS	"$20,782.00"	Outpatient	"$10,391.00"	Not Applicable	"$11,367.75"	"$13,861.59"	"$8,312.80"	Not Applicable	"$7,273.70"	"$14,547.40"	"$7,273.70"	"$14,547.40"
SUB BNGF 10CC INJ OSTCNDC RADOPQ HYDROSET HA 397010		STERILE SUPPLY	"$20,782.00"	Outpatient	"$10,391.00"	Not Applicable	"$11,367.75"	"$13,861.59"	"$8,312.80"	Not Applicable	"$7,273.70"	"$14,547.40"	"$7,273.70"	"$14,547.40"
TNSNR SRG CBL 223206001		STERILE SUPPLY	"$20,776.00"	Outpatient	"$10,388.00"	Not Applicable	"$11,364.47"	"$13,857.59"	"$8,310.40"	Not Applicable	"$7,271.60"	"$14,543.20"	"$7,271.60"	"$14,543.20"
LEAD NRSTM 1.27MM INTSTM 3MM SPC STRG INLN CNCT TN 3889	C1778	SUPPLY/IMPLANTS	"$20,762.00"	Outpatient	"$10,381.00"	Not Applicable	"$11,356.81"	"$13,848.25"	"$8,304.80"	Not Applicable	"$7,266.70"	"$14,533.40"	"$7,266.70"	"$14,533.40"
GFT SKN 6X3IN THERASKIN 116SQ CM XL ALGRF CRPRS PREMESH 103TSXL	Q4121	PHARMACY	"$20,757.00"	Outpatient	"$10,378.50"	$46.78	"$11,354.08"	"$13,844.92"	"$8,302.80"	Not Applicable	"$7,264.95"	"$14,529.90"	$46.78	"$14,529.90"
NAIL IM 360MM 10MM T2 TI FEM GT LT STRL 1850-1036S	C1713	SUPPLY/IMPLANTS	"$20,751.00"	Outpatient	"$10,375.50"	"$1,365.15"	"$11,350.80"	"$13,840.92"	"$8,300.40"	Not Applicable	"$7,262.85"	"$14,525.70"	"$1,365.15"	"$14,525.70"
NAIL EFT 3.0 X 130MM FIBULA FIB30130L	C1713	SUPPLY/IMPLANTS	"$20,749.00"	Outpatient	"$10,374.50"	"$1,365.15"	"$11,349.70"	"$13,839.58"	"$8,299.60"	Not Applicable	"$7,262.15"	"$14,524.30"	"$1,365.15"	"$14,524.30"
GRAFT STENT FLUENCY PLUS EPTFE CARBON L40 MM L80 CM OD9 MM O FEM09040	C1874	SUPPLY/IMPLANTS	"$20,748.00"	Outpatient	"$10,374.00"	Not Applicable	"$11,349.16"	"$13,838.92"	"$8,299.20"	Not Applicable	"$7,261.80"	"$14,523.60"	"$7,261.80"	"$14,523.60"
STNT HEP 8MM 8FR SPRFC FEM ART ILIUM 5CM DLV SYS VBHN EPRSTH VBH080502	C1884	SUPPLY/IMPLANTS	"$20,748.00"	Outpatient	"$10,374.00"	Not Applicable	"$11,349.16"	"$13,838.92"	"$8,299.20"	Not Applicable	"$7,261.80"	"$14,523.60"	"$7,261.80"	"$14,523.60"
CATH THRMB DYSON 132CM ARC-132		STERILE SUPPLY	"$20,748.00"	Outpatient	"$10,374.00"	Not Applicable	"$11,349.16"	"$13,838.92"	"$8,299.20"	Not Applicable	"$7,261.80"	"$14,523.60"	"$7,261.80"	"$14,523.60"
SYS O2DEL PORT CO2MMANDER CO2 COM12		STERILE SUPPLY	"$20,748.00"	Outpatient	"$10,374.00"	Not Applicable	"$11,349.16"	"$13,838.92"	"$8,299.20"	Not Applicable	"$7,261.80"	"$14,523.60"	"$7,261.80"	"$14,523.60"
GFT STNT 60MM 8MM 9FR FLN + EVAS C EPTFE 2 LYR KINK RST INR FEM08060	C1876	SUPPLY/IMPLANTS	"$20,743.00"	Outpatient	"$10,371.50"	Not Applicable	"$11,346.42"	"$13,835.58"	"$8,297.20"	Not Applicable	"$7,260.05"	"$14,520.10"	"$7,260.05"	"$14,520.10"
STEM FEM 150MM 18MM TPR ARCOS STS TI DIST PRFT SPLINE STRL 11-300818	C1776	SUPPLY/IMPLANTS	"$20,739.00"	Outpatient	"$10,369.50"	Not Applicable	"$11,344.23"	"$13,832.91"	"$8,295.60"	Not Applicable	"$7,258.65"	"$14,517.30"	"$7,258.65"	"$14,517.30"
STEM FEM 150MM 14MM TPR ARCOS STS TI DIST PRFT SPLINE STRL 11-300814	C1776	SUPPLY/IMPLANTS	"$20,739.00"	Outpatient	"$10,369.50"	Not Applicable	"$11,344.23"	"$13,832.91"	"$8,295.60"	Not Applicable	"$7,258.65"	"$14,517.30"	"$7,258.65"	"$14,517.30"
STEM FEM 150MM 22MM TPR ARCOS STS TI DIST PRFT SPLINE STRL 11-300822	C1776	SUPPLY/IMPLANTS	"$20,739.00"	Outpatient	"$10,369.50"	Not Applicable	"$11,344.23"	"$13,832.91"	"$8,295.60"	Not Applicable	"$7,258.65"	"$14,517.30"	"$7,258.65"	"$14,517.30"
GFT STNT 40MM 9FR 10MM FLN + EVAS EPTFE 2 LYR KINK RST FEM10040	C1874	SUPPLY/IMPLANTS	"$20,735.00"	Outpatient	"$10,367.50"	Not Applicable	"$11,342.05"	"$13,830.25"	"$8,294.00"	Not Applicable	"$7,257.25"	"$14,514.50"	"$7,257.25"	"$14,514.50"
GFT STNT 40MM 8MM 9FR FLN + EVAS EPTFE C 2 LYR KINK RST INR FEM08040	C1874	SUPPLY/IMPLANTS	"$20,735.00"	Outpatient	"$10,367.50"	Not Applicable	"$11,342.05"	"$13,830.25"	"$8,294.00"	Not Applicable	"$7,257.25"	"$14,514.50"	"$7,257.25"	"$14,514.50"
GFT STNT 60MM 9MM 9FR FLN + EVAS EPTFE C 2 LYR KINK RST INR FEM09060		SUPPLY/IMPLANTS	"$20,735.00"	Outpatient	"$10,367.50"	Not Applicable	"$11,342.05"	"$13,830.25"	"$8,294.00"	Not Applicable	"$7,257.25"	"$14,514.50"	"$7,257.25"	"$14,514.50"
STNT TRCHBR 10MM 9FR 80MM 80CM GFT FLN + NTNL STRL ACPT .035 FTM10080	C1876	SUPPLY/IMPLANTS	"$20,734.00"	Outpatient	"$10,367.00"	Not Applicable	"$11,341.50"	"$13,829.58"	"$8,293.60"	Not Applicable	"$7,256.90"	"$14,513.80"	"$7,256.90"	"$14,513.80"
TNSNR SRG CBL RD SS 30-100LB 1.8MM CBL NS 223200500		STERILE SUPPLY	"$20,730.00"	Outpatient	"$10,365.00"	Not Applicable	"$11,339.31"	"$13,826.91"	"$8,292.00"	Not Applicable	"$7,255.50"	"$14,511.00"	"$7,255.50"	"$14,511.00"
55513-0222-01 - romiPLOStim 500 mcg Powd	J2796	PHARMACY	"$20,729.00"	Outpatient	"$10,364.50"	$75.38	"$11,338.76"	"$13,826.24"	"$8,291.60"	Not Applicable	"$7,255.15"	"$14,510.30"	$75.38	"$14,510.30"
XTN FEM 30MM GMRS KN COCR 6495-6-030		STERILE SUPPLY	"$20,723.00"	Outpatient	"$10,361.50"	Not Applicable	"$11,335.48"	"$13,822.24"	"$8,289.20"	Not Applicable	"$7,253.05"	"$14,506.10"	"$7,253.05"	"$14,506.10"
STNT TRCHBR 10MM 9FR 60MM 80CM GFT FLN + NTNL STRL ACPT .035 FTM10060	C1874	SUPPLY/IMPLANTS	"$20,719.00"	Outpatient	"$10,359.50"	Not Applicable	"$11,333.29"	"$13,819.57"	"$8,287.60"	Not Applicable	"$7,251.65"	"$14,503.30"	"$7,251.65"	"$14,503.30"
XTN FEM 70MM GMRS KN COCR 64956070		STERILE SUPPLY	"$20,718.00"	Outpatient	"$10,359.00"	Not Applicable	"$11,332.75"	"$13,818.91"	"$8,287.20"	Not Applicable	"$7,251.30"	"$14,502.60"	"$7,251.30"	"$14,502.60"
XTN FEM 50MM GMRS KN COCR 64956050		STERILE SUPPLY	"$20,718.00"	Outpatient	"$10,359.00"	Not Applicable	"$11,332.75"	"$13,818.91"	"$8,287.20"	Not Applicable	"$7,251.30"	"$14,502.60"	"$7,251.30"	"$14,502.60"
MOD IMPL INTLK SCR NTR NL ANTGRD STD FEM 249000103	C1713	SUPPLY/IMPLANTS	"$20,712.00"	Outpatient	"$10,356.00"	"$1,365.15"	"$11,329.46"	"$13,814.90"	"$8,284.80"	Not Applicable	"$7,249.20"	"$14,498.40"	"$1,365.15"	"$14,498.40"
SCREW SACRAL 6.5 X 45MM Z62365-45	C1713	SUPPLY/IMPLANTS	"$20,696.00"	Outpatient	"$10,348.00"	"$1,365.15"	"$11,320.71"	"$13,804.23"	"$8,278.40"	Not Applicable	"$7,243.60"	"$14,487.20"	"$1,365.15"	"$14,487.20"
PLT 0D HMSPHR CRNMXF RT 6X17 HL BN 9228920	C1713	SUPPLY/IMPLANTS	"$20,693.00"	Outpatient	"$10,346.50"	"$1,365.15"	"$11,319.07"	"$13,802.23"	"$8,277.20"	Not Applicable	"$7,242.55"	"$14,485.10"	"$1,365.15"	"$14,485.10"
BRIDGE ADJUSTABLE 5.5MM A11-2042	C1713	SUPPLY/IMPLANTS	"$20,690.00"	Outpatient	"$10,345.00"	"$1,365.15"	"$11,317.43"	"$13,800.23"	"$8,276.00"	Not Applicable	"$7,241.50"	"$14,483.00"	"$1,365.15"	"$14,483.00"
SCREW SACRAL PA 6.5 X 35MM Z62365-35	C1713	SUPPLY/IMPLANTS	"$20,684.00"	Outpatient	"$10,342.00"	"$1,365.15"	"$11,314.15"	"$13,796.23"	"$8,273.60"	Not Applicable	"$7,239.40"	"$14,478.80"	"$1,365.15"	"$14,478.80"
SCREW SACRAL ZODIAK PA 6.5 X 40MM Z62365-40	C1713	SUPPLY/IMPLANTS	"$20,684.00"	Outpatient	"$10,342.00"	"$1,365.15"	"$11,314.15"	"$13,796.23"	"$8,273.60"	Not Applicable	"$7,239.40"	"$14,478.80"	"$1,365.15"	"$14,478.80"
BRIDGE MED ADJUSTABLE 5.5MM A11-2053	C1713	SUPPLY/IMPLANTS	"$20,679.00"	Outpatient	"$10,339.50"	"$1,365.15"	"$11,311.41"	"$13,792.89"	"$8,271.60"	Not Applicable	"$7,237.65"	"$14,475.30"	"$1,365.15"	"$14,475.30"
NAIL IM 380MM 11MM RECON T2 TI LT STRL 1846-1138S	C1713	SUPPLY/IMPLANTS	"$20,655.00"	Outpatient	"$10,327.50"	"$1,365.15"	"$11,298.29"	"$13,776.89"	"$8,262.00"	Not Applicable	"$7,229.25"	"$14,458.50"	"$1,365.15"	"$14,458.50"
NAIL IM 340MM 9MM RECON T2 TI LT STRL 1846-0934S	C1713	SUPPLY/IMPLANTS	"$20,655.00"	Outpatient	"$10,327.50"	"$1,365.15"	"$11,298.29"	"$13,776.89"	"$8,262.00"	Not Applicable	"$7,229.25"	"$14,458.50"	"$1,365.15"	"$14,458.50"
CASE GRPH LCK SCR SIRUS 10099108		STERILE SUPPLY	"$20,652.00"	Outpatient	"$10,326.00"	Not Applicable	"$11,296.64"	"$13,774.88"	"$8,260.80"	Not Applicable	"$7,228.20"	"$14,456.40"	"$7,228.20"	"$14,456.40"
CEMENT BONE HYDROSET XT HA 10 CC INJECTABLE STERILE LATEX FR 897010	C1713	SUPPLY/IMPLANTS	"$20,621.00"	Outpatient	"$10,310.50"	"$1,365.15"	"$11,279.69"	"$13,754.21"	"$8,248.40"	Not Applicable	"$7,217.35"	"$14,434.70"	"$1,365.15"	"$14,434.70"
IMPL FX 1 NCEM STABLYX CMC STRL ARTHPL STX-CMA-IS1	C1776	SUPPLY/IMPLANTS	"$20,609.00"	Outpatient	"$10,304.50"	Not Applicable	"$11,273.12"	"$13,746.20"	"$8,243.60"	Not Applicable	"$7,213.15"	"$14,426.30"	"$7,213.15"	"$14,426.30"
IMPL FX 2 11.3MM NCEM LNG PLMR LIP STABLYX 15.2MMX13.20MM STX-CMA-IS2	C1776	SUPPLY/IMPLANTS	"$20,609.00"	Outpatient	"$10,304.50"	Not Applicable	"$11,273.12"	"$13,746.20"	"$8,243.60"	Not Applicable	"$7,213.15"	"$14,426.30"	"$7,213.15"	"$14,426.30"
IMPL FX 3 NCEM STABLYX CMC STRL ARTHPL STX-CMA-IS3	C1776	SUPPLY/IMPLANTS	"$20,609.00"	Outpatient	"$10,304.50"	Not Applicable	"$11,273.12"	"$13,746.20"	"$8,243.60"	Not Applicable	"$7,213.15"	"$14,426.30"	"$7,213.15"	"$14,426.30"
IMPL FX 5 NCEM STABLYX CMC STRL ARTHPL STX-CMA-IS5	C1776	SUPPLY/IMPLANTS	"$20,609.00"	Outpatient	"$10,304.50"	Not Applicable	"$11,273.12"	"$13,746.20"	"$8,243.60"	Not Applicable	"$7,213.15"	"$14,426.30"	"$7,213.15"	"$14,426.30"
JNT FNGR 18.7X14.37MM 7.8MM STABLYX 4 CMC 13.9MM ARTHPL STX-CMA-IS4	C1776	SUPPLY/IMPLANTS	"$20,609.00"	Outpatient	"$10,304.50"	Not Applicable	"$11,273.12"	"$13,746.20"	"$8,243.60"	Not Applicable	"$7,213.15"	"$14,426.30"	"$7,213.15"	"$14,426.30"
VLV SHNT STRT2 2IN FULL PORT SM CSF 30MM 42856		SUPPLY/IMPLANTS	"$20,604.00"	Outpatient	"$10,302.00"	Not Applicable	"$11,270.39"	"$13,742.87"	"$8,241.60"	Not Applicable	"$7,211.40"	"$14,422.80"	"$7,211.40"	"$14,422.80"
STEM FEM 120MM 127D 9 53MM OFST ACLD II V40 PUREFIX TI PLSM 6721-0937	C1776	SUPPLY/IMPLANTS	"$20,583.00"	Outpatient	"$10,291.50"	Not Applicable	"$11,258.90"	"$13,728.86"	"$8,233.20"	Not Applicable	"$7,204.05"	"$14,408.10"	"$7,204.05"	"$14,408.10"
STEM FEM 117MM 127D 8 TPR ACLD 37MM HIP MDLR STRL 6721-0837	C1776	SUPPLY/IMPLANTS	"$20,583.00"	Outpatient	"$10,291.50"	Not Applicable	"$11,258.90"	"$13,728.86"	"$8,233.20"	Not Applicable	"$7,204.05"	"$14,408.10"	"$7,204.05"	"$14,408.10"
STEM FEM 155MM 14MM 8 RSTR TI HA HIP 6012-0814	C1776	SUPPLY/IMPLANTS	"$20,576.00"	Outpatient	"$10,288.00"	Not Applicable	"$11,255.07"	"$13,724.19"	"$8,230.40"	Not Applicable	"$7,201.60"	"$14,403.20"	"$7,201.60"	"$14,403.20"
ETEX GAMMA-BSM 10CC 76-6010		STERILE SUPPLY	"$20,576.00"	Outpatient	"$10,288.00"	Not Applicable	"$11,255.07"	"$13,724.19"	"$8,230.40"	Not Applicable	"$7,201.60"	"$14,403.20"	"$7,201.60"	"$14,403.20"
ETEX GAMMA-BSM 5CC 76-6005		STERILE SUPPLY	"$20,576.00"	Outpatient	"$10,288.00"	Not Applicable	"$11,255.07"	"$13,724.19"	"$8,230.40"	Not Applicable	"$7,201.60"	"$14,403.20"	"$7,201.60"	"$14,403.20"
FIL BN VOID CERAMENT 10ML 800-4001	C9362	SUPPLY/IMPLANTS	"$20,575.00"	Outpatient	"$10,287.50"	$110.85	"$11,254.53"	"$13,723.53"	"$8,230.00"	Not Applicable	"$7,201.25"	"$14,402.50"	$110.85	"$14,402.50"
FIL BN VOID CERAMENT HA CA SLF 10ML VLV STRL DISP A 0210-08	C9362	SUPPLY/IMPLANTS	"$20,575.00"	Outpatient	"$10,287.50"	$110.85	"$11,254.53"	"$13,723.53"	"$8,230.00"	Not Applicable	"$7,201.25"	"$14,402.50"	$110.85	"$14,402.50"
STEM FEMORAL RESTORATION PUREFIX TITANIUM CONICAL STRAIGHT L 6276-7-014	C1776	SUPPLY/IMPLANTS	"$20,571.00"	Outpatient	"$10,285.50"	Not Applicable	"$11,252.34"	"$13,720.86"	"$8,228.40"	Not Applicable	"$7,199.85"	"$14,399.70"	"$7,199.85"	"$14,399.70"
DXTEND MBLOC HUM EPI 2 D14 STD 1307-14-200	C1776	SUPPLY/IMPLANTS	"$20,570.00"	Outpatient	"$10,285.00"	Not Applicable	"$11,251.79"	"$13,720.19"	"$8,228.00"	Not Applicable	"$7,199.50"	"$14,399.00"	"$7,199.50"	"$14,399.00"
STEM FEM 120MM 11MM 132D 2 36MM OFST CITN PUREFIX TMZF 26MM 6265-5-102	C1776	SUPPLY/IMPLANTS	"$20,559.00"	Outpatient	"$10,279.50"	Not Applicable	"$11,245.77"	"$13,712.85"	"$8,223.60"	Not Applicable	"$7,195.65"	"$14,391.30"	"$7,195.65"	"$14,391.30"
CNN GD CORRIDOR KRSH SCR WRE STRL 648.010S		NON-STER SUPPLY	"$20,507.00"	Outpatient	"$10,253.50"	Not Applicable	"$11,217.33"	"$13,678.17"	"$8,202.80"	Not Applicable	"$7,177.45"	"$14,354.90"	"$7,177.45"	"$14,354.90"
GD OBLQ MDN SRG SS TIB PROX NS IM NL 225503300	C1713	SUPPLY/IMPLANTS	"$20,481.00"	Outpatient	"$10,240.50"	"$1,365.15"	"$11,203.11"	"$13,660.83"	"$8,192.40"	Not Applicable	"$7,168.35"	"$14,336.70"	"$1,365.15"	"$14,336.70"
PLT 54X17X2MM SPNE CRV ANT TI 3 LVL PRECONTOUR LOPRFL ACP354	C1713	SUPPLY/IMPLANTS	"$20,444.00"	Outpatient	"$10,222.00"	"$1,365.15"	"$11,182.87"	"$13,636.15"	"$8,177.60"	Not Applicable	"$7,155.40"	"$14,310.80"	"$1,365.15"	"$14,310.80"
PORCINE COLLAGEN WOUND MATRIX WITH PHMB ANTIMICROBIAL (8CM X PURAPLY AM-COM 8X16		STERILE SUPPLY	"$20,438.00"	Outpatient	"$10,219.00"	Not Applicable	"$11,179.59"	"$13,632.15"	"$8,175.20"	Not Applicable	"$7,153.30"	"$14,306.60"	"$7,153.30"	"$14,306.60"
HEAD SHOULDER HUMERAL 400 X18MM R5350-4521	C1776	SUPPLY/IMPLANTS	"$20,436.00"	Outpatient	"$10,218.00"	Not Applicable	"$11,178.49"	"$13,630.81"	"$8,174.40"	Not Applicable	"$7,152.60"	"$14,305.20"	"$7,152.60"	"$14,305.20"
CATH CHLGM SPYSCOPE DS ACC DLV DISP M00546600		STERILE SUPPLY	"$20,436.00"	Outpatient	"$10,218.00"	Not Applicable	"$11,178.49"	"$13,630.81"	"$8,174.40"	Not Applicable	"$7,152.60"	"$14,305.20"	"$7,152.60"	"$14,305.20"
HEAD HUM 18MM 40MM SHLDR REUNION 2 RDS STRL LF R5350-4018	C1776	SUPPLY/IMPLANTS	"$20,434.00"	Outpatient	"$10,217.00"	Not Applicable	"$11,177.40"	"$13,629.48"	"$8,173.60"	Not Applicable	"$7,151.90"	"$14,303.80"	"$7,151.90"	"$14,303.80"
CMPNT GLND 48MM KLD REUNION X3 SHLDR STRL 5542-K-0048	C1776	SUPPLY/IMPLANTS	"$20,421.00"	Outpatient	"$10,210.50"	Not Applicable	"$11,170.29"	"$13,620.81"	"$8,168.40"	Not Applicable	"$7,147.35"	"$14,294.70"	"$7,147.35"	"$14,294.70"
PLT ORTH 7 HL CBL BN 350824	C1713	SUPPLY/IMPLANTS	"$20,408.00"	Outpatient	"$10,204.00"	"$1,365.15"	"$11,163.18"	"$13,612.14"	"$8,163.20"	Not Applicable	"$7,142.80"	"$14,285.60"	"$1,365.15"	"$14,285.60"
SET ORTH DIST RADL 5070	C1713	SUPPLY/IMPLANTS	"$20,408.00"	Outpatient	"$10,204.00"	"$1,365.15"	"$11,163.18"	"$13,612.14"	"$8,163.20"	Not Applicable	"$7,142.80"	"$14,285.60"	"$1,365.15"	"$14,285.60"
NAIL IM 360MM 12MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.257S	C1713	SUPPLY/IMPLANTS	"$20,388.00"	Outpatient	"$10,194.00"	"$1,365.15"	"$11,152.24"	"$13,598.80"	"$8,155.20"	Not Applicable	"$7,135.80"	"$14,271.60"	"$1,365.15"	"$14,271.60"
NAIL IM 400MM 12MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.261S	C1713	SUPPLY/IMPLANTS	"$20,380.00"	Outpatient	"$10,190.00"	"$1,365.15"	"$11,147.86"	"$13,593.46"	"$8,152.00"	Not Applicable	"$7,133.00"	"$14,266.00"	"$1,365.15"	"$14,266.00"
NAIL IM 380MM 12MM 130D LNG CNN TFN-ADV TI COCR FEM PROX 04.037.259S	C1713	SUPPLY/IMPLANTS	"$20,380.00"	Outpatient	"$10,190.00"	"$1,365.15"	"$11,147.86"	"$13,593.46"	"$8,152.00"	Not Applicable	"$7,133.00"	"$14,266.00"	"$1,365.15"	"$14,266.00"
NAIL IM 400MM 12MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.260S	C1713	SUPPLY/IMPLANTS	"$20,380.00"	Outpatient	"$10,190.00"	"$1,365.15"	"$11,147.86"	"$13,593.46"	"$8,152.00"	Not Applicable	"$7,133.00"	"$14,266.00"	"$1,365.15"	"$14,266.00"
NAIL IM 380MM 10MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.059S	C1713	SUPPLY/IMPLANTS	"$20,380.00"	Outpatient	"$10,190.00"	"$1,365.15"	"$11,147.86"	"$13,593.46"	"$8,152.00"	Not Applicable	"$7,133.00"	"$14,266.00"	"$1,365.15"	"$14,266.00"
NAIL IM 400MM 10MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.060S	C1713	SUPPLY/IMPLANTS	"$20,380.00"	Outpatient	"$10,190.00"	"$1,365.15"	"$11,147.86"	"$13,593.46"	"$8,152.00"	Not Applicable	"$7,133.00"	"$14,266.00"	"$1,365.15"	"$14,266.00"
CATH ATHRCM 113CM 3.5-7MM TURBOHAWK MEC LOPRFL PERI LV XTD TH-LX-M	C1714	SUPPLY/IMPLANTS	"$20,368.00"	Outpatient	"$10,184.00"	Not Applicable	"$11,141.30"	"$13,585.46"	"$8,147.20"	Not Applicable	"$7,128.80"	"$14,257.60"	"$7,128.80"	"$14,257.60"
CATH ATHRCM 110CM 3.5-7MM TURBOHAWK MEC PERI LV STD CA TIP H THS-LS-C	C1714	SUPPLY/IMPLANTS	"$20,368.00"	Outpatient	"$10,184.00"	Not Applicable	"$11,141.30"	"$13,585.46"	"$8,147.20"	Not Applicable	"$7,128.80"	"$14,257.60"	"$7,128.80"	"$14,257.60"
CATH ATHRCM 110CM 3.5-7MM TURBOHAWK MEC 6CM PERI LV STD TIP TH-LS-M	C1714	SUPPLY/IMPLANTS	"$20,368.00"	Outpatient	"$10,184.00"	Not Applicable	"$11,141.30"	"$13,585.46"	"$8,147.20"	Not Applicable	"$7,128.80"	"$14,257.60"	"$7,128.80"	"$14,257.60"
CATH ATHRCM 135CM 2-4MM TURBOHAWK MEC PERI ART SV CA XTD TIP THS-SX-C	C1714	SUPPLY/IMPLANTS	"$20,368.00"	Outpatient	"$10,184.00"	Not Applicable	"$11,141.30"	"$13,585.46"	"$8,147.20"	Not Applicable	"$7,128.80"	"$14,257.60"	"$7,128.80"	"$14,257.60"
CATH ATHRCM 149CM 2-4MM TURBOHAWK MEC PERI SV CA H EFF CUT THS-SS-CL	C1714	SUPPLY/IMPLANTS	"$20,368.00"	Outpatient	"$10,184.00"	Not Applicable	"$11,141.30"	"$13,585.46"	"$8,147.20"	Not Applicable	"$7,128.80"	"$14,257.60"	"$7,128.80"	"$14,257.60"
MOD IMPL INTLK SCR NTR NL ANTGRD TLL FEM 249000153	C1713	SUPPLY/IMPLANTS	"$20,367.00"	Outpatient	"$10,183.50"	"$1,365.15"	"$11,140.75"	"$13,584.79"	"$8,146.80"	Not Applicable	"$7,128.45"	"$14,256.90"	"$1,365.15"	"$14,256.90"
STNT HEP 5MM 6FR SPRFC FEM ART ILIUM 5CM DLV SYS VBHN EPRSTH VBJ050502	C1874	SUPPLY/IMPLANTS	"$20,365.00"	Outpatient	"$10,182.50"	Not Applicable	"$11,139.66"	"$13,583.46"	"$8,146.00"	Not Applicable	"$7,127.75"	"$14,255.50"	"$7,127.75"	"$14,255.50"
STEM FEM 75MM 18MM UNV FLUT KN PRFT 867418	C1776	SUPPLY/IMPLANTS	"$20,334.00"	Outpatient	"$10,167.00"	Not Applicable	"$11,122.70"	"$13,562.78"	"$8,133.60"	Not Applicable	"$7,116.90"	"$14,233.80"	"$7,116.90"	"$14,233.80"
LINR ACTB 54MM 36MM 20D XLPE R3 HIP 71335754	C1776	SUPPLY/IMPLANTS	"$20,332.00"	Outpatient	"$10,166.00"	Not Applicable	"$11,121.60"	"$13,561.44"	"$8,132.80"	Not Applicable	"$7,116.20"	"$14,232.40"	"$7,116.20"	"$14,232.40"
50633-0120-11 - digoxin immune FAB 40 mg Inj	J1162	PHARMACY	"$20,313.00"	Outpatient	"$10,156.50"	"$4,366.54"	"$11,111.21"	"$13,548.77"	"$8,125.20"	Not Applicable	"$7,109.55"	"$14,219.10"	"$4,366.54"	"$14,219.10"
CASE STRL PLT MOD LG NS MATRIXMANDIBLE SYS 306.749	C1713	SUPPLY/IMPLANTS	"$20,312.00"	Outpatient	"$10,156.00"	"$1,365.15"	"$11,110.66"	"$13,548.10"	"$8,124.80"	Not Applicable	"$7,109.20"	"$14,218.40"	"$1,365.15"	"$14,218.40"
END CAP SPINAL OBELISC TITANIUM 5 D H1.5 MM OD24 MM THORACIC CS 2926-05	C1713	SUPPLY/IMPLANTS	"$20,290.00"	Outpatient	"$10,145.00"	"$1,365.15"	"$11,098.63"	"$13,533.43"	"$8,116.00"	Not Applicable	"$7,101.50"	"$14,203.00"	"$1,365.15"	"$14,203.00"
Revision of Aortic Valve	92986	CARDIAC CATH LAB	"$20,279.00"	Outpatient	"$10,139.50"	"$16,456.07"	"$11,092.61"	"$8,056.00"	"$8,111.60"	"$7,310.00"	"$7,097.65"	"$14,195.30"	"$7,097.65"	"$16,456.07"
00024-5841-01 - ziv-aflibercept 25 mg/mL Soln	J9400	PHARMACY	"$17,012.00"	Outpatient	"$8,506.00"	$9.30	"$11,057.80"	"$11,347.00"	"$6,804.80"	Not Applicable	"$5,954.20"	"$11,908.40"	$9.30	"$11,908.40"
STEM FEM 99MM 132D 2 33MM OFST ACLD II V40 PUREFIX TI PLSM 6720-0230	C1776	SUPPLY/IMPLANTS	"$20,193.00"	Outpatient	"$10,096.50"	Not Applicable	"$11,045.57"	"$13,468.73"	"$8,077.20"	Not Applicable	"$7,067.55"	"$14,135.10"	"$7,067.55"	"$14,135.10"
STEM FEM 108MM 127D 5 TPR ACLD 35MM HIP MDLR STRL 6721-0535	C1776	SUPPLY/IMPLANTS	"$20,193.00"	Outpatient	"$10,096.50"	Not Applicable	"$11,045.57"	"$13,468.73"	"$8,077.20"	Not Applicable	"$7,067.55"	"$14,135.10"	"$7,067.55"	"$14,135.10"
STEM FEM 105MM 127D 4 TPR ACLD 35MM HIP MDLR STRL 6721-0435	C1776	SUPPLY/IMPLANTS	"$20,193.00"	Outpatient	"$10,096.50"	Not Applicable	"$11,045.57"	"$13,468.73"	"$8,077.20"	Not Applicable	"$7,067.55"	"$14,135.10"	"$7,067.55"	"$14,135.10"
STEM FEM 120MM 132D 9 49MM OFST ACLD II V40 PUREFIX TI PLSM 6720-0937	C1776	SUPPLY/IMPLANTS	"$20,193.00"	Outpatient	"$10,096.50"	Not Applicable	"$11,045.57"	"$13,468.73"	"$8,077.20"	Not Applicable	"$7,067.55"	"$14,135.10"	"$7,067.55"	"$14,135.10"
STEM FEM 117MM 132D 8 47MM OFST ACLD II V40 PUREFIX TI PLSM 6720-0837	C1776	SUPPLY/IMPLANTS	"$20,193.00"	Outpatient	"$10,096.50"	Not Applicable	"$11,045.57"	"$13,468.73"	"$8,077.20"	Not Applicable	"$7,067.55"	"$14,135.10"	"$7,067.55"	"$14,135.10"
STEM HUMERAL COMPREHENSIVE POROUS MINI L83 MM OD10 MM SHOULD 113630	C1776	SUPPLY/IMPLANTS	"$20,190.00"	Outpatient	"$10,095.00"	Not Applicable	"$11,043.93"	"$13,466.73"	"$8,076.00"	Not Applicable	"$7,066.50"	"$14,133.00"	"$7,066.50"	"$14,133.00"
CAGE SPINAL ENDOSKELETON TO TITANIUM 4 D D13 MM LARGE W26 MM 3114-2613	C1821	SUPPLY/IMPLANTS	"$20,190.00"	Outpatient	"$10,095.00"	Not Applicable	"$11,043.93"	"$13,466.73"	"$8,076.00"	Not Applicable	"$7,066.50"	"$14,133.00"	"$7,066.50"	"$14,133.00"
STEM FEM 150MM 13MM TPR ARCOS STS TI DIST PRFT SPLINE STRL 11-300813	C1776	SUPPLY/IMPLANTS	"$20,157.00"	Outpatient	"$10,078.50"	Not Applicable	"$11,025.88"	"$13,444.72"	"$8,062.80"	Not Applicable	"$7,054.95"	"$14,109.90"	"$7,054.95"	"$14,109.90"
CASE INST 2.7MM 3.5MM PERC LCK PLT JIG 235806000	C1713	SUPPLY/IMPLANTS	"$20,139.00"	Outpatient	"$10,069.50"	"$1,365.15"	"$11,016.03"	"$13,432.71"	"$8,055.60"	Not Applicable	"$7,048.65"	"$14,097.30"	"$1,365.15"	"$14,097.30"
50242-0061-01 - bevacizumab 400mg vial	J9035	PHARMACY	"$16,947.00"	Outpatient	"$8,473.50"	$79.56	"$11,015.55"	"$11,303.65"	"$6,778.80"	Not Applicable	"$5,931.45"	"$11,862.90"	$79.56	"$11,862.90"
GFT EVAS 14CM 12MM GORE XCLDR CNTRLT LG PLC121400	C1874	SUPPLY/IMPLANTS	"$20,124.00"	Outpatient	"$10,062.00"	Not Applicable	"$11,007.83"	"$13,422.71"	"$8,049.60"	Not Applicable	"$7,043.40"	"$14,086.80"	"$7,043.40"	"$14,086.80"
CORNEA TISSUE 17-0256-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
CORNEA TISSUE 17-0257-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
CORNEA TISSUE 17-0428C 17-428-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
CORNEA TISSUE 17-0440C 17-0428-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
CORNEA TISSUE 17-0435-C 17-0435-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
CORNEAL TISSUE V0105000A	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
TISSUE CORNEA 16-1080-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
TISSUE CORNEA 16-1349-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
TISSUE CORNEA 17-0010-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
TISSUE CORNEA 17-0130-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
TISSUE CORNEA 17-0127-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
TISSUE CORNEAL 17-0655-C 17-0655-C	V2785	UNKNOWN/DONOR	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
CLP ESURG SNG ISLTR ACC 2 ELTRD ABLT SYS HNDPC JAW RF DISP EMT1		STERILE SUPPLY	"$20,098.00"	Outpatient	"$10,049.00"	Not Applicable	"$10,993.61"	"$13,405.37"	"$8,039.20"	Not Applicable	"$7,034.30"	"$14,068.60"	"$7,034.30"	"$14,068.60"
FCP LAPSCP DVNC XI EWRST MIC BP 470171		STERILE SUPPLY	"$20,090.00"	Outpatient	"$10,045.00"	Not Applicable	"$10,989.23"	"$13,400.03"	"$8,036.00"	Not Applicable	"$7,031.50"	"$14,063.00"	"$7,031.50"	"$14,063.00"
CATH ABLT 7FR 115CM 75MM CRV 2-5-2MM SPC TACTICATH 3.5MM 6 PN-004 075		STERILE SUPPLY	"$20,088.00"	Outpatient	"$10,044.00"	Not Applicable	"$10,988.14"	"$13,398.70"	"$8,035.20"	Not Applicable	"$7,030.80"	"$14,061.60"	"$7,030.80"	"$14,061.60"
HNDPC ESURG 13CM 13GA MYRIAD NN-8004		STERILE SUPPLY	"$20,087.00"	Outpatient	"$10,043.50"	Not Applicable	"$10,987.59"	"$13,398.03"	"$8,034.80"	Not Applicable	"$7,030.45"	"$14,060.90"	"$7,030.45"	"$14,060.90"
HNDPC ESURG 10CM 13GA MYRIAD NN-8003		STERILE SUPPLY	"$20,087.00"	Outpatient	"$10,043.50"	Not Applicable	"$10,987.59"	"$13,398.03"	"$8,034.80"	Not Applicable	"$7,030.45"	"$14,060.90"	"$7,030.45"	"$14,060.90"
HNDPC ESURG 10CM 11GA MYRIAD TISS AUTOMATE RESCT LTWT NN-8006		STERILE SUPPLY	"$20,087.00"	Outpatient	"$10,043.50"	Not Applicable	"$10,987.59"	"$13,398.03"	"$8,034.80"	Not Applicable	"$7,030.45"	"$14,060.90"	"$7,030.45"	"$14,060.90"
PLT 32-41MM MED SPNE TI VIRAGE BN OCT FX SYS 07.01693.005	C1713	SUPPLY/IMPLANTS	"$20,068.00"	Outpatient	"$10,034.00"	"$1,365.15"	"$10,977.20"	"$13,385.36"	"$8,027.20"	Not Applicable	"$7,023.80"	"$14,047.60"	"$1,365.15"	"$14,047.60"
STENT ELUVIA 7X120X130CM H74939294701210	C1874	SUPPLY/IMPLANTS	"$20,056.00"	Outpatient	"$10,028.00"	Not Applicable	"$10,970.63"	"$13,377.35"	"$8,022.40"	Not Applicable	"$7,019.60"	"$14,039.20"	"$7,019.60"	"$14,039.20"
STENT ELUVIA 6X120X130CM H74939294601210	C1874	SUPPLY/IMPLANTS	"$20,056.00"	Outpatient	"$10,028.00"	Not Applicable	"$10,970.63"	"$13,377.35"	"$8,022.40"	Not Applicable	"$7,019.60"	"$14,039.20"	"$7,019.60"	"$14,039.20"
TOWER ILICO SCREW EXTENDER SE-73724	C1713	SUPPLY/IMPLANTS	"$20,055.00"	Outpatient	"$10,027.50"	"$1,365.15"	"$10,970.09"	"$13,376.69"	"$8,022.00"	Not Applicable	"$7,019.25"	"$14,038.50"	"$1,365.15"	"$14,038.50"
SHTH LSR 50CM 16FR 11.5FR 12.5FR 17.2FR GLIDELIGHT 25-80HZ 500-303	C2629	SUPPLY/IMPLANTS	"$20,055.00"	Outpatient	"$10,027.50"	Not Applicable	"$10,970.09"	"$13,376.69"	"$8,022.00"	Not Applicable	"$7,019.25"	"$14,038.50"	"$7,019.25"	"$14,038.50"
SHTH LSR 50CM 14FR 9.5FR 10.2FR 14.7FR GLIDELIGHT 25-80HZ KT 500-302	C2629	SUPPLY/IMPLANTS	"$20,055.00"	Outpatient	"$10,027.50"	Not Applicable	"$10,970.09"	"$13,376.69"	"$8,022.00"	Not Applicable	"$7,019.25"	"$14,038.50"	"$7,019.25"	"$14,038.50"
SHTH LSR 50CM 12FR 7.5FR 8.3FR 12.5FR GLIDELIGHT 25-80HZ KT 500-301	C2629	SUPPLY/IMPLANTS	"$20,055.00"	Outpatient	"$10,027.50"	Not Applicable	"$10,970.09"	"$13,376.69"	"$8,022.00"	Not Applicable	"$7,019.25"	"$14,038.50"	"$7,019.25"	"$14,038.50"
FCP RDC SRG 398.9		STERILE SUPPLY	"$20,043.00"	Outpatient	"$10,021.50"	Not Applicable	"$10,963.52"	"$13,368.68"	"$8,017.20"	Not Applicable	"$7,015.05"	"$14,030.10"	"$7,015.05"	"$14,030.10"
GFT VASC 80CM 6MM PROPATEN THNWL GRTX HEP INTGR RING 80CM IRTH068080A	C1768	SUPPLY/IMPLANTS	"$20,027.00"	Outpatient	"$10,013.50"	Not Applicable	"$10,954.77"	"$13,358.01"	"$8,010.80"	Not Applicable	"$7,009.45"	"$14,018.90"	"$7,009.45"	"$14,018.90"
GFT VASC 80CM 8MM PROPATEN THNWL GRTX HEP INTGR RING 80CM IRTH088080A	C1768	SUPPLY/IMPLANTS	"$20,027.00"	Outpatient	"$10,013.50"	Not Applicable	"$10,954.77"	"$13,358.01"	"$8,010.80"	Not Applicable	"$7,009.45"	"$14,018.90"	"$7,009.45"	"$14,018.90"
CATHETER THROMBECTOMY INDIGO L115 CM OD8 FR LARGE LUMEN ASPI CAT8XTORQ115	C1757	SUPPLY/IMPLANTS	"$20,022.00"	Outpatient	"$10,011.00"	Not Applicable	"$10,952.03"	"$13,354.67"	"$8,008.80"	Not Applicable	"$7,007.70"	"$14,015.40"	"$7,007.70"	"$14,015.40"
51144-0030-01 - enfortumab vedotin 30 mg Powd	J9177	PHARMACY	"$16,826.00"	Outpatient	"$8,413.00"	Not Applicable	"$10,936.90"	"$11,222.94"	"$6,730.40"	Not Applicable	"$5,889.10"	"$11,778.20"	"$5,889.10"	"$11,778.20"
STEM FEMORAL RESTORATION PUREFIX TITANIUM CONICAL STRAIGHT L 6276-7-021	C1776	SUPPLY/IMPLANTS	"$19,971.00"	Outpatient	"$9,985.50"	Not Applicable	"$10,924.14"	"$13,320.66"	"$7,988.40"	Not Applicable	"$6,989.85"	"$13,979.70"	"$6,989.85"	"$13,979.70"
STEM FEM 155MM 17MM STRG CNCL RSTR HA HIP MDLR SYS 6276-7-017	C1776	SUPPLY/IMPLANTS	"$19,960.00"	Outpatient	"$9,980.00"	Not Applicable	"$10,918.12"	"$13,313.32"	"$7,984.00"	Not Applicable	"$6,986.00"	"$13,972.00"	"$6,986.00"	"$13,972.00"
SHL ACTB 56MM HIP MLHL SNPFT INTGR LCK TRB MTL TIV CONTIN KK 875705602	C1776	SUPPLY/IMPLANTS	"$19,951.00"	Outpatient	"$9,975.50"	Not Applicable	"$10,913.20"	"$13,307.32"	"$7,980.40"	Not Applicable	"$6,982.85"	"$13,965.70"	"$6,982.85"	"$13,965.70"
SHL ACTB 52MM HIP MLHL SNPFT INTGR LCK MECH TRB MTL TIV 875705202	C1776	SUPPLY/IMPLANTS	"$19,951.00"	Outpatient	"$9,975.50"	Not Applicable	"$10,913.20"	"$13,307.32"	"$7,980.40"	Not Applicable	"$6,982.85"	"$13,965.70"	"$6,982.85"	"$13,965.70"
PLT TIB RT DIST LAT JIG HD BN 27245-01	C1713	SUPPLY/IMPLANTS	"$19,951.00"	Outpatient	"$9,975.50"	"$1,365.15"	"$10,913.20"	"$13,307.32"	"$7,980.40"	Not Applicable	"$6,982.85"	"$13,965.70"	"$1,365.15"	"$13,965.70"
PLT TIB L/L DIST JIG HD OPTILOCK BN PERIART PLT SYS 26245-01	C1713	SUPPLY/IMPLANTS	"$19,951.00"	Outpatient	"$9,975.50"	"$1,365.15"	"$10,913.20"	"$13,307.32"	"$7,980.40"	Not Applicable	"$6,982.85"	"$13,965.70"	"$1,365.15"	"$13,965.70"
SHL ACTB 58MM HIP MLHL SNPFT INTGR LCK MECH TRB MTL TIV 875705802		STERILE SUPPLY	"$19,951.00"	Outpatient	"$9,975.50"	Not Applicable	"$10,913.20"	"$13,307.32"	"$7,980.40"	Not Applicable	"$6,982.85"	"$13,965.70"	"$6,982.85"	"$13,965.70"
NAIL IM 340MM 10MM LCK RTRGD T2 TI SP CNDL STRL 1826-1034S	C1713	SUPPLY/IMPLANTS	"$19,950.00"	Outpatient	"$9,975.00"	"$1,365.15"	"$10,912.65"	"$13,306.65"	"$7,980.00"	Not Applicable	"$6,982.50"	"$13,965.00"	"$1,365.15"	"$13,965.00"
NAIL IM 380MM 12MM LCK RTRGD T2 TI SP CNDL STRL 1826-1238S	C1713	SUPPLY/IMPLANTS	"$19,950.00"	Outpatient	"$9,975.00"	"$1,365.15"	"$10,912.65"	"$13,306.65"	"$7,980.00"	Not Applicable	"$6,982.50"	"$13,965.00"	"$1,365.15"	"$13,965.00"
SHL ACTB 60MM HIP MLHL SNPFT TRB MTL TIV CONTIN MM HMSPHR 875706002		STERILE SUPPLY	"$19,949.00"	Outpatient	"$9,974.50"	Not Applicable	"$10,912.10"	"$13,305.98"	"$7,979.60"	Not Applicable	"$6,982.15"	"$13,964.30"	"$6,982.15"	"$13,964.30"
50242-0088-01 - ADO-trastuzumab emtansine 100 mg Injection	J9354	PHARMACY	"$16,770.00"	Outpatient	"$8,385.00"	$33.86	"$10,900.50"	"$11,185.59"	"$6,708.00"	Not Applicable	"$5,869.50"	"$11,739.00"	$33.86	"$11,739.00"
PLT 2MM CRNFCL TI 20 HL MATRIXMANDIBLE BN NS PSPC SD449.502B	C1713	SUPPLY/IMPLANTS	"$19,922.00"	Outpatient	"$9,961.00"	"$1,365.15"	"$10,897.33"	"$13,287.97"	"$7,968.80"	Not Applicable	"$6,972.70"	"$13,945.40"	"$1,365.15"	"$13,945.40"
PLT 2XLONG RDS RT VOLR DIST CROSSLOCK EPAK DVR BN STRL 811812175	C1713	SUPPLY/IMPLANTS	"$19,917.00"	Outpatient	"$9,958.50"	"$1,365.15"	"$10,894.60"	"$13,284.64"	"$7,966.80"	Not Applicable	"$6,970.95"	"$13,941.90"	"$1,365.15"	"$13,941.90"
PLT 2XLONG RDS LT VOLR DIST CROSSLOCK EPAK DVR BN STRL 811822175	C1713	SUPPLY/IMPLANTS	"$19,917.00"	Outpatient	"$9,958.50"	"$1,365.15"	"$10,894.60"	"$13,284.64"	"$7,966.80"	Not Applicable	"$6,970.95"	"$13,941.90"	"$1,365.15"	"$13,941.90"
STEM FEM 127MM 15MM STRG GMRS KN CMNT STRL 6485-3-115	C1776	SUPPLY/IMPLANTS	"$19,899.00"	Outpatient	"$9,949.50"	Not Applicable	"$10,884.75"	"$13,272.63"	"$7,959.60"	Not Applicable	"$6,964.65"	"$13,929.30"	"$6,964.65"	"$13,929.30"
DEV ESURG RESCT HABIB 4X LAPSCP H7877001036591		STERILE SUPPLY	"$19,896.00"	Outpatient	"$9,948.00"	Not Applicable	"$10,883.11"	"$13,270.63"	"$7,958.40"	Not Applicable	"$6,963.60"	"$13,927.20"	"$6,963.60"	"$13,927.20"
CMPNT FEM 5 KN LT CRCTE RTN BEAD TRTHLN PA 5517F501	C1776	SUPPLY/IMPLANTS	"$19,875.00"	Outpatient	"$9,937.50"	Not Applicable	"$10,871.63"	"$13,256.63"	"$7,950.00"	Not Applicable	"$6,956.25"	"$13,912.50"	"$6,956.25"	"$13,912.50"
MODL ANTM CLR CRNM PLANNED OUTCM MXL NS SD900.238	C1713	SUPPLY/IMPLANTS	"$19,874.00"	Outpatient	"$9,937.00"	"$1,365.15"	"$10,871.08"	"$13,255.96"	"$7,949.60"	Not Applicable	"$6,955.90"	"$13,911.80"	"$1,365.15"	"$13,911.80"
SCREW SACRAL PA 7.5 X 35MM SE-73975-35	C1713	SUPPLY/IMPLANTS	"$19,873.00"	Outpatient	"$9,936.50"	"$1,365.15"	"$10,870.53"	"$13,255.29"	"$7,949.20"	Not Applicable	"$6,955.55"	"$13,911.10"	"$1,365.15"	"$13,911.10"
PLT 75MM SPNE CRV ANT TI ATL VS ELT BN 7200075	C1713	SUPPLY/IMPLANTS	"$19,865.00"	Outpatient	"$9,932.50"	"$1,365.15"	"$10,866.16"	"$13,249.96"	"$7,946.00"	Not Applicable	"$6,952.75"	"$13,905.50"	"$1,365.15"	"$13,905.50"
PLT 77.5MM SPNE CRV ANT TI ATL VS ELT BN 7200077	C1713	SUPPLY/IMPLANTS	"$19,865.00"	Outpatient	"$9,932.50"	"$1,365.15"	"$10,866.16"	"$13,249.96"	"$7,946.00"	Not Applicable	"$6,952.75"	"$13,905.50"	"$1,365.15"	"$13,905.50"
BASEPLATE TIBIAL 1 SMALL KNEE MODULAR ROTATE HINGE 6481-3-110	C1776	SUPPLY/IMPLANTS	"$19,864.00"	Outpatient	"$9,932.00"	Not Applicable	"$10,865.61"	"$13,249.29"	"$7,945.60"	Not Applicable	"$6,952.40"	"$13,904.80"	"$6,952.40"	"$13,904.80"
SCREW SACRAL PA 6.5 X 40MM SE-73965-40	C1713	SUPPLY/IMPLANTS	"$19,860.00"	Outpatient	"$9,930.00"	"$1,365.15"	"$10,863.42"	"$13,246.62"	"$7,944.00"	Not Applicable	"$6,951.00"	"$13,902.00"	"$1,365.15"	"$13,902.00"
SCREW CANNULATED SACRAL PA 6.5 X 45MM SE-73965-35	C1713	SUPPLY/IMPLANTS	"$19,860.00"	Outpatient	"$9,930.00"	"$1,365.15"	"$10,863.42"	"$13,246.62"	"$7,944.00"	Not Applicable	"$6,951.00"	"$13,902.00"	"$1,365.15"	"$13,902.00"
BASEPLATE TIBIAL MODULAR SIZE 2 MEDIUM COBALT CHROMIUM KEELE 64813112	C1776	SUPPLY/IMPLANTS	"$19,852.00"	Outpatient	"$9,926.00"	Not Applicable	"$10,859.04"	"$13,241.28"	"$7,940.80"	Not Applicable	"$6,948.20"	"$13,896.40"	"$6,948.20"	"$13,896.40"
BASEPLATE TIBIAL L2 KNEE MODULAR ROTATE HINGE 6481-3-113	C1776	SUPPLY/IMPLANTS	"$19,852.00"	Outpatient	"$9,926.00"	Not Applicable	"$10,859.04"	"$13,241.28"	"$7,940.80"	Not Applicable	"$6,948.20"	"$13,896.40"	"$6,948.20"	"$13,896.40"
SHL ACTB 54MM 54MM HIP MLHL RIM TRITANIUM X3 MDM TRDNT E 509-02-54E	C1776	SUPPLY/IMPLANTS	"$19,835.00"	Outpatient	"$9,917.50"	Not Applicable	"$10,849.75"	"$13,229.95"	"$7,934.00"	Not Applicable	"$6,942.25"	"$13,884.50"	"$6,942.25"	"$13,884.50"
KIT NRSTM 40CM STIMLOC .5MM SPC LD 3389S-40		SUPPLY/IMPLANTS	"$19,835.00"	Outpatient	"$9,917.50"	Not Applicable	"$10,849.75"	"$13,229.95"	"$7,934.00"	Not Applicable	"$6,942.25"	"$13,884.50"	"$6,942.25"	"$13,884.50"
PLT RB TI 24 HL PREBNT RIBFIX BLU BN NS 762604	C1713	SUPPLY/IMPLANTS	"$19,827.00"	Outpatient	"$9,913.50"	"$1,365.15"	"$10,845.37"	"$13,224.61"	"$7,930.80"	Not Applicable	"$6,939.45"	"$13,878.90"	"$1,365.15"	"$13,878.90"
PLT STRG STRNM TI 30 HL LCK BN STRL 2.4MM SCR TRNSV FX 460.024	C1713	SUPPLY/IMPLANTS	"$19,801.00"	Outpatient	"$9,900.50"	"$1,365.15"	"$10,831.15"	"$13,207.27"	"$7,920.40"	Not Applicable	"$6,930.35"	"$13,860.70"	"$1,365.15"	"$13,860.70"
Revas Tp Art Uni Ea Addl W St Ath Sm	37235	CARDIAC CATH LAB	"$19,780.00"	Outpatient	"$9,890.00"	"$18,911.20"	"$10,819.66"	"$1,592.00"	"$7,912.00"	"$7,310.00"	"$6,923.00"	"$13,846.00"	"$1,592.00"	"$18,911.20"
Revas T/P Art Uni Ea Addl W St Same	37234	CARDIAC CATH LAB	"$19,780.00"	Outpatient	"$9,890.00"	"$18,911.20"	"$10,819.66"	"$1,592.00"	"$7,912.00"	"$7,310.00"	"$6,923.00"	"$13,846.00"	"$1,592.00"	"$18,911.20"
Revasc Tib/Per Art Uni Ea Addl Vsl	37232	CARDIAC CATH LAB	"$19,780.00"	Outpatient	"$9,890.00"	"$18,911.20"	"$10,819.66"	"$1,592.00"	"$7,912.00"	"$7,310.00"	"$6,923.00"	"$13,846.00"	"$1,592.00"	"$18,911.20"
Revasc Tib/Peron Art Uni Vsl W Trans	37228	CARDIAC CATH LAB	"$19,780.00"	Outpatient	"$9,890.00"	"$18,911.20"	"$10,819.66"	"$1,592.00"	"$7,912.00"	"$7,310.00"	"$6,923.00"	"$13,846.00"	"$1,592.00"	"$18,911.20"
Revasc Iliac Artery Initial Vessel	37220	CARDIAC CATH LAB	"$19,780.00"	Outpatient	"$9,890.00"	"$18,911.20"	"$10,819.66"	"$1,592.00"	"$7,912.00"	"$7,310.00"	"$6,923.00"	"$13,846.00"	"$1,592.00"	"$18,911.20"
CMPNT FEM KN ICA 6647-1-018	C1776	SUPPLY/IMPLANTS	"$19,780.00"	Outpatient	"$9,890.00"	Not Applicable	"$10,819.66"	"$13,193.26"	"$7,912.00"	Not Applicable	"$6,923.00"	"$13,846.00"	"$6,923.00"	"$13,846.00"
Artherectomy Add On		CARDIAC CATH LAB	"$19,776.00"	Outpatient	"$9,888.00"	Not Applicable	"$10,817.47"	"$13,190.59"	"$7,910.40"	Not Applicable	"$6,921.60"	"$13,843.20"	"$6,921.60"	"$13,843.20"
CASE INST RDS DIST LCK SCR 235804505	C1713	SUPPLY/IMPLANTS	"$19,773.00"	Outpatient	"$9,886.50"	"$1,365.15"	"$10,815.83"	"$13,188.59"	"$7,909.20"	Not Applicable	"$6,920.55"	"$13,841.10"	"$1,365.15"	"$13,841.10"
STEM FEM 155MM 18MM STRG CNCL RSTR HA HIP MDLR SYS 6276-7-018	C1776	SUPPLY/IMPLANTS	"$19,769.00"	Outpatient	"$9,884.50"	Not Applicable	"$10,813.64"	"$13,185.92"	"$7,907.60"	Not Applicable	"$6,919.15"	"$13,838.30"	"$6,919.15"	"$13,838.30"
STEM FEM 155MM 16MM STRG CNCL RSTR HA HIP MDLR SYS 6276-7-016	C1776	SUPPLY/IMPLANTS	"$19,768.00"	Outpatient	"$9,884.00"	Not Applicable	"$10,813.10"	"$13,185.26"	"$7,907.20"	Not Applicable	"$6,918.80"	"$13,837.60"	"$6,918.80"	"$13,837.60"
PLATE 2.4MM VA LCP 2-COL DSTL RAD PLATE 6HH/3HS/LT KIT-STRL 02.111.631KS	C1713	SUPPLY/IMPLANTS	"$19,757.00"	Outpatient	"$9,878.50"	"$1,365.15"	"$10,807.08"	"$13,177.92"	"$7,902.80"	Not Applicable	"$6,914.95"	"$13,829.90"	"$1,365.15"	"$13,829.90"
QUICKCLEAR 8F ASPIRATION CATHETER 8F X 85CM SHAPED STERILE AC8SH085		STERILE SUPPLY	"$19,757.00"	Outpatient	"$9,878.50"	Not Applicable	"$10,807.08"	"$13,177.92"	"$7,902.80"	Not Applicable	"$6,914.95"	"$13,829.90"	"$6,914.95"	"$13,829.90"
HAND PIECE REPAIR ANSPACH EXCHANGE 62-0001-2		STERILE SUPPLY	"$19,752.00"	Outpatient	"$9,876.00"	Not Applicable	"$10,804.34"	"$13,174.58"	"$7,900.80"	Not Applicable	"$6,913.20"	"$13,826.40"	"$6,913.20"	"$13,826.40"
PLATE RADIAL COL 2 LCP VA 2.4MM 02.111.630KS	C1713	SUPPLY/IMPLANTS	"$19,745.00"	Outpatient	"$9,872.50"	"$1,365.15"	"$10,800.52"	"$13,169.92"	"$7,898.00"	Not Applicable	"$6,910.75"	"$13,821.50"	"$1,365.15"	"$13,821.50"
PLT 55MM 25.5MM W RDS LT DIST VOLR SS 7 HLE/HD 3 HL SHFT 2 02.111.731KS	C1713	SUPPLY/IMPLANTS	"$19,745.00"	Outpatient	"$9,872.50"	"$1,365.15"	"$10,800.52"	"$13,169.92"	"$7,898.00"	Not Applicable	"$6,910.75"	"$13,821.50"	"$1,365.15"	"$13,821.50"
CATH ATHRCM 150CM .9MM .038IN TRBO-ELT .047IN PERI OTW LSR 410-152	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 150CM .9MM TRBO-ELT PERI RX LUM LSR VERSATILITY 410-154	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 150CM 1.4MM .055IN TRBO-ELT .056IN PERI OTW LSR 414-151	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 150CM 1.4MM TRBO ELT PERI RX EXIMER LSR ACPT 414-159	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 150CM 1.7MM .069IN TRBO ELT .068IN PERI HDRPH 417-152	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 150CM 1.7MM .069IN TRBO ELT PERI RX LSR 417-156	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 150CM 2MM .08IN TRBO-ELT .081IN PERI OTW LSR 420-006	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 110CM 7FR 2MM TRBO-TNDM LSR GD ACPT .014IN GW 472-110	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 120CM 2.3MM .091IN TRBO-ELT PERI OTW LSR ACPT 423-001	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 110CM 2.5MM .101IN TRBO-ELT .102IN PERI OTW LSR 425-011	C1885	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
SURGIMESH XB TINTRAOK1522 TINTRAOK1522	C1781	SUPPLY/IMPLANTS	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 2.5MM TRBO ELT OTW LSR ACPT .035IN GW 423-135-01		STERILE SUPPLY	"$19,743.00"	Outpatient	"$9,871.50"	Not Applicable	"$10,799.42"	"$13,168.58"	"$7,897.20"	Not Applicable	"$6,910.05"	"$13,820.10"	"$6,910.05"	"$13,820.10"
CATH ATHRCM 135CM 1.5-2MM SLHWK .073IN PERI PLQ EXC DIST VSL P4028		STERILE SUPPLY	"$19,740.00"	Outpatient	"$9,870.00"	Not Applicable	"$10,797.78"	"$13,166.58"	"$7,896.00"	Not Applicable	"$6,909.00"	"$13,818.00"	"$6,909.00"	"$13,818.00"
PLT 2.5MM 2 ANG LG MNDB TI 6X24X6 HL RECON MATRIXMANDIBLE BN 04.503.743	C1713	SUPPLY/IMPLANTS	"$19,738.00"	Outpatient	"$9,869.00"	"$1,365.15"	"$10,796.69"	"$13,165.25"	"$7,895.20"	Not Applicable	"$6,908.30"	"$13,816.60"	"$1,365.15"	"$13,816.60"
TARGETER ORTH PED PROX LCK NL SYS 471641	C1713	SUPPLY/IMPLANTS	"$19,736.00"	Outpatient	"$9,868.00"	"$1,365.15"	"$10,795.59"	"$13,163.91"	"$7,894.40"	Not Applicable	"$6,907.60"	"$13,815.20"	"$1,365.15"	"$13,815.20"
Revasc Iliac Art Uni Init Vsl W/Transa Stent same Vsl	37221	CARDIAC CATH LAB	"$19,733.00"	Outpatient	"$9,866.50"	"$18,911.20"	"$10,793.95"	"$1,592.00"	"$7,893.20"	"$8,681.00"	"$6,906.55"	"$13,813.10"	"$1,592.00"	"$18,911.20"
Femoral Poplitial Revasc W/Transluminal Angioplasty	37224	CARDIAC CATH LAB	"$19,733.00"	Outpatient	"$9,866.50"	"$18,911.20"	"$10,793.95"	"$1,592.00"	"$7,893.20"	"$7,310.00"	"$6,906.55"	"$13,813.10"	"$1,592.00"	"$18,911.20"
Revascularization Open Percutaneous Iliac W/Stent	37223	CARDIAC CATH LAB	"$19,733.00"	Outpatient	"$9,866.50"	"$18,911.20"	"$10,793.95"	"$1,592.00"	"$7,893.20"	"$7,310.00"	"$6,906.55"	"$13,813.10"	"$1,592.00"	"$18,911.20"
Revasc Iliac Art Additional Vessel	37222	CARDIAC CATH LAB	"$19,733.00"	Outpatient	"$9,866.50"	"$18,911.20"	"$10,793.95"	"$1,592.00"	"$7,893.20"	"$7,310.00"	"$6,906.55"	"$13,813.10"	"$1,592.00"	"$18,911.20"
59676-0960-01 - DOXOrubicin liposomal 2 mg/mL DSPR	Q2050	PHARMACY	"$16,599.00"	Outpatient	"$8,299.50"	$335.19	"$10,789.35"	"$11,071.53"	"$6,639.60"	Not Applicable	"$5,809.65"	"$11,619.30"	$335.19	"$11,619.30"
CATH ATHRCM 110CM 4.5-7MM SH LS-M MEC .105IN PERI PLQ EXC LV P4052	C1714	SUPPLY/IMPLANTS	"$19,709.00"	Outpatient	"$9,854.50"	Not Applicable	"$10,780.82"	"$13,145.90"	"$7,883.60"	Not Applicable	"$6,898.15"	"$13,796.30"	"$6,898.15"	"$13,796.30"
FXTR XTRNFX DFS WRST RDS SS CMPLT DSTRCT MOD SYS NS LF DISP 4102	C1713	SUPPLY/IMPLANTS	"$19,702.00"	Outpatient	"$9,851.00"	"$1,365.15"	"$10,776.99"	"$13,141.23"	"$7,880.80"	Not Applicable	"$6,895.70"	"$13,791.40"	"$1,365.15"	"$13,791.40"
PLT 156MM HUM SS 5 HL BN 350823	C1713	SUPPLY/IMPLANTS	"$19,702.00"	Outpatient	"$9,851.00"	"$1,365.15"	"$10,776.99"	"$13,141.23"	"$7,880.80"	Not Applicable	"$6,895.70"	"$13,791.40"	"$1,365.15"	"$13,791.40"
CMNT BN QUICKSET MACROPOROUS 8ML CLS MX SYS INJ RSRB ABS-3008		STERILE SUPPLY	"$19,684.00"	Outpatient	"$9,842.00"	Not Applicable	"$10,767.15"	"$13,129.23"	"$7,873.60"	Not Applicable	"$6,889.40"	"$13,778.80"	"$6,889.40"	"$13,778.80"
SYS THRMB 8FR 6MM 105CM ANGJT ZELANTEDVT PWR PLS OTW CATH 114610-001	C1757	SUPPLY/IMPLANTS	"$19,673.00"	Outpatient	"$9,836.50"	Not Applicable	"$10,761.13"	"$13,121.89"	"$7,869.20"	Not Applicable	"$6,885.55"	"$13,771.10"	"$6,885.55"	"$13,771.10"
NAIL IM 380MM 9MM T2 TI FEM GT LT STRL 1850-0938S	C1713	SUPPLY/IMPLANTS	"$19,671.00"	Outpatient	"$9,835.50"	"$1,365.15"	"$10,760.04"	"$13,120.56"	"$7,868.40"	Not Applicable	"$6,884.85"	"$13,769.70"	"$1,365.15"	"$13,769.70"
NAIL IM 420MM 12MM T2 TI FEM GT LT STRL 1850-1242S	C1713	SUPPLY/IMPLANTS	"$19,662.00"	Outpatient	"$9,831.00"	"$1,365.15"	"$10,755.11"	"$13,114.55"	"$7,864.80"	Not Applicable	"$6,881.70"	"$13,763.40"	"$1,365.15"	"$13,763.40"
SEPRTR THRMB 200CM .03IN 5MAX REPERFUSION CATH 3MAXS	C1887	SUPPLY/IMPLANTS	"$19,644.00"	Outpatient	"$9,822.00"	Not Applicable	"$10,745.27"	"$13,102.55"	"$7,857.60"	Not Applicable	"$6,875.40"	"$13,750.80"	"$6,875.40"	"$13,750.80"
SEPRTR THRMB 142CM .035IN PENUMBRA SYS SEPRTR FLX 175CM .041 PSF041		SUPPLY/IMPLANTS	"$19,644.00"	Outpatient	"$9,822.00"	Not Applicable	"$10,745.27"	"$13,102.55"	"$7,857.60"	Not Applicable	"$6,875.40"	"$13,750.80"	"$6,875.40"	"$13,750.80"
CATH PENUMBRA JET 7 HI FLOW ASPIRATION TUBING KIT 5MAXJET7KIT	C1757	SUPPLY/IMPLANTS	"$19,641.00"	Outpatient	"$9,820.50"	Not Applicable	"$10,743.63"	"$13,100.55"	"$7,856.40"	Not Applicable	"$6,874.35"	"$13,748.70"	"$6,874.35"	"$13,748.70"
KIT THRMB 132CM PENUMBRA SYS 5MAX ACE STRL LF DISP 5MAXACE132KIT	C1757	SUPPLY/IMPLANTS	"$19,641.00"	Outpatient	"$9,820.50"	Not Applicable	"$10,743.63"	"$13,100.55"	"$7,856.40"	Not Applicable	"$6,874.35"	"$13,748.70"	"$6,874.35"	"$13,748.70"
KIT THRMB 132CM 6FR ACE 68 REPERFUSION CATH 5MAXACE068KIT		STERILE SUPPLY	"$19,641.00"	Outpatient	"$9,820.50"	Not Applicable	"$10,743.63"	"$13,100.55"	"$7,856.40"	Not Applicable	"$6,874.35"	"$13,748.70"	"$6,874.35"	"$13,748.70"
SHL ACTB 66MM HIP MLHL RIM TRITANIUM X3 MDM TRDNT H HMSPHR 509-02-66H	C1776	SUPPLY/IMPLANTS	"$19,630.00"	Outpatient	"$9,815.00"	Not Applicable	"$10,737.61"	"$13,093.21"	"$7,852.00"	Not Applicable	"$6,870.50"	"$13,741.00"	"$6,870.50"	"$13,741.00"
SHL ACTB 68MM HIP MLHL RIM TRITANIUM X3 MDM TRDNT H HMSPHR 509-02-68H	C1776	SUPPLY/IMPLANTS	"$19,630.00"	Outpatient	"$9,815.00"	Not Applicable	"$10,737.61"	"$13,093.21"	"$7,852.00"	Not Applicable	"$6,870.50"	"$13,741.00"	"$6,870.50"	"$13,741.00"
RAIL XTRNFX 420MM DNFX C ADLT NS 6316	C1713	SUPPLY/IMPLANTS	"$19,626.00"	Outpatient	"$9,813.00"	"$1,365.15"	"$10,735.42"	"$13,090.54"	"$7,850.40"	Not Applicable	"$6,869.10"	"$13,738.20"	"$1,365.15"	"$13,738.20"
HEAD SCR TI CNDYL NS 04.449.000	C1713	SUPPLY/IMPLANTS	"$19,623.00"	Outpatient	"$9,811.50"	"$1,365.15"	"$10,733.78"	"$13,088.54"	"$7,849.20"	Not Applicable	"$6,868.05"	"$13,736.10"	"$1,365.15"	"$13,736.10"
NAIL INTRAMEDULLARY TFN-ADVANCED LATERAL RELIEF CUT TITANIUM 04.037.954S	C1713	SUPPLY/IMPLANTS	"$19,611.00"	Outpatient	"$9,805.50"	"$1,365.15"	"$10,727.22"	"$13,080.54"	"$7,844.40"	Not Applicable	"$6,863.85"	"$13,727.70"	"$1,365.15"	"$13,727.70"
NAIL INTRAMEDULLARY TFN-ADVANCED LATERAL RELIEF CUT TITANIUM 04.037.927S	C1713	SUPPLY/IMPLANTS	"$19,598.00"	Outpatient	"$9,799.00"	"$1,365.15"	"$10,720.11"	"$13,071.87"	"$7,839.20"	Not Applicable	"$6,859.30"	"$13,718.60"	"$1,365.15"	"$13,718.60"
NAIL INTRAMEDULLARY TFN-ADVANCED LATERAL RELIEF CUT TITANIUM 04.037.926S	C1713	SUPPLY/IMPLANTS	"$19,598.00"	Outpatient	"$9,799.00"	"$1,365.15"	"$10,720.11"	"$13,071.87"	"$7,839.20"	Not Applicable	"$6,859.30"	"$13,718.60"	"$1,365.15"	"$13,718.60"
NAIL INTRAMEDULLARY TFN-ADVANCED LATERAL RELIEF CUT TITANIUM 04.037.952S	C1713	SUPPLY/IMPLANTS	"$19,598.00"	Outpatient	"$9,799.00"	"$1,365.15"	"$10,720.11"	"$13,071.87"	"$7,839.20"	Not Applicable	"$6,859.30"	"$13,718.60"	"$1,365.15"	"$13,718.60"
SHFT RMR 40CM PHNX TIB NL SYS 27958		STERILE SUPPLY	"$19,591.00"	Outpatient	"$9,795.50"	Not Applicable	"$10,716.28"	"$13,067.20"	"$7,836.40"	Not Applicable	"$6,856.85"	"$13,713.70"	"$6,856.85"	"$13,713.70"
Percutaneous Transcath Septal Reduction	93583	CARDIAC CATH LAB	"$19,526.00"	Outpatient	"$9,763.00"	"$15,735.19"	"$10,680.72"	"$8,056.00"	"$7,810.40"	"$1,563.00"	"$6,834.10"	"$13,668.20"	"$1,563.00"	"$15,735.19"
STEM HUM 118MM 8MM PRFT REUNION SHLDR STRL 5569-P-2008	C1776	SUPPLY/IMPLANTS	"$19,512.00"	Outpatient	"$9,756.00"	Not Applicable	"$10,673.06"	"$13,014.50"	"$7,804.80"	Not Applicable	"$6,829.20"	"$13,658.40"	"$6,829.20"	"$13,658.40"
NAIL IM 360MM 14MM LCK RTRGD T2 TI SP CNDL STRL 1826-1436S	C1713	SUPPLY/IMPLANTS	"$19,464.00"	Outpatient	"$9,732.00"	"$1,365.15"	"$10,646.81"	"$12,982.49"	"$7,785.60"	Not Applicable	"$6,812.40"	"$13,624.80"	"$1,365.15"	"$13,624.80"
STRAIGHT TAPERED SPLINED DISTAL STEM 21 X 150MM W/ LOCKING S 11-300821	C1713	SUPPLY/IMPLANTS	"$19,457.00"	Outpatient	"$9,728.50"	"$1,365.15"	"$10,642.98"	"$12,977.82"	"$7,782.80"	Not Applicable	"$6,809.95"	"$13,619.90"	"$1,365.15"	"$13,619.90"
INS ACTB 44MM 36MM 22MM 0D E HIP CNSTRN LCK RING OUTR BRNG 690-00-22E	C1776	SUPPLY/IMPLANTS	"$19,450.00"	Outpatient	"$9,725.00"	Not Applicable	"$10,639.15"	"$12,973.15"	"$7,780.00"	Not Applicable	"$6,807.50"	"$13,615.00"	"$6,807.50"	"$13,615.00"
PRC SND GRY BAHA CORDELLE II HCB 402-0	L8690	SUPPLY/IMPLANTS	"$19,430.00"	Outpatient	"$9,715.00"	Not Applicable	"$10,628.21"	"$12,959.81"	"$7,772.00"	Not Applicable	"$6,800.50"	"$13,601.00"	"$6,800.50"	"$13,601.00"
PRC SND BLK BAHA CORDELLE II HCB 401-0	L8690	SUPPLY/IMPLANTS	"$19,430.00"	Outpatient	"$9,715.00"	Not Applicable	"$10,628.21"	"$12,959.81"	"$7,772.00"	Not Applicable	"$6,800.50"	"$13,601.00"	"$6,800.50"	"$13,601.00"
PRC SND BGE 90X34X26MM CORDELLE II BAHA 7.5-9.5V 250-6500HZ HCB 400-0	L8690	SUPPLY/IMPLANTS	"$19,430.00"	Outpatient	"$9,715.00"	Not Applicable	"$10,628.21"	"$12,959.81"	"$7,772.00"	Not Applicable	"$6,800.50"	"$13,601.00"	"$6,800.50"	"$13,601.00"
STEM FEM 102MM 132D 3 TPR ACLD 30MM HIP MDLR STRL 6720-0330	C1776	SUPPLY/IMPLANTS	"$19,429.00"	Outpatient	"$9,714.50"	Not Applicable	"$10,627.66"	"$12,959.14"	"$7,771.60"	Not Applicable	"$6,800.15"	"$13,600.30"	"$6,800.15"	"$13,600.30"
PLT 5-7MM STD SPNE LVL 2 LCK ROI-C BN MC1005T	C1713	SUPPLY/IMPLANTS	"$19,410.00"	Outpatient	"$9,705.00"	"$1,365.15"	"$10,617.27"	"$12,946.47"	"$7,764.00"	Not Applicable	"$6,793.50"	"$13,587.00"	"$1,365.15"	"$13,587.00"
CAGE SPINAL RENOVIS T3 2 D LORDOSIS L16 MM X W13.5 MM X H12 1053-161-312	C1821	SUPPLY/IMPLANTS	"$19,410.00"	Outpatient	"$9,705.00"	Not Applicable	"$10,617.27"	"$12,946.47"	"$7,764.00"	Not Applicable	"$6,793.50"	"$13,587.00"	"$6,793.50"	"$13,587.00"
Temporary Pacemaker	33210	CARDIAC CATH LAB	"$19,407.00"	Outpatient	"$9,703.50"	"$10,177.31"	"$10,615.63"	"$1,592.00"	"$7,762.80"	"$7,310.00"	"$6,792.45"	"$13,584.90"	"$1,592.00"	"$13,584.90"
PURAPLY AM 5 X5 515006	Q4196	PHARMACY	"$19,406.00"	Outpatient	"$9,703.00"	$120.62	"$10,615.08"	"$12,943.80"	"$7,762.40"	Not Applicable	"$6,792.10"	"$13,584.20"	$120.62	"$13,584.20"
CAGE SPNL 15.5X2.3-5MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR CMC 1451 P	C1821	SUPPLY/IMPLANTS	"$19,406.00"	Outpatient	"$9,703.00"	Not Applicable	"$10,615.08"	"$12,943.80"	"$7,762.40"	Not Applicable	"$6,792.10"	"$13,584.20"	"$6,792.10"	"$13,584.20"
FIL BN VOID 20CC 50CC CA SLF STIMULAN RPD CURE KT PST BEAD 620-020		STERILE SUPPLY	"$19,406.00"	Outpatient	"$9,703.00"	Not Applicable	"$10,615.08"	"$12,943.80"	"$7,762.40"	Not Applicable	"$6,792.10"	"$13,584.20"	"$6,792.10"	"$13,584.20"
STEM FEM SM RMD HIP MDLR RHSTSM	C1776	SUPPLY/IMPLANTS	"$19,400.00"	Outpatient	"$9,700.00"	Not Applicable	"$10,611.80"	"$12,939.80"	"$7,760.00"	Not Applicable	"$6,790.00"	"$13,580.00"	"$6,790.00"	"$13,580.00"
CAGE SPNL 17X14X9MM CRNT SM INTLK 7D LRDTC CRV NS LF 6790229	C1821	SUPPLY/IMPLANTS	"$19,400.00"	Outpatient	"$9,700.00"	Not Applicable	"$10,611.80"	"$12,939.80"	"$7,760.00"	Not Applicable	"$6,790.00"	"$13,580.00"	"$6,790.00"	"$13,580.00"
CAGE SPNL 17X14X11MM CRNT SM INTLK 7D LRDTC CRV NS LF 6790231	C1821	SUPPLY/IMPLANTS	"$19,400.00"	Outpatient	"$9,700.00"	Not Applicable	"$10,611.80"	"$12,939.80"	"$7,760.00"	Not Applicable	"$6,790.00"	"$13,580.00"	"$6,790.00"	"$13,580.00"
DEV ABLT CRDBLT LOPRFL NS 60841		NON-STER SUPPLY	"$19,400.00"	Outpatient	"$9,700.00"	Not Applicable	"$10,611.80"	"$12,939.80"	"$7,760.00"	Not Applicable	"$6,790.00"	"$13,580.00"	"$6,790.00"	"$13,580.00"
CATHETER ABLATION TACTICATH 2-2-2 MM SPACE DAMATO TYPE FIX C A-TCSE-DF	C2630	SUPPLY/IMPLANTS	"$19,398.00"	Outpatient	"$9,699.00"	Not Applicable	"$10,610.71"	"$12,938.47"	"$7,759.20"	Not Applicable	"$6,789.30"	"$13,578.60"	"$6,789.30"	"$13,578.60"
CAGE SPINAL AVS ANCHOR-C PEEK-OPTIMA LT1 4 D D12 MM RECTANGU 48321114	C1821	SUPPLY/IMPLANTS	"$19,398.00"	Outpatient	"$9,699.00"	Not Applicable	"$10,610.71"	"$12,938.47"	"$7,759.20"	Not Applicable	"$6,789.30"	"$13,578.60"	"$6,789.30"	"$13,578.60"
CAGE SPINAL RENOVIS T3 2 D LORDOSIS L16 MM X W13.5 MM X H11 1053-161-311	C1821	SUPPLY/IMPLANTS	"$19,398.00"	Outpatient	"$9,699.00"	Not Applicable	"$10,610.71"	"$12,938.47"	"$7,759.20"	Not Applicable	"$6,789.30"	"$13,578.60"	"$6,789.30"	"$13,578.60"
"STAND ALONE CERVICAL CAGE, 16 X 10 MM 1053-161-310"	C1821	SUPPLY/IMPLANTS	"$19,398.00"	Outpatient	"$9,699.00"	Not Applicable	"$10,610.71"	"$12,938.47"	"$7,759.20"	Not Applicable	"$6,789.30"	"$13,578.60"	"$6,789.30"	"$13,578.60"
CAGE SPNL 15.5X4.1-7MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR MC 1453 P	C1821	SUPPLY/IMPLANTS	"$19,396.00"	Outpatient	"$9,698.00"	Not Applicable	"$10,609.61"	"$12,937.13"	"$7,758.40"	Not Applicable	"$6,788.60"	"$13,577.20"	"$6,788.60"	"$13,577.20"
CAGE SPNL 15.5X4.1-7MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR CMC 1453 P	C1821	SUPPLY/IMPLANTS	"$19,396.00"	Outpatient	"$9,698.00"	Not Applicable	"$10,609.61"	"$12,937.13"	"$7,758.40"	Not Applicable	"$6,788.60"	"$13,577.20"	"$6,788.60"	"$13,577.20"
CAGE SPNL 15.5X5.2-8MM ROI-C VERTEBRIDGE 7D LRDTC 14MM TPR CMC 1424 P		SUPPLY/IMPLANTS	"$19,396.00"	Outpatient	"$9,698.00"	Not Applicable	"$10,609.61"	"$12,937.13"	"$7,758.40"	Not Applicable	"$6,788.60"	"$13,577.20"	"$6,788.60"	"$13,577.20"
ANCHORING PLATES LONG MC10006T	C1713	SUPPLY/IMPLANTS	"$19,394.00"	Outpatient	"$9,697.00"	"$1,365.15"	"$10,608.52"	"$12,935.80"	"$7,757.60"	Not Applicable	"$6,787.90"	"$13,575.80"	"$1,365.15"	"$13,575.80"
IMPL URO 61-70CU CM INHBZN PRSS BLN A800 SPHNCR STRL URN 72400024	C1815	SUPPLY/IMPLANTS	"$19,384.00"	Outpatient	"$9,692.00"	Not Applicable	"$10,603.05"	"$12,929.13"	"$7,753.60"	Not Applicable	"$6,784.40"	"$13,568.80"	"$6,784.40"	"$13,568.80"
CASE STRL BMP INST XPD CBL 592054	C1713	SUPPLY/IMPLANTS	"$19,383.00"	Outpatient	"$9,691.50"	"$1,365.15"	"$10,602.50"	"$12,928.46"	"$7,753.20"	Not Applicable	"$6,784.05"	"$13,568.10"	"$1,365.15"	"$13,568.10"
PHALANX TOTAL PROXIMAL MGT-890-40PPT	C1776	SUPPLY/IMPLANTS	"$19,381.00"	Outpatient	"$9,690.50"	Not Applicable	"$10,601.41"	"$12,927.13"	"$7,752.40"	Not Applicable	"$6,783.35"	"$13,566.70"	"$6,783.35"	"$13,566.70"
PHALANX TOTAL PROXIMAL SZ 20 MGT-890-20PPT	C1713	SUPPLY/IMPLANTS	"$19,381.00"	Outpatient	"$9,690.50"	"$1,365.15"	"$10,601.41"	"$12,927.13"	"$7,752.40"	Not Applicable	"$6,783.35"	"$13,566.70"	"$1,365.15"	"$13,566.70"
PHALANX TOTAL PROXIMAL SZ 30 MGT-890-30PPT	C1713	SUPPLY/IMPLANTS	"$19,381.00"	Outpatient	"$9,690.50"	"$1,365.15"	"$10,601.41"	"$12,927.13"	"$7,752.40"	Not Applicable	"$6,783.35"	"$13,566.70"	"$1,365.15"	"$13,566.70"
SHL ACTB 54MM HIP PRM MDLR CUP MLHL REV TRB MTL STRL 620205420		STERILE SUPPLY	"$19,363.00"	Outpatient	"$9,681.50"	Not Applicable	"$10,591.56"	"$12,915.12"	"$7,745.20"	Not Applicable	"$6,777.05"	"$13,554.10"	"$6,777.05"	"$13,554.10"
SUB BNGF 10ML BIOACTIVE VOID FIL CMPR RST VITOSS BTCP CLGN 2102-2110	C1713	SUPPLY/IMPLANTS	"$19,344.00"	Outpatient	"$9,672.00"	"$1,365.15"	"$10,581.17"	"$12,902.45"	"$7,737.60"	Not Applicable	"$6,770.40"	"$13,540.80"	"$1,365.15"	"$13,540.80"
SYS GSTRC BAND ACC PORT I ADJ CNCT RADOPQ LPBND AP OMNIFORM B-2245		SUPPLY/IMPLANTS	"$19,315.00"	Outpatient	"$9,657.50"	Not Applicable	"$10,565.31"	"$12,883.11"	"$7,726.00"	Not Applicable	"$6,760.25"	"$13,520.50"	"$6,760.25"	"$13,520.50"
SYS GSTRC BAND ACC PORT I ADJ CNCT RADOPQ LPBND AP OMNIFORM B-2240		SUPPLY/IMPLANTS	"$19,315.00"	Outpatient	"$9,657.50"	Not Applicable	"$10,565.31"	"$12,883.11"	"$7,726.00"	Not Applicable	"$6,760.25"	"$13,520.50"	"$6,760.25"	"$13,520.50"
PLT 30X17.4X2.5MM SPNE CRV ANT TI LVL 2 ATO LCK SYS SPRG LD 48811230	C1713	SUPPLY/IMPLANTS	"$19,292.00"	Outpatient	"$9,646.00"	"$1,365.15"	"$10,552.72"	"$12,867.76"	"$7,716.80"	Not Applicable	"$6,752.20"	"$13,504.40"	"$1,365.15"	"$13,504.40"
ANKLE TRANS PIN LT TEMPFIX STER 8081-09-000	C1713	SUPPLY/IMPLANTS	"$19,284.00"	Outpatient	"$9,642.00"	"$1,365.15"	"$10,548.35"	"$12,862.43"	"$7,713.60"	Not Applicable	"$6,749.40"	"$13,498.80"	"$1,365.15"	"$13,498.80"
ANKLE TRANS PIN RT TEMPFIX STER 808110000	C1713	SUPPLY/IMPLANTS	"$19,284.00"	Outpatient	"$9,642.00"	"$1,365.15"	"$10,548.35"	"$12,862.43"	"$7,713.60"	Not Applicable	"$6,749.40"	"$13,498.80"	"$1,365.15"	"$13,498.80"
HEAD HUM 23MM 52MM SHLDR REUNION STD STRL 5552-S-5223	C1776	SUPPLY/IMPLANTS	"$19,281.00"	Outpatient	"$9,640.50"	Not Applicable	"$10,546.71"	"$12,860.43"	"$7,712.40"	Not Applicable	"$6,748.35"	"$13,496.70"	"$6,748.35"	"$13,496.70"
HEAD HUM 16MM 44MM SHLDR REUNION STD STRL 5552-S-4416	C1776	SUPPLY/IMPLANTS	"$19,281.00"	Outpatient	"$9,640.50"	Not Applicable	"$10,546.71"	"$12,860.43"	"$7,712.40"	Not Applicable	"$6,748.35"	"$13,496.70"	"$6,748.35"	"$13,496.70"
HEAD HUM 20MM 52MM SHLDR REUNION STD STRL 5552-S-5220	C1776	SUPPLY/IMPLANTS	"$19,281.00"	Outpatient	"$9,640.50"	Not Applicable	"$10,546.71"	"$12,860.43"	"$7,712.40"	Not Applicable	"$6,748.35"	"$13,496.70"	"$6,748.35"	"$13,496.70"
SINGLE RADIUS HUMERAL HEAD 5552-S-S-40147	C1776	SUPPLY/IMPLANTS	"$19,281.00"	Outpatient	"$9,640.50"	Not Applicable	"$10,546.71"	"$12,860.43"	"$7,712.40"	Not Applicable	"$6,748.35"	"$13,496.70"	"$6,748.35"	"$13,496.70"
HEAD HUM 14MM 40MM REUNION STD RDS T/S ARTHPL 5552-S-4014	C1776	SUPPLY/IMPLANTS	"$19,273.00"	Outpatient	"$9,636.50"	Not Applicable	"$10,542.33"	"$12,855.09"	"$7,709.20"	Not Applicable	"$6,745.55"	"$13,491.10"	"$6,745.55"	"$13,491.10"
Inferior Vena Cava Filter Placement	37191	CARDIAC CATH LAB	"$19,272.00"	Outpatient	"$9,636.00"	"$15,491.50"	"$10,541.78"	"$1,592.00"	"$7,708.80"	"$7,310.00"	"$6,745.20"	"$13,490.40"	"$1,592.00"	"$15,491.50"
CASE INST SS RADEL AL 2 CMPR CNTR SM FRAG PLT NS 480103550	C1713	SUPPLY/IMPLANTS	"$19,272.00"	Outpatient	"$9,636.00"	"$1,365.15"	"$10,541.78"	"$12,854.42"	"$7,708.80"	Not Applicable	"$6,745.20"	"$13,490.40"	"$1,365.15"	"$13,490.40"
GFT VASC 50CM 6MM 7MM NTNL PTFE HBRD REINF COAT 10CM 0650HYB0710A	C1768	SUPPLY/IMPLANTS	"$19,254.00"	Outpatient	"$9,627.00"	Not Applicable	"$10,531.94"	"$12,842.42"	"$7,701.60"	Not Applicable	"$6,738.90"	"$13,477.80"	"$6,738.90"	"$13,477.80"
GFT VASC 50CM 6MM 6MM NTNL PTFE HBRD REINF COAT 10CM 0650HYB0610A	C1768	SUPPLY/IMPLANTS	"$19,245.00"	Outpatient	"$9,622.50"	Not Applicable	"$10,527.02"	"$12,836.42"	"$7,698.00"	Not Applicable	"$6,735.75"	"$13,471.50"	"$6,735.75"	"$13,471.50"
SET SRG INST OPTRM 3154		STERILE SUPPLY	"$19,245.00"	Outpatient	"$9,622.50"	Not Applicable	"$10,527.02"	"$12,836.42"	"$7,698.00"	Not Applicable	"$6,735.75"	"$13,471.50"	"$6,735.75"	"$13,471.50"
LEAD DBS  3387S 3387S	C1778	SUPPLY/IMPLANTS	"$19,224.00"	Outpatient	"$9,612.00"	Not Applicable	"$10,515.53"	"$12,822.41"	"$7,689.60"	Not Applicable	"$6,728.40"	"$13,456.80"	"$6,728.40"	"$13,456.80"
NAIL IM 38CM 130D 1.5MM INTERTAN 11.5MM LT INTERTROCHANTER 71676579	C1713	SUPPLY/IMPLANTS	"$19,222.00"	Outpatient	"$9,611.00"	"$1,365.15"	"$10,514.43"	"$12,821.07"	"$7,688.80"	Not Applicable	"$6,727.70"	"$13,455.40"	"$1,365.15"	"$13,455.40"
MODL ANTM CLR MED SD900.214	C1713	SUPPLY/IMPLANTS	"$19,203.00"	Outpatient	"$9,601.50"	"$1,365.15"	"$10,504.04"	"$12,808.40"	"$7,681.20"	Not Applicable	"$6,721.05"	"$13,442.10"	"$1,365.15"	"$13,442.10"
NAIL IM 320MM 9MM RTRGD PHNX FEM 14-444132	C1713	SUPPLY/IMPLANTS	"$19,194.00"	Outpatient	"$9,597.00"	"$1,365.15"	"$10,499.12"	"$12,802.40"	"$7,677.60"	Not Applicable	"$6,717.90"	"$13,435.80"	"$1,365.15"	"$13,435.80"
59676-0610-01 - trabectedin 1 mg Powd	J9352	PHARMACY	"$16,143.00"	Outpatient	"$8,071.50"	$344.23	"$10,492.95"	"$10,767.38"	"$6,457.20"	Not Applicable	"$5,650.05"	"$11,300.10"	$344.23	"$11,300.10"
 PK PAPYRUS 2.5/15 434887	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PK PAPYRUS 3.0/15 434888	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PK PAPYRUS 3.0/20 434894	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PK PAPYRUS 3.5/15 434889	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PK PAPYRUS 3.5/20 434895	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PK PAPYRUS 4.0/15 434890	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PK PAPYRUS 4.5/20 434897	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PK PAPYRUS 2.5/20 434893	C1874	SUPPLY/IMPLANTS	"$19,181.00"	Outpatient	"$9,590.50"	Not Applicable	"$10,492.01"	"$12,793.73"	"$7,672.40"	Not Applicable	"$6,713.35"	"$13,426.70"	"$6,713.35"	"$13,426.70"
PLT 100X100X.5MM CRNMXF MESH RPD RSRB BN STRL 1.5MM SCR 851.512.01S	C1713	SUPPLY/IMPLANTS	"$19,166.00"	Outpatient	"$9,583.00"	"$1,365.15"	"$10,483.80"	"$12,783.72"	"$7,666.40"	Not Applicable	"$6,708.10"	"$13,416.20"	"$1,365.15"	"$13,416.20"
PLT 100X100X.5MM CRNMXF STRG ROW MESH RPD RSRB BN STRL 1.5MM 851.712.01S	C1713	SUPPLY/IMPLANTS	"$19,166.00"	Outpatient	"$9,583.00"	"$1,365.15"	"$10,483.80"	"$12,783.72"	"$7,666.40"	Not Applicable	"$6,708.10"	"$13,416.20"	"$1,365.15"	"$13,416.20"
CASE STRL GRPH NS MATRIXMANDILBE SYS 306.701	C1713	SUPPLY/IMPLANTS	"$19,130.00"	Outpatient	"$9,565.00"	"$1,365.15"	"$10,464.11"	"$12,759.71"	"$7,652.00"	Not Applicable	"$6,695.50"	"$13,391.00"	"$1,365.15"	"$13,391.00"
MESH MATRIXNEURO 100X100X.4MM TI CNTR CRNL RGD NS SLVR 04.503.083	C1713	SUPPLY/IMPLANTS	"$19,116.00"	Outpatient	"$9,558.00"	"$1,365.15"	"$10,456.45"	"$12,750.37"	"$7,646.40"	Not Applicable	"$6,690.60"	"$13,381.20"	"$1,365.15"	"$13,381.20"
LINR ACTB 32MM 0D GVF POLY-DIAL L SER SR HIP 873557		STERILE SUPPLY	"$19,107.00"	Outpatient	"$9,553.50"	Not Applicable	"$10,451.53"	"$12,744.37"	"$7,642.80"	Not Applicable	"$6,687.45"	"$13,374.90"	"$6,687.45"	"$13,374.90"
MTRX TISS 16X6CM ALDRM XTHICK ACLR DERM ALGRF RGNRT FRZDR 982196	C1762	SUPPLY/IMPLANTS	"$19,101.00"	Outpatient	"$9,550.50"	Not Applicable	"$10,448.25"	"$12,740.37"	"$7,640.40"	Not Applicable	"$6,685.35"	"$13,370.70"	"$6,685.35"	"$13,370.70"
NAIL IM 44CM 15MM LCK T2 TI FEM STRL R1.5 18281544S	C1713	SUPPLY/IMPLANTS	"$19,098.00"	Outpatient	"$9,549.00"	"$1,365.15"	"$10,446.61"	"$12,738.37"	"$7,639.20"	Not Applicable	"$6,684.30"	"$13,368.60"	"$1,365.15"	"$13,368.60"
CMPNT FEM SM PRT KN PHS 3 TWN PG UNCMP OXFD COCRMO 161468	C1776	SUPPLY/IMPLANTS	"$19,092.00"	Outpatient	"$9,546.00"	Not Applicable	"$10,443.32"	"$12,734.36"	"$7,636.80"	Not Applicable	"$6,682.20"	"$13,364.40"	"$6,682.20"	"$13,364.40"
STEM HUM 55MM 11MM CMPRH POR MIC SHLDR RVRS SYS 113611	C1776	SUPPLY/IMPLANTS	"$19,085.00"	Outpatient	"$9,542.50"	Not Applicable	"$10,439.50"	"$12,729.70"	"$7,634.00"	Not Applicable	"$6,679.75"	"$13,359.50"	"$6,679.75"	"$13,359.50"
STENT VASCULAR COVERA STRAIGHT L60 MM L80 CM OD8 MM ID8 FR C AVSM08060	C1874	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
STENT VASCULAR COVERA FLARE L60 MM L80 CM OD9 MM ID8 FR ARTE AVFM09060	C1874	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
STENT PERIPHERAL 40MML X 7MM DIA CATHETER 80CML STRAIGHT VAS AVSM07040	C1876	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
CAGE SPINAL RENOVIS T3 2 D LORDOSIS L16 MM X W13.5 MM X H7 M 1053-161-307	C1821	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
CATHETER ULTRASOUND LITHOPLASTY OD.064 IN L110 CM L60 MM ODS M732LPBC7060DX1	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
CATHETER ULTRASOUND LITHOPLASTY OD.064 IN L110 CM L60 MM ODS M732LPBC5560DX1	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
CATHETER BALLOON DILATATION LITHOPLASTY OD.064 IN L110 CM L6 M732LPBC6060DX1	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
CATHETER BALLOON DILATATION LITHOPLASTY OD.064 IN L110 CM L6 M732LPBC6560DX1	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
Lithoplasty BDC 7.0mm x 60mm - 110cb M732LBC7060DXK	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
SHOCKWAVE M IVL CATHETER  6.0X60 M5IVL6060	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
SHOCKWAVE CATHETER 7.0X60 M5IVL7060	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
SHOCKWAVE IVL CATHETER 6.5X60 M5IVL6560	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
"SHOCKWAVE M5 IVL CATHETER, 5.0X60 MM M732LPBC5060DX1"	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
SHOCKWAVE S IVL CATHETER 3.5X4.0 S4IVL3540	C1725	SUPPLY/IMPLANTS	"$19,064.00"	Outpatient	"$9,532.00"	Not Applicable	"$10,428.01"	"$12,715.69"	"$7,625.60"	Not Applicable	"$6,672.40"	"$13,344.80"	"$6,672.40"	"$13,344.80"
CMPNT FEM 64X49.3X10.5MM RMD GNTA PMMA STRL RKFMMD	C1776	SUPPLY/IMPLANTS	"$19,059.00"	Outpatient	"$9,529.50"	Not Applicable	"$10,425.27"	"$12,712.35"	"$7,623.60"	Not Applicable	"$6,670.65"	"$13,341.30"	"$6,670.65"	"$13,341.30"
CMPNT FEM 74X56.3X11.5MM RMD GNTA PMMA STRL RKFMLG	C1776	SUPPLY/IMPLANTS	"$19,059.00"	Outpatient	"$9,529.50"	Not Applicable	"$10,425.27"	"$12,712.35"	"$7,623.60"	Not Applicable	"$6,670.65"	"$13,341.30"	"$6,670.65"	"$13,341.30"
SPCR TIB 42X70X25MM 14MM RMD MED KN GNTA PMMA 8.2MM STRL RKTBMD	C1776	SUPPLY/IMPLANTS	"$19,059.00"	Outpatient	"$9,529.50"	Not Applicable	"$10,425.27"	"$12,712.35"	"$7,623.60"	Not Applicable	"$6,670.65"	"$13,341.30"	"$6,670.65"	"$13,341.30"
SPCR TIB 48X80X25MM 14MM RMD LG KN GNTA PMMA 8.8MM STRL RKTBLG	C1776	SUPPLY/IMPLANTS	"$19,059.00"	Outpatient	"$9,529.50"	Not Applicable	"$10,425.27"	"$12,712.35"	"$7,623.60"	Not Applicable	"$6,670.65"	"$13,341.30"	"$6,670.65"	"$13,341.30"
REMEDY TIBIAL COMPONENT MEDIUM/ML70 AP43 RFKMMD	C1713	SUPPLY/IMPLANTS	"$19,059.00"	Outpatient	"$9,529.50"	"$1,365.15"	"$10,425.27"	"$12,712.35"	"$7,623.60"	Not Applicable	"$6,670.65"	"$13,341.30"	"$1,365.15"	"$13,341.30"
STEM FEM 227MM 16.5MM 10MM SM RMD HIP STRL RHLSSM	C1776	SUPPLY/IMPLANTS	"$19,052.00"	Outpatient	"$9,526.00"	Not Applicable	"$10,421.44"	"$12,707.68"	"$7,620.80"	Not Applicable	"$6,668.20"	"$13,336.40"	"$6,668.20"	"$13,336.40"
"INTRBDY STND-ALONE CERV CAGE TESERA SC, 17.5MMX15MMX8MM HGHT 1055-171-508"	C1821	SUPPLY/IMPLANTS	"$19,052.00"	Outpatient	"$9,526.00"	Not Applicable	"$10,421.44"	"$12,707.68"	"$7,620.80"	Not Applicable	"$6,668.20"	"$13,336.40"	"$6,668.20"	"$13,336.40"
"INTRBDY STND-ALONE CERV CAGE TESERA SC, 17.5MMX15MMX7MM HGHT 1053-171-507"	C1821	SUPPLY/IMPLANTS	"$19,052.00"	Outpatient	"$9,526.00"	Not Applicable	"$10,421.44"	"$12,707.68"	"$7,620.80"	Not Applicable	"$6,668.20"	"$13,336.40"	"$6,668.20"	"$13,336.40"
"INTRBDY STND-ALONE CERV CAGE TESERA SC, 17.5MMX15MMX9MM HGHT 1055-171-509"	C1821	SUPPLY/IMPLANTS	"$19,052.00"	Outpatient	"$9,526.00"	Not Applicable	"$10,421.44"	"$12,707.68"	"$7,620.80"	Not Applicable	"$6,668.20"	"$13,336.40"	"$6,668.20"	"$13,336.40"
CASE STRL VHS GRPH SET INST 595034	C1713	SUPPLY/IMPLANTS	"$19,051.00"	Outpatient	"$9,525.50"	"$1,365.15"	"$10,420.90"	"$12,707.02"	"$7,620.40"	Not Applicable	"$6,667.85"	"$13,335.70"	"$1,365.15"	"$13,335.70"
CATH BRCHTX 4.4CM 4.4CM 3 CNCV TIP INTRO MTLUM BLN CONTURA B01245		STERILE SUPPLY	"$19,051.00"	Outpatient	"$9,525.50"	Not Applicable	"$10,420.90"	"$12,707.02"	"$7,620.40"	Not Applicable	"$6,667.85"	"$13,335.70"	"$6,667.85"	"$13,335.70"
GFT SNTH TISS STD CA SLF 15ML M2GX3 RSRB INJ HI STRTH 84XS-0415		STERILE SUPPLY	"$19,051.00"	Outpatient	"$9,525.50"	Not Applicable	"$10,420.90"	"$12,707.02"	"$7,620.40"	Not Applicable	"$6,667.85"	"$13,335.70"	"$6,667.85"	"$13,335.70"
STEM FEM 96MM 127D 1 34MM OFST ACLD II V40 PUREFIX TI PLSM 6721-0127	C1776	SUPPLY/IMPLANTS	"$19,050.00"	Outpatient	"$9,525.00"	Not Applicable	"$10,420.35"	"$12,706.35"	"$7,620.00"	Not Applicable	"$6,667.50"	"$13,335.00"	"$6,667.50"	"$13,335.00"
MOLD CEMENT STAGEONE SILICONE H21 MM OD10 MM ODSEC57 MM ID50 431410	C1776	SUPPLY/IMPLANTS	"$19,049.00"	Outpatient	"$9,524.50"	Not Applicable	"$10,419.80"	"$12,705.68"	"$7,619.60"	Not Applicable	"$6,667.15"	"$13,334.30"	"$6,667.15"	"$13,334.30"
NAIL IM 360MM 11MM 130D LNG CNN PREASSEMBLE LCK MECH STC 04.037.156S	C1713	SUPPLY/IMPLANTS	"$19,044.00"	Outpatient	"$9,522.00"	"$1,365.15"	"$10,417.07"	"$12,702.35"	"$7,617.60"	Not Applicable	"$6,665.40"	"$13,330.80"	"$1,365.15"	"$13,330.80"
NAIL IM 380MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.158S	C1713	SUPPLY/IMPLANTS	"$19,044.00"	Outpatient	"$9,522.00"	"$1,365.15"	"$10,417.07"	"$12,702.35"	"$7,617.60"	Not Applicable	"$6,665.40"	"$13,330.80"	"$1,365.15"	"$13,330.80"
NAIL IM 380MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.159S	C1713	SUPPLY/IMPLANTS	"$19,044.00"	Outpatient	"$9,522.00"	"$1,365.15"	"$10,417.07"	"$12,702.35"	"$7,617.60"	Not Applicable	"$6,665.40"	"$13,330.80"	"$1,365.15"	"$13,330.80"
NAIL IM 360MM 15.66-10MM 130D LNG CNN TFN-ADV LAT RLF CUT TI 04.037.056S	C1713	SUPPLY/IMPLANTS	"$19,044.00"	Outpatient	"$9,522.00"	"$1,365.15"	"$10,417.07"	"$12,702.35"	"$7,617.60"	Not Applicable	"$6,665.40"	"$13,330.80"	"$1,365.15"	"$13,330.80"
NAIL IM 400MM 10MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.061S	C1713	SUPPLY/IMPLANTS	"$19,044.00"	Outpatient	"$9,522.00"	"$1,365.15"	"$10,417.07"	"$12,702.35"	"$7,617.60"	Not Applicable	"$6,665.40"	"$13,330.80"	"$1,365.15"	"$13,330.80"
MODL ANTM CLR ACRL MNDB ORBT ADLT NS SD900.206	C1713	SUPPLY/IMPLANTS	"$19,007.00"	Outpatient	"$9,503.50"	"$1,365.15"	"$10,396.83"	"$12,677.67"	"$7,602.80"	Not Applicable	"$6,652.45"	"$13,304.90"	"$1,365.15"	"$13,304.90"
MODL ANTM CLR ACRL MXL THR CRNL ABL TO CUT ADLT NS SD900.208	C1713	SUPPLY/IMPLANTS	"$19,007.00"	Outpatient	"$9,503.50"	"$1,365.15"	"$10,396.83"	"$12,677.67"	"$7,602.80"	Not Applicable	"$6,652.45"	"$13,304.90"	"$1,365.15"	"$13,304.90"
MODL ANTM CLR LNR PLN DSTRCT OUTCM SD900.235	C1713	SUPPLY/IMPLANTS	"$19,007.00"	Outpatient	"$9,503.50"	"$1,365.15"	"$10,396.83"	"$12,677.67"	"$7,602.80"	Not Applicable	"$6,652.45"	"$13,304.90"	"$1,365.15"	"$13,304.90"
MODL ANTM CLR PLANNED FULL MNDB ORBT SD900.236	C1713	SUPPLY/IMPLANTS	"$19,007.00"	Outpatient	"$9,503.50"	"$1,365.15"	"$10,396.83"	"$12,677.67"	"$7,602.80"	Not Applicable	"$6,652.45"	"$13,304.90"	"$1,365.15"	"$13,304.90"
MODL ANTM CLR FULL MNDB MXL PS SIM OUTCM SD900.237	C1713	SUPPLY/IMPLANTS	"$19,007.00"	Outpatient	"$9,503.50"	"$1,365.15"	"$10,396.83"	"$12,677.67"	"$7,602.80"	Not Applicable	"$6,652.45"	"$13,304.90"	"$1,365.15"	"$13,304.90"
CATH US 2D 10FR 90CM INTRCRD 4W STEER RLTM VIS GS DPLR MODE 8255790		STERILE SUPPLY	"$19,005.00"	Outpatient	"$9,502.50"	Not Applicable	"$10,395.74"	"$12,676.34"	"$7,602.00"	Not Applicable	"$6,651.75"	"$13,303.50"	"$6,651.75"	"$13,303.50"
MODL ANTM CLRVW MXL 6500000007	C1713	SUPPLY/IMPLANTS	"$18,993.00"	Outpatient	"$9,496.50"	"$1,365.15"	"$10,389.17"	"$12,668.33"	"$7,597.20"	Not Applicable	"$6,647.55"	"$13,295.10"	"$1,365.15"	"$13,295.10"
SLV TIB 45X27X40MM MBT KN MTPHSL POR REV STRL LF 129454110		SUPPLY/IMPLANTS	"$18,993.00"	Outpatient	"$9,496.50"	Not Applicable	"$10,389.17"	"$12,668.33"	"$7,597.20"	Not Applicable	"$6,647.55"	"$13,295.10"	"$6,647.55"	"$13,295.10"
PLATE HUM. LATERAL 14 HOLE 6272445	C1713	SUPPLY/IMPLANTS	"$18,977.00"	Outpatient	"$9,488.50"	"$1,365.15"	"$10,380.42"	"$12,657.66"	"$7,590.80"	Not Applicable	"$6,641.95"	"$13,283.90"	"$1,365.15"	"$13,283.90"
PLATE BONE LCP TITANIUM CURVE L301 MM CONDYLAR LEFT 14 HOLE 04.124.415	C1713	SUPPLY/IMPLANTS	"$18,969.00"	Outpatient	"$9,484.50"	"$1,365.15"	"$10,376.04"	"$12,652.32"	"$7,587.60"	Not Applicable	"$6,639.15"	"$13,278.30"	"$1,365.15"	"$13,278.30"
STEM HUM 210MM 6.5MM RVRS CMNT AQLS SHLDR STRL LF DWB943	C1776	SUPPLY/IMPLANTS	"$18,933.00"	Outpatient	"$9,466.50"	Not Applicable	"$10,356.35"	"$12,628.31"	"$7,573.20"	Not Applicable	"$6,626.55"	"$13,253.10"	"$6,626.55"	"$13,253.10"
GD ASIA BRL ITST SRG MIS 225805212	C1713	SUPPLY/IMPLANTS	"$18,906.00"	Outpatient	"$9,453.00"	"$1,365.15"	"$10,341.58"	"$12,610.30"	"$7,562.40"	Not Applicable	"$6,617.10"	"$13,234.20"	"$1,365.15"	"$13,234.20"
SET TRMA FX PERIART 4MM CMBN SCR INST 2.7-3.5-4MM 234803000	C1713	SUPPLY/IMPLANTS	"$18,906.00"	Outpatient	"$9,453.00"	"$1,365.15"	"$10,341.58"	"$12,610.30"	"$7,562.40"	Not Applicable	"$6,617.10"	"$13,234.20"	"$1,365.15"	"$13,234.20"
COIL EMBOLIZATION XL TARGET LARGE L50 CM OD16 MM DETACHABLE M0036121650		SUPPLY/IMPLANTS	"$18,897.00"	Outpatient	"$9,448.50"	Not Applicable	"$10,336.66"	"$12,604.30"	"$7,558.80"	Not Applicable	"$6,613.95"	"$13,227.90"	"$6,613.95"	"$13,227.90"
GFT VASC 80CM 7MM GORE THNWL HEP PROPATEN PTFE REM RING HT076080A	C1768	SUPPLY/IMPLANTS	"$18,891.00"	Outpatient	"$9,445.50"	Not Applicable	"$10,333.38"	"$12,600.30"	"$7,556.40"	Not Applicable	"$6,611.85"	"$13,223.70"	"$6,611.85"	"$13,223.70"
GRAFT PROPATEN HT070050A		SUPPLY/IMPLANTS	"$18,891.00"	Outpatient	"$9,445.50"	Not Applicable	"$10,333.38"	"$12,600.30"	"$7,556.40"	Not Applicable	"$6,611.85"	"$13,223.70"	"$6,611.85"	"$13,223.70"
DEVICE FIXATION LSSS POLYESTER L9 CM ACROMIOCLAVICULAR 2 BRA LD090	C1713	SUPPLY/IMPLANTS	"$18,890.00"	Outpatient	"$9,445.00"	"$1,365.15"	"$10,332.83"	"$12,599.63"	"$7,556.00"	Not Applicable	"$6,611.50"	"$13,223.00"	"$1,365.15"	"$13,223.00"
DEVICE FIXATION LOCKDOWN L12 CM ACROMIOCLAVICULAR STERILE LA LD120	C1713	SUPPLY/IMPLANTS	"$18,890.00"	Outpatient	"$9,445.00"	"$1,365.15"	"$10,332.83"	"$12,599.63"	"$7,556.00"	Not Applicable	"$6,611.50"	"$13,223.00"	"$1,365.15"	"$13,223.00"
DSTRCT HNDHLD SRG 14501		STERILE SUPPLY	"$18,885.00"	Outpatient	"$9,442.50"	Not Applicable	"$10,330.10"	"$12,596.30"	"$7,554.00"	Not Applicable	"$6,609.75"	"$13,219.50"	"$6,609.75"	"$13,219.50"
"AC DEVICE, 10CM LD100"		STERILE SUPPLY	"$18,878.00"	Outpatient	"$9,439.00"	Not Applicable	"$10,326.27"	"$12,591.63"	"$7,551.20"	Not Applicable	"$6,607.30"	"$13,214.60"	"$6,607.30"	"$13,214.60"
LOCKDOWN AC DEVICE 11CM LD110		SUPPLY/IMPLANTS	"$18,878.00"	Outpatient	"$9,439.00"	Not Applicable	"$10,326.27"	"$12,591.63"	"$7,551.20"	Not Applicable	"$6,607.30"	"$13,214.60"	"$6,607.30"	"$13,214.60"
STEM EXTENSION GMRS COCR L80 MM KNEE PIECE 6495-6-080	C1776	SUPPLY/IMPLANTS	"$18,876.00"	Outpatient	"$9,438.00"	Not Applicable	"$10,325.17"	"$12,590.29"	"$7,550.40"	Not Applicable	"$6,606.60"	"$13,213.20"	"$6,606.60"	"$13,213.20"
PLT 20MMX8MM 6D SPNE INTERCONTINENTAL BN 187.058	C1713	SUPPLY/IMPLANTS	"$18,851.00"	Outpatient	"$9,425.50"	"$1,365.15"	"$10,311.50"	"$12,573.62"	"$7,540.40"	Not Applicable	"$6,597.85"	"$13,195.70"	"$1,365.15"	"$13,195.70"
PLT 8 SPNE 2 HL DECADE BN NS XLIF 7140208	C1713	SUPPLY/IMPLANTS	"$18,851.00"	Outpatient	"$9,425.50"	"$1,365.15"	"$10,311.50"	"$12,573.62"	"$7,540.40"	Not Applicable	"$6,597.85"	"$13,195.70"	"$1,365.15"	"$13,195.70"
PLT LG SPNE 2 HL BN STRL OLIF25 2140002	C1713	SUPPLY/IMPLANTS	"$18,851.00"	Outpatient	"$9,425.50"	"$1,365.15"	"$10,311.50"	"$12,573.62"	"$7,540.40"	Not Applicable	"$6,597.85"	"$13,195.70"	"$1,365.15"	"$13,195.70"
STNT GRTX NTNL FEP 10MM BIL PERC 8CM EXPANDABLE PUL LN HL VN1008040	C1874	SUPPLY/IMPLANTS	"$18,847.00"	Outpatient	"$9,423.50"	Not Applicable	"$10,309.31"	"$12,570.95"	"$7,538.80"	Not Applicable	"$6,596.45"	"$13,192.90"	"$6,596.45"	"$13,192.90"
STNT GRTX NTNL FEP 10MM BIL PERC 6CM EXPANDABLE PUL LN SLD VN1006040	C1874	SUPPLY/IMPLANTS	"$18,847.00"	Outpatient	"$9,423.50"	Not Applicable	"$10,309.31"	"$12,570.95"	"$7,538.80"	Not Applicable	"$6,596.45"	"$13,192.90"	"$6,596.45"	"$13,192.90"
PLATE 18MM 2 HOLE 190-2H18	C1713	SUPPLY/IMPLANTS	"$18,844.00"	Outpatient	"$9,422.00"	"$1,365.15"	"$10,307.67"	"$12,568.95"	"$7,537.60"	Not Applicable	"$6,595.40"	"$13,190.80"	"$1,365.15"	"$13,190.80"
CATHETER ABLATION TACTICATH SENSOR ENABLED 2-2-2 MM SPACE F- A-TCSE-FJ	C2630	SUPPLY/IMPLANTS	"$18,833.00"	Outpatient	"$9,416.50"	Not Applicable	"$10,301.65"	"$12,561.61"	"$7,533.20"	Not Applicable	"$6,591.55"	"$13,183.10"	"$6,591.55"	"$13,183.10"
Right and Left Heart Catheter	93453	CARDIAC CATH LAB	"$17,342.00"	Outpatient	"$8,671.00"	"$13,641.70"	"$10,301.15"	"$6,201.00"	"$6,936.80"	"$6,120.00"	"$6,069.70"	"$12,139.40"	"$6,069.70"	"$13,641.70"
Right Heart Cath	93451	CARDIAC CATH LAB	"$17,342.00"	Outpatient	"$8,671.00"	"$13,641.70"	"$10,301.15"	"$6,201.00"	"$6,936.80"	"$6,120.00"	"$6,069.70"	"$12,139.40"	"$6,069.70"	"$13,641.70"
PLT 125X24MM XLNG RT CROSSLOCK DVR BN STRL 811812125	C1713	SUPPLY/IMPLANTS	"$18,822.00"	Outpatient	"$9,411.00"	"$1,365.15"	"$10,295.63"	"$12,554.27"	"$7,528.80"	Not Applicable	"$6,587.70"	"$13,175.40"	"$1,365.15"	"$13,175.40"
PLT 125X24MM XLNG LT CROSSLOCK DVR BN STRL 811822125	C1713	SUPPLY/IMPLANTS	"$18,822.00"	Outpatient	"$9,411.00"	"$1,365.15"	"$10,295.63"	"$12,554.27"	"$7,528.80"	Not Applicable	"$6,587.70"	"$13,175.40"	"$1,365.15"	"$13,175.40"
IMPL COCLR TI HA 1 STG ABTMNT DERMALOCK BAHA 6MM 4MM STRL BA 93329	L8690	SUPPLY/IMPLANTS	"$18,814.00"	Outpatient	"$9,407.00"	Not Applicable	"$10,291.26"	"$12,548.94"	"$7,525.60"	Not Applicable	"$6,584.90"	"$13,169.80"	"$6,584.90"	"$13,169.80"
IMPL COCLR TI HA 1 STG ABTMNT DERMALOCK BAHA 8MM 4MM STRL BA 93330	L8690	SUPPLY/IMPLANTS	"$18,814.00"	Outpatient	"$9,407.00"	Not Applicable	"$10,291.26"	"$12,548.94"	"$7,525.60"	Not Applicable	"$6,584.90"	"$13,169.80"	"$6,584.90"	"$13,169.80"
IMPL COCLR TI HA 1 STG ABTMNT DERMALOCK BAHA 10MM 4MM STRL 93331	L8690	SUPPLY/IMPLANTS	"$18,814.00"	Outpatient	"$9,407.00"	Not Applicable	"$10,291.26"	"$12,548.94"	"$7,525.60"	Not Applicable	"$6,584.90"	"$13,169.80"	"$6,584.90"	"$13,169.80"
IMPL COCLR TI HA 1 STG ABTMNT DERMALOCK BAHA 12MM 4MM STRL 93332	L8690	SUPPLY/IMPLANTS	"$18,814.00"	Outpatient	"$9,407.00"	Not Applicable	"$10,291.26"	"$12,548.94"	"$7,525.60"	Not Applicable	"$6,584.90"	"$13,169.80"	"$6,584.90"	"$13,169.80"
IMPL COCLR ABTMNT BAHA 14MM 4MM STRL LF DISP BIA400 93338	L8690	SUPPLY/IMPLANTS	"$18,814.00"	Outpatient	"$9,407.00"	Not Applicable	"$10,291.26"	"$12,548.94"	"$7,525.60"	Not Applicable	"$6,584.90"	"$13,169.80"	"$6,584.90"	"$13,169.80"
WDG TIB IBALANCE 15D 13D S/MED KN HTO AR-13400M-13	C1776	SUPPLY/IMPLANTS	"$18,808.00"	Outpatient	"$9,404.00"	Not Applicable	"$10,287.98"	"$12,544.94"	"$7,523.20"	Not Applicable	"$6,582.80"	"$13,165.60"	"$6,582.80"	"$13,165.60"
LEAD ATTAIN MRI 479888	C1900	PACE MAKER	"$18,804.00"	Outpatient	"$9,402.00"	Not Applicable	"$10,285.79"	"$12,542.27"	"$7,521.60"	Not Applicable	"$6,581.40"	"$13,162.80"	"$6,581.40"	"$13,162.80"
CLP XTRNFX DNFX ADLT C RL GRADUAL SWVL NS 6350	C1713	SUPPLY/IMPLANTS	"$18,801.00"	Outpatient	"$9,400.50"	"$1,365.15"	"$10,284.15"	"$12,540.27"	"$7,520.40"	Not Applicable	"$6,580.35"	"$13,160.70"	"$1,365.15"	"$13,160.70"
CLP XTRNFX DNFX ADLT C RL TRANSLATIONAL NS 6360	C1713	SUPPLY/IMPLANTS	"$18,801.00"	Outpatient	"$9,400.50"	"$1,365.15"	"$10,284.15"	"$12,540.27"	"$7,520.40"	Not Applicable	"$6,580.35"	"$13,160.70"	"$1,365.15"	"$13,160.70"
Vertebral Angiogram	36226	CARDIAC CATH LAB	"$18,791.00"	Outpatient	"$9,395.50"	"$18,161.90"	"$10,278.68"	"$12,533.60"	"$7,516.40"	"$7,310.00"	"$6,576.85"	"$13,153.70"	"$6,576.85"	"$18,161.90"
Subclavian or Innominate Angiogram	36225	CARDIAC CATH LAB	"$18,791.00"	Outpatient	"$9,395.50"	"$11,105.17"	"$10,278.68"	"$12,533.60"	"$7,516.40"	"$4,680.00"	"$6,576.85"	"$13,153.70"	"$4,680.00"	"$13,153.70"
RMR VHS CMB HDSN END SRG 35-463108	C1713	SUPPLY/IMPLANTS	"$18,788.00"	Outpatient	"$9,394.00"	"$1,365.15"	"$10,277.04"	"$12,531.60"	"$7,515.20"	Not Applicable	"$6,575.80"	"$13,151.60"	"$1,365.15"	"$13,151.60"
COIL EMBL 20CM 6MM XL TRGT LG DTCH SFT SMTH STAB DLV STRL M0036126200		SUPPLY/IMPLANTS	"$18,784.00"	Outpatient	"$9,392.00"	Not Applicable	"$10,274.85"	"$12,528.93"	"$7,513.60"	Not Applicable	"$6,574.40"	"$13,148.80"	"$6,574.40"	"$13,148.80"
TARGET COIL 360 ULTRA 5MM X 15CM 612515		SUPPLY/IMPLANTS	"$18,784.00"	Outpatient	"$9,392.00"	Not Applicable	"$10,274.85"	"$12,528.93"	"$7,513.60"	Not Applicable	"$6,574.40"	"$13,148.80"	"$6,574.40"	"$13,148.80"
COIL TARGET SOFT 360 16MM X 50CM M003612165		SUPPLY/IMPLANTS	"$18,783.00"	Outpatient	"$9,391.50"	Not Applicable	"$10,274.30"	"$12,528.26"	"$7,513.20"	Not Applicable	"$6,574.05"	"$13,148.10"	"$6,574.05"	"$13,148.10"
63459-0391-20 - bendamustine 1 mg Injection	J9033	PHARMACY	"$15,799.00"	Outpatient	"$7,899.50"	$28.83	"$10,269.35"	"$10,537.93"	"$6,319.60"	Not Applicable	"$5,529.65"	"$11,059.30"	$28.83	"$11,059.30"
GFT EVAS 3.3CM 28.5MM 24-26MM AORTA PLA280300	C1874	SUPPLY/IMPLANTS	"$18,760.00"	Outpatient	"$9,380.00"	Not Applicable	"$10,261.72"	"$12,512.92"	"$7,504.00"	Not Applicable	"$6,566.00"	"$13,132.00"	"$6,566.00"	"$13,132.00"
PLT 55MM SPNE CRV ANT TI LCK ATLNTS TRANSLATIONAL BN NS 6190055	C1713	SUPPLY/IMPLANTS	"$18,758.00"	Outpatient	"$9,379.00"	"$1,365.15"	"$10,260.63"	"$12,511.59"	"$7,503.20"	Not Applicable	"$6,565.30"	"$13,130.60"	"$1,365.15"	"$13,130.60"
PLT 62.5MM SPNE CRV ANT TI LCK ATLNTS TRANSLATIONAL BN NS 6190062	C1713	SUPPLY/IMPLANTS	"$18,758.00"	Outpatient	"$9,379.00"	"$1,365.15"	"$10,260.63"	"$12,511.59"	"$7,503.20"	Not Applicable	"$6,565.30"	"$13,130.60"	"$1,365.15"	"$13,130.60"
PLT 2.8MM LT ANG MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS 04.503.772	C1713	SUPPLY/IMPLANTS	"$18,746.00"	Outpatient	"$9,373.00"	"$1,365.15"	"$10,254.06"	"$12,503.58"	"$7,498.40"	Not Applicable	"$6,561.10"	"$13,122.20"	"$1,365.15"	"$13,122.20"
PLT 2.8MM RT ANG MNDB TI 7X23 HL RECON MATRIXMANDIBLE BN NS 04.503.773	C1713	SUPPLY/IMPLANTS	"$18,746.00"	Outpatient	"$9,373.00"	"$1,365.15"	"$10,254.06"	"$12,503.58"	"$7,498.40"	Not Applicable	"$6,561.10"	"$13,122.20"	"$1,365.15"	"$13,122.20"
LINR ACTB 36MM 0D D X3 3.9MM HIP 623-00-36D	C1776	SUPPLY/IMPLANTS	"$18,738.00"	Outpatient	"$9,369.00"	Not Applicable	"$10,249.69"	"$12,498.25"	"$7,495.20"	Not Applicable	"$6,558.30"	"$13,116.60"	"$6,558.30"	"$13,116.60"
RAIL XTRNFX 250MM SM C SYS 6616	C1713	SUPPLY/IMPLANTS	"$18,731.00"	Outpatient	"$9,365.50"	"$1,365.15"	"$10,245.86"	"$12,493.58"	"$7,492.40"	Not Applicable	"$6,555.85"	"$13,111.70"	"$1,365.15"	"$13,111.70"
CASE INST PLV 480107520	C1713	SUPPLY/IMPLANTS	"$18,723.00"	Outpatient	"$9,361.50"	"$1,365.15"	"$10,241.48"	"$12,488.24"	"$7,489.20"	Not Applicable	"$6,553.05"	"$13,106.10"	"$1,365.15"	"$13,106.10"
MITRAL VALVE MECHANICAL SZ 25MM 20.8MM ID 25.5 50ODM25		SUPPLY/IMPLANTS	"$18,717.00"	Outpatient	"$9,358.50"	Not Applicable	"$10,238.20"	"$12,484.24"	"$7,486.80"	Not Applicable	"$6,550.95"	"$13,101.90"	"$6,550.95"	"$13,101.90"
VALVE MITRAL OPEN PIVOT OD25 MM MECHANICAL STANDARD SERIES 500DM25		SUPPLY/IMPLANTS	"$18,717.00"	Outpatient	"$9,358.50"	Not Applicable	"$10,238.20"	"$12,484.24"	"$7,486.80"	Not Applicable	"$6,550.95"	"$13,101.90"	"$6,550.95"	"$13,101.90"
VALVE MITRAL ATS OPEN PIVOT STANDARD OD31 MM MECHANICAL 500DM31		SUPPLY/IMPLANTS	"$18,705.00"	Outpatient	"$9,352.50"	Not Applicable	"$10,231.64"	"$12,476.24"	"$7,482.00"	Not Applicable	"$6,546.75"	"$13,093.50"	"$6,546.75"	"$13,093.50"
CATH VASC 70CM 5FR 5.4MM OFFROAD SHRT PLTN IR PSTN BLN LNCT H74939202070540		STERILE SUPPLY	"$18,703.00"	Outpatient	"$9,351.50"	Not Applicable	"$10,230.54"	"$12,474.90"	"$7,481.20"	Not Applicable	"$6,546.05"	"$13,092.10"	"$6,546.05"	"$13,092.10"
CATH VASC 100CM 5FR 5.4MM OFFROAD 2.4FR MIC LNG PLTN IR PSTN H74939202100540		STERILE SUPPLY	"$18,703.00"	Outpatient	"$9,351.50"	Not Applicable	"$10,230.54"	"$12,474.90"	"$7,481.20"	Not Applicable	"$6,546.05"	"$13,092.10"	"$6,546.05"	"$13,092.10"
DRSG BIO INTGR 2X2IN BVN CLGN GAG POLYSILOXANE BL MX MESH MWM2021	C9363	PHARMACY	"$18,702.00"	Outpatient	"$9,351.00"	$38.51	"$10,229.99"	"$12,474.23"	"$7,480.80"	Not Applicable	"$6,545.70"	"$13,091.40"	$38.51	"$13,091.40"
PLT 2.5MM 2 ANG MED MNDB TI 5X22X5 HL RECON MATRIXMANDIBLE 04.503.742	C1713	SUPPLY/IMPLANTS	"$18,702.00"	Outpatient	"$9,351.00"	"$1,365.15"	"$10,229.99"	"$12,474.23"	"$7,480.80"	Not Applicable	"$6,545.70"	"$13,091.40"	"$1,365.15"	"$13,091.40"
FCP LAPSCP 8MM PRCS DVNC S/SI EWRST 420110		STERILE SUPPLY	"$18,701.00"	Outpatient	"$9,350.50"	Not Applicable	"$10,229.45"	"$12,473.57"	"$7,480.40"	Not Applicable	"$6,545.35"	"$13,090.70"	"$6,545.35"	"$13,090.70"
SYS REPR CMBN LFT PROSIMA PLVC FLR PROC2		STERILE SUPPLY	"$18,698.00"	Outpatient	"$9,349.00"	Not Applicable	"$10,227.81"	"$12,471.57"	"$7,479.20"	Not Applicable	"$6,544.30"	"$13,088.60"	"$6,544.30"	"$13,088.60"
STNT BIL 10MM 8.5FR 60MM 194CM .035IN FLLY CVR CATH GW DLV M00570370	C1874	SUPPLY/IMPLANTS	"$18,693.00"	Outpatient	"$9,346.50"	Not Applicable	"$10,225.07"	"$12,468.23"	"$7,477.20"	Not Applicable	"$6,542.55"	"$13,085.10"	"$6,542.55"	"$13,085.10"
STNT BIL 10MM 8.5FR 80MM 194CM .035IN FLLY CVR CATH GW DLV M00570380	C1874	SUPPLY/IMPLANTS	"$18,693.00"	Outpatient	"$9,346.50"	Not Applicable	"$10,225.07"	"$12,468.23"	"$7,477.20"	Not Applicable	"$6,542.55"	"$13,085.10"	"$6,542.55"	"$13,085.10"
STNT BIL 10MM 8.5FR 40MM 194CM .035IN FLLY CVR CATH GW DLV M00570360	C1874	SUPPLY/IMPLANTS	"$18,693.00"	Outpatient	"$9,346.50"	Not Applicable	"$10,225.07"	"$12,468.23"	"$7,477.20"	Not Applicable	"$6,542.55"	"$13,085.10"	"$6,542.55"	"$13,085.10"
SCREW PEDICLE PA CANNULATED 6.5 X 55MM SE-73865-55	C1713	SUPPLY/IMPLANTS	"$18,688.00"	Outpatient	"$9,344.00"	"$1,365.15"	"$10,222.34"	"$12,464.90"	"$7,475.20"	Not Applicable	"$6,540.80"	"$13,081.60"	"$1,365.15"	"$13,081.60"
(BC3) FRACTURE HEAD HIP BALL 47MM	C1776	SUPPLY/IMPLANTS	"$18,682.00"	Outpatient	"$9,341.00"	Not Applicable	"$10,219.05"	"$12,460.89"	"$7,472.80"	Not Applicable	"$6,538.70"	"$13,077.40"	"$6,538.70"	"$13,077.40"
STEM FEMORAL OMNIFIT EON COCR 127 D 4 33 MM OFFSET L100 MM O 6097-0425	C1776	SUPPLY/IMPLANTS	"$18,682.00"	Outpatient	"$9,341.00"	Not Applicable	"$10,219.05"	"$12,460.89"	"$7,472.80"	Not Applicable	"$6,538.70"	"$13,077.40"	"$6,538.70"	"$13,077.40"
SCREW CANNULATED PA 6.5 X 45MM SE-73865-45	C1713	SUPPLY/IMPLANTS	"$18,676.00"	Outpatient	"$9,338.00"	"$1,365.15"	"$10,215.77"	"$12,456.89"	"$7,470.40"	Not Applicable	"$6,536.60"	"$13,073.20"	"$1,365.15"	"$13,073.20"
SCREW PEDICLE PA CANNULATED 6.5 X 50MM SE-73865-50	C1713	SUPPLY/IMPLANTS	"$18,676.00"	Outpatient	"$9,338.00"	"$1,365.15"	"$10,215.77"	"$12,456.89"	"$7,470.40"	Not Applicable	"$6,536.60"	"$13,073.20"	"$1,365.15"	"$13,073.20"
SCREW CANNULATED PA 6.5 X 45MM SE-73965-45	C1713	SUPPLY/IMPLANTS	"$18,676.00"	Outpatient	"$9,338.00"	"$1,365.15"	"$10,215.77"	"$12,456.89"	"$7,470.40"	Not Applicable	"$6,536.60"	"$13,073.20"	"$1,365.15"	"$13,073.20"
DEV DRG DLV EKOSONIC MACH 4 INFS CATH US COR TX ZN EVAS ACPT 500-55124		STERILE SUPPLY	"$18,670.00"	Outpatient	"$9,335.00"	Not Applicable	"$10,212.49"	"$12,452.89"	"$7,468.00"	Not Applicable	"$6,534.50"	"$13,069.00"	"$6,534.50"	"$13,069.00"
GFT SFT TIS AMNIOHEAL + AMNIO ALGRF 2 LYR PWDR REPST 50MG TAH2050		STERILE SUPPLY	"$18,670.00"	Outpatient	"$9,335.00"	Not Applicable	"$10,212.49"	"$12,452.89"	"$7,468.00"	Not Applicable	"$6,534.50"	"$13,069.00"	"$6,534.50"	"$13,069.00"
SYS DRG DLV 135CM 12CM TX ZN INTLGNT CATH EVAS DEV EKOSONIC 500-56112		STERILE SUPPLY	"$18,670.00"	Outpatient	"$9,335.00"	Not Applicable	"$10,212.49"	"$12,452.89"	"$7,468.00"	Not Applicable	"$6,534.50"	"$13,069.00"	"$6,534.50"	"$13,069.00"
GFT BN CLGN MTRX 2-3CM ALGRF PURION PRC AGT-5230	C9363	SUPPLY/IMPLANTS	"$18,666.00"	Outpatient	"$9,333.00"	$38.51	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	$38.51	"$13,066.20"
CATHETER 135 CM WRK ZONE 30 CM TX ZONE 500-56130	C1757	SUPPLY/IMPLANTS	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
CATHETER 135 CM WRK ZONE 40 CM TX ZONE 500-56140	C1757	SUPPLY/IMPLANTS	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
CATHETER 135 CM WRK ZONE 50 CM TX ZONE 500-56150	C1757	SUPPLY/IMPLANTS	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
SYS DRG DLV 106CM 40CM INTLGNT CATH MICROSONIC DEV EKOSONIC 500-55140	C1757	SUPPLY/IMPLANTS	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
CATHETER 135 CM WRK ZONE 24MM TX ZONE 500-56124		STERILE SUPPLY	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
DEV DRG DLV EKOSONIC MACH 4 INFS CATH US COR TX ZN EVAS ACPT 500-55112		STERILE SUPPLY	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
DEV DRG DLV EKOSONIC MACH 4 INFS CATH US COR TX ZN EVAS ACPT 500-55106		STERILE SUPPLY	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
DEV DRG DLV EKOSONIC MACH 4 INFS CATH US COR TX ZN EVAS ACPT 500-55118		STERILE SUPPLY	"$18,666.00"	Outpatient	"$9,333.00"	Not Applicable	"$10,210.30"	"$12,450.22"	"$7,466.40"	Not Applicable	"$6,533.10"	"$13,066.20"	"$6,533.10"	"$13,066.20"
CATH ATHRCM 154CM 5FR 1.3MM CROSSER PERI TRNLMN CRUS6A	C1877	SUPPLY/IMPLANTS	"$18,656.00"	Outpatient	"$9,328.00"	Not Applicable	"$10,204.83"	"$12,443.55"	"$7,462.40"	Not Applicable	"$6,529.60"	"$13,059.20"	"$6,529.60"	"$13,059.20"
ADULT CARBON RAIL 350MM 6311	C1713	SUPPLY/IMPLANTS	"$18,649.00"	Outpatient	"$9,324.50"	"$1,365.15"	"$10,201.00"	"$12,438.88"	"$7,459.60"	Not Applicable	"$6,527.15"	"$13,054.30"	"$1,365.15"	"$13,054.30"
NAIL IM 360MM 9MM RTRGD FEM 14-444136	C1713	SUPPLY/IMPLANTS	"$18,632.00"	Outpatient	"$9,316.00"	"$1,365.15"	"$10,191.70"	"$12,427.54"	"$7,452.80"	Not Applicable	"$6,521.20"	"$13,042.40"	"$1,365.15"	"$13,042.40"
NAIL IM 380MM 12MM RTRGD RDLCNT TRGT ARM PREASSEMBLE EMBED 14-444338	C1713	SUPPLY/IMPLANTS	"$18,632.00"	Outpatient	"$9,316.00"	"$1,365.15"	"$10,191.70"	"$12,427.54"	"$7,452.80"	Not Applicable	"$6,521.20"	"$13,042.40"	"$1,365.15"	"$13,042.40"
STEM FEM 130MM 10.4MM 132D 7 41MM OFST OMFT EON COCR 35MM 6098-0735	C1776	SUPPLY/IMPLANTS	"$18,623.00"	Outpatient	"$9,311.50"	Not Applicable	"$10,186.78"	"$12,421.54"	"$7,449.20"	Not Applicable	"$6,518.05"	"$13,036.10"	"$6,518.05"	"$13,036.10"
GRAFT SOFT TISSUE BIODFENCE G3 PLACENTAL MEMBRANE ALLOGRAFT MIS TUBE DF-020206		SUPPLY/IMPLANTS	"$18,623.00"	Outpatient	"$9,311.50"	Not Applicable	"$10,186.78"	"$12,421.54"	"$7,449.20"	Not Applicable	"$6,518.05"	"$13,036.10"	"$6,518.05"	"$13,036.10"
JNT WRST PYROSPHERE 10 CRPMTCRPL PYROCARBON PCS-430-10-WW		STERILE SUPPLY	"$18,621.00"	Outpatient	"$9,310.50"	Not Applicable	"$10,185.69"	"$12,420.21"	"$7,448.40"	Not Applicable	"$6,517.35"	"$13,034.70"	"$6,517.35"	"$13,034.70"
STEM RADL 6.5MM EVOL +4MM ELB PRLN MOD HD 496S465	C1776	SUPPLY/IMPLANTS	"$18,606.00"	Outpatient	"$9,303.00"	Not Applicable	"$10,177.48"	"$12,410.20"	"$7,442.40"	Not Applicable	"$6,512.10"	"$13,024.20"	"$6,512.10"	"$13,024.20"
PLT 237MM SM BND TIB RT PERIART PROX SS 14 HL VA LCP CMBN BN 02.127.260	C1713	SUPPLY/IMPLANTS	"$18,605.00"	Outpatient	"$9,302.50"	"$1,365.15"	"$10,176.94"	"$12,409.54"	"$7,442.00"	Not Applicable	"$6,511.75"	"$13,023.50"	"$1,365.15"	"$13,023.50"
NAIL IM 340MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.155S	C1713	SUPPLY/IMPLANTS	"$18,602.00"	Outpatient	"$9,301.00"	"$1,365.15"	"$10,175.29"	"$12,407.53"	"$7,440.80"	Not Applicable	"$6,510.70"	"$13,021.40"	"$1,365.15"	"$13,021.40"
NAIL INTRAMEDULLARY TFN-ADVANCED LATERAL RELIEF CUT TITANIUM 04.037.224S	C1713	SUPPLY/IMPLANTS	"$18,602.00"	Outpatient	"$9,301.00"	"$1,365.15"	"$10,175.29"	"$12,407.53"	"$7,440.80"	Not Applicable	"$6,510.70"	"$13,021.40"	"$1,365.15"	"$13,021.40"
CASE GRPH FEM SCR BS TRY STD NCB PERIPROSTHETIC PLT SYS 200024902	C1713	SUPPLY/IMPLANTS	"$18,597.00"	Outpatient	"$9,298.50"	"$1,365.15"	"$10,172.56"	"$12,404.20"	"$7,438.80"	Not Applicable	"$6,508.95"	"$13,017.90"	"$1,365.15"	"$13,017.90"
NAIL IM 340MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.154S	C1713	SUPPLY/IMPLANTS	"$18,591.00"	Outpatient	"$9,295.50"	"$1,365.15"	"$10,169.28"	"$12,400.20"	"$7,436.40"	Not Applicable	"$6,506.85"	"$13,013.70"	"$1,365.15"	"$13,013.70"
NAIL IM 320MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.153S	C1713	SUPPLY/IMPLANTS	"$18,591.00"	Outpatient	"$9,295.50"	"$1,365.15"	"$10,169.28"	"$12,400.20"	"$7,436.40"	Not Applicable	"$6,506.85"	"$13,013.70"	"$1,365.15"	"$13,013.70"
NAIL IM 380MM 12MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.228S	C1713	SUPPLY/IMPLANTS	"$18,591.00"	Outpatient	"$9,295.50"	"$1,365.15"	"$10,169.28"	"$12,400.20"	"$7,436.40"	Not Applicable	"$6,506.85"	"$13,013.70"	"$1,365.15"	"$13,013.70"
NAIL INTRAMEDULLARY TFN-ADVANCED TITANIUM COCR 125 D LONG L380 MM OD10 MM FEMORAL LEFT PROXIMAL CANN	C1713	SUPPLY/IMPLANTS	"$18,591.00"	Outpatient	"$9,295.50"	"$1,365.15"	"$10,169.28"	"$12,400.20"	"$7,436.40"	Not Applicable	"$6,506.85"	"$13,013.70"	"$1,365.15"	"$13,013.70"
NAIL INTRAMEDULLARY TFN-ADVANCED TITANIUM COCR 125 D LONG L3 04.037.022S	C1713	SUPPLY/IMPLANTS	"$18,591.00"	Outpatient	"$9,295.50"	"$1,365.15"	"$10,169.28"	"$12,400.20"	"$7,436.40"	Not Applicable	"$6,506.85"	"$13,013.70"	"$1,365.15"	"$13,013.70"
NAIL INTRAMEDULLARY TFN-ADVANCED LATERAL RELIEF CUT TITANIUM 04.037.233S	C1713	SUPPLY/IMPLANTS	"$18,591.00"	Outpatient	"$9,295.50"	"$1,365.15"	"$10,169.28"	"$12,400.20"	"$7,436.40"	Not Applicable	"$6,506.85"	"$13,013.70"	"$1,365.15"	"$13,013.70"
"TFNA CAN TI 10MM/125 DEG, 360MM/RT-STERILE 04.037.026S"		STERILE SUPPLY	"$18,591.00"	Outpatient	"$9,295.50"	Not Applicable	"$10,169.28"	"$12,400.20"	"$7,436.40"	Not Applicable	"$6,506.85"	"$13,013.70"	"$6,506.85"	"$13,013.70"
CADDY SCR PERIART 234803400	C1713	SUPPLY/IMPLANTS	"$18,586.00"	Outpatient	"$9,293.00"	"$1,365.15"	"$10,166.54"	"$12,396.86"	"$7,434.40"	Not Applicable	"$6,505.10"	"$13,010.20"	"$1,365.15"	"$13,010.20"
JIG PSTN VERSANAIL TIB XTD CMPLT 2810-12-003	C1713	SUPPLY/IMPLANTS	"$18,586.00"	Outpatient	"$9,293.00"	"$1,365.15"	"$10,166.54"	"$12,396.86"	"$7,434.40"	Not Applicable	"$6,505.10"	"$13,010.20"	"$1,365.15"	"$13,010.20"
TUBE XTRNFX YLW 15MM MNTB TRX SM C DYNMC SNPFT 5150-0-465		STERILE SUPPLY	"$18,580.00"	Outpatient	"$9,290.00"	Not Applicable	"$10,163.26"	"$12,392.86"	"$7,432.00"	Not Applicable	"$6,503.00"	"$13,006.00"	"$6,503.00"	"$13,006.00"
NAIL IM 21CM 10MM LCK PHNX TI ANKL ARTHDS 14-440121	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 15CM 11MM LCK PHNX TI ANKL ARTHDS 14-440215	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 15CM 12MM LCK PHNX TI ANKL ARTHDS 14-440315	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 180MM 11MM LCK PHNX TI ANKL ARTHDS 14440218	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 18CM 12MM LCK PHNX TI ANKL ARTHDS 14-440318	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 21CM 12MM LCK PHNX TI ANKL ARTHDS 14-440321	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 24CM 10MM LCK PHNX TI ANKL ARTHDS 14-440124	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 24CM 11MM LCK PHNX TI ANKL ARTHDS 14-440224	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 24CM 12MM LCK PHNX TI ANKL ARTHDS 14-440324	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 27CM 10MM LCK PHNX TI ANKL ARTHDS 14-440127	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 27CM 11MM LCK PHNX TI ANKL ARTHDS 14-440227	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 27CM 12MM LCK PHNX TI ANKL ARTHDS 14-440327	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 30CM 10MM LCK PHNX TI ANKL ARTHDS 14-440130	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 30CM 11MM LCK PHNX TI ANKL ARTHDS 14-440230	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
NAIL IM 30CM 12MM LCK PHNX TI ANKL ARTHDS 14-440330	C1713	SUPPLY/IMPLANTS	"$18,572.00"	Outpatient	"$9,286.00"	"$1,365.15"	"$10,158.88"	"$12,387.52"	"$7,428.80"	Not Applicable	"$6,500.20"	"$13,000.40"	"$1,365.15"	"$13,000.40"
DSTRCT HIP DEV SRG 1220	C1713	SUPPLY/IMPLANTS	"$18,566.00"	Outpatient	"$9,283.00"	"$1,365.15"	"$10,155.60"	"$12,383.52"	"$7,426.40"	Not Applicable	"$6,498.10"	"$12,996.20"	"$1,365.15"	"$12,996.20"
LINR ACTB 54MM 32MM 10D MRTHN LIP DRLC HIP STRL LF 122032154	C1776	SUPPLY/IMPLANTS	"$18,564.00"	Outpatient	"$9,282.00"	Not Applicable	"$10,154.51"	"$12,382.19"	"$7,425.60"	Not Applicable	"$6,497.40"	"$12,994.80"	"$6,497.40"	"$12,994.80"
CMPNT GLND 44MM KLD REUNION X3 SHLDR STRL 5542-K-0044	C1776	SUPPLY/IMPLANTS	"$18,560.00"	Outpatient	"$9,280.00"	Not Applicable	"$10,152.32"	"$12,379.52"	"$7,424.00"	Not Applicable	"$6,496.00"	"$12,992.00"	"$6,496.00"	"$12,992.00"
CMPNT GLND 52MM KLD REUNION X3 SHLDR STRL 5542-K-0052	C1776	SUPPLY/IMPLANTS	"$18,560.00"	Outpatient	"$9,280.00"	Not Applicable	"$10,152.32"	"$12,379.52"	"$7,424.00"	Not Applicable	"$6,496.00"	"$12,992.00"	"$6,496.00"	"$12,992.00"
HEAD HUM 22MM 44MM SHLDR REUNION STD STRL 5552-S-4422	C1776	SUPPLY/IMPLANTS	"$18,545.00"	Outpatient	"$9,272.50"	Not Applicable	"$10,144.12"	"$12,369.52"	"$7,418.00"	Not Applicable	"$6,490.75"	"$12,981.50"	"$6,490.75"	"$12,981.50"
HEAD HUM 15MM 48MM SHLDR REUNION STD STRL 5552-S-4815	C1776	SUPPLY/IMPLANTS	"$18,543.00"	Outpatient	"$9,271.50"	Not Applicable	"$10,143.02"	"$12,368.18"	"$7,417.20"	Not Applicable	"$6,490.05"	"$12,980.10"	"$6,490.05"	"$12,980.10"
CASE INST 3.5/2.7MM PERIART LCK SCR 235804005		STERILE SUPPLY	"$18,539.00"	Outpatient	"$9,269.50"	Not Applicable	"$10,140.83"	"$12,365.51"	"$7,415.60"	Not Applicable	"$6,488.65"	"$12,977.30"	"$6,488.65"	"$12,977.30"
59676-0960-02 - DOXOrubicin liposomal 2 mg/mL DSPR	Q2050	PHARMACY	"$15,601.00"	Outpatient	"$7,800.50"	$335.19	"$10,140.65"	"$10,405.87"	"$6,240.40"	Not Applicable	"$5,460.35"	"$10,920.70"	$335.19	"$10,920.70"
HEAD HUM 19MM 56MM SHLDR REUNION STD STRL 5552-S-5619	C1776	SUPPLY/IMPLANTS	"$18,531.00"	Outpatient	"$9,265.50"	Not Applicable	"$10,136.46"	"$12,360.18"	"$7,412.40"	Not Applicable	"$6,485.85"	"$12,971.70"	"$6,485.85"	"$12,971.70"
HEAD HUM 21MM 48MM SHLDR REUNION STD RDS STRL LF 5552-S-4821	C1776	SUPPLY/IMPLANTS	"$18,531.00"	Outpatient	"$9,265.50"	Not Applicable	"$10,136.46"	"$12,360.18"	"$7,412.40"	Not Applicable	"$6,485.85"	"$12,971.70"	"$6,485.85"	"$12,971.70"
NAIL IM 40CM 10MM 130D INTERTAN RT TROCH 71675538	C1713	SUPPLY/IMPLANTS	"$18,523.00"	Outpatient	"$9,261.50"	"$1,365.15"	"$10,132.08"	"$12,354.84"	"$7,409.20"	Not Applicable	"$6,483.05"	"$12,966.10"	"$1,365.15"	"$12,966.10"
STENT VASCULAR COVERA STRAIGHT L80 MM L80 CM OD9 MM ID8 FR A AVSM09080	C1874	SUPPLY/IMPLANTS	"$18,508.00"	Outpatient	"$9,254.00"	Not Applicable	"$10,123.88"	"$12,344.84"	"$7,403.20"	Not Applicable	"$6,477.80"	"$12,955.60"	"$6,477.80"	"$12,955.60"
SHOCKWAVE S IVL CATHETER 3.0X4.0 S4IVL3040	C1725	SUPPLY/IMPLANTS	"$18,508.00"	Outpatient	"$9,254.00"	Not Applicable	"$10,123.88"	"$12,344.84"	"$7,403.20"	Not Applicable	"$6,477.80"	"$12,955.60"	"$6,477.80"	"$12,955.60"
SHOCKWAVE S IVL CATHETER 4.0X4.0 S4IVL4040	C1725	SUPPLY/IMPLANTS	"$18,508.00"	Outpatient	"$9,254.00"	Not Applicable	"$10,123.88"	"$12,344.84"	"$7,403.20"	Not Applicable	"$6,477.80"	"$12,955.60"	"$6,477.80"	"$12,955.60"
GFT BN CANC ALGRF FRZN VIABLE CELL MORSELIZE TRN ELT MED 410002	C1713	SUPPLY/IMPLANTS	"$18,497.00"	Outpatient	"$9,248.50"	"$1,365.15"	"$10,117.86"	"$12,337.50"	"$7,398.80"	Not Applicable	"$6,473.95"	"$12,947.90"	"$1,365.15"	"$12,947.90"
MODL ANTM WHT ADLT PLAMD MNDB THR ORBT SD900.306	C1713	SUPPLY/IMPLANTS	"$18,483.00"	Outpatient	"$9,241.50"	"$1,365.15"	"$10,110.20"	"$12,328.16"	"$7,393.20"	Not Applicable	"$6,469.05"	"$12,938.10"	"$1,365.15"	"$12,938.10"
MODL ANTM PROPLAN CMF ADLT PLAMD MXL CRNM SD900.308	C1713	SUPPLY/IMPLANTS	"$18,483.00"	Outpatient	"$9,241.50"	"$1,365.15"	"$10,110.20"	"$12,328.16"	"$7,393.20"	Not Applicable	"$6,469.05"	"$12,938.10"	"$1,365.15"	"$12,938.10"
FXTR XTRNFX DFS RADL DIST SS CMPLT 4100	C1713	SUPPLY/IMPLANTS	"$18,469.00"	Outpatient	"$9,234.50"	"$1,365.15"	"$10,102.54"	"$12,318.82"	"$7,387.60"	Not Applicable	"$6,464.15"	"$12,928.30"	"$1,365.15"	"$12,928.30"
SCR BN MNDB TI 5MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 20 PK 04.503.605.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
SCR BN MNDB TI 6MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 04.503.606.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
SCR BN MNDB TI 8MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 04.503.608.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
SCR BN MNDB TI 10MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 04.503.610.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
SCR BN MNDB TI 12MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 04.503.612.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
SCR BN MNDB TI 14MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 04.503.614.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
SCR BN MNDB TI 16MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 20 PK 04.503.616.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
SCR BN MNDB TI 18MM 2MM MATRIXMANDIBLE ST LCK NS SLVR 20 PK 04.503.618.20	C1713	SUPPLY/IMPLANTS	"$18,465.00"	Outpatient	"$9,232.50"	"$1,365.15"	"$10,100.36"	"$12,316.16"	"$7,386.00"	Not Applicable	"$6,462.75"	"$12,925.50"	"$1,365.15"	"$12,925.50"
CMPNT TIB KN XS-XL MNGR MDLR ROT HNG 64812100	C1776	SUPPLY/IMPLANTS	"$18,451.00"	Outpatient	"$9,225.50"	Not Applicable	"$10,092.70"	"$12,306.82"	"$7,380.40"	Not Applicable	"$6,457.85"	"$12,915.70"	"$6,457.85"	"$12,915.70"
BRNG TIB 63/67MMX12MM KN VNGRD E1 POST STAB STRL LF EP-183622	C1776	SUPPLY/IMPLANTS	"$18,448.00"	Outpatient	"$9,224.00"	Not Applicable	"$10,091.06"	"$12,304.82"	"$7,379.20"	Not Applicable	"$6,456.80"	"$12,913.60"	"$6,456.80"	"$12,913.60"
BRNG TIB 63/67MMX14MM KN VNGRD E1 POST STAB EP-183624	C1776	SUPPLY/IMPLANTS	"$18,448.00"	Outpatient	"$9,224.00"	Not Applicable	"$10,091.06"	"$12,304.82"	"$7,379.20"	Not Applicable	"$6,456.80"	"$12,913.60"	"$6,456.80"	"$12,913.60"
STEM RADL 24MM 6MM EXPLOR ELB MDLR STRL 11-210061	C1776	SUPPLY/IMPLANTS	"$18,441.00"	Outpatient	"$9,220.50"	Not Applicable	"$10,087.23"	"$12,300.15"	"$7,376.40"	Not Applicable	"$6,454.35"	"$12,908.70"	"$6,454.35"	"$12,908.70"
CMPNT FEM 2 KN RT CR CMNT TRTHLN 5510-F-202	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 3 KN RT CR CMNT TRTHLN 5510-F-302	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 7 KN LT CR CMNT TRTHLN 5510-F-701	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 7 KN RT CR CMNT TRTHLN 5510-F-702	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 8 KN LT CR CMNT TRTHLN 5510-F-801	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 8 KN RT CR CMNT TRTHLN 5510-F-802	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 3 KN LT CMNT POST STAB TRTHLN 5515-F-301	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 3 KN RT CMNT POST STAB TRTHLN 5515-F-302	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 4 KN LT CMNT POST STAB TRTHLN 5515-F-401	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 4 KN RT CMNT POST STAB TRTHLN 5515-F-402	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 5 KN LT CMNT POST STAB TRTHLN 5515-F-501	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 5 KN RT CMNT POST STAB TRTHLN 5515-F-502	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 6 KN LT CMNT POST STAB TRTHLN 5515-F-601	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 6 KN RT CMNT POST STAB TRTHLN 5515-F-602	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
CMPNT FEM 7 KN LT CMNT POST STAB TRTHLN 5515-F-701	C1776	SUPPLY/IMPLANTS	"$18,410.00"	Outpatient	"$9,205.00"	Not Applicable	"$10,070.27"	"$12,279.47"	"$7,364.00"	Not Applicable	"$6,443.50"	"$12,887.00"	"$6,443.50"	"$12,887.00"
STNT GRTX NTNL FEP 10MM BIL PERC 6CM EXPANDABLE PUL LN HL VH1006040	C1874	SUPPLY/IMPLANTS	"$18,389.00"	Outpatient	"$9,194.50"	Not Applicable	"$10,058.78"	"$12,265.46"	"$7,355.60"	Not Applicable	"$6,436.15"	"$12,872.30"	"$6,436.15"	"$12,872.30"
ACTIS COLLARED HIGH SIZE 5 1010-12-050	C1776	SUPPLY/IMPLANTS	"$18,371.00"	Outpatient	"$9,185.50"	Not Applicable	"$10,048.94"	"$12,253.46"	"$7,348.40"	Not Applicable	"$6,429.85"	"$12,859.70"	"$6,429.85"	"$12,859.70"
ACTIS COLLARED STD SIZE 7 1010-11-070	C1776	SUPPLY/IMPLANTS	"$18,371.00"	Outpatient	"$9,185.50"	Not Applicable	"$10,048.94"	"$12,253.46"	"$7,348.40"	Not Applicable	"$6,429.85"	"$12,859.70"	"$6,429.85"	"$12,859.70"
FEMORAL STEM 12/14 TAPER ACTIS DUOFFIX HIP 1010-12-040	C1776	SUPPLY/IMPLANTS	"$18,371.00"	Outpatient	"$9,185.50"	Not Applicable	"$10,048.94"	"$12,253.46"	"$7,348.40"	Not Applicable	"$6,429.85"	"$12,859.70"	"$6,429.85"	"$12,859.70"
PROSTHESIS ORTHOPEDIC HIP FEMORAL STEM 12/14 CEMENTLESS SIZE 1010-11-040	C1776	SUPPLY/IMPLANTS	"$18,371.00"	Outpatient	"$9,185.50"	Not Applicable	"$10,048.94"	"$12,253.46"	"$7,348.40"	Not Applicable	"$6,429.85"	"$12,859.70"	"$6,429.85"	"$12,859.70"
STEM FEMORAL ACTIS DUOFIX 9 12/14 HIGH OFFSET TAPER L113 MM 1010-12-090	C1776	SUPPLY/IMPLANTS	"$18,371.00"	Outpatient	"$9,185.50"	Not Applicable	"$10,048.94"	"$12,253.46"	"$7,348.40"	Not Applicable	"$6,429.85"	"$12,859.70"	"$6,429.85"	"$12,859.70"
STEM FEMORAL ACTIS DUOFIX 3 12/14 HIGH OFFSET TAPER L101 MM 1010-12-030	C1776	SUPPLY/IMPLANTS	"$18,371.00"	Outpatient	"$9,185.50"	Not Applicable	"$10,048.94"	"$12,253.46"	"$7,348.40"	Not Applicable	"$6,429.85"	"$12,859.70"	"$6,429.85"	"$12,859.70"
STEM FEMORAL ACTIS DUOFIX 2 12/14 HIGH OFFSET TAPER L99 MM H 1010-12-020	C1776	SUPPLY/IMPLANTS	"$18,371.00"	Outpatient	"$9,185.50"	Not Applicable	"$10,048.94"	"$12,253.46"	"$7,348.40"	Not Applicable	"$6,429.85"	"$12,859.70"	"$6,429.85"	"$12,859.70"
STEM FEMORAL ACTIS DUOFIX 6 12/14 HIGH OFFSET TAPER L107 MM 1010-12-060	C1776	SUPPLY/IMPLANTS	"$18,359.00"	Outpatient	"$9,179.50"	Not Applicable	"$10,042.37"	"$12,245.45"	"$7,343.60"	Not Applicable	"$6,425.65"	"$12,851.30"	"$6,425.65"	"$12,851.30"
STEM FEMORAL ACTIS DUOFIX 5 12/14 STANDARD OFFSET TAPER L105 1010-11-050	C1776	SUPPLY/IMPLANTS	"$18,359.00"	Outpatient	"$9,179.50"	Not Applicable	"$10,042.37"	"$12,245.45"	"$7,343.60"	Not Applicable	"$6,425.65"	"$12,851.30"	"$6,425.65"	"$12,851.30"
STEM FEMORAL ACTIS DUOFIX 7 12/14 HIGH OFFSET TAPER L109 MM 1010-12-070	C1776	SUPPLY/IMPLANTS	"$18,359.00"	Outpatient	"$9,179.50"	Not Applicable	"$10,042.37"	"$12,245.45"	"$7,343.60"	Not Applicable	"$6,425.65"	"$12,851.30"	"$6,425.65"	"$12,851.30"
STEM FEMORAL ACTIS DUOFIX 8 12/14 STANDARD OFFSET TAPER L111 1010-11-080	C1776	SUPPLY/IMPLANTS	"$18,359.00"	Outpatient	"$9,179.50"	Not Applicable	"$10,042.37"	"$12,245.45"	"$7,343.60"	Not Applicable	"$6,425.65"	"$12,851.30"	"$6,425.65"	"$12,851.30"
STEM FEMORAL ACTIS DUOFIX 6 12/14 STANDARD OFFSET TAPER L107 1010-11-060	C1776	SUPPLY/IMPLANTS	"$18,359.00"	Outpatient	"$9,179.50"	Not Applicable	"$10,042.37"	"$12,245.45"	"$7,343.60"	Not Applicable	"$6,425.65"	"$12,851.30"	"$6,425.65"	"$12,851.30"
STEM FEMORAL ACTIS DUOFIX 9 12/14 STANDARD OFFSET TAPER L113 1010-11-090	C1776	SUPPLY/IMPLANTS	"$18,359.00"	Outpatient	"$9,179.50"	Not Applicable	"$10,042.37"	"$12,245.45"	"$7,343.60"	Not Applicable	"$6,425.65"	"$12,851.30"	"$6,425.65"	"$12,851.30"
SCOPE SPY M00546610		NON-STER SUPPLY	"$18,359.00"	Outpatient	"$9,179.50"	Not Applicable	"$10,042.37"	"$12,245.45"	"$7,343.60"	Not Applicable	"$6,425.65"	"$12,851.30"	"$6,425.65"	"$12,851.30"
PLT 228MM HUM LT PROX LAT TI 14 HL AXSOS 3 BN STRL 627214S	C1713	SUPPLY/IMPLANTS	"$18,351.00"	Outpatient	"$9,175.50"	"$1,365.15"	"$10,038.00"	"$12,240.12"	"$7,340.40"	Not Applicable	"$6,422.85"	"$12,845.70"	"$1,365.15"	"$12,845.70"
SYS DRG DLV 106CM 50CM INTLGNT CATH MICROSONIC DEV EKOSONIC 500-55150	C1757	SUPPLY/IMPLANTS	"$18,333.00"	Outpatient	"$9,166.50"	Not Applicable	"$10,028.15"	"$12,228.11"	"$7,333.20"	Not Applicable	"$6,416.55"	"$12,833.10"	"$6,416.55"	"$12,833.10"
CLP CRYOFLEX SRG ABLT PRB LF 60CM1-005		STERILE SUPPLY	"$18,333.00"	Outpatient	"$9,166.50"	Not Applicable	"$10,028.15"	"$12,228.11"	"$7,333.20"	Not Applicable	"$6,416.55"	"$12,833.10"	"$6,416.55"	"$12,833.10"
NAIL IM 320MM 9MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.953S		SUPPLY/IMPLANTS	"$18,321.00"	Outpatient	"$9,160.50"	Not Applicable	"$10,021.59"	"$12,220.11"	"$7,328.40"	Not Applicable	"$6,412.35"	"$12,824.70"	"$6,412.35"	"$12,824.70"
NAIL IM 360MM 13MM LCK RTRGD T2 TI SP CNDL STRL 1826-1336S	C1713	SUPPLY/IMPLANTS	"$18,318.00"	Outpatient	"$9,159.00"	"$1,365.15"	"$10,019.95"	"$12,218.11"	"$7,327.20"	Not Applicable	"$6,411.30"	"$12,822.60"	"$1,365.15"	"$12,822.60"
NAIL IM 360MM 9MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.956S	C1713	SUPPLY/IMPLANTS	"$18,316.00"	Outpatient	"$9,158.00"	"$1,365.15"	"$10,018.85"	"$12,216.77"	"$7,326.40"	Not Applicable	"$6,410.60"	"$12,821.20"	"$1,365.15"	"$12,821.20"
NAIL IM 36CM 10MM LNG LCK RTRGD T2 TI SP CNDL STRL 18261036S	C1713	SUPPLY/IMPLANTS	"$18,313.00"	Outpatient	"$9,156.50"	"$1,365.15"	"$10,017.21"	"$12,214.77"	"$7,325.20"	Not Applicable	"$6,409.55"	"$12,819.10"	"$1,365.15"	"$12,819.10"
PLT 2MM 2 ANG LG MNDB TI 6X24X6 HL RECON MATRIXMANDIBLE BN 04.503.736	C1713	SUPPLY/IMPLANTS	"$18,313.00"	Outpatient	"$9,156.50"	"$1,365.15"	"$10,017.21"	"$12,214.77"	"$7,325.20"	Not Applicable	"$6,409.55"	"$12,819.10"	"$1,365.15"	"$12,819.10"
CMPNT FEM 2 KN RT CRCTE RTN BEAD TRTHLN PA 5517F202		STERILE SUPPLY	"$18,312.00"	Outpatient	"$9,156.00"	Not Applicable	"$10,016.66"	"$12,214.10"	"$7,324.80"	Not Applicable	"$6,409.20"	"$12,818.40"	"$6,409.20"	"$12,818.40"
HNDL SRG PHNX CORELOCK TIB T CHK KYLS NL SYS 14-442078		STERILE SUPPLY	"$18,310.00"	Outpatient	"$9,155.00"	Not Applicable	"$10,015.57"	"$12,212.77"	"$7,324.00"	Not Applicable	"$6,408.50"	"$12,817.00"	"$6,408.50"	"$12,817.00"
CMPNT FEM 1 KN RT CRCTE RTN BEAD TRTHLN PA 5517-F-102	C1776	SUPPLY/IMPLANTS	"$18,307.00"	Outpatient	"$9,153.50"	Not Applicable	"$10,013.93"	"$12,210.77"	"$7,322.80"	Not Applicable	"$6,407.45"	"$12,814.90"	"$6,407.45"	"$12,814.90"
CMPNT FEM 2 KN LT CRCTE RTN BEAD TRTHLN PA 5517F201	C1776	SUPPLY/IMPLANTS	"$18,305.00"	Outpatient	"$9,152.50"	Not Applicable	"$10,012.84"	"$12,209.44"	"$7,322.00"	Not Applicable	"$6,406.75"	"$12,813.50"	"$6,406.75"	"$12,813.50"
CMPNT FEM 3 KN RT CRCTE RTN BEAD TRTHLN PA 5517F302	C1776	SUPPLY/IMPLANTS	"$18,303.00"	Outpatient	"$9,151.50"	Not Applicable	"$10,011.74"	"$12,208.10"	"$7,321.20"	Not Applicable	"$6,406.05"	"$12,812.10"	"$6,406.05"	"$12,812.10"
CMPNT FEM 7 KN LT CRCTE RTN BEAD TRTHLN PA 5517F701	C1776	SUPPLY/IMPLANTS	"$18,303.00"	Outpatient	"$9,151.50"	Not Applicable	"$10,011.74"	"$12,208.10"	"$7,321.20"	Not Applicable	"$6,406.05"	"$12,812.10"	"$6,406.05"	"$12,812.10"
CMPNT FEM 4 KN LT CRCTE RTN BEAD TRTHLN PA STRL 5517-F-401	C1776	SUPPLY/IMPLANTS	"$18,303.00"	Outpatient	"$9,151.50"	Not Applicable	"$10,011.74"	"$12,208.10"	"$7,321.20"	Not Applicable	"$6,406.05"	"$12,812.10"	"$6,406.05"	"$12,812.10"
CMPNT FEM 3 KN LT CRCTE RTN BEAD TRTHLN PA 5517F301	C1776	SUPPLY/IMPLANTS	"$18,303.00"	Outpatient	"$9,151.50"	Not Applicable	"$10,011.74"	"$12,208.10"	"$7,321.20"	Not Applicable	"$6,406.05"	"$12,812.10"	"$6,406.05"	"$12,812.10"
CMPNT FEM 4 KN RT CRCTE RTN BEAD TRTHLN PA 5517F402	C1776	SUPPLY/IMPLANTS	"$18,303.00"	Outpatient	"$9,151.50"	Not Applicable	"$10,011.74"	"$12,208.10"	"$7,321.20"	Not Applicable	"$6,406.05"	"$12,812.10"	"$6,406.05"	"$12,812.10"
CMPNT FEM 6 KN LT CRCTE RTN BEAD TRTHLN PA 5517-F-601	C1776	SUPPLY/IMPLANTS	"$18,303.00"	Outpatient	"$9,151.50"	Not Applicable	"$10,011.74"	"$12,208.10"	"$7,321.20"	Not Applicable	"$6,406.05"	"$12,812.10"	"$6,406.05"	"$12,812.10"
PLATE BONE LCP COMBI STAINLESS STEEL L292 MM TIBIA RIGHT DIS 02.118.114S	C1713	SUPPLY/IMPLANTS	"$18,294.00"	Outpatient	"$9,147.00"	"$1,365.15"	"$10,006.82"	"$12,202.10"	"$7,317.60"	Not Applicable	"$6,402.90"	"$12,805.80"	"$1,365.15"	"$12,805.80"
59572-0711-01 - luspatercept 25 mg Powd	C9399	PHARMACY	"$18,293.00"	Outpatient	"$9,146.50"	Not Applicable	"$10,006.27"	"$12,201.43"	"$7,317.20"	Not Applicable	"$6,402.55"	"$12,805.10"	"$6,402.55"	"$12,805.10"
CMPNT FEM 6 KN RT CRCTE RTN BEAD TRTHLN PA 5517-F-602	C1776	SUPPLY/IMPLANTS	"$18,289.00"	Outpatient	"$9,144.50"	Not Applicable	"$10,004.08"	"$12,198.76"	"$7,315.60"	Not Applicable	"$6,401.15"	"$12,802.30"	"$6,401.15"	"$12,802.30"
NAIL IM 38CM 11.5MM 130D SET ANTGRD TRGN TI RT TROCH ROSE 71648338	C1713	SUPPLY/IMPLANTS	"$18,286.00"	Outpatient	"$9,143.00"	"$1,365.15"	"$10,002.44"	"$12,196.76"	"$7,314.40"	Not Applicable	"$6,400.10"	"$12,800.20"	"$1,365.15"	"$12,800.20"
ANKLE TRANS PIN LT TEMPFIX 818109000	C1713	SUPPLY/IMPLANTS	"$18,282.00"	Outpatient	"$9,141.00"	"$1,365.15"	"$10,000.25"	"$12,194.09"	"$7,312.80"	Not Applicable	"$6,398.70"	"$12,797.40"	"$1,365.15"	"$12,797.40"
KIT IM NL 340MM 11MM GMA 125D LNG R1.5 FEM RT TI STRL LF 3425-1340S	C1713	SUPPLY/IMPLANTS	"$18,275.00"	Outpatient	"$9,137.50"	"$1,365.15"	"$9,996.43"	"$12,189.43"	"$7,310.00"	Not Applicable	"$6,396.25"	"$12,792.50"	"$1,365.15"	"$12,792.50"
KIT IM NL 420MM 11MM 130D R1.5 LNG LT TI 3530-1420S	C1713	SUPPLY/IMPLANTS	"$18,275.00"	Outpatient	"$9,137.50"	"$1,365.15"	"$9,996.43"	"$12,189.43"	"$7,310.00"	Not Applicable	"$6,396.25"	"$12,792.50"	"$1,365.15"	"$12,792.50"
KIT IM NL 360MM 11MM GMA 125D LNG R1.5 FEM LT TI STRL LF 3525-1360S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 400MM 13MM 125D R1.5 LNG RT TI 3425-3400S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 360MM 15MM 125D R1.5 LNG RT TI 3425-5360S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 360MM 13MM 125D R1.5 LNG LT TI 3525-3360S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 360MM 13MM 125D R1.5 LNG RT TI 3425-3360S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 380MM 11MM GMA 125D LNG R1.5 FEM LT TI STRL LF 3525-1380S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 380MM 13MM 130D R1.5 LNG LT TI 3530-3380S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 360MM 11MM 130D R1.5 LNG RT TI 3430-1360S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 420MM 11MM GMA 125D LNG R1.5 FEM RT TI STRL LF 3425-1420S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 380MM 11MM GMA 130D LNG R1.5 FEM LT TI STRL LF 3530-1380S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
KIT IM NL 360MM 11MM GMA 125D LNG R1.5 FEM RT TI STRL LF 3425-1360S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 400MM 13MM 125D LNG KT GMA TI FEM LT STRL R1.5 3525-3400S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 400MM 11MM 125D LNG KT GMA TI FEM RT STRL R1.5 3425-1400S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 420MM 13MM 125D LNG KT GMA TI FEM LT STRL R1.5 3525-3420S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 380MM 13MM 125D LNG KT GMA TI FEM LT STRL R1.5 3525-3380S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 340MM 10MM 130D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3430-0340S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 400MM 11MM 125D LNG KT GMA TI FEM LT STRL R1.5 3525-1400S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 380MM 11MM 125D LNG KT GMA TI FEM RT STRL R1.5 3425-1380S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 340MM 11MM 125D LNG KT GMA TI FEM LT STRL R1.5 3525-1340S	C1713	SUPPLY/IMPLANTS	"$18,269.00"	Outpatient	"$9,134.50"	"$1,365.15"	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$1,365.15"	"$12,788.30"
NAIL IM 440MM 13MM 125D R1/5 LNG KT GAMMA3 TI LT 3525-3440S		STERILE SUPPLY	"$18,269.00"	Outpatient	"$9,134.50"	Not Applicable	"$9,993.14"	"$12,185.42"	"$7,307.60"	Not Applicable	"$6,394.15"	"$12,788.30"	"$6,394.15"	"$12,788.30"
NAIL IM 300MM 10MM 125D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3425-0300S	C1713	SUPPLY/IMPLANTS	"$18,267.00"	Outpatient	"$9,133.50"	"$1,365.15"	"$9,992.05"	"$12,184.09"	"$7,306.80"	Not Applicable	"$6,393.45"	"$12,786.90"	"$1,365.15"	"$12,786.90"
NAIL IM 320MM 10MM 125D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3525-0320S	C1713	SUPPLY/IMPLANTS	"$18,267.00"	Outpatient	"$9,133.50"	"$1,365.15"	"$9,992.05"	"$12,184.09"	"$7,306.80"	Not Applicable	"$6,393.45"	"$12,786.90"	"$1,365.15"	"$12,786.90"
NAIL IM 340MM 10MM 130D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3530-0340S	C1713	SUPPLY/IMPLANTS	"$18,267.00"	Outpatient	"$9,133.50"	"$1,365.15"	"$9,992.05"	"$12,184.09"	"$7,306.80"	Not Applicable	"$6,393.45"	"$12,786.90"	"$1,365.15"	"$12,786.90"
CASE INST 3MM CNN SCR 114703001		STERILE SUPPLY	"$18,267.00"	Outpatient	"$9,133.50"	Not Applicable	"$9,992.05"	"$12,184.09"	"$7,306.80"	Not Applicable	"$6,393.45"	"$12,786.90"	"$6,393.45"	"$12,786.90"
STNT TRCHBR 10MM 59MM 80CM COVERED CATH ICAST 85421	C1874	SUPPLY/IMPLANTS	"$18,261.00"	Outpatient	"$9,130.50"	Not Applicable	"$9,988.77"	"$12,180.09"	"$7,304.40"	Not Applicable	"$6,391.35"	"$12,782.70"	"$6,391.35"	"$12,782.70"
INS TIB 6 13MM KN X3 TL STAB + TRTHLN 5537-G-613	C1776	SUPPLY/IMPLANTS	"$18,246.00"	Outpatient	"$9,123.00"	Not Applicable	"$9,980.56"	"$12,170.08"	"$7,298.40"	Not Applicable	"$6,386.10"	"$12,772.20"	"$6,386.10"	"$12,772.20"
INS TIB 7 11MM KN X3 TL STAB + TRTHLN 5537-G-711	C1776	SUPPLY/IMPLANTS	"$18,246.00"	Outpatient	"$9,123.00"	Not Applicable	"$9,980.56"	"$12,170.08"	"$7,298.40"	Not Applicable	"$6,386.10"	"$12,772.20"	"$6,386.10"	"$12,772.20"
INS TIB 5 11MM KN X3 TL STAB + TRTHLN 5537-G-511	C1776	SUPPLY/IMPLANTS	"$18,246.00"	Outpatient	"$9,123.00"	Not Applicable	"$9,980.56"	"$12,170.08"	"$7,298.40"	Not Applicable	"$6,386.10"	"$12,772.20"	"$6,386.10"	"$12,772.20"
INS TIB 1 13MM KN X3 TL STAB + TRTHLN 5537-G-113	C1776	SUPPLY/IMPLANTS	"$18,246.00"	Outpatient	"$9,123.00"	Not Applicable	"$9,980.56"	"$12,170.08"	"$7,298.40"	Not Applicable	"$6,386.10"	"$12,772.20"	"$6,386.10"	"$12,772.20"
PLT 147MM TIB LT PROX LAT TI 6 HL AXSOS 3 BN NS 627306	C1713	SUPPLY/IMPLANTS	"$18,246.00"	Outpatient	"$9,123.00"	"$1,365.15"	"$9,980.56"	"$12,170.08"	"$7,298.40"	Not Applicable	"$6,386.10"	"$12,772.20"	"$1,365.15"	"$12,772.20"
NAIL IM 360MM 11MM RECON T2 TI LT STRL 1846-1136S	C1713	SUPPLY/IMPLANTS	"$18,228.00"	Outpatient	"$9,114.00"	"$1,365.15"	"$9,970.72"	"$12,158.08"	"$7,291.20"	Not Applicable	"$6,379.80"	"$12,759.60"	"$1,365.15"	"$12,759.60"
INSERT TIBIAL SIGMA TC3 GVF UHMWPE 3 H20 MM KNEE ROTATE PLAT 96-2345	C1776	SUPPLY/IMPLANTS	"$18,214.00"	Outpatient	"$9,107.00"	Not Applicable	"$9,963.06"	"$12,148.74"	"$7,285.60"	Not Applicable	"$6,374.90"	"$12,749.80"	"$6,374.90"	"$12,749.80"
MESH MATRIXNEURO 100X100X.6MM TI CRNL RECON RGD STRL AU 04.503.145S	C1713	SUPPLY/IMPLANTS	"$18,210.00"	Outpatient	"$9,105.00"	"$1,365.15"	"$9,960.87"	"$12,146.07"	"$7,284.00"	Not Applicable	"$6,373.50"	"$12,747.00"	"$1,365.15"	"$12,747.00"
INS TIB 4 17.5MM KN GVF UHMWPE ROT PLAT SGM TC3 STRL 962354	C1776	SUPPLY/IMPLANTS	"$18,204.00"	Outpatient	"$9,102.00"	Not Applicable	"$9,957.59"	"$12,142.07"	"$7,281.60"	Not Applicable	"$6,371.40"	"$12,742.80"	"$6,371.40"	"$12,742.80"
INS TIB 2.5 10MM KN GVF UHMWPE ROT PLAT SGM TC3 STRL 962331	C1776	SUPPLY/IMPLANTS	"$18,204.00"	Outpatient	"$9,102.00"	Not Applicable	"$9,957.59"	"$12,142.07"	"$7,281.60"	Not Applicable	"$6,371.40"	"$12,742.80"	"$6,371.40"	"$12,742.80"
INS TIB 4 15MM KN GVF UHMWPE ROT PLAT SGM TC3 STRL 962353	C1776	SUPPLY/IMPLANTS	"$18,204.00"	Outpatient	"$9,102.00"	Not Applicable	"$9,957.59"	"$12,142.07"	"$7,281.60"	Not Applicable	"$6,371.40"	"$12,742.80"	"$6,371.40"	"$12,742.80"
INSERT TIBIAL SIGMA TC3 GVF UHMWPE 4 H10 MM KNEE ROTATE PLAT 962351	C1776	SUPPLY/IMPLANTS	"$18,204.00"	Outpatient	"$9,102.00"	Not Applicable	"$9,957.59"	"$12,142.07"	"$7,281.60"	Not Applicable	"$6,371.40"	"$12,742.80"	"$6,371.40"	"$12,742.80"
INSERT TIBIAL SIGMA TC3 GVF UHMWPE 3 H17.5 MM KNEE ROTATE PL 96-2344	C1776	SUPPLY/IMPLANTS	"$18,204.00"	Outpatient	"$9,102.00"	Not Applicable	"$9,957.59"	"$12,142.07"	"$7,281.60"	Not Applicable	"$6,371.40"	"$12,742.80"	"$6,371.40"	"$12,742.80"
INSERT TIBIAL SIGMA TC3 GVF UHMWPE 4 H22.5 MM KNEE ROTATE PL 96-2356	C1776	SUPPLY/IMPLANTS	"$18,204.00"	Outpatient	"$9,102.00"	Not Applicable	"$9,957.59"	"$12,142.07"	"$7,281.60"	Not Applicable	"$6,371.40"	"$12,742.80"	"$6,371.40"	"$12,742.80"
NAIL IM 400MM 12MM LCK RTRGD T2 TI SP CNDL STRL 1826-1240S	C1713	SUPPLY/IMPLANTS	"$18,188.00"	Outpatient	"$9,094.00"	"$1,365.15"	"$9,948.84"	"$12,131.40"	"$7,275.20"	Not Applicable	"$6,365.80"	"$12,731.60"	"$1,365.15"	"$12,731.60"
NAIL IM 34CM 9MM LCK T2 TI FEM STRL R1.5 18280934S	C1713	SUPPLY/IMPLANTS	"$18,188.00"	Outpatient	"$9,094.00"	"$1,365.15"	"$9,948.84"	"$12,131.40"	"$7,275.20"	Not Applicable	"$6,365.80"	"$12,731.60"	"$1,365.15"	"$12,731.60"
NAIL IM 32CM 12MM LCK T2 TI FEM STRL R1.5 18281232S	C1713	SUPPLY/IMPLANTS	"$18,188.00"	Outpatient	"$9,094.00"	"$1,365.15"	"$9,948.84"	"$12,131.40"	"$7,275.20"	Not Applicable	"$6,365.80"	"$12,731.60"	"$1,365.15"	"$12,731.60"
Place radiothrpy brachy catheter breast RT 19298	19298	OR SERVICES	"$18,180.00"	Outpatient	"$9,090.00"	"$16,258.87"	"$9,944.46"	"$4,649.00"	"$7,272.00"	"$7,310.00"	"$6,363.00"	"$12,726.00"	"$4,649.00"	"$16,258.87"
Place radiothrpy brachy catheter breast LT 19298	19298	OR SERVICES	"$18,180.00"	Outpatient	"$9,090.00"	"$16,258.87"	"$9,944.46"	"$4,649.00"	"$7,272.00"	"$7,310.00"	"$6,363.00"	"$12,726.00"	"$4,649.00"	"$16,258.87"
PLT 20MM MNDB TI HEMI RECON BN 9215920	C1713	SUPPLY/IMPLANTS	"$18,179.00"	Outpatient	"$9,089.50"	"$1,365.15"	"$9,943.91"	"$12,125.39"	"$7,271.60"	Not Applicable	"$6,362.65"	"$12,725.30"	"$1,365.15"	"$12,725.30"
HEAD HUM 21MM 64MM 54MM SHLDR CMPRH VERSA-DIAL 113063	C1776	SUPPLY/IMPLANTS	"$18,170.00"	Outpatient	"$9,085.00"	Not Applicable	"$9,938.99"	"$12,119.39"	"$7,268.00"	Not Applicable	"$6,359.50"	"$12,719.00"	"$6,359.50"	"$12,719.00"
MTRX TISS 16X6CM ALDRM THK ACLR DERM ALGRF RGNRT LG PC 102196	C1762	SUPPLY/IMPLANTS	"$18,170.00"	Outpatient	"$9,085.00"	Not Applicable	"$9,938.99"	"$12,119.39"	"$7,268.00"	Not Applicable	"$6,359.50"	"$12,719.00"	"$6,359.50"	"$12,719.00"
EXTENSION STEM GMRS COCR L60 MM KNEE PIECE 6495-6-060	C1776	SUPPLY/IMPLANTS	"$18,152.00"	Outpatient	"$9,076.00"	Not Applicable	"$9,929.14"	"$12,107.38"	"$7,260.80"	Not Applicable	"$6,353.20"	"$12,706.40"	"$6,353.20"	"$12,706.40"
HEAD HUM 18MM 48MM SHLDR AQLS ASCND FLX COCR 1.5MM LO OFST DWF048	C1776	SUPPLY/IMPLANTS	"$18,150.00"	Outpatient	"$9,075.00"	Not Applicable	"$9,928.05"	"$12,106.05"	"$7,260.00"	Not Applicable	"$6,352.50"	"$12,705.00"	"$6,352.50"	"$12,705.00"
PLT 343MM FEM LT DIST LAT SS 16X5X 8 HL AXSOS BN NS 437516	C1713	SUPPLY/IMPLANTS	"$18,148.00"	Outpatient	"$9,074.00"	"$1,365.15"	"$9,926.96"	"$12,104.72"	"$7,259.20"	Not Applicable	"$6,351.80"	"$12,703.60"	"$1,365.15"	"$12,703.60"
NAIL IM 225MM 7MM 9.5MM LNG STRG CNN MULTILOC TI AL NIOBIUM 04.016.225S	C1713	SUPPLY/IMPLANTS	"$18,147.00"	Outpatient	"$9,073.50"	"$1,365.15"	"$9,926.41"	"$12,104.05"	"$7,258.80"	Not Applicable	"$6,351.45"	"$12,702.90"	"$1,365.15"	"$12,702.90"
SPIKED SCREW INSERTER FOR 3.5MM 703960	C1713	SUPPLY/IMPLANTS	"$18,110.00"	Outpatient	"$9,055.00"	"$1,365.15"	"$9,906.17"	"$12,079.37"	"$7,244.00"	Not Applicable	"$6,338.50"	"$12,677.00"	"$1,365.15"	"$12,677.00"
PLATE SCREW INSERTER 703964		STERILE SUPPLY	"$18,110.00"	Outpatient	"$9,055.00"	Not Applicable	"$9,906.17"	"$12,079.37"	"$7,244.00"	Not Applicable	"$6,338.50"	"$12,677.00"	"$6,338.50"	"$12,677.00"
STNT DDNL 22-27MM 10FR 12CM 230CM DLV SYS FLXB RADOPQ M00565030	C1876	SUPPLY/IMPLANTS	"$18,102.00"	Outpatient	"$9,051.00"	Not Applicable	"$9,901.79"	"$12,074.03"	"$7,240.80"	Not Applicable	"$6,335.70"	"$12,671.40"	"$6,335.70"	"$12,671.40"
PLT 2.5MM MNDB 11 HL LEIBINGER UNV 2 BN 9255011	C1713	SUPPLY/IMPLANTS	"$18,092.00"	Outpatient	"$9,046.00"	"$1,365.15"	"$9,896.32"	"$12,067.36"	"$7,236.80"	Not Applicable	"$6,332.20"	"$12,664.40"	"$1,365.15"	"$12,664.40"
GFT BN DBM 5X1.75CM MAGNIFUSE 7509145	C9362	SUPPLY/IMPLANTS	"$18,086.00"	Outpatient	"$9,043.00"	$110.85	"$9,893.04"	"$12,063.36"	"$7,234.40"	Not Applicable	"$6,330.10"	"$12,660.20"	$110.85	"$12,660.20"
END CAP SPINAL OBELISC TITANIUM 0 D H1.5 MM OD24 MM THORACIC CS 2926 00	C1713	SUPPLY/IMPLANTS	"$18,086.00"	Outpatient	"$9,043.00"	"$1,365.15"	"$9,893.04"	"$12,063.36"	"$7,234.40"	Not Applicable	"$6,330.10"	"$12,660.20"	"$1,365.15"	"$12,660.20"
CUP ACTB 60MM PNCL 12 DOME SCR MLHL II HIP STRL GRIPTION LF 121730060		STERILE SUPPLY	"$18,080.00"	Outpatient	"$9,040.00"	Not Applicable	"$9,889.76"	"$12,059.36"	"$7,232.00"	Not Applicable	"$6,328.00"	"$12,656.00"	"$6,328.00"	"$12,656.00"
STNT BIL 10MM 8.5FR 80MM 3.2MM .035IN RX PRT CVR GW WALLFLEX M00570740	C1874	SUPPLY/IMPLANTS	"$18,069.00"	Outpatient	"$9,034.50"	Not Applicable	"$9,883.74"	"$12,052.02"	"$7,227.60"	Not Applicable	"$6,324.15"	"$12,648.30"	"$6,324.15"	"$12,648.30"
NAIL IM 38CM 12MM 130D LNG IMHS CP SS LT HIP 71683138L	C1713	SUPPLY/IMPLANTS	"$18,069.00"	Outpatient	"$9,034.50"	"$1,365.15"	"$9,883.74"	"$12,052.02"	"$7,227.60"	Not Applicable	"$6,324.15"	"$12,648.30"	"$1,365.15"	"$12,648.30"
PLATFORM KIT UNILATERAL 4-LEGGED W/D HW MP-KIT-14D		STERILE SUPPLY	"$18,068.00"	Outpatient	"$9,034.00"	Not Applicable	"$9,883.20"	"$12,051.36"	"$7,227.20"	Not Applicable	"$6,323.80"	"$12,647.60"	"$6,323.80"	"$12,647.60"
PLT 216MM HUM LT PROX SS 13 HL LCK PRLC BN 3.5MM SCR 71801413	C1713	SUPPLY/IMPLANTS	"$18,045.00"	Outpatient	"$9,022.50"	"$1,365.15"	"$9,870.62"	"$12,036.02"	"$7,218.00"	Not Applicable	"$6,315.75"	"$12,631.50"	"$1,365.15"	"$12,631.50"
GFT BN CLLR BN MTRX 5CC OSTEOCEL PRO MED 5016005	C9363	SUPPLY/IMPLANTS	"$18,039.00"	Outpatient	"$9,019.50"	$38.51	"$9,867.33"	"$12,032.01"	"$7,215.60"	Not Applicable	"$6,313.65"	"$12,627.30"	$38.51	"$12,627.30"
STNT BIL 10MM 8.5FR 40MM 3.2MM .035IN RX PRT CVR GW WALLFLEX M00570720	C1874	SUPPLY/IMPLANTS	"$18,036.00"	Outpatient	"$9,018.00"	Not Applicable	"$9,865.69"	"$12,030.01"	"$7,214.40"	Not Applicable	"$6,312.60"	"$12,625.20"	"$6,312.60"	"$12,625.20"
STNT BIL 10MM 8.5FR 60MM 3.2MM .035IN FLRSCP MRKR RX PRT CVR M00570730	C1874	SUPPLY/IMPLANTS	"$18,036.00"	Outpatient	"$9,018.00"	Not Applicable	"$9,865.69"	"$12,030.01"	"$7,214.40"	Not Applicable	"$6,312.60"	"$12,625.20"	"$6,312.60"	"$12,625.20"
CATHETER ACUNAV ULTRASOUND ICE 8 FR 90CM 101359362		STERILE SUPPLY	"$18,028.00"	Outpatient	"$9,014.00"	Not Applicable	"$9,861.32"	"$12,024.68"	"$7,211.20"	Not Applicable	"$6,309.80"	"$12,619.60"	"$6,309.80"	"$12,619.60"
DEV CLSR 45MM ATRICLIP PRO2 GILLINOV-CSGRV STRL LF DISP LT PRO245		STERILE SUPPLY	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 26MM MTRL C-E PH II 5200M26		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 28MM MTRL C-E PH II 5200M28		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 30MM MTRL C-E PH II 5200M30		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 32MM MTRL C-E PH II 5200M32		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 34MM MTRL C-E PH II 5200M34		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 36MM MTRL HLDR C-E PH II COCR SIL PLSTR STRL 5200M36		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 38MM MTRL C-E PH II 5200M38		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
RING ANLPLS 40MM MTRL HLDR SW C-E PH II COCR SIL PLSTR STRL 5200M40		SUPPLY/IMPLANTS	"$18,019.00"	Outpatient	"$9,009.50"	Not Applicable	"$9,856.39"	"$12,018.67"	"$7,207.60"	Not Applicable	"$6,306.65"	"$12,613.30"	"$6,306.65"	"$12,613.30"
GFT SNTH TISS 6X4CM ORTH NUSHIELD NO-1460	Q4160	SUPPLY/IMPLANTS	"$18,013.00"	Outpatient	"$9,006.50"	$98.34	"$9,853.11"	"$12,014.67"	"$7,205.20"	Not Applicable	"$6,304.55"	"$12,609.10"	$98.34	"$12,609.10"
CATH US .014IN CRV 6FR 120CM RE ENTRY IVUS PNR + PPLUS120		STERILE SUPPLY	"$18,013.00"	Outpatient	"$9,006.50"	Not Applicable	"$9,853.11"	"$12,014.67"	"$7,205.20"	Not Applicable	"$6,304.55"	"$12,609.10"	"$6,304.55"	"$12,609.10"
STEM HUM 14MM CMNTLS MDLR DLT XTEND HA SHLDR STRL LF RVRS 130714000	C1776	SUPPLY/IMPLANTS	"$18,012.00"	Outpatient	"$9,006.00"	Not Applicable	"$9,852.56"	"$12,014.00"	"$7,204.80"	Not Applicable	"$6,304.20"	"$12,608.40"	"$6,304.20"	"$12,608.40"
STEM HUM 10MM CMNTLS MDLR DLT XTEND HA SHLDR STRL LF RVRS 130710000	C1776	SUPPLY/IMPLANTS	"$18,012.00"	Outpatient	"$9,006.00"	Not Applicable	"$9,852.56"	"$12,014.00"	"$7,204.80"	Not Applicable	"$6,304.20"	"$12,608.40"	"$6,304.20"	"$12,608.40"
STEM HUMERAL DELTA XTEND HA OD12 MM SHOULDER CEMENTLESS MODU 130712000	C1776	SUPPLY/IMPLANTS	"$18,012.00"	Outpatient	"$9,006.00"	Not Applicable	"$9,852.56"	"$12,014.00"	"$7,204.80"	Not Applicable	"$6,304.20"	"$12,608.40"	"$6,304.20"	"$12,608.40"
STEM HUMERAL GLOBAL UNITE POROCOAT STANDARD L113 MM OD10 MM 110010100	C1776	SUPPLY/IMPLANTS	"$18,012.00"	Outpatient	"$9,006.00"	Not Applicable	"$9,852.56"	"$12,014.00"	"$7,204.80"	Not Applicable	"$6,304.20"	"$12,608.40"	"$6,304.20"	"$12,608.40"
STEM HUMERAL DELTA XTEND HA OD16 MM SHOULDER CEMENTLESS MODU 130716000	C1776	SUPPLY/IMPLANTS	"$18,012.00"	Outpatient	"$9,006.00"	Not Applicable	"$9,852.56"	"$12,014.00"	"$7,204.80"	Not Applicable	"$6,304.20"	"$12,608.40"	"$6,304.20"	"$12,608.40"
STEM HUMERAL GLOBAL UNITE POROCOAT STANDARD L120 MM OD12 MM 110012100	C1776	SUPPLY/IMPLANTS	"$18,012.00"	Outpatient	"$9,006.00"	Not Applicable	"$9,852.56"	"$12,014.00"	"$7,204.80"	Not Applicable	"$6,304.20"	"$12,608.40"	"$6,304.20"	"$12,608.40"
CLIP INTNL 60D 40MM ATRICLIP PRO GILLINOV-CSGRV HD ARTC QCK PRO 140		STERILE SUPPLY	"$18,008.00"	Outpatient	"$9,004.00"	Not Applicable	"$9,850.38"	"$12,011.34"	"$7,203.20"	Not Applicable	"$6,302.80"	"$12,605.60"	"$6,302.80"	"$12,605.60"
PLT 2 ANG MNDB TI 6X24X6 HL LCK RECON LOPRFL CLR CD BN NS 449.638	C1713	SUPPLY/IMPLANTS	"$18,007.00"	Outpatient	"$9,003.50"	"$1,365.15"	"$9,849.83"	"$12,010.67"	"$7,202.80"	Not Applicable	"$6,302.45"	"$12,604.90"	"$1,365.15"	"$12,604.90"
OPTIROM LEFT DISTAL COMP 9605	C1713	SUPPLY/IMPLANTS	"$18,004.00"	Outpatient	"$9,002.00"	"$1,365.15"	"$9,848.19"	"$12,008.67"	"$7,201.60"	Not Applicable	"$6,301.40"	"$12,602.80"	"$1,365.15"	"$12,602.80"
OPTIROM RIGHT DISTAL COMP 9610	C1713	SUPPLY/IMPLANTS	"$18,004.00"	Outpatient	"$9,002.00"	"$1,365.15"	"$9,848.19"	"$12,008.67"	"$7,201.60"	Not Applicable	"$6,301.40"	"$12,602.80"	"$1,365.15"	"$12,602.80"
CLIP INTNL 35MM ATRICLIP PRO GILLINOV-CSGRV LT ATR APPENDAGE PRO135		STERILE SUPPLY	"$17,998.00"	Outpatient	"$8,999.00"	Not Applicable	"$9,844.91"	"$12,004.67"	"$7,199.20"	Not Applicable	"$6,299.30"	"$12,598.60"	"$6,299.30"	"$12,598.60"
CLIP INTNL 50MM ATRICLIP PRO GILLINOV-CSGRV LT ATR APPENDAGE PRO150		STERILE SUPPLY	"$17,998.00"	Outpatient	"$8,999.00"	Not Applicable	"$9,844.91"	"$12,004.67"	"$7,199.20"	Not Applicable	"$6,299.30"	"$12,598.60"	"$6,299.30"	"$12,598.60"
DEV CLSR 40MM 45D ATRICLIP FLXB SHFT PLNG GRP NTNL PLSTR 6CM ACH 240		STERILE SUPPLY	"$17,998.00"	Outpatient	"$8,999.00"	Not Applicable	"$9,844.91"	"$12,004.67"	"$7,199.20"	Not Applicable	"$6,299.30"	"$12,598.60"	"$6,299.30"	"$12,598.60"
DEV CLSR 45MM ATRICLIP PRO RGD SHFT PLSTR 25CM LT ATR PRO145		STERILE SUPPLY	"$17,998.00"	Outpatient	"$8,999.00"	Not Applicable	"$9,844.91"	"$12,004.67"	"$7,199.20"	Not Applicable	"$6,299.30"	"$12,598.60"	"$6,299.30"	"$12,598.60"
COIL EMBL 10CM 6MM .038IN AZUR PLTN DDRGL .035IN 135CM PERI 45-450610		SUPPLY/IMPLANTS	"$17,998.00"	Outpatient	"$8,999.00"	Not Applicable	"$9,844.91"	"$12,004.67"	"$7,199.20"	Not Applicable	"$6,299.30"	"$12,598.60"	"$6,299.30"	"$12,598.60"
HEAD HUM 18MM 48MM SHLDR COCR STRL 5331-48/18		STERILE SUPPLY	"$17,996.00"	Outpatient	"$8,998.00"	Not Applicable	"$9,843.81"	"$12,003.33"	"$7,198.40"	Not Applicable	"$6,298.60"	"$12,597.20"	"$6,298.60"	"$12,597.20"
SCR BN SPNE COCR 45MM 6.5MM SOLERA MA CNN 5.5MM ROD 55840016545	C1713	SUPPLY/IMPLANTS	"$17,988.00"	Outpatient	"$8,994.00"	"$1,365.15"	"$9,839.44"	"$11,998.00"	"$7,195.20"	Not Applicable	"$6,295.80"	"$12,591.60"	"$1,365.15"	"$12,591.60"
SCR BN SPNE COCR 40MM 6.5MM SOLERA MA CNN 5.5MM ROD 55840016540	C1713	SUPPLY/IMPLANTS	"$17,988.00"	Outpatient	"$8,994.00"	"$1,365.15"	"$9,839.44"	"$11,998.00"	"$7,195.20"	Not Applicable	"$6,295.80"	"$12,591.60"	"$1,365.15"	"$12,591.60"
SCR BN SPNE COCR 50MM 6.5MM SOLERA MA CNN 5.5MM ROD 55840016550	C1713	SUPPLY/IMPLANTS	"$17,988.00"	Outpatient	"$8,994.00"	"$1,365.15"	"$9,839.44"	"$11,998.00"	"$7,195.20"	Not Applicable	"$6,295.80"	"$12,591.60"	"$1,365.15"	"$12,591.60"
SCR BN SPNE COCR 35MM 5.5MM MA CNN 54840015535	C1713	SUPPLY/IMPLANTS	"$17,988.00"	Outpatient	"$8,994.00"	"$1,365.15"	"$9,839.44"	"$11,998.00"	"$7,195.20"	Not Applicable	"$6,295.80"	"$12,591.60"	"$1,365.15"	"$12,591.60"
SCREW 5.5 X 45MM 54840010540	C1713	SUPPLY/IMPLANTS	"$17,988.00"	Outpatient	"$8,994.00"	"$1,365.15"	"$9,839.44"	"$11,998.00"	"$7,195.20"	Not Applicable	"$6,295.80"	"$12,591.60"	"$1,365.15"	"$12,591.60"
SCREW CANNULATED ILICO PA 6.5 X 40MM SE-73865-40	C1713	SUPPLY/IMPLANTS	"$17,985.00"	Outpatient	"$8,992.50"	"$1,365.15"	"$9,837.80"	"$11,996.00"	"$7,194.00"	Not Applicable	"$6,294.75"	"$12,589.50"	"$1,365.15"	"$12,589.50"
STENT ELUVIA 6X100X130CM H74939294601010	C1874	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	Not Applicable	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$6,291.95"	"$12,583.90"
STENT ELUVIA 7X60X130CM H74939294700610	C1874	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	Not Applicable	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$6,291.95"	"$12,583.90"
STENT ELUVIA 7X80X130CM H74939294700810	C1874	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	Not Applicable	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$6,291.95"	"$12,583.90"
STENT ELUVIA 7X100X130CM H74939294701010	C1874	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	Not Applicable	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$6,291.95"	"$12,583.90"
STENT ELUVIA 6X80X130CM H74939294600810	C1874	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	Not Applicable	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$6,291.95"	"$12,583.90"
SCR BN SPNE TI COCR 45MM 6.5MM SOLERA CD HZN OSTEOGRIP 2 LD 54840016545	C1713	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	"$1,365.15"	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$1,365.15"	"$12,583.90"
SCR BN SPNE TI COCR 50MM 6.5MM SOLERA CD HZN OSTEOGRIP 2 LD 54840016550	C1713	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	"$1,365.15"	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$1,365.15"	"$12,583.90"
SCR BN SPNE TI COCR 30MM 4.5MM SOLERA CD HZN OSTEOGRIP 2 LD 54840004530	C1713	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	"$1,365.15"	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$1,365.15"	"$12,583.90"
SCR BN SPNE COCR 40MM 4.5MM SOLERA CD HZN MA CNN 54840014540	C1713	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	"$1,365.15"	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$1,365.15"	"$12,583.90"
SCR BN SPNE COCR 40MM 5.5MM SOLERA CD HZN MA CNN 54840015540	C1713	SUPPLY/IMPLANTS	"$17,977.00"	Outpatient	"$8,988.50"	"$1,365.15"	"$9,833.42"	"$11,990.66"	"$7,190.80"	Not Applicable	"$6,291.95"	"$12,583.90"	"$1,365.15"	"$12,583.90"
STNT VASC 6FR 80MM 125CM DRG ELUT OTW SET PERI ZL PTX ACPT G34313	C1874	SUPPLY/IMPLANTS	"$17,973.00"	Outpatient	"$8,986.50"	Not Applicable	"$9,831.23"	"$11,987.99"	"$7,189.20"	Not Applicable	"$6,290.55"	"$12,581.10"	"$6,290.55"	"$12,581.10"
GFT BN AMNIO TISS 3X2CM 2 LYR REPST DSGN AMNIOHEAL + TAH1203	C9363	SUPPLY/IMPLANTS	"$17,973.00"	Outpatient	"$8,986.50"	$38.51	"$9,831.23"	"$11,987.99"	"$7,189.20"	Not Applicable	"$6,290.55"	"$12,581.10"	$38.51	"$12,581.10"
TISSUE AMNIOJECT 0.5 ML AGT-5050	C9363	SUPPLY/IMPLANTS	"$17,973.00"	Outpatient	"$8,986.50"	$38.51	"$9,831.23"	"$11,987.99"	"$7,189.20"	Not Applicable	"$6,290.55"	"$12,581.10"	$38.51	"$12,581.10"
CASE STRL PA TIB SCR 8299-13-100	C1713	SUPPLY/IMPLANTS	"$17,970.00"	Outpatient	"$8,985.00"	"$1,365.15"	"$9,829.59"	"$11,985.99"	"$7,188.00"	Not Applicable	"$6,289.50"	"$12,579.00"	"$1,365.15"	"$12,579.00"
NAIL IM 420MM 10MM T2 TI FEM GT RT STRL 1851-1042S	C1713	SUPPLY/IMPLANTS	"$17,969.00"	Outpatient	"$8,984.50"	"$1,365.15"	"$9,829.04"	"$11,985.32"	"$7,187.60"	Not Applicable	"$6,289.15"	"$12,578.30"	"$1,365.15"	"$12,578.30"
NAIL IM 400MM 12MM T2 TI FEM GT RT STRL 1851-1240S	C1713	SUPPLY/IMPLANTS	"$17,969.00"	Outpatient	"$8,984.50"	"$1,365.15"	"$9,829.04"	"$11,985.32"	"$7,187.60"	Not Applicable	"$6,289.15"	"$12,578.30"	"$1,365.15"	"$12,578.30"
NAIL IM 380MM 11MM T2 TI FEM GT LT STRL 1850-1138S	C1713	SUPPLY/IMPLANTS	"$17,969.00"	Outpatient	"$8,984.50"	"$1,365.15"	"$9,829.04"	"$11,985.32"	"$7,187.60"	Not Applicable	"$6,289.15"	"$12,578.30"	"$1,365.15"	"$12,578.30"
NAIL IM 400MM 9MM T2 TI FEM GT LT STRL 1850-0940S	C1713	SUPPLY/IMPLANTS	"$17,969.00"	Outpatient	"$8,984.50"	"$1,365.15"	"$9,829.04"	"$11,985.32"	"$7,187.60"	Not Applicable	"$6,289.15"	"$12,578.30"	"$1,365.15"	"$12,578.30"
NAIL IM 360MM 12MM T2 TI FEM GT LT STRL 1850-1236S	C1713	SUPPLY/IMPLANTS	"$17,969.00"	Outpatient	"$8,984.50"	"$1,365.15"	"$9,829.04"	"$11,985.32"	"$7,187.60"	Not Applicable	"$6,289.15"	"$12,578.30"	"$1,365.15"	"$12,578.30"
53270-3000-01 - RHo (D) immune globulin 15000 intl units/13 mL Soln	J2792	PHARMACY	"$17,965.00"	Outpatient	"$8,982.50"	$31.61	"$9,826.86"	"$11,982.66"	"$7,186.00"	Not Applicable	"$6,287.75"	"$12,575.50"	$31.61	"$12,575.50"
NAIL IM 400MM 10MM T2 TI FEM GT LT STRL 1850-1040S	C1713	SUPPLY/IMPLANTS	"$17,963.00"	Outpatient	"$8,981.50"	"$1,365.15"	"$9,825.76"	"$11,981.32"	"$7,185.20"	Not Applicable	"$6,287.05"	"$12,574.10"	"$1,365.15"	"$12,574.10"
MINI REAIL EX FIX 1132313		STERILE SUPPLY	"$17,955.00"	Outpatient	"$8,977.50"	Not Applicable	"$9,821.39"	"$11,975.99"	"$7,182.00"	Not Applicable	"$6,284.25"	"$12,568.50"	"$6,284.25"	"$12,568.50"
MODL ANTM BN MXL THR CRNL PED SD900.268	C1713	SUPPLY/IMPLANTS	"$17,953.00"	Outpatient	"$8,976.50"	"$1,365.15"	"$9,820.29"	"$11,974.65"	"$7,181.20"	Not Applicable	"$6,283.55"	"$12,567.10"	"$1,365.15"	"$12,567.10"
NAIL IM 150MM 8MM T2 TI HUM LT PROX STRL 1832-1035S	C1713	SUPPLY/IMPLANTS	"$17,911.00"	Outpatient	"$8,955.50"	"$1,365.15"	"$9,797.32"	"$11,946.64"	"$7,164.40"	Not Applicable	"$6,268.85"	"$12,537.70"	"$1,365.15"	"$12,537.70"
STENT DUODENAL WALLFLEX NITINOL L60 MM L230 CM OD22-27 MM DE M00565010	C1876	SUPPLY/IMPLANTS	"$17,905.00"	Outpatient	"$8,952.50"	Not Applicable	"$9,794.04"	"$11,942.64"	"$7,162.00"	Not Applicable	"$6,266.75"	"$12,533.50"	"$6,266.75"	"$12,533.50"
NAIL IM 340MM 11MM LCK RTRGD T2 TI SP CNDL STRL 1826-1134S	C1713	SUPPLY/IMPLANTS	"$17,858.00"	Outpatient	"$8,929.00"	"$1,365.15"	"$9,768.33"	"$11,911.29"	"$7,143.20"	Not Applicable	"$6,250.30"	"$12,500.60"	"$1,365.15"	"$12,500.60"
CASE INST NTR NL SM CEPHALOMEDULLARY SS AL 1OF 2 249004050	C1713	SUPPLY/IMPLANTS	"$17,856.00"	Outpatient	"$8,928.00"	"$1,365.15"	"$9,767.23"	"$11,909.95"	"$7,142.40"	Not Applicable	"$6,249.60"	"$12,499.20"	"$1,365.15"	"$12,499.20"
WOUND MATRIX 6 LAYER 7X10CM WSX0710		STERILE SUPPLY	"$17,843.00"	Outpatient	"$8,921.50"	Not Applicable	"$9,760.12"	"$11,901.28"	"$7,137.20"	Not Applicable	"$6,245.05"	"$12,490.10"	"$6,245.05"	"$12,490.10"
STNT ESPH 18MM 18.5FR 15CM 120CM FLR LOPRFL SLF XPD WRE REM M00516720	C1874	SUPPLY/IMPLANTS	"$17,837.00"	Outpatient	"$8,918.50"	Not Applicable	"$9,756.84"	"$11,897.28"	"$7,134.80"	Not Applicable	"$6,242.95"	"$12,485.90"	"$6,242.95"	"$12,485.90"
PURAPLY 5X5 25SQ CM 515-008	Q4195	PHARMACY	"$17,837.00"	Outpatient	"$8,918.50"	$124.92	"$9,756.84"	"$11,897.28"	"$7,134.80"	Not Applicable	"$6,242.95"	"$12,485.90"	$124.92	"$12,485.90"
 ACTIS COLLARED STD SIZE 3 1010-11-030	C1776	SUPPLY/IMPLANTS	"$17,835.00"	Outpatient	"$8,917.50"	Not Applicable	"$9,755.75"	"$11,895.95"	"$7,134.00"	Not Applicable	"$6,242.25"	"$12,484.50"	"$6,242.25"	"$12,484.50"
PLT 207MM SM BND TIB RT PERIART PROX SS 12 HL VA LCP CMBN BN 02.127.250	C1713	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	"$1,365.15"	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$1,365.15"	"$12,477.50"
PLT 207MM SM BND TIB LT PERIART PROX SS 12 HL VA LCP CMBN BN 02.127.251	C1713	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	"$1,365.15"	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$1,365.15"	"$12,477.50"
STNT BIL 8MM 8FR 40MM 75CM .035IN GW CATH TRNSHEP WALLFLEX M00574620	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
STNT BIL 8MM 8FR 60MM 75CM .035IN GW CATH TRNSHEP WALLFLEX M00574630	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
STNT BIL 8MM 8FR 80MM 75CM .035IN GW CATH TRNSHEP WALLFLEX M00574640	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
STNT BIL 8MM 8FR 100MM 75CM .035IN GW CATH TRNSHEP WALLFLEX M00574650	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
STNT BIL 10MM 8FR 40MM 75CM .035IN GW CATH TRNSHEP WALLFLEX M00574660	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
STNT BIL 10MM 8FR 60MM 75CM .035IN GW CATH TRNSHEP WALLFLEX M00574670	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
STNT BIL 10MM 8FR 80MM 75CM .035IN GW CATH UNCOVER WALLFLEX M00574680	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
STNT BIL 10MM 8FR 100MM 75CM .035IN GW CATH TRNSHEP WALLFLEX M00574690	C1876	SUPPLY/IMPLANTS	"$17,825.00"	Outpatient	"$8,912.50"	Not Applicable	"$9,750.28"	"$11,889.28"	"$7,130.00"	Not Applicable	"$6,238.75"	"$12,477.50"	"$6,238.75"	"$12,477.50"
AUG ACTB 20MM 58MM HIP TRB MTL 489405820	C1776	SUPPLY/IMPLANTS	"$17,822.00"	Outpatient	"$8,911.00"	Not Applicable	"$9,748.63"	"$11,887.27"	"$7,128.80"	Not Applicable	"$6,237.70"	"$12,475.40"	"$6,237.70"	"$12,475.40"
"13533-0318-05 - rabies immune globulin, human 300 intl units/mL Soln"	90375	PHARMACY	"$17,821.00"	Outpatient	"$8,910.50"	Not Applicable	"$9,748.09"	"$11,886.61"	"$7,128.40"	Not Applicable	"$6,237.35"	"$12,474.70"	"$6,237.35"	"$12,474.70"
GFT SFT TIS 8X6CM THK DRML XCLR MTRX HDRT RTU REINF STRL ABS-30002S	C9363	SUPPLY/IMPLANTS	"$17,814.00"	Outpatient	"$8,907.00"	$38.51	"$9,744.26"	"$11,881.94"	"$7,125.60"	Not Applicable	"$6,234.90"	"$12,469.80"	$38.51	"$12,469.80"
CASE INST NTR NL SM CEPHALOMEDULLARY SS AL 2OF 2 249006350	C1713	SUPPLY/IMPLANTS	"$17,810.00"	Outpatient	"$8,905.00"	"$1,365.15"	"$9,742.07"	"$11,879.27"	"$7,124.00"	Not Applicable	"$6,233.50"	"$12,467.00"	"$1,365.15"	"$12,467.00"
CASE INST ZMR MTL RMR FLXB 222804000		STERILE SUPPLY	"$17,810.00"	Outpatient	"$8,905.00"	Not Applicable	"$9,742.07"	"$11,879.27"	"$7,124.00"	Not Applicable	"$6,233.50"	"$12,467.00"	"$6,233.50"	"$12,467.00"
RAIL XTRNFX 200MM SM C SYS 6611	C1713	SUPPLY/IMPLANTS	"$17,798.00"	Outpatient	"$8,899.00"	"$1,365.15"	"$9,735.51"	"$11,871.27"	"$7,119.20"	Not Applicable	"$6,229.30"	"$12,458.60"	"$1,365.15"	"$12,458.60"
CMPNT FEM 2 KN LT PTLFEM MULTICOMPARTMENTAL KN SYS 180402	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 3 KN PTLFEM LT MCK SYS 180403	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 4 KN PTLFEM LT MCK SYS 180404	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 5 KN PTLFEM LT MCK SYS 180405	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 6 KN LT PTLFEM MULTICOMPARTMENTAL KN SYS 180406	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 7 KN PTLFEM LT MCK SYS 180407	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 2 KN PTLFEM RT MCK SYS 180412	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 3 KN RT PTLFEM MULTICOMPARTMENTAL KN SYS 180413	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 4 KN PTLFEM RT MCK SYS 180414	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 5 KN PTLFEM RT MCK SYS 180415	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
CMPNT FEM 6 KN PTLFEM RT MCK SYS 180416	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
RESTORIS  MCK PATELLOFEMORAL LEFT SIZE 8 180408	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
RESTORIS  MCK PATELLOFEMORAL R SIZE 7 180417	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
RESTORIS  MCK PATELLOFEMORAL R SIZE 8 180418	C1776	SUPPLY/IMPLANTS	"$17,795.00"	Outpatient	"$8,897.50"	Not Applicable	"$9,733.87"	"$11,869.27"	"$7,118.00"	Not Applicable	"$6,228.25"	"$12,456.50"	"$6,228.25"	"$12,456.50"
PLT 60MM SPNE CRV ANT TI LCK ATLNTS TRANSLATIONAL BN NS 6190060	C1713	SUPPLY/IMPLANTS	"$17,791.00"	Outpatient	"$8,895.50"	"$1,365.15"	"$9,731.68"	"$11,866.60"	"$7,116.40"	Not Applicable	"$6,226.85"	"$12,453.70"	"$1,365.15"	"$12,453.70"
PLT 100X100X.4MM RECT CRNFCL TI CNTR MESH RGD BN STRL AU 1.3 421.008S	C1713	SUPPLY/IMPLANTS	"$17,788.00"	Outpatient	"$8,894.00"	"$1,365.15"	"$9,730.04"	"$11,864.60"	"$7,115.20"	Not Applicable	"$6,225.80"	"$12,451.60"	"$1,365.15"	"$12,451.60"
PLATE BONE LCP TITANIUM CURVE L266 MM CONDYLAR LEFT 12 HOLE 04.124.413	C1713	SUPPLY/IMPLANTS	"$17,777.00"	Outpatient	"$8,888.50"	"$1,365.15"	"$9,724.02"	"$11,857.26"	"$7,110.80"	Not Applicable	"$6,221.95"	"$12,443.90"	"$1,365.15"	"$12,443.90"
GFT SKN 4X6CM AMNIOBAND PLCNT MEMBR ALGRF WC3046	Q4151	SUPPLY/IMPLANTS	"$17,750.00"	Outpatient	"$8,875.00"	$141.19	"$9,709.25"	"$11,839.25"	"$7,100.00"	Not Applicable	"$6,212.50"	"$12,425.00"	$141.19	"$12,425.00"
SHL ACTB 54MM HIP MLHL SNPFT INTGR LCK MECH TRB MTL TIV 875705402	C1776	SUPPLY/IMPLANTS	"$17,748.00"	Outpatient	"$8,874.00"	Not Applicable	"$9,708.16"	"$11,837.92"	"$7,099.20"	Not Applicable	"$6,211.80"	"$12,423.60"	"$6,211.80"	"$12,423.60"
STENT ENDOPROSTHESIS 8MM DIA 59MML 120CML STAINLESS STEEL EP 85417	C1874	SUPPLY/IMPLANTS	"$17,742.00"	Outpatient	"$8,871.00"	Not Applicable	"$9,704.87"	"$11,833.91"	"$7,096.80"	Not Applicable	"$6,209.70"	"$12,419.40"	"$6,209.70"	"$12,419.40"
COAGULATOR ELSURG HABIB 4X 4401US		STERILE SUPPLY	"$17,724.00"	Outpatient	"$8,862.00"	Not Applicable	"$9,695.03"	"$11,821.91"	"$7,089.60"	Not Applicable	"$6,203.40"	"$12,406.80"	"$6,203.40"	"$12,406.80"
PLT 2.5MM 2 ANG SM MNDB TI 4X20X4 HL RECON MATRIXMANDIBLE BN 04.503.741	C1713	SUPPLY/IMPLANTS	"$17,720.00"	Outpatient	"$8,860.00"	"$1,365.15"	"$9,692.84"	"$11,819.24"	"$7,088.00"	Not Applicable	"$6,202.00"	"$12,404.00"	"$1,365.15"	"$12,404.00"
PLT 302MM HUM RT EXTRAARTICULAR DIST SS 14 HL PRECONTOUR LMT 02.104.014	C1713	SUPPLY/IMPLANTS	"$17,720.00"	Outpatient	"$8,860.00"	"$1,365.15"	"$9,692.84"	"$11,819.24"	"$7,088.00"	Not Applicable	"$6,202.00"	"$12,404.00"	"$1,365.15"	"$12,404.00"
PLT 302MM HUM LT EXTRAARTICULAR DIST SS 14 HL PRECONTOUR LMT 02.104.034	C1713	SUPPLY/IMPLANTS	"$17,720.00"	Outpatient	"$8,860.00"	"$1,365.15"	"$9,692.84"	"$11,819.24"	"$7,088.00"	Not Applicable	"$6,202.00"	"$12,404.00"	"$1,365.15"	"$12,404.00"
STENT CRTD SLF XPNDG STR 8MM X 300MM  XACT 82092-01	C1876	SUPPLY/IMPLANTS	"$17,677.00"	Outpatient	"$8,838.50"	Not Applicable	"$9,669.32"	"$11,790.56"	"$7,070.80"	Not Applicable	"$6,186.95"	"$12,373.90"	"$6,186.95"	"$12,373.90"
STENT VASCULAR XACT NICKEL TITANIUM STRAIGHT L30 MM OD9 MM C 82088-01	C1876	SUPPLY/IMPLANTS	"$17,677.00"	Outpatient	"$8,838.50"	Not Applicable	"$9,669.32"	"$11,790.56"	"$7,070.80"	Not Applicable	"$6,186.95"	"$12,373.90"	"$6,186.95"	"$12,373.90"
PACK PRC ATLGS PLTL CONC HRVT SMARTPREP 30ML 51404		STERILE SUPPLY	"$17,672.00"	Outpatient	"$8,836.00"	Not Applicable	"$9,666.58"	"$11,787.22"	"$7,068.80"	Not Applicable	"$6,185.20"	"$12,370.40"	"$6,185.20"	"$12,370.40"
STENT CRTD SLF XPNDG STR 10MM 30MM XACT 82098-01	C1876	SUPPLY/IMPLANTS	"$17,667.00"	Outpatient	"$8,833.50"	Not Applicable	"$9,663.85"	"$11,783.89"	"$7,066.80"	Not Applicable	"$6,183.45"	"$12,366.90"	"$6,183.45"	"$12,366.90"
RAIL XTRNFX 250MM DNFX STD C ADLT NS 6306	C1713	SUPPLY/IMPLANTS	"$17,666.00"	Outpatient	"$8,833.00"	"$1,365.15"	"$9,663.30"	"$11,783.22"	"$7,066.40"	Not Applicable	"$6,183.10"	"$12,366.20"	"$1,365.15"	"$12,366.20"
CATH US CNSL VIEWFLEXXICE VIEWMATE D087031		STERILE SUPPLY	"$17,666.00"	Outpatient	"$8,833.00"	Not Applicable	"$9,663.30"	"$11,783.22"	"$7,066.40"	Not Applicable	"$6,183.10"	"$12,366.20"	"$6,183.10"	"$12,366.20"
ACHILLES TENDON WITH WHOLE BONE BLOCK NOT OVER AGE 40 43200		SUPPLY/IMPLANTS	"$17,643.00"	Outpatient	"$8,821.50"	Not Applicable	"$9,650.72"	"$11,767.88"	"$7,057.20"	Not Applicable	"$6,175.05"	"$12,350.10"	"$6,175.05"	"$12,350.10"
PLT 166MM FEM RT DIST LAT SS 6X5X 3 HL AXSOS BN NS 4.5/5/6.5 437526	C1713	SUPPLY/IMPLANTS	"$17,636.00"	Outpatient	"$8,818.00"	"$1,365.15"	"$9,646.89"	"$11,763.21"	"$7,054.40"	Not Applicable	"$6,172.60"	"$12,345.20"	"$1,365.15"	"$12,345.20"
PLT 202MM FEM RT DIST LAT SS 8X5X 4 HL AXSOS BN NS 4.5/5/6.5 437528	C1713	SUPPLY/IMPLANTS	"$17,636.00"	Outpatient	"$8,818.00"	"$1,365.15"	"$9,646.89"	"$11,763.21"	"$7,054.40"	Not Applicable	"$6,172.60"	"$12,345.20"	"$1,365.15"	"$12,345.20"
KIT IM NL 400MM 11MM 130D R1.5 LNG LT TI 3530-1400S	C1713	SUPPLY/IMPLANTS	"$17,631.00"	Outpatient	"$8,815.50"	"$1,365.15"	"$9,644.16"	"$11,759.88"	"$7,052.40"	Not Applicable	"$6,170.85"	"$12,341.70"	"$1,365.15"	"$12,341.70"
KIT IM NL 340MM 13MM 125D R1.5 LNG LT TI 3525-3340S	C1713	SUPPLY/IMPLANTS	"$17,631.00"	Outpatient	"$8,815.50"	"$1,365.15"	"$9,644.16"	"$11,759.88"	"$7,052.40"	Not Applicable	"$6,170.85"	"$12,341.70"	"$1,365.15"	"$12,341.70"
KIT IM NL 360MM 13MM 130D R1.5 LNG RT TI 3430-3360S	C1713	SUPPLY/IMPLANTS	"$17,631.00"	Outpatient	"$8,815.50"	"$1,365.15"	"$9,644.16"	"$11,759.88"	"$7,052.40"	Not Applicable	"$6,170.85"	"$12,341.70"	"$1,365.15"	"$12,341.70"
KIT IM NL 320MM 11MM 125D R1.5 LT TI 3525-1320S	C1713	SUPPLY/IMPLANTS	"$17,631.00"	Outpatient	"$8,815.50"	"$1,365.15"	"$9,644.16"	"$11,759.88"	"$7,052.40"	Not Applicable	"$6,170.85"	"$12,341.70"	"$1,365.15"	"$12,341.70"
KIT IM NL 420MM 13MM 130D R1.5 LNG LT TI 3530-3420S	C1713	SUPPLY/IMPLANTS	"$17,631.00"	Outpatient	"$8,815.50"	"$1,365.15"	"$9,644.16"	"$11,759.88"	"$7,052.40"	Not Applicable	"$6,170.85"	"$12,341.70"	"$1,365.15"	"$12,341.70"
NAIL IM 400MM 11MM 130D LNG R1.5 KT GMA TI FEM RT STRL 3430-1400S	C1713	SUPPLY/IMPLANTS	"$17,631.00"	Outpatient	"$8,815.50"	"$1,365.15"	"$9,644.16"	"$11,759.88"	"$7,052.40"	Not Applicable	"$6,170.85"	"$12,341.70"	"$1,365.15"	"$12,341.70"
NAIL IM 380MM 10MM 130D LNG LCK GAMMA3 TI FEM LT STRL R1.5 3530-0380S	C1713	SUPPLY/IMPLANTS	"$17,631.00"	Outpatient	"$8,815.50"	"$1,365.15"	"$9,644.16"	"$11,759.88"	"$7,052.40"	Not Applicable	"$6,170.85"	"$12,341.70"	"$1,365.15"	"$12,341.70"
PLT 42MM SPNE CRV ANT TI 2 LVL TRNC SL BN NS 07.00341.003	C1713	SUPPLY/IMPLANTS	"$17,628.00"	Outpatient	"$8,814.00"	"$1,365.15"	"$9,642.52"	"$11,757.88"	"$7,051.20"	Not Applicable	"$6,169.80"	"$12,339.60"	"$1,365.15"	"$12,339.60"
KIT IM NL 420MM 11MM GMA 125D LNG R1.5 FEM LT TI STRL LF 3525-1420S	C1713	SUPPLY/IMPLANTS	"$17,624.00"	Outpatient	"$8,812.00"	"$1,365.15"	"$9,640.33"	"$11,755.21"	"$7,049.60"	Not Applicable	"$6,168.40"	"$12,336.80"	"$1,365.15"	"$12,336.80"
PLT TIB LT DIST MDL JIG HD BN 26120-01	C1713	SUPPLY/IMPLANTS	"$17,623.00"	Outpatient	"$8,811.50"	"$1,365.15"	"$9,639.78"	"$11,754.54"	"$7,049.20"	Not Applicable	"$6,168.05"	"$12,336.10"	"$1,365.15"	"$12,336.10"
PLT TIB L/L PROX JIG HD BN 26145-01	C1713	SUPPLY/IMPLANTS	"$17,623.00"	Outpatient	"$8,811.50"	"$1,365.15"	"$9,639.78"	"$11,754.54"	"$7,049.20"	Not Applicable	"$6,168.05"	"$12,336.10"	"$1,365.15"	"$12,336.10"
PLT TIB RT DIST MDL JIG HD BN 27120-01	C1713	SUPPLY/IMPLANTS	"$17,623.00"	Outpatient	"$8,811.50"	"$1,365.15"	"$9,639.78"	"$11,754.54"	"$7,049.20"	Not Applicable	"$6,168.05"	"$12,336.10"	"$1,365.15"	"$12,336.10"
PLT TIB LT PROX LAT JIG HD BN 27145-01	C1713	SUPPLY/IMPLANTS	"$17,623.00"	Outpatient	"$8,811.50"	"$1,365.15"	"$9,639.78"	"$11,754.54"	"$7,049.20"	Not Applicable	"$6,168.05"	"$12,336.10"	"$1,365.15"	"$12,336.10"
MODL ANTM CLR PROPLAN CMF ACRL MNDB ATCH MXL ADLT SD900.205	C1713	SUPPLY/IMPLANTS	"$17,605.00"	Outpatient	"$8,802.50"	"$1,365.15"	"$9,629.94"	"$11,742.54"	"$7,042.00"	Not Applicable	"$6,161.75"	"$12,323.50"	"$1,365.15"	"$12,323.50"
KIT GRAFT HARVEST RIA 2 03.404.000S		STERILE SUPPLY	"$17,594.00"	Outpatient	"$8,797.00"	Not Applicable	"$9,623.92"	"$11,735.20"	"$7,037.60"	Not Applicable	"$6,157.90"	"$12,315.80"	"$6,157.90"	"$12,315.80"
KIT INST MNDB BSC RECON FIB GFT CUT GD SD900.003	C1713	SUPPLY/IMPLANTS	"$17,593.00"	Outpatient	"$8,796.50"	"$1,365.15"	"$9,623.37"	"$11,734.53"	"$7,037.20"	Not Applicable	"$6,157.55"	"$12,315.10"	"$1,365.15"	"$12,315.10"
KIT INST 2 SPLNT PTSPC OTHGN NS SD900.008	C1713	SUPPLY/IMPLANTS	"$17,593.00"	Outpatient	"$8,796.50"	"$1,365.15"	"$9,623.37"	"$11,734.53"	"$7,037.20"	Not Applicable	"$6,157.55"	"$12,315.10"	"$1,365.15"	"$12,315.10"
HEAD HUM 19MM 44MM SHLDR REUNION STD STRL 5552-S-4419	C1776	SUPPLY/IMPLANTS	"$17,588.00"	Outpatient	"$8,794.00"	Not Applicable	"$9,620.64"	"$11,731.20"	"$7,035.20"	Not Applicable	"$6,155.80"	"$12,311.60"	"$6,155.80"	"$12,311.60"
HEAD HUM 18MM 48MM SHLDR REUNION STD STRL 5552-S-4818	C1776	SUPPLY/IMPLANTS	"$17,588.00"	Outpatient	"$8,794.00"	Not Applicable	"$9,620.64"	"$11,731.20"	"$7,035.20"	Not Applicable	"$6,155.80"	"$12,311.60"	"$6,155.80"	"$12,311.60"
CATHETER THROMBECTOMY AXS VECTA 71 2-4 MM L132 CM L150 CM OD INC-11129-132	C1757	SUPPLY/IMPLANTS	"$17,583.00"	Outpatient	"$8,791.50"	Not Applicable	"$9,617.90"	"$11,727.86"	"$7,033.20"	Not Applicable	"$6,154.05"	"$12,308.10"	"$6,154.05"	"$12,308.10"
MESH MATRIXNEURO .6MM TI CRNL 100MM RECON RGD STRL AU 04.503.150S	C1713	SUPPLY/IMPLANTS	"$17,582.00"	Outpatient	"$8,791.00"	"$1,365.15"	"$9,617.35"	"$11,727.19"	"$7,032.80"	Not Applicable	"$6,153.70"	"$12,307.40"	"$1,365.15"	"$12,307.40"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 140 D L3 04.033.069S	C1713	SUPPLY/IMPLANTS	"$17,573.00"	Outpatient	"$8,786.50"	"$1,365.15"	"$9,612.43"	"$11,721.19"	"$7,029.20"	Not Applicable	"$6,150.55"	"$12,301.10"	"$1,365.15"	"$12,301.10"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 140 D L3 04.033.969S	C1713	SUPPLY/IMPLANTS	"$17,573.00"	Outpatient	"$8,786.50"	"$1,365.15"	"$9,612.43"	"$11,721.19"	"$7,029.20"	Not Applicable	"$6,150.55"	"$12,301.10"	"$1,365.15"	"$12,301.10"
NAIL FRNTI CANN 11MM X 380MM 04.033.168S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL IM 400MM 10MM 135D 8 HL CNN RECON TI NIOBIUM AL ADLT 04.033.041S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL IM 380MM 11MM 135D 8 HL CNN RECON TI NIOBIUM AL ADLT 04.033.139S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL IM 400MM 9MM 140D 8 HL CNN RECON TI NIOBIUM AL ADLT FEM 04.033.970S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL IM 420MM 12MM 135D 8 HL CNN RECON TI NIOBIUM AL ADLT 04.033.242S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL IM 400MM 10MM 135D 8 HL CNN RECON TI NIOBIUM AL ADLT 04.033.040S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 135 D L3 04.033.239S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 140 D L3 04.033.062S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 140 D L3 04.033.967S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 135 D L4 04.033.240S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 135 D L3 04.033.038S	C1713	SUPPLY/IMPLANTS	"$17,563.00"	Outpatient	"$8,781.50"	"$1,365.15"	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$1,365.15"	"$12,294.10"
NAIL IM 360MM 10MM 135D 8 HL CNN RECON TI NIOBIUM AL ADLT 04.033.036S		STERILE SUPPLY	"$17,563.00"	Outpatient	"$8,781.50"	Not Applicable	"$9,606.96"	"$11,714.52"	"$7,025.20"	Not Applicable	"$6,147.05"	"$12,294.10"	"$6,147.05"	"$12,294.10"
STEM RADL 28MM 8MM EXPLOR ELB MDLR 11-210063	C1776	SUPPLY/IMPLANTS	"$17,561.00"	Outpatient	"$8,780.50"	Not Applicable	"$9,605.87"	"$11,713.19"	"$7,024.40"	Not Applicable	"$6,146.35"	"$12,292.70"	"$6,146.35"	"$12,292.70"
CASE STRL PA SCR 8299-13-200	C1713	SUPPLY/IMPLANTS	"$17,533.00"	Outpatient	"$8,766.50"	"$1,365.15"	"$9,590.55"	"$11,694.51"	"$7,013.20"	Not Applicable	"$6,136.55"	"$12,273.10"	"$1,365.15"	"$12,273.10"
PLT 379MM FEM LT DIST LAT TI 18 HL AXSOS 3 BN STRL 627618S	C1713	SUPPLY/IMPLANTS	"$17,528.00"	Outpatient	"$8,764.00"	"$1,365.15"	"$9,587.82"	"$11,691.18"	"$7,011.20"	Not Applicable	"$6,134.80"	"$12,269.60"	"$1,365.15"	"$12,269.60"
24856-0001-00 - ocriplasmin ophthalmic 0.5 mg/0.2 mL Soln	J7316	PHARMACY	"$17,499.00"	Outpatient	"$8,749.50"	"$1,151.62"	"$9,571.95"	"$11,671.83"	"$6,999.60"	Not Applicable	"$6,124.65"	"$12,249.30"	"$1,151.62"	"$12,249.30"
59075-0730-15 - natalizumab 300 mg Vial - 15mL	J2323	PHARMACY	"$17,497.00"	Outpatient	"$8,748.50"	$22.97	"$9,570.86"	"$11,670.50"	"$6,998.80"	Not Applicable	"$6,123.95"	"$12,247.90"	$22.97	"$12,247.90"
PLT 55MM SPNE CRV ANT TI 3 LVL ATL VS ELT BN NS 7200055	C1713	SUPPLY/IMPLANTS	"$17,490.00"	Outpatient	"$8,745.00"	"$1,365.15"	"$9,567.03"	"$11,665.83"	"$6,996.00"	Not Applicable	"$6,121.50"	"$12,243.00"	"$1,365.15"	"$12,243.00"
PLT 62.5MM SPNE CRV ANT TI 3 LVL ATL VS ELT BN NS 7200062	C1713	SUPPLY/IMPLANTS	"$17,490.00"	Outpatient	"$8,745.00"	"$1,365.15"	"$9,567.03"	"$11,665.83"	"$6,996.00"	Not Applicable	"$6,121.50"	"$12,243.00"	"$1,365.15"	"$12,243.00"
Insertion of Pacer Lead 2 Electrodes	33217	CARDIAC CATH LAB	"$17,487.00"	Outpatient	"$8,743.50"	"$10,177.31"	"$9,565.39"	"$1,592.00"	"$6,994.80"	"$7,310.00"	"$6,120.45"	"$12,240.90"	"$1,592.00"	"$12,240.90"
"Insertion of pacer lead, single lead"	33216	CARDIAC CATH LAB	"$17,487.00"	Outpatient	"$8,743.50"	"$10,177.31"	"$9,565.39"	"$1,592.00"	"$6,994.80"	"$7,310.00"	"$6,120.45"	"$12,240.90"	"$1,592.00"	"$12,240.90"
PLT 40MM SPNE CRV ANT TI 2 LVL ATL VS ELT BN NS 7200040	C1713	SUPPLY/IMPLANTS	"$17,480.00"	Outpatient	"$8,740.00"	"$1,365.15"	"$9,561.56"	"$11,659.16"	"$6,992.00"	Not Applicable	"$6,118.00"	"$12,236.00"	"$1,365.15"	"$12,236.00"
PLT 47.5MM SPNE CRV ANT TI 2 LVL ATL VS ELT BN NS 7200047	C1713	SUPPLY/IMPLANTS	"$17,480.00"	Outpatient	"$8,740.00"	"$1,365.15"	"$9,561.56"	"$11,659.16"	"$6,992.00"	Not Applicable	"$6,118.00"	"$12,236.00"	"$1,365.15"	"$12,236.00"
PLT 57.5MM SPNE CRV ANT TI 3 LVL ATL VS ELT BN NS 7200057	C1713	SUPPLY/IMPLANTS	"$17,480.00"	Outpatient	"$8,740.00"	"$1,365.15"	"$9,561.56"	"$11,659.16"	"$6,992.00"	Not Applicable	"$6,118.00"	"$12,236.00"	"$1,365.15"	"$12,236.00"
PLT 60MM SPNE CRV ANT TI 3 LVL ATL VS ELT BN NS 7200060	C1713	SUPPLY/IMPLANTS	"$17,480.00"	Outpatient	"$8,740.00"	"$1,365.15"	"$9,561.56"	"$11,659.16"	"$6,992.00"	Not Applicable	"$6,118.00"	"$12,236.00"	"$1,365.15"	"$12,236.00"
PLT 67.5MM SPNE CRV ANT TI 3 LVL ATL VS ELT BN NS 7200067	C1713	SUPPLY/IMPLANTS	"$17,480.00"	Outpatient	"$8,740.00"	"$1,365.15"	"$9,561.56"	"$11,659.16"	"$6,992.00"	Not Applicable	"$6,118.00"	"$12,236.00"	"$1,365.15"	"$12,236.00"
CAGE COLIX 12 X 10 X 26MM X-034-0393	C1713	SUPPLY/IMPLANTS	"$17,464.00"	Outpatient	"$8,732.00"	"$1,365.15"	"$9,552.81"	"$11,648.49"	"$6,985.60"	Not Applicable	"$6,112.40"	"$12,224.80"	"$1,365.15"	"$12,224.80"
TRAY STRL OPTILOCK DIST FEM PERIART PLT SYS 26552	C1713	SUPPLY/IMPLANTS	"$17,464.00"	Outpatient	"$8,732.00"	"$1,365.15"	"$9,552.81"	"$11,648.49"	"$6,985.60"	Not Applicable	"$6,112.40"	"$12,224.80"	"$1,365.15"	"$12,224.80"
CAGE 11 X 24 P2011	C1821	SUPPLY/IMPLANTS	"$17,464.00"	Outpatient	"$8,732.00"	Not Applicable	"$9,552.81"	"$11,648.49"	"$6,985.60"	Not Applicable	"$6,112.40"	"$12,224.80"	"$6,112.40"	"$12,224.80"
CAGE 13 X 10 X 26 X034-0394	C1821	SUPPLY/IMPLANTS	"$17,464.00"	Outpatient	"$8,732.00"	Not Applicable	"$9,552.81"	"$11,648.49"	"$6,985.60"	Not Applicable	"$6,112.40"	"$12,224.80"	"$6,112.40"	"$12,224.80"
CAGE 26 X 10 X14 X034-0395	C1821	SUPPLY/IMPLANTS	"$17,464.00"	Outpatient	"$8,732.00"	Not Applicable	"$9,552.81"	"$11,648.49"	"$6,985.60"	Not Applicable	"$6,112.40"	"$12,224.80"	"$6,112.40"	"$12,224.80"
CAGE CALIX-TI 13 X 26 X 10MM X-034-0391	C1821	SUPPLY/IMPLANTS	"$17,464.00"	Outpatient	"$8,732.00"	Not Applicable	"$9,552.81"	"$11,648.49"	"$6,985.60"	Not Applicable	"$6,112.40"	"$12,224.80"	"$6,112.40"	"$12,224.80"
MODL ANTM PROPLAN CMF CHLD PLAMD MXL CRNM SD900.368	C1713	SUPPLY/IMPLANTS	"$17,460.00"	Outpatient	"$8,730.00"	"$1,365.15"	"$9,550.62"	"$11,645.82"	"$6,984.00"	Not Applicable	"$6,111.00"	"$12,222.00"	"$1,365.15"	"$12,222.00"
CAGE COLIX 10 X 26 X 9MM X-034-0310	C1713	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	"$1,365.15"	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$1,365.15"	"$12,221.30"
CAGE PLASMA COATED 10MM X034-0284PC	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TLIF 12 X 26 X 10 PLASMA COATED X034-0286PL	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TLIF 26 X 12MM C034-0286PC	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TLIF 26 X 13MM X034-0287PC	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TLIF 26 X 11MM X034-0285PC	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TLIF 26 X 14MM X034-0288PC	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TLIF TI 27MM X 9MM X 13MM 1043-279-013	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TI TLIF ALLOY 27 X 9 X 12MM 1043-279-012	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE TLIF TI 25MM X 9MM X 13MM 1043-259-013	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
CAGE X SPINE 26 X 15MM X034-0289PC	C1821	SUPPLY/IMPLANTS	"$17,459.00"	Outpatient	"$8,729.50"	Not Applicable	"$9,550.07"	"$11,645.15"	"$6,983.60"	Not Applicable	"$6,110.65"	"$12,221.30"	"$6,110.65"	"$12,221.30"
NAIL IM 360MM 10MM 125D LCK GAMMA3 TI FEM LT STRL R1.5 3525-0360S	C1713	SUPPLY/IMPLANTS	"$17,454.00"	Outpatient	"$8,727.00"	"$1,365.15"	"$9,547.34"	"$11,641.82"	"$6,981.60"	Not Applicable	"$6,108.90"	"$12,217.80"	"$1,365.15"	"$12,217.80"
LEAD PCNG 90CM 5.4FR .078IN COR VNS EZTRK 2 2 ELTRD BP PSV 4543	C1900	SUPPLY/IMPLANTS	"$17,448.00"	Outpatient	"$8,724.00"	Not Applicable	"$9,544.06"	"$11,637.82"	"$6,979.20"	Not Applicable	"$6,106.80"	"$12,213.60"	"$6,106.80"	"$12,213.60"
STNT MTL 10MM 10FR 70MM CVR COAT DLV SYS UNSTP + WLGRF M001705070	C1874	SUPPLY/IMPLANTS	"$17,440.00"	Outpatient	"$8,720.00"	Not Applicable	"$9,539.68"	"$11,632.48"	"$6,976.00"	Not Applicable	"$6,104.00"	"$12,208.00"	"$6,104.00"	"$12,208.00"
STNT MTL 12MM 11FR 70MM CVR COAT DLV SYS UNSTP + WLGRF M001705270	C1874	SUPPLY/IMPLANTS	"$17,440.00"	Outpatient	"$8,720.00"	Not Applicable	"$9,539.68"	"$11,632.48"	"$6,976.00"	Not Applicable	"$6,104.00"	"$12,208.00"	"$6,104.00"	"$12,208.00"
STNT MTL 14MM 12FR 70MM CVR COAT DLV SYS UNSTP + WLGRF M001705470	C1874	SUPPLY/IMPLANTS	"$17,440.00"	Outpatient	"$8,720.00"	Not Applicable	"$9,539.68"	"$11,632.48"	"$6,976.00"	Not Applicable	"$6,104.00"	"$12,208.00"	"$6,104.00"	"$12,208.00"
STNT MTL 6MM 9FR 70MM CVR COAT DLV SYS UNSTP + WLGRF EPRSTH M001705670	C1874	SUPPLY/IMPLANTS	"$17,440.00"	Outpatient	"$8,720.00"	Not Applicable	"$9,539.68"	"$11,632.48"	"$6,976.00"	Not Applicable	"$6,104.00"	"$12,208.00"	"$6,104.00"	"$12,208.00"
STNT MTL 7MM 9FR 90MM CVR COAT DLV SYS UNSTP + WLGRF EPRSTH M001705770	C1874	SUPPLY/IMPLANTS	"$17,440.00"	Outpatient	"$8,720.00"	Not Applicable	"$9,539.68"	"$11,632.48"	"$6,976.00"	Not Applicable	"$6,104.00"	"$12,208.00"	"$6,104.00"	"$12,208.00"
STNT MTL 8MM 9FR 70MM CVR COAT DLV SYS UNSTP + WLGRF EPRSTH M001705870	C1874	SUPPLY/IMPLANTS	"$17,440.00"	Outpatient	"$8,720.00"	Not Applicable	"$9,539.68"	"$11,632.48"	"$6,976.00"	Not Applicable	"$6,104.00"	"$12,208.00"	"$6,104.00"	"$12,208.00"
STNT MTL 9MM 10FR 70MM CVR COAT DLV SYS UNSTP + WLGRF EPRSTH M001705970	C1874	SUPPLY/IMPLANTS	"$17,440.00"	Outpatient	"$8,720.00"	Not Applicable	"$9,539.68"	"$11,632.48"	"$6,976.00"	Not Applicable	"$6,104.00"	"$12,208.00"	"$6,104.00"	"$12,208.00"
4.5MM TI VA-LCP CRVD CONDYLAR 04.124.411	C1713	SUPPLY/IMPLANTS	"$17,419.00"	Outpatient	"$8,709.50"	"$1,365.15"	"$9,528.19"	"$11,618.47"	"$6,967.60"	Not Applicable	"$6,096.65"	"$12,193.30"	"$1,365.15"	"$12,193.30"
NAIL IM 160MM 8MM 9.5MM SHRT STRG CNN MULTILOC TI HUM LT 04.016.035S	C1713	SUPPLY/IMPLANTS	"$17,414.00"	Outpatient	"$8,707.00"	"$1,365.15"	"$9,525.46"	"$11,615.14"	"$6,965.60"	Not Applicable	"$6,094.90"	"$12,189.80"	"$1,365.15"	"$12,189.80"
PLT 301MM CRV CNDRL LT PERIART SS 14 HL 4 CLMN THRD VA LCP 02.124.415	C1713	SUPPLY/IMPLANTS	"$17,398.00"	Outpatient	"$8,699.00"	"$1,365.15"	"$9,516.71"	"$11,604.47"	"$6,959.20"	Not Applicable	"$6,089.30"	"$12,178.60"	"$1,365.15"	"$12,178.60"
PLT 2MM 2 ANG MED MNDB TI 5X22X5 HL RECON MATRIXMANDIBLE BN 04.503.735	C1713	SUPPLY/IMPLANTS	"$17,387.00"	Outpatient	"$8,693.50"	"$1,365.15"	"$9,510.69"	"$11,597.13"	"$6,954.80"	Not Applicable	"$6,085.45"	"$12,170.90"	"$1,365.15"	"$12,170.90"
NAIL IM 38CM 13MM 130D ANTGRD TRGN TI LT TROCH LIME IM NL 71647438	C1713	SUPPLY/IMPLANTS	"$17,386.00"	Outpatient	"$8,693.00"	"$1,365.15"	"$9,510.14"	"$11,596.46"	"$6,954.40"	Not Applicable	"$6,085.10"	"$12,170.20"	"$1,365.15"	"$12,170.20"
NAIL IM 38CM 13MM 130D ANTGRD TRGN TI RT TROCH ROSE 71648438	C1713	SUPPLY/IMPLANTS	"$17,386.00"	Outpatient	"$8,693.00"	"$1,365.15"	"$9,510.14"	"$11,596.46"	"$6,954.40"	Not Applicable	"$6,085.10"	"$12,170.20"	"$1,365.15"	"$12,170.20"
CRMPR SRG CRNL TI FLP TBG 329.315		STERILE SUPPLY	"$17,379.00"	Outpatient	"$8,689.50"	Not Applicable	"$9,506.31"	"$11,591.79"	"$6,951.60"	Not Applicable	"$6,082.65"	"$12,165.30"	"$6,082.65"	"$12,165.30"
NAIL IM 360MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.157S	C1713	SUPPLY/IMPLANTS	"$17,376.00"	Outpatient	"$8,688.00"	"$1,365.15"	"$9,504.67"	"$11,589.79"	"$6,950.40"	Not Applicable	"$6,081.60"	"$12,163.20"	"$1,365.15"	"$12,163.20"
NAIL IM 380MM 12MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.258S	C1713	SUPPLY/IMPLANTS	"$17,376.00"	Outpatient	"$8,688.00"	"$1,365.15"	"$9,504.67"	"$11,589.79"	"$6,950.40"	Not Applicable	"$6,081.60"	"$12,163.20"	"$1,365.15"	"$12,163.20"
NAIL IM 400MM 11MM 130D LNG CNN PREASSEMBLE LCK MECH STC 04.037.160S	C1713	SUPPLY/IMPLANTS	"$17,376.00"	Outpatient	"$8,688.00"	"$1,365.15"	"$9,504.67"	"$11,589.79"	"$6,950.40"	Not Applicable	"$6,081.60"	"$12,163.20"	"$1,365.15"	"$12,163.20"
NAIL IM 340MM 12MM 130D LNG CNN TFN-ADV TI COCR FEM PROX 04.037.254S	C1713	SUPPLY/IMPLANTS	"$17,376.00"	Outpatient	"$8,688.00"	"$1,365.15"	"$9,504.67"	"$11,589.79"	"$6,950.40"	Not Applicable	"$6,081.60"	"$12,163.20"	"$1,365.15"	"$12,163.20"
NAIL IM 420MM 10MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.063S	C1713	SUPPLY/IMPLANTS	"$17,376.00"	Outpatient	"$8,688.00"	"$1,365.15"	"$9,504.67"	"$11,589.79"	"$6,950.40"	Not Applicable	"$6,081.60"	"$12,163.20"	"$1,365.15"	"$12,163.20"
NAIL IM 420MM 11MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.163S		STERILE SUPPLY	"$17,376.00"	Outpatient	"$8,688.00"	Not Applicable	"$9,504.67"	"$11,589.79"	"$6,950.40"	Not Applicable	"$6,081.60"	"$12,163.20"	"$6,081.60"	"$12,163.20"
NAIL IM 340MM 10MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.057S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 360MM 10MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.027S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 400MM 12MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.230S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 400MM 11MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.130S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 360MM 12MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.256S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 440MM 12MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.235S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 380MM 11MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.128S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 340MM 10MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.025S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 400MM 11MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.131S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 380MM 12MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.229S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 340MM 11MM 125D LNG CNN TFN-ADV TI COCR FEM LT PROX 04.037.125S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 380MM 11MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.129S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL IM 340MM 10MM 125D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.024S	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
NAIL INTRAMEDULLARY TFN-ADVANCED LATERAL RELIEF CUT TITANIUM COCR 125 D LONG L400 MM OD10 MM FEMORAL	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
"TFNA CANN TI 125 DEG., 11MM X 340MM, RT-STRL 04.037.124S"	C1713	SUPPLY/IMPLANTS	"$17,370.00"	Outpatient	"$8,685.00"	"$1,365.15"	"$9,501.39"	"$11,585.79"	"$6,948.00"	Not Applicable	"$6,079.50"	"$12,159.00"	"$1,365.15"	"$12,159.00"
GD DRL TMPLT MN FXTR CNVGNT SCR 7125		STERILE SUPPLY	"$17,362.00"	Outpatient	"$8,681.00"	Not Applicable	"$9,497.01"	"$11,580.45"	"$6,944.80"	Not Applicable	"$6,076.70"	"$12,153.40"	"$6,076.70"	"$12,153.40"
(BC4) TIBIAL TRAY CEMENTED SZ 3 1581-30-000 158130000	C1776	SUPPLY/IMPLANTS	"$17,355.00"	Outpatient	"$8,677.50"	Not Applicable	"$9,493.19"	"$11,575.79"	"$6,942.00"	Not Applicable	"$6,074.25"	"$12,148.50"	"$6,074.25"	"$12,148.50"
CMPNT FEM 5 LT MDL RL PRT KN RSRFC TRTHLN 5610-F-501	C1776	SUPPLY/IMPLANTS	"$17,354.00"	Outpatient	"$8,677.00"	Not Applicable	"$9,492.64"	"$11,575.12"	"$6,941.60"	Not Applicable	"$6,073.90"	"$12,147.80"	"$6,073.90"	"$12,147.80"
CMPNT FEM 4 LT MDL RL PRT KN RSRFC TRTHLN 5610-F-401	C1776	SUPPLY/IMPLANTS	"$17,354.00"	Outpatient	"$8,677.00"	Not Applicable	"$9,492.64"	"$11,575.12"	"$6,941.60"	Not Applicable	"$6,073.90"	"$12,147.80"	"$6,073.90"	"$12,147.80"
CMPNT FEM 4 RMLL PRT KN RSRFC TRTHLN 5610-F-402	C1776	SUPPLY/IMPLANTS	"$17,350.00"	Outpatient	"$8,675.00"	Not Applicable	"$9,490.45"	"$11,572.45"	"$6,940.00"	Not Applicable	"$6,072.50"	"$12,145.00"	"$6,072.50"	"$12,145.00"
STNT VASC 6MM 200MM 120CM SLF XPD DLV CATH SYS SPRL CELL PRB35-06-200-120	C1876	SUPPLY/IMPLANTS	"$17,347.00"	Outpatient	"$8,673.50"	Not Applicable	"$9,488.81"	"$11,570.45"	"$6,938.80"	Not Applicable	"$6,071.45"	"$12,142.90"	"$6,071.45"	"$12,142.90"
MODL ANTM CLR PROPLAN CMF ACRL MNDB THR ORBT DTCH ABL TO CUT SD900.266	C1713	SUPPLY/IMPLANTS	"$17,344.00"	Outpatient	"$8,672.00"	"$1,365.15"	"$9,487.17"	"$11,568.45"	"$6,937.60"	Not Applicable	"$6,070.40"	"$12,140.80"	"$1,365.15"	"$12,140.80"
HEAD HUM 16MM 50MM SHLDR AQLS ASCND FLX COCR 4MM HI OFST DWF150	C1776	SUPPLY/IMPLANTS	"$17,326.00"	Outpatient	"$8,663.00"	Not Applicable	"$9,477.32"	"$11,556.44"	"$6,930.40"	Not Applicable	"$6,064.10"	"$12,128.20"	"$6,064.10"	"$12,128.20"
TIBIAL TRAY ROTATING PLATFORM M.B.T. REVISION 129435130	C1713	SUPPLY/IMPLANTS	"$17,326.00"	Outpatient	"$8,663.00"	"$1,365.15"	"$9,477.32"	"$11,556.44"	"$6,930.40"	Not Applicable	"$6,064.10"	"$12,128.20"	"$1,365.15"	"$12,128.20"
SET CATH 70CM 28MM INOUE SS PVC PLSTR BLN 2.5CM PTMC STRL PTMC-28	C1725	SUPPLY/IMPLANTS	"$17,326.00"	Outpatient	"$8,663.00"	Not Applicable	"$9,477.32"	"$11,556.44"	"$6,930.40"	Not Applicable	"$6,064.10"	"$12,128.20"	"$6,064.10"	"$12,128.20"
SET CATH 70CM 30MM INOUE SS PVC PLSTR BLN 2.5CM PTMC STRL PTMC-30	C1725	SUPPLY/IMPLANTS	"$17,326.00"	Outpatient	"$8,663.00"	Not Applicable	"$9,477.32"	"$11,556.44"	"$6,930.40"	Not Applicable	"$6,064.10"	"$12,128.20"	"$6,064.10"	"$12,128.20"
LINR ACTB 60MM 40MM 10D +4MM ALTRX LD PNCL HIP STRL LF 122140160	C1776	SUPPLY/IMPLANTS	"$17,323.00"	Outpatient	"$8,661.50"	Not Applicable	"$9,475.68"	"$11,554.44"	"$6,929.20"	Not Applicable	"$6,063.05"	"$12,126.10"	"$6,063.05"	"$12,126.10"
00003-3774-12 - nivolumab 10 mg/mL Soln	J9299	PHARMACY	"$14,576.00"	Outpatient	"$7,288.00"	$27.39	"$9,474.40"	"$9,722.19"	"$5,830.40"	Not Applicable	"$5,101.60"	"$10,203.20"	$27.39	"$10,203.20"
CATH BALLOON KYPOPLASTY ACCESS KIT 10G INTVM-10-DDK		STERILE SUPPLY	"$17,320.00"	Outpatient	"$8,660.00"	Not Applicable	"$9,474.04"	"$11,552.44"	"$6,928.00"	Not Applicable	"$6,062.00"	"$12,124.00"	"$6,062.00"	"$12,124.00"
STNT TRCHBR 5MM 7FR 59MM 80CM COVERED CATH INTRO ICAST SS 85401	C1874	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
STNT TRCHBR 6MM 7FR 59MM 80CM .035IN COVERED BLN EXPANDABLE 85403	C1874	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
STNT TRCHBR 8MM 7FR 59MM 80CM CVR CATH INTRO BLN XPD ICAST 85407	C1874	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
STNT TRCHBR 9MM 7FR 59MM 80CM CVR CATH INTRO BLN XPD ICAST 85409	C1874	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
STNT TRCHBR 6MM 7FR 59MM 120CM CVR CATH INTRO ICAST SS PTFE 85413	C1874	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
SPHR GLND 36MM THK2MM 2MM ECNTRC SHLDR 5573-2E-3602	C1776	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
CUP HUM 10MM 40MM SHLDR 5570-4010	C1713	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	"$1,365.15"	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$1,365.15"	"$12,123.30"
ELTRD BP 20MM ISLTR 80D LNR PEN MLP1	C1713	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	"$1,365.15"	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$1,365.15"	"$12,123.30"
IMPL ORBT 3D LG MDPR TN CRNMXF LT MTB 81043	C1713	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	"$1,365.15"	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$1,365.15"	"$12,123.30"
CAGE ROI-C LORDOTIC CERVICAL  17X14 H 7MM MC1433P	C1821	SUPPLY/IMPLANTS	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
DISC ARTF 14X13MM 9MM SCR-C SPNE COR FTPRNT STRL 414.209S		STERILE SUPPLY	"$17,319.00"	Outpatient	"$8,659.50"	Not Applicable	"$9,473.49"	"$11,551.77"	"$6,927.60"	Not Applicable	"$6,061.65"	"$12,123.30"	"$6,061.65"	"$12,123.30"
HEAD GLND 40MM REUNION 2MM OFST GLENOSPHERE CONC STRL 5573-C-4002	C1776	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	Not Applicable	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$6,061.30"	"$12,122.60"
INS HUM 4MM 40MM REUNION STD X3 STRL 5571-S-4004	C1776	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	Not Applicable	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$6,061.30"	"$12,122.60"
SPHR GLND 36MM REUNION 2MM OFST SHLDR CONC STRL LF 5573-C-3602	C1776	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	Not Applicable	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$6,061.30"	"$12,122.60"
CORE SECURE C 11 X 12 X 7MM 414.107S	C1713	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	"$1,365.15"	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$1,365.15"	"$12,122.60"
CUP HUM 4MM 36MM REUNION SHLDR STRL LF 5570-3604	C1713	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	"$1,365.15"	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$1,365.15"	"$12,122.60"
CUP HUM 4MM 40MM SHLDR 5570-4004	C1713	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	"$1,365.15"	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$1,365.15"	"$12,122.60"
CAGE ROI-C LORDOTIC 5 X 12 X 14 MC1441P	C1821	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	Not Applicable	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$6,061.30"	"$12,122.60"
CAGE SPNL 14X3.1-6MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR MC 1442 P	C1821	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	Not Applicable	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$6,061.30"	"$12,122.60"
CAGE SPNL 17X5.2-8MM ROI-C VERTEBRIDGE 7D LRDTC 14MM TPR MC 1434 P	C1821	SUPPLY/IMPLANTS	"$17,318.00"	Outpatient	"$8,659.00"	Not Applicable	"$9,472.95"	"$11,551.11"	"$6,927.20"	Not Applicable	"$6,061.30"	"$12,122.60"	"$6,061.30"	"$12,122.60"
SPCR ALGRF 12X14X8MM FORGE LRDTC CRV 865.408S	C1713	SUPPLY/IMPLANTS	"$17,317.00"	Outpatient	"$8,658.50"	"$1,365.15"	"$9,472.40"	"$11,550.44"	"$6,926.80"	Not Applicable	"$6,060.95"	"$12,121.90"	"$1,365.15"	"$12,121.90"
CAGE SPNL 14X7.1-10MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR MC 1446 P	C1821	SUPPLY/IMPLANTS	"$17,317.00"	Outpatient	"$8,658.50"	Not Applicable	"$9,472.40"	"$11,550.44"	"$6,926.80"	Not Applicable	"$6,060.95"	"$12,121.90"	"$6,060.95"	"$12,121.90"
CAGE SPNL 15.5X5.2-8MM ROI-C VERTEBRIDGE 7D LRDTC 14MM TPR MC 1424 P	C1821	SUPPLY/IMPLANTS	"$17,317.00"	Outpatient	"$8,658.50"	Not Applicable	"$9,472.40"	"$11,550.44"	"$6,926.80"	Not Applicable	"$6,060.95"	"$12,121.90"	"$6,060.95"	"$12,121.90"
CAGE SPNL 14X5.1-8MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR MC 1444 P	C1821	SUPPLY/IMPLANTS	"$17,317.00"	Outpatient	"$8,658.50"	Not Applicable	"$9,472.40"	"$11,550.44"	"$6,926.80"	Not Applicable	"$6,060.95"	"$12,121.90"	"$6,060.95"	"$12,121.90"
SPCR SPNL 14X8MM CLN 7D LRDTC 12MM LG PEEK ACDF NS LF 365.408	C1821	SUPPLY/IMPLANTS	"$17,317.00"	Outpatient	"$8,658.50"	Not Applicable	"$9,472.40"	"$11,550.44"	"$6,926.80"	Not Applicable	"$6,060.95"	"$12,121.90"	"$6,060.95"	"$12,121.90"
MICROWAVE ABLATION GENERATOR SYSTEM VTSYSRENT		STERILE SUPPLY	"$17,317.00"	Outpatient	"$8,658.50"	Not Applicable	"$9,472.40"	"$11,550.44"	"$6,926.80"	Not Applicable	"$6,060.95"	"$12,121.90"	"$6,060.95"	"$12,121.90"
FTSWTCH HNDPC PDL PIEZOELECTRIC SYS NS 05.001.402.98		STERILE SUPPLY	"$17,313.00"	Outpatient	"$8,656.50"	Not Applicable	"$9,470.21"	"$11,547.77"	"$6,925.20"	Not Applicable	"$6,059.55"	"$12,119.10"	"$6,059.55"	"$12,119.10"
STNT ESPH 23MM 24FR 90CM 150CM FLLY COVERED OTW LOPRFL FLXB MAXX-2315	C1874	SUPPLY/IMPLANTS	"$17,306.00"	Outpatient	"$8,653.00"	Not Applicable	"$9,466.38"	"$11,543.10"	"$6,922.40"	Not Applicable	"$6,057.10"	"$12,114.20"	"$6,057.10"	"$12,114.20"
INS HUM 36MM AQLS 12MM SHLDR LATERALIZE RVRS ADPR PRM DWD862	C1776	SUPPLY/IMPLANTS	"$17,306.00"	Outpatient	"$8,653.00"	Not Applicable	"$9,466.38"	"$11,543.10"	"$6,922.40"	Not Applicable	"$6,057.10"	"$12,114.20"	"$6,057.10"	"$12,114.20"
CAGE SPNL 15.5X4.2-7MM ROI-C VERTEBRIDGE 7D LRDTC 14MM TPR MC 1423 P	C1821	SUPPLY/IMPLANTS	"$17,306.00"	Outpatient	"$8,653.00"	Not Applicable	"$9,466.38"	"$11,543.10"	"$6,922.40"	Not Applicable	"$6,057.10"	"$12,114.20"	"$6,057.10"	"$12,114.20"
CAGE SPNL 14X4.1-7MM ROI-C VERTEBRIDGE 7D LRDTC 12MM TPR MC 1443 P	C1821	SUPPLY/IMPLANTS	"$17,306.00"	Outpatient	"$8,653.00"	Not Applicable	"$9,466.38"	"$11,543.10"	"$6,922.40"	Not Applicable	"$6,057.10"	"$12,114.20"	"$6,057.10"	"$12,114.20"
STNT TRCHBR 7MM 7FR 38MM 80CM CVR CATH INTRO BLN XPD ICAST 85404	C1874	SUPPLY/IMPLANTS	"$17,303.00"	Outpatient	"$8,651.50"	Not Applicable	"$9,464.74"	"$11,541.10"	"$6,921.20"	Not Applicable	"$6,056.05"	"$12,112.10"	"$6,056.05"	"$12,112.10"
BSPLT TIB 5 UNV KN TRTHLN COCR 5521-B-500	C1776	SUPPLY/IMPLANTS	"$17,287.00"	Outpatient	"$8,643.50"	Not Applicable	"$9,455.99"	"$11,530.43"	"$6,914.80"	Not Applicable	"$6,050.45"	"$12,100.90"	"$6,050.45"	"$12,100.90"
BSPLT TIB 7 UNV KN TRTHLN COCR 5521-B-700		SUPPLY/IMPLANTS	"$17,287.00"	Outpatient	"$8,643.50"	Not Applicable	"$9,455.99"	"$11,530.43"	"$6,914.80"	Not Applicable	"$6,050.45"	"$12,100.90"	"$6,050.45"	"$12,100.90"
GRAFT BONE OSTEOCHONDRAL L10 MM ALLOGRAFT PRECUT MATURE HYAL 45647010	C9362	SUPPLY/IMPLANTS	"$17,285.00"	Outpatient	"$8,642.50"	$110.85	"$9,454.90"	"$11,529.10"	"$6,914.00"	Not Applicable	"$6,049.75"	"$12,099.50"	$110.85	"$12,099.50"
CATH THRMB PENUMBRA SYS 5MAX ACE 132CM REPERFUSION LF 5MAXACE132		STERILE SUPPLY	"$17,283.00"	Outpatient	"$8,641.50"	Not Applicable	"$9,453.80"	"$11,527.76"	"$6,913.20"	Not Applicable	"$6,049.05"	"$12,098.10"	"$6,049.05"	"$12,098.10"
CATH THRMB PENUMBRA SYS 5MAX ACE 6FR .64IN 132CM REPERFUSION 5MAXACE064		STERILE SUPPLY	"$17,283.00"	Outpatient	"$8,641.50"	Not Applicable	"$9,453.80"	"$11,527.76"	"$6,913.20"	Not Applicable	"$6,049.05"	"$12,098.10"	"$6,049.05"	"$12,098.10"
EPIFIX 4X4 EPIFIX 4X4	C9360	SUPPLY/IMPLANTS	"$17,271.00"	Outpatient	"$8,635.50"	$16.07	"$9,447.24"	"$11,519.76"	"$6,908.40"	Not Applicable	"$6,044.85"	"$12,089.70"	$16.07	"$12,089.70"
GFT SFT TIS EPIFIX 16SQ CM AMNIO MEMBR ALGRF MLT LYR CHRNC GS-5440	C9363	SUPPLY/IMPLANTS	"$17,271.00"	Outpatient	"$8,635.50"	$38.51	"$9,447.24"	"$11,519.76"	"$6,908.40"	Not Applicable	"$6,044.85"	"$12,089.70"	$38.51	"$12,089.70"
PLATE BONE LCP STAINLESS STEEL 22 MM STANDARD XLONG L186 MM 02.111.690S	C1713	SUPPLY/IMPLANTS	"$17,260.00"	Outpatient	"$8,630.00"	"$1,365.15"	"$9,441.22"	"$11,512.42"	"$6,904.00"	Not Applicable	"$6,041.00"	"$12,082.00"	"$1,365.15"	"$12,082.00"
PLT 292MM TIB RT DIST ALAT SS 18 HL VA LOPRFL LCP CMBN BN 02.118.216S	C1713	SUPPLY/IMPLANTS	"$17,247.00"	Outpatient	"$8,623.50"	"$1,365.15"	"$9,434.11"	"$11,503.75"	"$6,898.80"	Not Applicable	"$6,036.45"	"$12,072.90"	"$1,365.15"	"$12,072.90"
STEM HUMERAL ARTHREX UNIVERS REVERS 10 SHOULDER STERILE AR-9501-10P	C1776	SUPPLY/IMPLANTS	"$17,226.00"	Outpatient	"$8,613.00"	Not Applicable	"$9,422.62"	"$11,489.74"	"$6,890.40"	Not Applicable	"$6,029.10"	"$12,058.20"	"$6,029.10"	"$12,058.20"
STEM HUMERAL ARTHREX UNIVERS REVERS 6 SHOULDER STERILE AR-9501-06P	C1776	SUPPLY/IMPLANTS	"$17,226.00"	Outpatient	"$8,613.00"	Not Applicable	"$9,422.62"	"$11,489.74"	"$6,890.40"	Not Applicable	"$6,029.10"	"$12,058.20"	"$6,029.10"	"$12,058.20"
TRAY TIB 71MM INTLK KN STM 141513		STERILE SUPPLY	"$17,226.00"	Outpatient	"$8,613.00"	Not Applicable	"$9,422.62"	"$11,489.74"	"$6,890.40"	Not Applicable	"$6,029.10"	"$12,058.20"	"$6,029.10"	"$12,058.20"
SUB BNGF 64MM 56MM VOID FIL CUP VITOSS BTCP CLGN FM POR 2102-1056	C1713	SUPPLY/IMPLANTS	"$17,207.00"	Outpatient	"$8,603.50"	"$1,365.15"	"$9,412.23"	"$11,477.07"	"$6,882.80"	Not Applicable	"$6,022.45"	"$12,044.90"	"$1,365.15"	"$12,044.90"
RING SPNL 220MM ROT 15250	C1713	SUPPLY/IMPLANTS	"$17,200.00"	Outpatient	"$8,600.00"	"$1,365.15"	"$9,408.40"	"$11,472.40"	"$6,880.00"	Not Applicable	"$6,020.00"	"$12,040.00"	"$1,365.15"	"$12,040.00"
PLATE LCP VA 2.7 X 3.5MM 14 HOLE 02.118.212S	C1713	SUPPLY/IMPLANTS	"$17,193.00"	Outpatient	"$8,596.50"	"$1,365.15"	"$9,404.57"	"$11,467.73"	"$6,877.20"	Not Applicable	"$6,017.55"	"$12,035.10"	"$1,365.15"	"$12,035.10"
PLATE DSTL TIBA VA LCP 2.7X 3.5MM 02.118.213S	C1713	SUPPLY/IMPLANTS	"$17,193.00"	Outpatient	"$8,596.50"	"$1,365.15"	"$9,404.57"	"$11,467.73"	"$6,877.20"	Not Applicable	"$6,017.55"	"$12,035.10"	"$1,365.15"	"$12,035.10"
SCREW PEDICLE PA 5.5 X 45MM Z62055-45	C1713	SUPPLY/IMPLANTS	"$17,192.00"	Outpatient	"$8,596.00"	"$1,365.15"	"$9,404.02"	"$11,467.06"	"$6,876.80"	Not Applicable	"$6,017.20"	"$12,034.40"	"$1,365.15"	"$12,034.40"
SCREW PEDICLE PA 6.5 X 50MM Z62065-50	C1713	SUPPLY/IMPLANTS	"$17,192.00"	Outpatient	"$8,596.00"	"$1,365.15"	"$9,404.02"	"$11,467.06"	"$6,876.80"	Not Applicable	"$6,017.20"	"$12,034.40"	"$1,365.15"	"$12,034.40"
SCREW PEDICLE PA 6.5 X 55MM Z62065-55	C1713	SUPPLY/IMPLANTS	"$17,192.00"	Outpatient	"$8,596.00"	"$1,365.15"	"$9,404.02"	"$11,467.06"	"$6,876.80"	Not Applicable	"$6,017.20"	"$12,034.40"	"$1,365.15"	"$12,034.40"
PLT 25MM SPNE 5-S1 BN ALIF 1177909	C1713	SUPPLY/IMPLANTS	"$17,187.00"	Outpatient	"$8,593.50"	"$1,365.15"	"$9,401.29"	"$11,463.73"	"$6,874.80"	Not Applicable	"$6,015.45"	"$12,030.90"	"$1,365.15"	"$12,030.90"
PLT 26MM 32MM INTVRTB LCK ENZA BN NS CB-001-038	C1713	SUPPLY/IMPLANTS	"$17,187.00"	Outpatient	"$8,593.50"	"$1,365.15"	"$9,401.29"	"$11,463.73"	"$6,874.80"	Not Applicable	"$6,015.45"	"$12,030.90"	"$1,365.15"	"$12,030.90"
PLT 27MM SPNE SCRL ANT TI AL VNDM 1 LVL LT BN NS 49171127	C1713	SUPPLY/IMPLANTS	"$17,187.00"	Outpatient	"$8,593.50"	"$1,365.15"	"$9,401.29"	"$11,463.73"	"$6,874.80"	Not Applicable	"$6,015.45"	"$12,030.90"	"$1,365.15"	"$12,030.90"
STNT ESPH 23MM 18.5FR 10CM 120CM SLF XPD LOPRFL FLLY COVERED M00516730		SUPPLY/IMPLANTS	"$17,186.00"	Outpatient	"$8,593.00"	Not Applicable	"$9,400.74"	"$11,463.06"	"$6,874.40"	Not Applicable	"$6,015.10"	"$12,030.20"	"$6,015.10"	"$12,030.20"
PLATE BONE RENOVIS TESERA LOCK COVER STERILE 1028-003-001	C1713	SUPPLY/IMPLANTS	"$17,182.00"	Outpatient	"$8,591.00"	"$1,365.15"	"$9,398.55"	"$11,460.39"	"$6,872.80"	Not Applicable	"$6,013.70"	"$12,027.40"	"$1,365.15"	"$12,027.40"
PLT 22X21X4.5MM SPNE LAT TI AL VNDM 4 SCR LT BN NS 49174122	C1713	SUPPLY/IMPLANTS	"$17,182.00"	Outpatient	"$8,591.00"	"$1,365.15"	"$9,398.55"	"$11,460.39"	"$6,872.80"	Not Applicable	"$6,013.70"	"$12,027.40"	"$1,365.15"	"$12,027.40"
PLT 23MM 28MM INTVRTB LCK ENZA BN NS CB-001-037	C1713	SUPPLY/IMPLANTS	"$17,182.00"	Outpatient	"$8,591.00"	"$1,365.15"	"$9,398.55"	"$11,460.39"	"$6,872.80"	Not Applicable	"$6,013.70"	"$12,027.40"	"$1,365.15"	"$12,027.40"
PLT 28X21X4.5MM SPNE LAT TI AL VNDM 4 SCR LT BN NS 49174128	C1713	SUPPLY/IMPLANTS	"$17,182.00"	Outpatient	"$8,591.00"	"$1,365.15"	"$9,398.55"	"$11,460.39"	"$6,872.80"	Not Applicable	"$6,013.70"	"$12,027.40"	"$1,365.15"	"$12,027.40"
SCREW ZODIAC PA 6.5 X 40MM Z62065-40	C1713	SUPPLY/IMPLANTS	"$17,182.00"	Outpatient	"$8,591.00"	"$1,365.15"	"$9,398.55"	"$11,460.39"	"$6,872.80"	Not Applicable	"$6,013.70"	"$12,027.40"	"$1,365.15"	"$12,027.40"
SCREW PEDICLE PA ZODIAK 6.5 X 45MM Z62065-45	C1713	SUPPLY/IMPLANTS	"$17,182.00"	Outpatient	"$8,591.00"	"$1,365.15"	"$9,398.55"	"$11,460.39"	"$6,872.80"	Not Applicable	"$6,013.70"	"$12,027.40"	"$1,365.15"	"$12,027.40"
SCREW PEDICLE PA 5.5 X 40MM Z62055-40	C1713	SUPPLY/IMPLANTS	"$17,182.00"	Outpatient	"$8,591.00"	"$1,365.15"	"$9,398.55"	"$11,460.39"	"$6,872.80"	Not Applicable	"$6,013.70"	"$12,027.40"	"$1,365.15"	"$12,027.40"
LINR ACTB 62MM 36MM 10D LNGVT PRM MDLR CUP ELEV RM 10.8MM 631006236	C1776	SUPPLY/IMPLANTS	"$17,173.00"	Outpatient	"$8,586.50"	Not Applicable	"$9,393.63"	"$11,454.39"	"$6,869.20"	Not Applicable	"$6,010.55"	"$12,021.10"	"$6,010.55"	"$12,021.10"
JIG PSTN BLK TIB RT PROX LAT SS CF PEEK 5.5MM SCR MIS 236009115	C1713	SUPPLY/IMPLANTS	"$17,171.00"	Outpatient	"$8,585.50"	"$1,365.15"	"$9,392.54"	"$11,453.06"	"$6,868.40"	Not Applicable	"$6,009.85"	"$12,019.70"	"$1,365.15"	"$12,019.70"
JIG PSTN BLK TIB LT PROX LAT SS CF PEEK 5.5MM SCR MIS 236009116	C1713	SUPPLY/IMPLANTS	"$17,171.00"	Outpatient	"$8,585.50"	"$1,365.15"	"$9,392.54"	"$11,453.06"	"$6,868.40"	Not Applicable	"$6,009.85"	"$12,019.70"	"$1,365.15"	"$12,019.70"
NAIL IM 200MM 12MM LCK T2 TI ANKL LT STRL ARTHDS 1818-1220S	C1713	SUPPLY/IMPLANTS	"$17,147.00"	Outpatient	"$8,573.50"	"$1,365.15"	"$9,379.41"	"$11,437.05"	"$6,858.80"	Not Applicable	"$6,001.45"	"$12,002.90"	"$1,365.15"	"$12,002.90"
OCLR CV 31MM 17.5FR DLV SYS STNT GARFT CATH TLNT AAA OCL10US	C1817	SUPPLY/IMPLANTS	"$17,146.00"	Outpatient	"$8,573.00"	Not Applicable	"$9,378.86"	"$11,436.38"	"$6,858.40"	Not Applicable	"$6,001.10"	"$12,002.20"	"$6,001.10"	"$12,002.20"
OCLR CV 12MM DLV SYS TLNT OCL12US	C1817	SUPPLY/IMPLANTS	"$17,146.00"	Outpatient	"$8,573.00"	Not Applicable	"$9,378.86"	"$11,436.38"	"$6,858.40"	Not Applicable	"$6,001.10"	"$12,002.20"	"$6,001.10"	"$12,002.20"
STEM FEM +20MM HIP SEG REV 158-02-03		STERILE SUPPLY	"$17,146.00"	Outpatient	"$8,573.00"	Not Applicable	"$9,378.86"	"$11,436.38"	"$6,858.40"	Not Applicable	"$6,001.10"	"$12,002.20"	"$6,001.10"	"$12,002.20"
NAIL IM 15CM 11MM LCK T2 TI ANKL RT STRL ARTHDS 1819-1115S	C1713	SUPPLY/IMPLANTS	"$17,141.00"	Outpatient	"$8,570.50"	"$1,365.15"	"$9,376.13"	"$11,433.05"	"$6,856.40"	Not Applicable	"$5,999.35"	"$11,998.70"	"$1,365.15"	"$11,998.70"
NAIL IM 20CM 11MM STD ANTM FIT CNN PROX LCK MLT END CAP T2 1819-1120S	C1713	SUPPLY/IMPLANTS	"$17,141.00"	Outpatient	"$8,570.50"	"$1,365.15"	"$9,376.13"	"$11,433.05"	"$6,856.40"	Not Applicable	"$5,999.35"	"$11,998.70"	"$1,365.15"	"$11,998.70"
NAIL IM 200MM 11MM LCK T2 TI ANKL LT STRL ARTHDS 1818-1120S	C1713	SUPPLY/IMPLANTS	"$17,141.00"	Outpatient	"$8,570.50"	"$1,365.15"	"$9,376.13"	"$11,433.05"	"$6,856.40"	Not Applicable	"$5,999.35"	"$11,998.70"	"$1,365.15"	"$11,998.70"
57665-0331-01 - cytarabine liposomal 10 mg/mL Susp	J9098	PHARMACY	"$14,421.00"	Outpatient	"$7,210.50"	$640.22	"$9,373.65"	"$9,618.81"	"$5,768.40"	Not Applicable	"$5,047.35"	"$10,094.70"	$640.22	"$10,094.70"
SPCR SPNL 14X4MM AVS AS 4D 12MM PEEK CRV INTRBD FS 48322044	C1821	SUPPLY/IMPLANTS	"$17,128.00"	Outpatient	"$8,564.00"	Not Applicable	"$9,369.02"	"$11,424.38"	"$6,851.20"	Not Applicable	"$5,994.80"	"$11,989.60"	"$5,994.80"	"$11,989.60"
SPCR SPNL 14X6MM AVS AS 4D 12MM PEEK CRV INTRBD FS 48322064	C1821	SUPPLY/IMPLANTS	"$17,128.00"	Outpatient	"$8,564.00"	Not Applicable	"$9,369.02"	"$11,424.38"	"$6,851.20"	Not Applicable	"$5,994.80"	"$11,989.60"	"$5,994.80"	"$11,989.60"
CATHETER THROMBECTOMY JET STERILE LATEX FREE 5MAXJETD	C1757	SUPPLY/IMPLANTS	"$17,122.00"	Outpatient	"$8,561.00"	Not Applicable	"$9,365.73"	"$11,420.37"	"$6,848.80"	Not Applicable	"$5,992.70"	"$11,985.40"	"$5,992.70"	"$11,985.40"
NAIL IM 30CM 11MM ARTHDS LCK T2 TI LT ANKL STRL 18181130S	C1713	SUPPLY/IMPLANTS	"$17,120.00"	Outpatient	"$8,560.00"	"$1,365.15"	"$9,364.64"	"$11,419.04"	"$6,848.00"	Not Applicable	"$5,992.00"	"$11,984.00"	"$1,365.15"	"$11,984.00"
CADDY SCR 2.5MM 231218106	C1713	SUPPLY/IMPLANTS	"$17,117.00"	Outpatient	"$8,558.50"	"$1,365.15"	"$9,363.00"	"$11,417.04"	"$6,846.80"	Not Applicable	"$5,990.95"	"$11,981.90"	"$1,365.15"	"$11,981.90"
MODL ANTM PROPLAN CMF ADLT PLAMD MNDB ATCH MXL SD900.305	C1713	SUPPLY/IMPLANTS	"$17,117.00"	Outpatient	"$8,558.50"	"$1,365.15"	"$9,363.00"	"$11,417.04"	"$6,846.80"	Not Applicable	"$5,990.95"	"$11,981.90"	"$1,365.15"	"$11,981.90"
GFT BN DBM 10X1CM MAGNIFUSE 7509211	C9362	SUPPLY/IMPLANTS	"$17,100.00"	Outpatient	"$8,550.00"	$110.85	"$9,353.70"	"$11,405.70"	"$6,840.00"	Not Applicable	"$5,985.00"	"$11,970.00"	$110.85	"$11,970.00"
GFT EVAS 3.3CM 23MM 19-21MM AORTA PLA230300	C1874	SUPPLY/IMPLANTS	"$17,080.00"	Outpatient	"$8,540.00"	Not Applicable	"$9,342.76"	"$11,392.36"	"$6,832.00"	Not Applicable	"$5,978.00"	"$11,956.00"	"$5,978.00"	"$11,956.00"
GFT EVAS 7CM 14.5MM 12-13.5MM GORE XCLDR ILC ART XTD ACPT 12 PLL161407	C1874	SUPPLY/IMPLANTS	"$17,080.00"	Outpatient	"$8,540.00"	Not Applicable	"$9,342.76"	"$11,392.36"	"$6,832.00"	Not Applicable	"$5,978.00"	"$11,956.00"	"$5,978.00"	"$11,956.00"
SET SPNL APL DEV RSRB CRNL CLP 329.317		STERILE SUPPLY	"$17,076.00"	Outpatient	"$8,538.00"	Not Applicable	"$9,340.57"	"$11,389.69"	"$6,830.40"	Not Applicable	"$5,976.60"	"$11,953.20"	"$5,976.60"	"$11,953.20"
SCREW 6.5 X 40MM 54840016540	C1713	SUPPLY/IMPLANTS	"$17,061.00"	Outpatient	"$8,530.50"	"$1,365.15"	"$9,332.37"	"$11,379.69"	"$6,824.40"	Not Applicable	"$5,971.35"	"$11,942.70"	"$1,365.15"	"$11,942.70"
HEAD HUM 15MM 52MM SHLDR GB ADV STD STRL 112852000		STERILE SUPPLY	"$17,061.00"	Outpatient	"$8,530.50"	Not Applicable	"$9,332.37"	"$11,379.69"	"$6,824.40"	Not Applicable	"$5,971.35"	"$11,942.70"	"$5,971.35"	"$11,942.70"
INS TIB 4 CRV 15MM KN GVF UHMWPE FX BRNG ROT PLAT PFC S STRL 962043	C1776	SUPPLY/IMPLANTS	"$17,056.00"	Outpatient	"$8,528.00"	Not Applicable	"$9,329.63"	"$11,376.35"	"$6,822.40"	Not Applicable	"$5,969.60"	"$11,939.20"	"$5,969.60"	"$11,939.20"
PLT 152MM SP CNDL VHS BN 200321	C1713	SUPPLY/IMPLANTS	"$17,055.00"	Outpatient	"$8,527.50"	"$1,365.15"	"$9,329.09"	"$11,375.69"	"$6,822.00"	Not Applicable	"$5,969.25"	"$11,938.50"	"$1,365.15"	"$11,938.50"
ACETABULAR WEDGE AUGMENT 54MM X 20MM 5096-5420	C1776	SUPPLY/IMPLANTS	"$17,053.00"	Outpatient	"$8,526.50"	Not Applicable	"$9,327.99"	"$11,374.35"	"$6,821.20"	Not Applicable	"$5,968.55"	"$11,937.10"	"$5,968.55"	"$11,937.10"
NAIL INTRAMEDULLARY TITANIUM NIOBIUM ALUMINUM ADULT 135 D L4 04.033.243S	C1713	SUPPLY/IMPLANTS	"$17,051.00"	Outpatient	"$8,525.50"	"$1,365.15"	"$9,326.90"	"$11,373.02"	"$6,820.40"	Not Applicable	"$5,967.85"	"$11,935.70"	"$1,365.15"	"$11,935.70"
NAIL IM 220MM 7MM RND CNN TRNSV SLOT LCK HL XPRT TI HUM STRL 04.001.224S	C1713	SUPPLY/IMPLANTS	"$17,048.00"	Outpatient	"$8,524.00"	"$1,365.15"	"$9,325.26"	"$11,371.02"	"$6,819.20"	Not Applicable	"$5,966.80"	"$11,933.60"	"$1,365.15"	"$11,933.60"
PLT 8X2.5MM 2 ANG MNDB TI 5X22X5 HL LCK RECON BN NS 2.4MM 449.637	C1713	SUPPLY/IMPLANTS	"$17,045.00"	Outpatient	"$8,522.50"	"$1,365.15"	"$9,323.62"	"$11,369.02"	"$6,818.00"	Not Applicable	"$5,965.75"	"$11,931.50"	"$1,365.15"	"$11,931.50"
HEAD FEM 36MM +0MM 12/14 TPR COCR HIP 71303600	C1776	SUPPLY/IMPLANTS	"$17,042.00"	Outpatient	"$8,521.00"	Not Applicable	"$9,321.97"	"$11,367.01"	"$6,816.80"	Not Applicable	"$5,964.70"	"$11,929.40"	"$5,964.70"	"$11,929.40"
NAIL IM 37CM 11.5MM MT-NL TI TIB 71655237	C1713	SUPPLY/IMPLANTS	"$17,038.00"	Outpatient	"$8,519.00"	"$1,365.15"	"$9,319.79"	"$11,364.35"	"$6,815.20"	Not Applicable	"$5,963.30"	"$11,926.60"	"$1,365.15"	"$11,926.60"
NAIL IM 38CM 11.5MM HMR SLT TRGN MT-NL TI TIB STRL AU 71655238	C1713	SUPPLY/IMPLANTS	"$17,038.00"	Outpatient	"$8,519.00"	"$1,365.15"	"$9,319.79"	"$11,364.35"	"$6,815.20"	Not Applicable	"$5,963.30"	"$11,926.60"	"$1,365.15"	"$11,926.60"
BEARING HUMERAL 44-36MM DIA STD +3MMH E1 SHLDR REVERSED COMP EP-115393	C1776	SUPPLY/IMPLANTS	"$17,029.00"	Outpatient	"$8,514.50"	Not Applicable	"$9,314.86"	"$11,358.34"	"$6,811.60"	Not Applicable	"$5,960.15"	"$11,920.30"	"$5,960.15"	"$11,920.30"
TI MATRIXMANDIBLE DOUBLE ANGLE RECON PLATE1.5MM THICKLARGE 04.503.789S	C1713	SUPPLY/IMPLANTS	"$17,026.00"	Outpatient	"$8,513.00"	"$1,365.15"	"$9,313.22"	"$11,356.34"	"$6,810.40"	Not Applicable	"$5,959.10"	"$11,918.20"	"$1,365.15"	"$11,918.20"
BRNG TIB 63/67MMX14MM KN VNGRD E1 CR EP-183424	C1776	SUPPLY/IMPLANTS	"$17,025.00"	Outpatient	"$8,512.50"	Not Applicable	"$9,312.68"	"$11,355.68"	"$6,810.00"	Not Applicable	"$5,958.75"	"$11,917.50"	"$5,958.75"	"$11,917.50"
17314-9600-02 - DOXOrubicin liposomal 50mg Vial - 25mL	Q2050	PHARMACY	"$14,326.00"	Outpatient	"$7,163.00"	$335.19	"$9,311.90"	"$9,555.44"	"$5,730.40"	Not Applicable	"$5,014.10"	"$10,028.20"	$335.19	"$10,028.20"
DEV TRGT UNV ARM VERSANAIL 2810-13-009	C1713	SUPPLY/IMPLANTS	"$17,013.00"	Outpatient	"$8,506.50"	"$1,365.15"	"$9,306.11"	"$11,347.67"	"$6,805.20"	Not Applicable	"$5,954.55"	"$11,909.10"	"$1,365.15"	"$11,909.10"
CASE GRPH ADON SET NCB PERIPROSTHETIC TROCH PLT 200024930	C1713	SUPPLY/IMPLANTS	"$17,006.00"	Outpatient	"$8,503.00"	"$1,365.15"	"$9,302.28"	"$11,343.00"	"$6,802.40"	Not Applicable	"$5,952.10"	"$11,904.20"	"$1,365.15"	"$11,904.20"
MTRX TISS 4X4CM AMNIOBAND PLCNT ALGRF WC3044	Q4151	SUPPLY/IMPLANTS	"$17,005.00"	Outpatient	"$8,502.50"	$141.19	"$9,301.74"	"$11,342.34"	"$6,802.00"	Not Applicable	"$5,951.75"	"$11,903.50"	$141.19	"$11,903.50"
50633-0110-12 - antivenin (Crotalidae) polyvalent - Soln	J0840	PHARMACY	"$17,001.00"	Outpatient	"$8,500.50"	"$3,492.10"	"$9,299.55"	"$11,339.67"	"$6,800.40"	Not Applicable	"$5,950.35"	"$11,900.70"	"$3,492.10"	"$11,900.70"
GFT BN DBM 10ML PTTY SYR AC CNXS 02-3000-100	C1713	SUPPLY/IMPLANTS	"$16,994.00"	Outpatient	"$8,497.00"	"$1,365.15"	"$9,295.72"	"$11,335.00"	"$6,797.60"	Not Applicable	"$5,947.90"	"$11,895.80"	"$1,365.15"	"$11,895.80"
GFT BN DBM 10ML PTTY ACCELL EVO3 02-6000-100	C9359	SUPPLY/IMPLANTS	"$16,990.00"	Outpatient	"$8,495.00"	$130.50	"$9,293.53"	"$11,332.33"	"$6,796.00"	Not Applicable	"$5,946.50"	"$11,893.00"	$130.50	"$11,893.00"
STNT TRCHBR 7MM 7FR 59MM 120CM CVR CATH INTRO BLN XPD ICAST 85415	C1874	SUPPLY/IMPLANTS	"$16,988.00"	Outpatient	"$8,494.00"	Not Applicable	"$9,292.44"	"$11,331.00"	"$6,795.20"	Not Applicable	"$5,945.80"	"$11,891.60"	"$5,945.80"	"$11,891.60"
STNT TRCHBR 9MM 7FR 59MM 120CM CVR CATH INTRO ICAST SS PTFE 85419	C1874	SUPPLY/IMPLANTS	"$16,988.00"	Outpatient	"$8,494.00"	Not Applicable	"$9,292.44"	"$11,331.00"	"$6,795.20"	Not Applicable	"$5,945.80"	"$11,891.60"	"$5,945.80"	"$11,891.60"
NAIL IM 40CM 10MM 125D ANTGRD TRGN INTERTAN TI 71675537	C1713	SUPPLY/IMPLANTS	"$16,988.00"	Outpatient	"$8,494.00"	"$1,365.15"	"$9,292.44"	"$11,331.00"	"$6,795.20"	Not Applicable	"$5,945.80"	"$11,891.60"	"$1,365.15"	"$11,891.60"
NAIL IM 32CM 10MM LCK T2 TI FEM STRL R1.5 18281032S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
NAIL IM 40CM 11MM ANTGRD LCK T2 TI FEM STRL R1.5 1828-1140S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
NAIL IM 36CM 11MM LCK T2 TI FEM STRL R1.5 18281136S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
NAIL IM 34CM 11MM LCK T2 TI FEM STRL R1.5 18281134S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
NAIL IM 36CM 8MM LCK T2 TI FEM STRL R1.5 18280836S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
NAIL IM 34CM 8MM LCK T2 TI FEM STRL R1.5 18280834S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
NAIL IM 38CM 10MM LCK T2 TI FEM STRL R1.5 18281038S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
NAIL IM 32CM 9MM LCK T2 TI FEM STRL R1.5 18280932S	C1713	SUPPLY/IMPLANTS	"$16,986.00"	Outpatient	"$8,493.00"	"$1,365.15"	"$9,291.34"	"$11,329.66"	"$6,794.40"	Not Applicable	"$5,945.10"	"$11,890.20"	"$1,365.15"	"$11,890.20"
STEM FEM 150MM 6 12/14 STD OFST TPR SMT PRCT HIP CMNTLS STRL 157001120	C1776	SUPPLY/IMPLANTS	"$16,984.00"	Outpatient	"$8,492.00"	Not Applicable	"$9,290.25"	"$11,328.33"	"$6,793.60"	Not Applicable	"$5,944.40"	"$11,888.80"	"$5,944.40"	"$11,888.80"
CMPNT FEM 2 KN LT MDL RL MCK SYS 180502	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 3 KN LT MDL RL MCK SYS 180503	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 4 KN LT MDL RL MCK SYS 180504	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 5 KN LT MDL RL MCK SYS 180505	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 6 KN LT MDL RL MCK SYS 180506	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 7 KN LT MDL RL MCK SYS 180507	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 2 KN RMLL MCK SYS 180512	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 3 KN RMLL MCK SYS 180513	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 4 KN RMLL MCK SYS 180514	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 5 KN RMLL MCK SYS 180515	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
CMPNT FEM 6 KN RMLL MCK SYS 180516	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
RESTORIS  MCK FEMORAL LM RL SIZE 1 180501	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
RESTORIS  MCK FEMORAL LM RL SIZE 8 180508	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
RESTORIS  MCK FEMORAL RM LL SIZE 1 180511	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
RESTORIS  MCK FEMORAL RM LL SIZE 7 180517	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
RESTORIS  MCK FEMORAL RM LL SIZE 8 180518	C1776	SUPPLY/IMPLANTS	"$16,983.00"	Outpatient	"$8,491.50"	Not Applicable	"$9,289.70"	"$11,327.66"	"$6,793.20"	Not Applicable	"$5,944.05"	"$11,888.10"	"$5,944.05"	"$11,888.10"
Remove Intra Aortic Balloon Pump Percutaneous	33968	CARDIAC CATH LAB	"$16,982.00"	Outpatient	"$8,491.00"	Not Applicable	"$9,289.15"	"$1,592.00"	"$6,792.80"	"$15,995.00"	"$5,943.70"	"$11,887.40"	"$1,592.00"	"$15,995.00"
STEM FEM 145MM 5 12/14 HI OFST TPR SMT PRCT HIP CMNTLS STRL 157011110	C1776	SUPPLY/IMPLANTS	"$16,974.00"	Outpatient	"$8,487.00"	Not Applicable	"$9,284.78"	"$11,321.66"	"$6,789.60"	Not Applicable	"$5,940.90"	"$11,881.80"	"$5,940.90"	"$11,881.80"
STEM FEM 135MM 3 12/14 HI OFST TPR SMT PRCT HIP CMNTLS STRL 157011090	C1776	SUPPLY/IMPLANTS	"$16,974.00"	Outpatient	"$8,487.00"	Not Applicable	"$9,284.78"	"$11,321.66"	"$6,789.60"	Not Applicable	"$5,940.90"	"$11,881.80"	"$5,940.90"	"$11,881.80"
STEM FEM 150MM 6 12/14 HI OFST TPR SMT PRCT HIP CMNTLS STRL 157011120	C1776	SUPPLY/IMPLANTS	"$16,974.00"	Outpatient	"$8,487.00"	Not Applicable	"$9,284.78"	"$11,321.66"	"$6,789.60"	Not Applicable	"$5,940.90"	"$11,881.80"	"$5,940.90"	"$11,881.80"
STEM FEM 135MM 3 12/14 STD OFST TPR SMT PRCT HIP STRL 157001090	C1776	SUPPLY/IMPLANTS	"$16,974.00"	Outpatient	"$8,487.00"	Not Applicable	"$9,284.78"	"$11,321.66"	"$6,789.60"	Not Applicable	"$5,940.90"	"$11,881.80"	"$5,940.90"	"$11,881.80"
STEM FEM 140MM 4 12/14 STD OFST TPR SMT PRCT HIP CMNTLS STRL 157001100	C1776	SUPPLY/IMPLANTS	"$16,974.00"	Outpatient	"$8,487.00"	Not Applicable	"$9,284.78"	"$11,321.66"	"$6,789.60"	Not Applicable	"$5,940.90"	"$11,881.80"	"$5,940.90"	"$11,881.80"
STEM FEMORAL S-ROM CERAMIC +8 MM 40 MM STANDARD LATERAL OFFSET L165 MM L36 MM OD20 MM ODSEC15 MM HIP	C1776	SUPPLY/IMPLANTS	"$16,974.00"	Outpatient	"$8,487.00"	Not Applicable	"$9,284.78"	"$11,321.66"	"$6,789.60"	Not Applicable	"$5,940.90"	"$11,881.80"	"$5,940.90"	"$11,881.80"
HFN LT 125 DEG 9X260MM STER 8144-09-260	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 9X280MM STER 8144-09-280	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 9X300MM STER 8144-09-300	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 9X360MM STER 8144-09-360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 9X380MM STER 8144-09-380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 9X420MM STER 8144-09-420	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 9X440MM STER 8144-09-440	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 9X460MM STER 8144-09-460	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 13X260MM STER 8144-13-260	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 13X280MM STER 8144-13-280	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 13X300MM STER 8144-13-300	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 13X320MM STER 8144-13-320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 13X340MM STER 8144-13-340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN LT 125 DEG 13X460MM STER 8144-13-460	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 9X280MM STER 8143-09-280	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 9X300MM STER 8143-09-300	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 9X320MM STER 8143-09-320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 9X380MM STER 8143-09-380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 9X440MM STER 8143-09-440	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 13X260MM STER 8143-13-260	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 13X280MM STER 8143-13-280	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 13X300MM STER 8143-13-300	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 13X320MM STER 8143-13-320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 13X400MM STER 8143-13-400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
HFN RT 125 DEG 13X460MM STER 8143-13-460	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 360MM 9MM 125D LNG GOAL POST TCH LG SCR DSGN UNQ 8143-09-360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 400MM 9MM 125D LNG GOAL POST LG SCR UNQ DIST BND MLT 8143-09-400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 34CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814311340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 36CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814311360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 38CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814311380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 40CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814311400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 44CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814311440	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 34CM 13MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814313340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 380MM 13MM 125D LNG UNQ DIST BND MLT LCK AFFIXUS 814313380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 340MM 9MM 125D LNG GOAL POST TCH LG SCR DSGN UNQ 8144-09-340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 320MM 11MM 125D LNG GOAL POST LG SCR UNQ DIST BND 8144-11-320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 340MM 11MM 125D LNG GOAL POST LG SCR UNQ DIST BND 8144-11-340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 36CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814411360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 38CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814411380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 40CM 11MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814411400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 36CM 13MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814413360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 38CM 13MM 125D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814413380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 320MM 9MM 130D LNG DIST BND MLT LCK AFFIXUS GOAL 814509320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 36CM 9MM 15.6MM 130D LNG LG SCR CHMFR FRN DIST TIP 814509360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 38CM 9MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814509380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 320MM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814511320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 34CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814511340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 36CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814511360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 380MM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814511380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 40CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814511400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 42CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814511420	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 44CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814511440	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 34CM 13MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814513340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 40CM 13MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814513400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 32CM 9MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814609320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 34CM 9MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814609340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 36CM 9MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814609360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 38CM 9MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814609380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 30CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814611300	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 32CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814611320	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 34CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814611340	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 36CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814611360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 38CM 11MM 130D LNG GOAL POST MLT LCK CHMFR AFFIXUS 814611380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 400MM 11MM 130D LNG LG SCR UNQ DIST BND MLT LCK 814611400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 420MM 11MM 130D LNG GOAL POST LG SCR DIST BND MLT 8146-11-420	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 440MM 11MM 130D LNG VERSATILITY SMP ANTM GOAL POST 8146-11-440	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 360CM 13MM 130D LNG JIG NOSE VRSTL LCK LG SCR 814613360	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 380CM 13MM 130D LNG LG SCR GOAL POST DIST BND MLT 814613380	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 400MM 13MM 130D LNG JIG NOSE LCK LG SCR AFFIXUS HIP 814613400	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
NAIL IM 420CM 13MM 130D LNG LG SCR GOAL POST DIST BND MLT 814613420	C1713	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	"$1,365.15"	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$1,365.15"	"$11,881.10"
CATH ATHRCM 135CM 5FR 1.4MM ELCA ECNTRC RX ADJ LSR ENRG ATO 114-009	C1885	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	Not Applicable	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$5,940.55"	"$11,881.10"
CATH ATHRCM 135CM 6FR .9MM ELCA COR SS PTCA RX PROVEN TCH 110-004	C1885	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	Not Applicable	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$5,940.55"	"$11,881.10"
GFT CV 80CM 6MM XTRN SPRT REVOLUTIONIZE GDLN STRP HMSHLD LN M002015030860	C1768	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	Not Applicable	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$5,940.55"	"$11,881.10"
GFT CV 80CM 8MM XTRN SPRT REVOLUTIONIZE GDLN STRP HMSHLD LN M002015030880	C1768	SUPPLY/IMPLANTS	"$16,973.00"	Outpatient	"$8,486.50"	Not Applicable	"$9,284.23"	"$11,320.99"	"$6,789.20"	Not Applicable	"$5,940.55"	"$11,881.10"	"$5,940.55"	"$11,881.10"
GFT VASC 50CM 6MM 9MM NTNL PTFE HBRD REINF COAT 10CM 0650HYB0910A	C1768	SUPPLY/IMPLANTS	"$16,971.00"	Outpatient	"$8,485.50"	Not Applicable	"$9,283.14"	"$11,319.66"	"$6,788.40"	Not Applicable	"$5,939.85"	"$11,879.70"	"$5,939.85"	"$11,879.70"
GFT VASC 50CM 6MM 8MM NTNL PTFE HBRD REINF COAT 10CM 0650HYB0810A	C1768	SUPPLY/IMPLANTS	"$16,971.00"	Outpatient	"$8,485.50"	Not Applicable	"$9,283.14"	"$11,319.66"	"$6,788.40"	Not Applicable	"$5,939.85"	"$11,879.70"	"$5,939.85"	"$11,879.70"
PLT 237MM SM BND TIB LT PERIART PROX SS 14 HL VA LCP CMBN BN 02.127.261	C1713	SUPPLY/IMPLANTS	"$16,967.00"	Outpatient	"$8,483.50"	"$1,365.15"	"$9,280.95"	"$11,316.99"	"$6,786.80"	Not Applicable	"$5,938.45"	"$11,876.90"	"$1,365.15"	"$11,876.90"
CASE GRPH MED NS MATRIXMANDIBLE SYS 306.777	C1713	SUPPLY/IMPLANTS	"$16,947.00"	Outpatient	"$8,473.50"	"$1,365.15"	"$9,270.01"	"$11,303.65"	"$6,778.80"	Not Applicable	"$5,931.45"	"$11,862.90"	"$1,365.15"	"$11,862.90"
CASE GRPH NS MATRIXCOMBO SET 60.511.100		STERILE SUPPLY	"$16,947.00"	Outpatient	"$8,473.50"	Not Applicable	"$9,270.01"	"$11,303.65"	"$6,778.80"	Not Applicable	"$5,931.45"	"$11,862.90"	"$5,931.45"	"$11,862.90"
PLT 202MM FEM LT DIST LAT SS 8X5X 4 HL AXSOS BN NS 4.5/5/6.5 437508	C1713	SUPPLY/IMPLANTS	"$16,945.00"	Outpatient	"$8,472.50"	"$1,365.15"	"$9,268.92"	"$11,302.32"	"$6,778.00"	Not Applicable	"$5,930.75"	"$11,861.50"	"$1,365.15"	"$11,861.50"
PLT 238MM FEM RT DIST LAT SS 10X5X 5 HL AXSOS BN NS 437530	C1713	SUPPLY/IMPLANTS	"$16,945.00"	Outpatient	"$8,472.50"	"$1,365.15"	"$9,268.92"	"$11,302.32"	"$6,778.00"	Not Applicable	"$5,930.75"	"$11,861.50"	"$1,365.15"	"$11,861.50"
NAIL IM 280MM 9MM PHNX FEM TROCH LT 14-443128	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 9MM PHNX FEM TROCH LT 14-443130	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 9MM PHNX FEM TROCH LT 14-443132	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 9MM FEM TROCH LT 14-443134	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 9MM FEM TROCH LT 14-443136	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 9MM PHNX FEM TROCH LT 14-443138	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 9MM ENTRY FEM TROCH LT 14-443140	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 9MM PHNX FEM TROCH LT 14-443142	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 9MM PHNX FEM TROCH LT 14-443144	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 9MM PHNX FEM TROCH LT 14-443146	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 280MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443228	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443230	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443232	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443234	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443236	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443240	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443242	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443244	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 9MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443246	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 10.5MM PHNX FEM TROCH LT 14-443330	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 10.5MM ENTRY PHNX FEM TROCH LT 14-443334	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 10.5MM FEM TROCH LT 14-443336	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 10.5MM FEM TROCH LT 14-443342	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 10.5MM ENTRY PHNX FEM TROCH LT 14-443344	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 10.5MM ENTRY PHNX FEM TROCH LT 14-443346	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 10.5MM ENTRY PHNX FEM TROCH LT 14-443348	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443430	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443432	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443434	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443436	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 10.5MM FEM TROCH RT 14-443438	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443440	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443444	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443446	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 10.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443448	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 12MM ENTRY PHNX FEM TROCH LT 14-443530	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 12MM ENTRY PHNX FEM TROCH LT 14-443532	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 12MM ENTRY PHNX FEM TROCH LT 14-443534	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 12MM PHNX FEM LT TROCH 14-443536	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 12MM ENTRY PHNX FEM TROCH LT 14-443538	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 12MM FEM TROCH LT 14-443540	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 12MM ENTRY FEM TROCH LT 14-443542	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 12MM TI FEM 14-443544	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 12MM ENTRY PHNX FEM TROCH LT 14-443546	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 12MM ENTRY PHNX FEM TROCH LT 14-443548	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443630	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443632	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443634	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443636	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443638	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 12MM FEM TROCH RT 14-443642	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443644	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443646	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 12MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443648	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 13.5MM ENTRY PHNX FEM TROCH LT 14-443730	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 13.5MM ENTRY PHNX FEM TROCH LT 14-443732	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 13.5MM ENTRY PHNX FEM TROCH LT 14-443734	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 13.5MM ENTRY PHNX FEM TROCH LT 14-443736	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 13.5MM PHNX FEM TROCH LT 14-443738	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 13.5MM ENTRY PHNX FEM TROCH LT 14-443740	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 13.5MM ENTRY PHNX FEM TROCH LT 14-443742	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 13.5MM ENTRY PHNX FEM TROCH LT 14-443744	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443746	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443748	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443830	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443832	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443834	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443836	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443838	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443840	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443842	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 13.5MM ANTGRD ENTRY PHNX FEM TROCH RT 14-443844	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 13.5MM ENTRY FEM TROCH RT 14-443846	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 13.5MM ENTRY FEM TROCH RT 14-443848	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443030	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443032	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443034	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443036	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443038	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443040	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443042	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443044	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443046	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 15MM PHNX RT PIRIFORMIS FOSSA FEM 14-443048	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 300MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443930	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 320MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443932	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 340MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443934	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 360MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443936	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 380MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443938	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 400MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443940	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 420MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443942	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 440MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443944	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 460MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443946	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
NAIL IM 480MM 15MM ANTGRD ENTRY PHNX FEM TROCH LT 14-443948	C1713	SUPPLY/IMPLANTS	"$16,938.00"	Outpatient	"$8,469.00"	"$1,365.15"	"$9,265.09"	"$11,297.65"	"$6,775.20"	Not Applicable	"$5,928.30"	"$11,856.60"	"$1,365.15"	"$11,856.60"
PLT 262MM TIB LT DIST ALAT SS 16 HL VA LOPRFL LCP CMBN BN 02.118.215S	C1713	SUPPLY/IMPLANTS	"$16,935.00"	Outpatient	"$8,467.50"	"$1,365.15"	"$9,263.45"	"$11,295.65"	"$6,774.00"	Not Applicable	"$5,927.25"	"$11,854.50"	"$1,365.15"	"$11,854.50"
NAIL IM 320MM 10MM RND CNN RTRGD ANTGRD XPRT TI FEM STRL GRN 04.013.444S	C1713	SUPPLY/IMPLANTS	"$16,923.00"	Outpatient	"$8,461.50"	"$1,365.15"	"$9,256.88"	"$11,287.64"	"$6,769.20"	Not Applicable	"$5,923.05"	"$11,846.10"	"$1,365.15"	"$11,846.10"
LINR ACTB 44MM 36MM CNSTRN NOVATION HIP 134-36-44		STERILE SUPPLY	"$16,914.00"	Outpatient	"$8,457.00"	Not Applicable	"$9,251.96"	"$11,281.64"	"$6,765.60"	Not Applicable	"$5,919.90"	"$11,839.80"	"$5,919.90"	"$11,839.80"
STENT TRACH ICAST STNLS STEEL PTFE L22 MM L120 CM OD6 MM 85453	C1874	SUPPLY/IMPLANTS	"$16,911.00"	Outpatient	"$8,455.50"	Not Applicable	"$9,250.32"	"$11,279.64"	"$6,764.40"	Not Applicable	"$5,918.85"	"$11,837.70"	"$5,918.85"	"$11,837.70"
SCREW PA 3.5 X 14MM 63035-14-S	C1713	SUPPLY/IMPLANTS	"$16,900.00"	Outpatient	"$8,450.00"	"$1,365.15"	"$9,244.30"	"$11,272.30"	"$6,760.00"	Not Applicable	"$5,915.00"	"$11,830.00"	"$1,365.15"	"$11,830.00"
SCREW 3.5 X 10MM PA 63035-10-S	C1713	SUPPLY/IMPLANTS	"$16,900.00"	Outpatient	"$8,450.00"	"$1,365.15"	"$9,244.30"	"$11,272.30"	"$6,760.00"	Not Applicable	"$5,915.00"	"$11,830.00"	"$1,365.15"	"$11,830.00"
SCREW PA 3.5 X 18MM 63035-18-S	C1713	SUPPLY/IMPLANTS	"$16,900.00"	Outpatient	"$8,450.00"	"$1,365.15"	"$9,244.30"	"$11,272.30"	"$6,760.00"	Not Applicable	"$5,915.00"	"$11,830.00"	"$1,365.15"	"$11,830.00"
CASE STRL LCK CMPLT LG FRAG SET 8299-52-040	C1713	SUPPLY/IMPLANTS	"$16,896.00"	Outpatient	"$8,448.00"	"$1,365.15"	"$9,242.11"	"$11,269.63"	"$6,758.40"	Not Applicable	"$5,913.60"	"$11,827.20"	"$1,365.15"	"$11,827.20"
GFT BN DBM 10X2.5CM GRFTN PLIF 42200	C9359	SUPPLY/IMPLANTS	"$16,894.00"	Outpatient	"$8,447.00"	$130.50	"$9,241.02"	"$11,268.30"	"$6,757.60"	Not Applicable	"$5,912.90"	"$11,825.80"	$130.50	"$11,825.80"
SCREW PA 3.5 X 12MM 63035-12-S	C1713	SUPPLY/IMPLANTS	"$16,892.00"	Outpatient	"$8,446.00"	"$1,365.15"	"$9,239.92"	"$11,266.96"	"$6,756.80"	Not Applicable	"$5,912.20"	"$11,824.40"	"$1,365.15"	"$11,824.40"
APOLLO CATHETER 1.5CM TIP 105-5095-000	C1725	SUPPLY/IMPLANTS	"$16,880.00"	Outpatient	"$8,440.00"	Not Applicable	"$9,233.36"	"$11,258.96"	"$6,752.00"	Not Applicable	"$5,908.00"	"$11,816.00"	"$5,908.00"	"$11,816.00"
CASE IMPL NS 4 MM 5 MM CNN SCR 110008471	C1713	SUPPLY/IMPLANTS	"$16,874.00"	Outpatient	"$8,437.00"	"$1,365.15"	"$9,230.08"	"$11,254.96"	"$6,749.60"	Not Applicable	"$5,905.90"	"$11,811.80"	"$1,365.15"	"$11,811.80"
MODL ANTM WHT PLAMD MNDB THR ORBT DTCH STRL PED SD900.366	C1713	SUPPLY/IMPLANTS	"$16,873.00"	Outpatient	"$8,436.50"	"$1,365.15"	"$9,229.53"	"$11,254.29"	"$6,749.20"	Not Applicable	"$5,905.55"	"$11,811.10"	"$1,365.15"	"$11,811.10"
RAIL XTRNFX 150MM SM CFBR 6606	C1713	SUPPLY/IMPLANTS	"$16,863.00"	Outpatient	"$8,431.50"	"$1,365.15"	"$9,224.06"	"$11,247.62"	"$6,745.20"	Not Applicable	"$5,902.05"	"$11,804.10"	"$1,365.15"	"$11,804.10"
HEAD HUM 28MM 56MM SHLDR 1 RDS REUNION STD T/S ARTHPL 5552-S-5628	C1776	SUPPLY/IMPLANTS	"$16,856.00"	Outpatient	"$8,428.00"	Not Applicable	"$9,220.23"	"$11,242.95"	"$6,742.40"	Not Applicable	"$5,899.60"	"$11,799.20"	"$5,899.60"	"$11,799.20"
HEAD HUMERAL OFFSET R5352-5015	C1776	SUPPLY/IMPLANTS	"$16,848.00"	Outpatient	"$8,424.00"	Not Applicable	"$9,215.86"	"$11,237.62"	"$6,739.20"	Not Applicable	"$5,896.80"	"$11,793.60"	"$5,896.80"	"$11,793.60"
NAIL IM 21CM 11MM LCK PHNX TI ANKL ARTHDS 14-440221	C1713	SUPPLY/IMPLANTS	"$16,840.00"	Outpatient	"$8,420.00"	"$1,365.15"	"$9,211.48"	"$11,232.28"	"$6,736.00"	Not Applicable	"$5,894.00"	"$11,788.00"	"$1,365.15"	"$11,788.00"
KYPOPLASTY ACCESS KIT INTVM-20-DDK		STERILE SUPPLY	"$16,825.00"	Outpatient	"$8,412.50"	Not Applicable	"$9,203.28"	"$11,222.28"	"$6,730.00"	Not Applicable	"$5,888.75"	"$11,777.50"	"$5,888.75"	"$11,777.50"
PLT 266MM CRV CNDRL LT PERIART SS 12 HL 4 CLMN THRD VA LCP 02.124.413	C1713	SUPPLY/IMPLANTS	"$16,803.00"	Outpatient	"$8,401.50"	"$1,365.15"	"$9,191.24"	"$11,207.60"	"$6,721.20"	Not Applicable	"$5,881.05"	"$11,762.10"	"$1,365.15"	"$11,762.10"
GFT VASC 80CM 8MM GORE THNWL HEP PROPATEN PTFE REM RING HT087080A	C1768	SUPPLY/IMPLANTS	"$16,776.00"	Outpatient	"$8,388.00"	Not Applicable	"$9,176.47"	"$11,189.59"	"$6,710.40"	Not Applicable	"$5,871.60"	"$11,743.20"	"$5,871.60"	"$11,743.20"
STNT ESPH 18MM 18.5FR 10.3CM 120CM FLR SLF XPD WRE REM SUT M00516700	C1874	SUPPLY/IMPLANTS	"$16,772.00"	Outpatient	"$8,386.00"	Not Applicable	"$9,174.28"	"$11,186.92"	"$6,708.80"	Not Applicable	"$5,870.20"	"$11,740.40"	"$5,870.20"	"$11,740.40"
DRVR CNN QCK CNCT CRFRM 4.5MM SRG 114704501		STERILE SUPPLY	"$16,760.00"	Outpatient	"$8,380.00"	Not Applicable	"$9,167.72"	"$11,178.92"	"$6,704.00"	Not Applicable	"$5,866.00"	"$11,732.00"	"$5,866.00"	"$11,732.00"
BIT DRL 489MM 6MM SLD RECON 14-442083		STERILE SUPPLY	"$16,750.00"	Outpatient	"$8,375.00"	Not Applicable	"$9,162.25"	"$11,172.25"	"$6,700.00"	Not Applicable	"$5,862.50"	"$11,725.00"	"$5,862.50"	"$11,725.00"
NAIL IM 28CM 9MM RTRGD ANTGRD LCK T2 TI HUM STRL 1830-0928S	C1713	SUPPLY/IMPLANTS	"$16,735.00"	Outpatient	"$8,367.50"	"$1,365.15"	"$9,154.05"	"$11,162.25"	"$6,694.00"	Not Applicable	"$5,857.25"	"$11,714.50"	"$1,365.15"	"$11,714.50"
NAIL IM 235MM 11MM 130D SHRT CNN TFN-ADV LAT RLF CUT TI COCR 04.037.145S	C1713	SUPPLY/IMPLANTS	"$16,729.00"	Outpatient	"$8,364.50"	"$1,365.15"	"$9,150.76"	"$11,158.24"	"$6,691.60"	Not Applicable	"$5,855.15"	"$11,710.30"	"$1,365.15"	"$11,710.30"
LEAD PCNG 78CM 5.3FR 5.1FR LV TRNVNS ATN PRFM QDPL ELTRD 459888	C1900	PACE MAKER	"$16,724.00"	Outpatient	"$8,362.00"	Not Applicable	"$9,148.03"	"$11,154.91"	"$6,689.60"	Not Applicable	"$5,853.40"	"$11,706.80"	"$5,853.40"	"$11,706.80"
LEAD PCNG 88CM 5.3FR 5.1FR LV ATN PRFM QDPL IS4-LLLL CNCT 4398-88CM	C1900	PACE MAKER	"$16,724.00"	Outpatient	"$8,362.00"	Not Applicable	"$9,148.03"	"$11,154.91"	"$6,689.60"	Not Applicable	"$5,853.40"	"$11,706.80"	"$5,853.40"	"$11,706.80"
NAIL IM 235MM 10MM 130D SHRT CNN TFN-ADV LAT RLF CUT TI COCR 04.037.045S	C1713	SUPPLY/IMPLANTS	"$16,723.00"	Outpatient	"$8,361.50"	"$1,365.15"	"$9,147.48"	"$11,154.24"	"$6,689.20"	Not Applicable	"$5,853.05"	"$11,706.10"	"$1,365.15"	"$11,706.10"
PLT 355MM FEM LT PROX SS 14 HL LMT CNTCT LCP CMBN BN NS 4.5 242.114	C1713	SUPPLY/IMPLANTS	"$16,723.00"	Outpatient	"$8,361.50"	"$1,365.15"	"$9,147.48"	"$11,154.24"	"$6,689.20"	Not Applicable	"$5,853.05"	"$11,706.10"	"$1,365.15"	"$11,706.10"
LEAD PCNG 88CM 5.3FR 5.1FR LV ATN STARFIX PRFM QDPL IS4-LLLL 439888	C1900	PACE MAKER	"$16,717.00"	Outpatient	"$8,358.50"	Not Applicable	"$9,144.20"	"$11,150.24"	"$6,686.80"	Not Applicable	"$5,850.95"	"$11,701.90"	"$5,850.95"	"$11,701.90"
LEAD PCNG 88CM 5.3FR LV ATN STARFIX PRFM LV-1 QDPL OTW STRD 429888	C1900	PACE MAKER	"$16,717.00"	Outpatient	"$8,358.50"	Not Applicable	"$9,144.20"	"$11,150.24"	"$6,686.80"	Not Applicable	"$5,850.95"	"$11,701.90"	"$5,850.95"	"$11,701.90"
CTR NL WIN FLXB 466114		STERILE SUPPLY	"$16,716.00"	Outpatient	"$8,358.00"	Not Applicable	"$9,143.65"	"$11,149.57"	"$6,686.40"	Not Applicable	"$5,850.60"	"$11,701.20"	"$5,850.60"	"$11,701.20"
SPANNING KNEE TEMPFIX STER 808112000	C1713	SUPPLY/IMPLANTS	"$16,702.00"	Outpatient	"$8,351.00"	"$1,365.15"	"$9,135.99"	"$11,140.23"	"$6,680.80"	Not Applicable	"$5,845.70"	"$11,691.40"	"$1,365.15"	"$11,691.40"
STNT ESPH 18MM 18.5FR 10CM 7CM PRT CVR COAX RADOPQ LOPRFL M00516900	C1874	SUPPLY/IMPLANTS	"$16,692.00"	Outpatient	"$8,346.00"	Not Applicable	"$9,130.52"	"$11,133.56"	"$6,676.80"	Not Applicable	"$5,842.20"	"$11,684.40"	"$5,842.20"	"$11,684.40"
PLT 142MM TIB RT DIST ALAT SS 8 HL VA LOPRFL LCP CMBN BN NS 02.118.206	C1713	SUPPLY/IMPLANTS	"$16,692.00"	Outpatient	"$8,346.00"	"$1,365.15"	"$9,130.52"	"$11,133.56"	"$6,676.80"	Not Applicable	"$5,842.20"	"$11,684.40"	"$1,365.15"	"$11,684.40"
GD TRGT MDN SRG SS FEM PROX NS IM NL 225500200	C1713	SUPPLY/IMPLANTS	"$16,691.00"	Outpatient	"$8,345.50"	"$1,365.15"	"$9,129.98"	"$11,132.90"	"$6,676.40"	Not Applicable	"$5,841.85"	"$11,683.70"	"$1,365.15"	"$11,683.70"
MATRIX BONE GRAFT BIOACTIVE BONE GRAFT10CC 6.25CMX2CMX0.8CM MCCBA1006	C1713	SUPPLY/IMPLANTS	"$16,690.00"	Outpatient	"$8,345.00"	"$1,365.15"	"$9,129.43"	"$11,132.23"	"$6,676.00"	Not Applicable	"$5,841.50"	"$11,683.00"	"$1,365.15"	"$11,683.00"
PLT 6.5X2MM 2 ANG XL MNDB TI 6X24X6 HL LCK LOPRFL BN NS 2MM 447.426	C1713	SUPPLY/IMPLANTS	"$16,684.00"	Outpatient	"$8,342.00"	"$1,365.15"	"$9,126.15"	"$11,128.23"	"$6,673.60"	Not Applicable	"$5,839.40"	"$11,678.80"	"$1,365.15"	"$11,678.80"
RAIL XTRNFX 150MM DNFX C ADLT NS 6301	C1713	SUPPLY/IMPLANTS	"$16,681.00"	Outpatient	"$8,340.50"	"$1,365.15"	"$9,124.51"	"$11,126.23"	"$6,672.40"	Not Applicable	"$5,838.35"	"$11,676.70"	"$1,365.15"	"$11,676.70"
STENT ESOPHAGEAL WALLFLEX PERMALUME TEFLON NITINOL OD28 MM L M00516950	C1874	SUPPLY/IMPLANTS	"$16,671.00"	Outpatient	"$8,335.50"	Not Applicable	"$9,119.04"	"$11,119.56"	"$6,668.40"	Not Applicable	"$5,834.85"	"$11,669.70"	"$5,834.85"	"$11,669.70"
CASE INST 5.5MM 4.5MM PERIART LCK SCR 235803505	C1713	SUPPLY/IMPLANTS	"$16,668.00"	Outpatient	"$8,334.00"	"$1,365.15"	"$9,117.40"	"$11,117.56"	"$6,667.20"	Not Applicable	"$5,833.80"	"$11,667.60"	"$1,365.15"	"$11,667.60"
STNT ESPH 18MM 18.5FR 12CM 120CM FLR LOPRFL SLF XPD WRE REM M00516710	C1874	SUPPLY/IMPLANTS	"$16,651.00"	Outpatient	"$8,325.50"	Not Applicable	"$9,108.10"	"$11,106.22"	"$6,660.40"	Not Applicable	"$5,827.85"	"$11,655.70"	"$5,827.85"	"$11,655.70"
SPIKED SCREW INSERTER FOR 4.5 703972	C1713	SUPPLY/IMPLANTS	"$16,648.00"	Outpatient	"$8,324.00"	"$1,365.15"	"$9,106.46"	"$11,104.22"	"$6,659.20"	Not Applicable	"$5,826.80"	"$11,653.60"	"$1,365.15"	"$11,653.60"
Percutaneous Vertebral Augmentation Lumbar	22514	CARDIAC CATH LAB	"$16,638.00"	Outpatient	"$8,319.00"	"$12,967.22"	"$9,100.99"	"$11,097.55"	"$6,655.20"	"$7,310.00"	"$5,823.30"	"$11,646.60"	"$5,823.30"	"$12,967.22"
Percutaneous Vertebral Augmentation Each Addl	22515	CARDIAC CATH LAB	"$16,638.00"	Outpatient	"$8,319.00"	"$12,967.22"	"$9,100.99"	"$11,097.55"	"$6,655.20"	$819.00	"$5,823.30"	"$11,646.60"	$819.00	"$12,967.22"
STEM HUMERAL ARTHREX UNIVERS REVERS 8 SHOULDER STERILE AR-9501-08P	C1776	SUPPLY/IMPLANTS	"$16,637.00"	Outpatient	"$8,318.50"	Not Applicable	"$9,100.44"	"$11,096.88"	"$6,654.80"	Not Applicable	"$5,822.95"	"$11,645.90"	"$5,822.95"	"$11,645.90"
STEM HUMERAL ARTHREX UNIVERS REVERS 7 SHOULDER STERILE AR-9501-07P	C1776	SUPPLY/IMPLANTS	"$16,637.00"	Outpatient	"$8,318.50"	Not Applicable	"$9,100.44"	"$11,096.88"	"$6,654.80"	Not Applicable	"$5,822.95"	"$11,645.90"	"$5,822.95"	"$11,645.90"
"UNIVERS REVERS HUMERAL STEM, SIZE 9 AR9501-09P"	C1776	SUPPLY/IMPLANTS	"$16,637.00"	Outpatient	"$8,318.50"	Not Applicable	"$9,100.44"	"$11,096.88"	"$6,654.80"	Not Applicable	"$5,822.95"	"$11,645.90"	"$5,822.95"	"$11,645.90"
MODL ANTM WHT PROPLAN CMF ADLT PLAMD CRNL CAP STRL SD900.304	C1713	SUPPLY/IMPLANTS	"$16,636.00"	Outpatient	"$8,318.00"	"$1,365.15"	"$9,099.89"	"$11,096.21"	"$6,654.40"	Not Applicable	"$5,822.60"	"$11,645.20"	"$1,365.15"	"$11,645.20"
CAGE SPNL 14X7MM SHURFIT 5D LRDTC 12MM STD PEEK-OPTM RADOPQ ACIF05-07P	C1821	SUPPLY/IMPLANTS	"$16,633.00"	Outpatient	"$8,316.50"	Not Applicable	"$9,098.25"	"$11,094.21"	"$6,653.20"	Not Applicable	"$5,821.55"	"$11,643.10"	"$5,821.55"	"$11,643.10"
CAGE SPNL 14X6MM SHURFIT 10D LRDTC 12MM STD PEEK-OPTM RADOPQ ACIF10-06P	C1821	SUPPLY/IMPLANTS	"$16,633.00"	Outpatient	"$8,316.50"	Not Applicable	"$9,098.25"	"$11,094.21"	"$6,653.20"	Not Applicable	"$5,821.55"	"$11,643.10"	"$5,821.55"	"$11,643.10"
PEEK CAGE 8MM ACIF10-08P	C1821	SUPPLY/IMPLANTS	"$16,633.00"	Outpatient	"$8,316.50"	Not Applicable	"$9,098.25"	"$11,094.21"	"$6,653.20"	Not Applicable	"$5,821.55"	"$11,643.10"	"$5,821.55"	"$11,643.10"
GFT EVAS 40MM 7MM FLAIR FLR ARTERIOVENOUS EPTFE 2 LYR FAF07040		SUPPLY/IMPLANTS	"$16,633.00"	Outpatient	"$8,316.50"	Not Applicable	"$9,098.25"	"$11,094.21"	"$6,653.20"	Not Applicable	"$5,821.55"	"$11,643.10"	"$5,821.55"	"$11,643.10"
VIASORB STRIP 8155-12075		STERILE SUPPLY	"$16,627.00"	Outpatient	"$8,313.50"	Not Applicable	"$9,094.97"	"$11,090.21"	"$6,650.80"	Not Applicable	"$5,819.45"	"$11,638.90"	"$5,819.45"	"$11,638.90"
LEAD PCNG 86CM 3.9-5.2FR 2.6FR LT VNTRC ACTY X4 OTW QDPL LNG 4671	C1900	PACE MAKER	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
STNT MTL 10MM CRTD 24MM CLS CELL RCNSTRN FLXB RADOPQ WLSTNT M001719040	C1876	SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
STNT MTL 10MM CRTD 31MM CLS CELL RCNSTRN FLXB RADOPQ WLSTNT M001719050	C1876	SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
STNT MTL 10MM CRTD 37MM CLS CELL RCNSTRN FLXB RADOPQ WLSTNT M001719060	C1876	SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
STNT MTL 6MM CRTD 22MM CLS CELL RCNSTRN FLXB RADOPQ WLSTNT M001719000	C1876	SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
STNT MTL 8MM CRTD 21MM CLS CELL RCNSTRN FLXB RADOPQ WLSTNT M001719010	C1876	SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
STNT MTL 8MM CRTD 29MM CLS CELL RCNSTRN FLXB RADOPQ WLSTNT M001719020	C1876	SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
STNT MTL 8MM CRTD 36MM CLS CELL RCNSTRN FLXB RADOPQ WLSTNT M001719030	C1876	SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
LEAD PCNG 86CM 3.9-5.2FR 2.6FR LT VNTRC ACTY X4 OTW QDPL LNG 4677		SUPPLY/IMPLANTS	"$16,626.00"	Outpatient	"$8,313.00"	Not Applicable	"$9,094.42"	"$11,089.54"	"$6,650.40"	Not Applicable	"$5,819.10"	"$11,638.20"	"$5,819.10"	"$11,638.20"
PLT PLV SUPRAPECTINEAL RT QUADRILATERAL PRO BN STRL 425911S	C1713	SUPPLY/IMPLANTS	"$16,624.00"	Outpatient	"$8,312.00"	"$1,365.15"	"$9,093.33"	"$11,088.21"	"$6,649.60"	Not Applicable	"$5,818.40"	"$11,636.80"	"$1,365.15"	"$11,636.80"
CASE INST FT/ANKL GN 480107000		STERILE SUPPLY	"$16,622.00"	Outpatient	"$8,311.00"	Not Applicable	"$9,092.23"	"$11,086.87"	"$6,648.80"	Not Applicable	"$5,817.70"	"$11,635.40"	"$5,817.70"	"$11,635.40"
PRB CRYABL 10CM CRYOICE AL STRL LF DISP CRYO3		STERILE SUPPLY	"$16,614.00"	Outpatient	"$8,307.00"	Not Applicable	"$9,087.86"	"$11,081.54"	"$6,645.60"	Not Applicable	"$5,814.90"	"$11,629.80"	"$5,814.90"	"$11,629.80"
PLATE 85 X 85 MESH 54-00342	C1713	SUPPLY/IMPLANTS	"$16,613.00"	Outpatient	"$8,306.50"	"$1,365.15"	"$9,087.31"	"$11,080.87"	"$6,645.20"	Not Applicable	"$5,814.55"	"$11,629.10"	"$1,365.15"	"$11,629.10"
PLATE Z BETA 18MM 7100-ZB18	C1713	SUPPLY/IMPLANTS	"$16,600.00"	Outpatient	"$8,300.00"	"$1,365.15"	"$9,080.20"	"$11,072.20"	"$6,640.00"	Not Applicable	"$5,810.00"	"$11,620.00"	"$1,365.15"	"$11,620.00"
PLATE  15MM Z BETA 7100-ZB15	C1713	SUPPLY/IMPLANTS	"$16,600.00"	Outpatient	"$8,300.00"	"$1,365.15"	"$9,080.20"	"$11,072.20"	"$6,640.00"	Not Applicable	"$5,810.00"	"$11,620.00"	"$1,365.15"	"$11,620.00"
PLATE LAPIDUS LZ ALPHA 18MM 7100-LZ18-A	C1713	SUPPLY/IMPLANTS	"$16,599.00"	Outpatient	"$8,299.50"	"$1,365.15"	"$9,079.65"	"$11,071.53"	"$6,639.60"	Not Applicable	"$5,809.65"	"$11,619.30"	"$1,365.15"	"$11,619.30"
NAIL IM 360MM 11MM STD LCK T2 TI TIB STRL 1822-1136S	C1713	SUPPLY/IMPLANTS	"$16,597.00"	Outpatient	"$8,298.50"	"$1,365.15"	"$9,078.56"	"$11,070.20"	"$6,638.80"	Not Applicable	"$5,808.95"	"$11,617.90"	"$1,365.15"	"$11,617.90"
NAIL IM 285MM 10MM STD LCK T2 TI TIB STRL 1822-1028S	C1713	SUPPLY/IMPLANTS	"$16,597.00"	Outpatient	"$8,298.50"	"$1,365.15"	"$9,078.56"	"$11,070.20"	"$6,638.80"	Not Applicable	"$5,808.95"	"$11,617.90"	"$1,365.15"	"$11,617.90"
MODL ANTM MXL ACRL ABL TO CUT COLORIZABLE ADLT NS SD900.207	C1713	SUPPLY/IMPLANTS	"$16,594.00"	Outpatient	"$8,297.00"	"$1,365.15"	"$9,076.92"	"$11,068.20"	"$6,637.60"	Not Applicable	"$5,807.90"	"$11,615.80"	"$1,365.15"	"$11,615.80"
GFT EVAS 7CM 12MM XCLDR ILC NTNL EPTFE STNT XTD SL CUF AAA PLL161207	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
GRAFTMASTER 4.0 X 16 GCG1640UA	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
GRAFTMASTER 3.5 X 19 GCG1935UA	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
GRAFTMASTER 4.5 X 19 GCG1945UA	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
SYS COR STNT 16MM GFTMSTR SS EPTFE 3.5MM RX GFT SYS 1012581-16	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
SYS COR STNT 16MM GFTMSTR SS EPTFE 2.8MM RX GFT SYS 1012580-16	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
SYS COR STNT 16MM GFTMSTR SS EPTFE 4MM RX GFT SYS 1012582-16	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
SYS COR STNT 16MM GFTMSTR SS EPTFE 4.8MM RX GFT SYS 1012584-16	C1874	SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
GFT EVAS 4.5CM 32MM 27-29MM XCLDR GRTX NTNL FEP STNT XTD PLA320400		STERILE SUPPLY	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
SYS COR STNT 19MM GFTMSTR SS EPTFE 4MM RX GFT SYS 1012582-19		SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
SYS COR STNT 19MM GFTMSTR SS EPTFE 3.5MM RX GFT SYS 1012581-19		SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
SYS COR STNT 19MM GFTMSTR SS EPTFE 2.8MM RX GFT SYS 1012580-19		SUPPLY/IMPLANTS	"$16,591.00"	Outpatient	"$8,295.50"	Not Applicable	"$9,075.28"	"$11,066.20"	"$6,636.40"	Not Applicable	"$5,806.85"	"$11,613.70"	"$5,806.85"	"$11,613.70"
GFT BN DBM RVRS PHS MED 10CC ALGRF PTTY CHP PUROS STRL LF 84338010	C9359	SUPPLY/IMPLANTS	"$16,590.00"	Outpatient	"$8,295.00"	$130.50	"$9,074.73"	"$11,065.53"	"$6,636.00"	Not Applicable	"$5,806.50"	"$11,613.00"	$130.50	"$11,613.00"
AUGMENT ACETABULAR PINNACLE GRIPTION TF H10 MM OD54/56 MM HI 1217-10-154	C1776	SUPPLY/IMPLANTS	"$16,589.00"	Outpatient	"$8,294.50"	Not Applicable	"$9,074.18"	"$11,064.86"	"$6,635.60"	Not Applicable	"$5,806.15"	"$11,612.30"	"$5,806.15"	"$11,612.30"
PLT 336MM CRV CNDRL RT PERIART SS 16 HL 4 CLMN THRD VA LCP 02.124.416	C1713	SUPPLY/IMPLANTS	"$16,574.00"	Outpatient	"$8,287.00"	"$1,365.15"	"$9,065.98"	"$11,054.86"	"$6,629.60"	Not Applicable	"$5,800.90"	"$11,601.80"	"$1,365.15"	"$11,601.80"
PLT 336MM CRV CNDRL LT PERIART SS 16 HL 4 CLMN THRD VA LCP 02.124.417	C1713	SUPPLY/IMPLANTS	"$16,574.00"	Outpatient	"$8,287.00"	"$1,365.15"	"$9,065.98"	"$11,054.86"	"$6,629.60"	Not Applicable	"$5,800.90"	"$11,601.80"	"$1,365.15"	"$11,601.80"
IMPL CRNL PEEK-OPTM KT PTSPC BSC RECON MDFC NS SD900.056	C1713	SUPPLY/IMPLANTS	"$16,570.00"	Outpatient	"$8,285.00"	"$1,365.15"	"$9,063.79"	"$11,052.19"	"$6,628.00"	Not Applicable	"$5,799.50"	"$11,599.00"	"$1,365.15"	"$11,599.00"
RCHRGR NRSTM RESTOREADVANCED SURESCAN XTRN ANTNA AC PWR SPL 97754	C1820	SUPPLY/IMPLANTS	"$16,553.00"	Outpatient	"$8,276.50"	Not Applicable	"$9,054.49"	"$11,040.85"	"$6,621.20"	Not Applicable	"$5,793.55"	"$11,587.10"	"$5,793.55"	"$11,587.10"
NRSTM 2.2INX2.2IN ACTIVA RC IMPL ACT MVD 37651		STERILE SUPPLY	"$16,553.00"	Outpatient	"$8,276.50"	Not Applicable	"$9,054.49"	"$11,040.85"	"$6,621.20"	Not Applicable	"$5,793.55"	"$11,587.10"	"$5,793.55"	"$11,587.10"
OPTIROM PROXIMAL ARM ASSEMBLY 9630	C1713	SUPPLY/IMPLANTS	"$16,550.00"	Outpatient	"$8,275.00"	"$1,365.15"	"$9,052.85"	"$11,038.85"	"$6,620.00"	Not Applicable	"$5,792.50"	"$11,585.00"	"$1,365.15"	"$11,585.00"
NAIL IM 420MM 10MM 130D LNG CNN TFN-ADV LAT RLF CUT TI COCR 04.037.062S		STERILE SUPPLY	"$16,548.00"	Outpatient	"$8,274.00"	Not Applicable	"$9,051.76"	"$11,037.52"	"$6,619.20"	Not Applicable	"$5,791.80"	"$11,583.60"	"$5,791.80"	"$11,583.60"
SET XTRNFX 220MM DIST RDS SCR ROD MRI SAFE NS 03.390.053S	C1713	SUPPLY/IMPLANTS	"$16,546.00"	Outpatient	"$8,273.00"	"$1,365.15"	"$9,050.66"	"$11,036.18"	"$6,618.40"	Not Applicable	"$5,791.10"	"$11,582.20"	"$1,365.15"	"$11,582.20"
(BC3) GLOBAL ADVANTAGE POROCOAT STANDARD STEM SZ 10 138MM	C1776	SUPPLY/IMPLANTS	"$16,544.00"	Outpatient	"$8,272.00"	Not Applicable	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$5,790.40"	"$11,580.80"
HEAD HUM 21MM 40MM SHLDR GB ADV STD STRL 112840020	C1776	SUPPLY/IMPLANTS	"$16,544.00"	Outpatient	"$8,272.00"	Not Applicable	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$5,790.40"	"$11,580.80"
HEAD HUM 18MM 40MM SHLDR GB ADV STD STRL 112840010	C1776	SUPPLY/IMPLANTS	"$16,544.00"	Outpatient	"$8,272.00"	Not Applicable	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$5,790.40"	"$11,580.80"
HEAD HUM 18MM 44MM SHLDR GB ADV STD STRL 112844010	C1776	SUPPLY/IMPLANTS	"$16,544.00"	Outpatient	"$8,272.00"	Not Applicable	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$5,790.40"	"$11,580.80"
HEAD HUM 15MM 40MM SHLDR GB ADV STD STRL 112840000	C1776	SUPPLY/IMPLANTS	"$16,544.00"	Outpatient	"$8,272.00"	Not Applicable	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$5,790.40"	"$11,580.80"
STEM HUM 145MM 12MM GB ADV PRCT STD SHLDR STRL 113712050	C1776	SUPPLY/IMPLANTS	"$16,544.00"	Outpatient	"$8,272.00"	Not Applicable	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$5,790.40"	"$11,580.80"
HEAD HUM 21MM 48MM SHLDR GB ADV STD STRL 112848020	C1776	PACE MAKER	"$16,544.00"	Outpatient	"$8,272.00"	Not Applicable	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$5,790.40"	"$11,580.80"
PEG FX 40MM GLND ANCH PREMIERON GLBL AP 113640026	C1713	SUPPLY/IMPLANTS	"$16,544.00"	Outpatient	"$8,272.00"	"$1,365.15"	"$9,049.57"	"$11,034.85"	"$6,617.60"	Not Applicable	"$5,790.40"	"$11,580.80"	"$1,365.15"	"$11,580.80"
Fusion Transforaminal Lumbar Interbody with O - Arm	22630	CARDIAC CATH LAB	"$16,540.00"	Outpatient	"$8,270.00"	"$12,873.50"	"$9,047.38"	"$1,592.00"	"$6,616.00"	"$1,563.00"	"$5,789.00"	"$11,578.00"	"$1,563.00"	"$12,873.50"
BLDE STRG JIG HUENE HRBRT SS SCPHD SRG BN SCR NS LF 115401900	C1713	SUPPLY/IMPLANTS	"$16,530.00"	Outpatient	"$8,265.00"	"$1,365.15"	"$9,041.91"	"$11,025.51"	"$6,612.00"	Not Applicable	"$5,785.50"	"$11,571.00"	"$1,365.15"	"$11,571.00"
BSPLT TIB 2 SM KN MDLR ROT HNG 64813111	C1776	SUPPLY/IMPLANTS	"$16,514.00"	Outpatient	"$8,257.00"	Not Applicable	"$9,033.16"	"$11,014.84"	"$6,605.60"	Not Applicable	"$5,779.90"	"$11,559.80"	"$5,779.90"	"$11,559.80"
DRESSING BIOLOGICAL MICROMATRIX PORCINE EXTRACELLULAR MATRIX MM1000	Q4118	PHARMACY	"$16,508.00"	Outpatient	"$8,254.00"	$3.56	"$9,029.88"	"$11,010.84"	"$6,603.20"	Not Applicable	"$5,777.80"	"$11,555.60"	$3.56	"$11,555.60"
ELTRD ESURG 6.4FR 25CM STRB XLI 4-7CM 9 ARY TROC TIP DISP RF H7877001030241		STERILE SUPPLY	"$16,500.00"	Outpatient	"$8,250.00"	Not Applicable	"$9,025.50"	"$11,005.50"	"$6,600.00"	Not Applicable	"$5,775.00"	"$11,550.00"	"$5,775.00"	"$11,550.00"
PRB CRYOSURGICAL 100MM SRGFRST SS ADJ TEMP TCH SCRN CNSL 60SF2		STERILE SUPPLY	"$16,500.00"	Outpatient	"$8,250.00"	Not Applicable	"$9,025.50"	"$11,005.50"	"$6,600.00"	Not Applicable	"$5,775.00"	"$11,550.00"	"$5,775.00"	"$11,550.00"
PLT 176MM HUM LT PROX LAT TI 10 HL AXSOS 3 BN NS 627210		SUPPLY/IMPLANTS	"$16,499.00"	Outpatient	"$8,249.50"	Not Applicable	"$9,024.95"	"$11,004.83"	"$6,599.60"	Not Applicable	"$5,774.65"	"$11,549.30"	"$5,774.65"	"$11,549.30"
CAGE 12MM PLASMA COATED X034-0286PC	C1821	SUPPLY/IMPLANTS	"$16,489.00"	Outpatient	"$8,244.50"	Not Applicable	"$9,019.48"	"$10,998.16"	"$6,595.60"	Not Applicable	"$5,771.15"	"$11,542.30"	"$5,771.15"	"$11,542.30"
GFT SFT TIS 19.5+ CMX10-18MM AT ALGRF FRZN SHP BN BLCK 430207	C9356	SUPPLY/IMPLANTS	"$16,477.00"	Outpatient	"$8,238.50"	$69.06	"$9,012.92"	"$10,990.16"	"$6,590.80"	Not Applicable	"$5,766.95"	"$11,533.90"	$69.06	"$11,533.90"
PLT 177MM SM BND TIB LT PERIART PROX SS 10 HL VA LCP CMBN BN 02.127.241	C1713	SUPPLY/IMPLANTS	"$16,464.00"	Outpatient	"$8,232.00"	"$1,365.15"	"$9,005.81"	"$10,981.49"	"$6,585.60"	Not Applicable	"$5,762.40"	"$11,524.80"	"$1,365.15"	"$11,524.80"
Transcatheter Occlusion CNS	61624	CARDIAC CATH LAB	"$16,460.00"	Outpatient	"$8,230.00"	"$12,796.75"	"$9,003.62"	"$1,592.00"	"$6,584.00"	"$1,563.00"	"$5,761.00"	"$11,522.00"	"$1,563.00"	"$12,796.75"
PLT 2MM 2 ANG SM MNDB TI 4X20X4 HL RECON MATRIXMANDIBLE BN 04.503.734	C1713	SUPPLY/IMPLANTS	"$16,459.00"	Outpatient	"$8,229.50"	"$1,365.15"	"$9,003.07"	"$10,978.15"	"$6,583.60"	Not Applicable	"$5,760.65"	"$11,521.30"	"$1,365.15"	"$11,521.30"
STEM HUM 9MM PRFT PRM EQUINOXE SHLDR 300-01-09	C1776	SUPPLY/IMPLANTS	"$16,453.00"	Outpatient	"$8,226.50"	Not Applicable	"$8,999.79"	"$10,974.15"	"$6,581.20"	Not Applicable	"$5,758.55"	"$11,517.10"	"$5,758.55"	"$11,517.10"
TRAY HUM ADPR EQUINOXE +0MM SHLDR RVRS 320-10-00	C1776	SUPPLY/IMPLANTS	"$16,453.00"	Outpatient	"$8,226.50"	Not Applicable	"$8,999.79"	"$10,974.15"	"$6,581.20"	Not Applicable	"$5,758.55"	"$11,517.10"	"$5,758.55"	"$11,517.10"
NAIL IM 240MM 8.5MM 9.5MM LNG STRG CNN MULTILOC TI AL 04.019.240S	C1713	SUPPLY/IMPLANTS	"$16,453.00"	Outpatient	"$8,226.50"	"$1,365.15"	"$8,999.79"	"$10,974.15"	"$6,581.20"	Not Applicable	"$5,758.55"	"$11,517.10"	"$1,365.15"	"$11,517.10"
PLATE STANDARD 629579	C1713	SUPPLY/IMPLANTS	"$16,453.00"	Outpatient	"$8,226.50"	"$1,365.15"	"$8,999.79"	"$10,974.15"	"$6,581.20"	Not Applicable	"$5,758.55"	"$11,517.10"	"$1,365.15"	"$11,517.10"
PLT 123MM SHRT BND WRST FSN BN 629589	C1713	SUPPLY/IMPLANTS	"$16,453.00"	Outpatient	"$8,226.50"	"$1,365.15"	"$8,999.79"	"$10,974.15"	"$6,581.20"	Not Applicable	"$5,758.55"	"$11,517.10"	"$1,365.15"	"$11,517.10"
CATH ABLT 18-31MM 4CM BARRX 360 8CM SLF ADJ BLN RF ELTRD 64082	C1733	SUPPLY/IMPLANTS	"$16,453.00"	Outpatient	"$8,226.50"	Not Applicable	"$8,999.79"	"$10,974.15"	"$6,581.20"	Not Applicable	"$5,758.55"	"$11,517.10"	"$5,758.55"	"$11,517.10"
CASE INST BLU FEM SS AL 1 ANTGRD 249008250		STERILE SUPPLY	"$16,438.00"	Outpatient	"$8,219.00"	Not Applicable	"$8,991.59"	"$10,964.15"	"$6,575.20"	Not Applicable	"$5,753.30"	"$11,506.60"	"$5,753.30"	"$11,506.60"
Right/Left Heart Cath W/Angiogram inclu LT Vent w Bypass	93461	CARDIAC CATH LAB	"$15,137.00"	Outpatient	"$7,568.50"	"$13,641.70"	"$8,991.38"	"$6,201.00"	"$6,054.80"	"$6,120.00"	"$5,297.95"	"$10,595.90"	"$5,297.95"	"$13,641.70"
Right/Left Heart Cath w/Angio including Injections	93460	CARDIAC CATH LAB	"$15,137.00"	Outpatient	"$7,568.50"	"$13,641.70"	"$8,991.38"	"$6,201.00"	"$6,054.80"	"$6,120.00"	"$5,297.95"	"$10,595.90"	"$5,297.95"	"$13,641.70"
Left Heart Cath Including IT Vent W/Bypass Graft Angio	93459	CARDIAC CATH LAB	"$15,137.00"	Outpatient	"$7,568.50"	"$13,641.70"	"$8,991.38"	"$6,201.00"	"$6,054.80"	"$6,120.00"	"$5,297.95"	"$10,595.90"	"$5,297.95"	"$13,641.70"
Right Heart Cath W/Angio for Bypass Graft Angio	93457	CARDIAC CATH LAB	"$15,137.00"	Outpatient	"$7,568.50"	"$13,641.70"	"$8,991.38"	"$6,201.00"	"$6,054.80"	"$6,120.00"	"$5,297.95"	"$10,595.90"	"$5,297.95"	"$13,641.70"
Right Heart Catheterization with Angiography	93456	CARDIAC CATH LAB	"$15,137.00"	Outpatient	"$7,568.50"	"$13,641.70"	"$8,991.38"	"$6,201.00"	"$6,054.80"	"$6,120.00"	"$5,297.95"	"$10,595.90"	"$5,297.95"	"$13,641.70"
Left Heart Cath by Transeptal Puncture	93462	CARDIAC CATH LAB	"$15,137.00"	Outpatient	"$7,568.50"	"$13,641.70"	"$8,991.38"	"$10,096.38"	"$6,054.80"	$819.00	"$5,297.95"	"$10,595.90"	$819.00	"$13,641.70"
PLT 8-10MM LNG SPNE LVL 2 LCK ROI-C BN MC1006T	C1713	SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	"$1,365.15"	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$1,365.15"	"$11,497.50"
CAGE SPNL 14X4-6MM ROI-C VERTEBRIDGE 12MM PEEK OPTM LT1 CRV MC1342P		SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	Not Applicable	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$5,748.75"	"$11,497.50"
CAGE SPNL 14X6-8MM ROI-C VERTEBRIDGE 12MM PEEK-OPTM LT1 CRV MC1344P		SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	Not Applicable	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$5,748.75"	"$11,497.50"
CAGE SPNL 15.5X5-7MM ROI-C VERTEBRIDGE 12MM PEEK-OPTM LT1 MC1353P		SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	Not Applicable	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$5,748.75"	"$11,497.50"
CAGE SPNL 15.5X6-8MM ROI-C VERTEBRIDGE 12MM PEEK-OPTM LT1 MC1354P		SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	Not Applicable	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$5,748.75"	"$11,497.50"
CAGE SPNL 15.5X4-6MM ROI-C VERTEBRIDGE 14MM PEEK-OPTM LT1 MC1322P		SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	Not Applicable	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$5,748.75"	"$11,497.50"
CAGE SPNL 15.5X5-7MM ROI-C VERTEBRIDGE 14MM PEEK-OPTM LT1 MC1323P		SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	Not Applicable	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$5,748.75"	"$11,497.50"
CAGE SPNL 17X5-7MM ROI-C VERTEBRIDGE 14MM PEEK-OPTM LT1 CRV MC1333P		SUPPLY/IMPLANTS	"$16,425.00"	Outpatient	"$8,212.50"	Not Applicable	"$8,984.48"	"$10,955.48"	"$6,570.00"	Not Applicable	"$5,748.75"	"$11,497.50"	"$5,748.75"	"$11,497.50"
STEM FEM 127MM 17MM MRS KN 6485-3-117	C1776	SUPPLY/IMPLANTS	"$16,423.00"	Outpatient	"$8,211.50"	Not Applicable	"$8,983.38"	"$10,954.14"	"$6,569.20"	Not Applicable	"$5,748.05"	"$11,496.10"	"$5,748.05"	"$11,496.10"
HEAD HUM 17MM 44MM SHLDR AQLS ASCND 3.5MM HI OFST 502444	C1776	SUPPLY/IMPLANTS	"$16,413.00"	Outpatient	"$8,206.50"	Not Applicable	"$8,977.91"	"$10,947.47"	"$6,565.20"	Not Applicable	"$5,744.55"	"$11,489.10"	"$5,744.55"	"$11,489.10"
ANKLE HALF PIN TEMPFIX STER 8081-11-000	C1713	SUPPLY/IMPLANTS	"$16,390.00"	Outpatient	"$8,195.00"	"$1,365.15"	"$8,965.33"	"$10,932.13"	"$6,556.00"	Not Applicable	"$5,736.50"	"$11,473.00"	"$1,365.15"	"$11,473.00"
GFT BN CANC 5CC ALGRF FRZN VIABLE CELL MORSELIZE TRN EVOL 410105	C1713	SUPPLY/IMPLANTS	"$16,383.00"	Outpatient	"$8,191.50"	"$1,365.15"	"$8,961.50"	"$10,927.46"	"$6,553.20"	Not Applicable	"$5,734.05"	"$11,468.10"	"$1,365.15"	"$11,468.10"
NAIL IM 40CM 10MM 130D ANTGRD TRGN TI RT TROCH ROSE 71648240	C1713	SUPPLY/IMPLANTS	"$16,369.00"	Outpatient	"$8,184.50"	"$1,365.15"	"$8,953.84"	"$10,918.12"	"$6,547.60"	Not Applicable	"$5,729.15"	"$11,458.30"	"$1,365.15"	"$11,458.30"
INS TIB 3 13MM KN X3 TL STAB + TRTHLN 5537-G-313	C1776	SUPPLY/IMPLANTS	"$16,367.00"	Outpatient	"$8,183.50"	Not Applicable	"$8,952.75"	"$10,916.79"	"$6,546.80"	Not Applicable	"$5,728.45"	"$11,456.90"	"$5,728.45"	"$11,456.90"
INS TIB 6 16MM KN X3 TL STAB + TRTHLN 5537-G-616	C1776	SUPPLY/IMPLANTS	"$16,367.00"	Outpatient	"$8,183.50"	Not Applicable	"$8,952.75"	"$10,916.79"	"$6,546.80"	Not Applicable	"$5,728.45"	"$11,456.90"	"$5,728.45"	"$11,456.90"
PLT 176MM HUM RT PROX SS 10X7X 5 HL LCK AXSOS BN STRL 3.5/4 437130S	C1713	SUPPLY/IMPLANTS	"$16,366.00"	Outpatient	"$8,183.00"	"$1,365.15"	"$8,952.20"	"$10,916.12"	"$6,546.40"	Not Applicable	"$5,728.10"	"$11,456.20"	"$1,365.15"	"$11,456.20"
00003-4522-11 - elotuzumab 400 mg Powd	J9176	PHARMACY	"$13,765.00"	Outpatient	"$6,882.50"	$6.46	"$8,947.25"	"$9,181.26"	"$5,506.00"	Not Applicable	"$4,817.75"	"$9,635.50"	$6.46	"$9,635.50"
00173-0881-01 - mepolizumab 100 mg Powd	J2182	PHARMACY	"$16,342.00"	Outpatient	"$8,171.00"	$29.08	"$8,939.07"	"$10,900.11"	"$6,536.80"	Not Applicable	"$5,719.70"	"$11,439.40"	$29.08	"$11,439.40"
KIT REPR 4 BTN DRL PIN INSRTR LG EYLT NDL SHLDR PECTORALIS AR-2269		STERILE SUPPLY	"$16,341.00"	Outpatient	"$8,170.50"	Not Applicable	"$8,938.53"	"$10,899.45"	"$6,536.40"	Not Applicable	"$5,719.35"	"$11,438.70"	"$5,719.35"	"$11,438.70"
HEAD FEMORAL ARTICUL/EZE BIOLOX DELTA TITANIUM +8.5 MM 12/14 136536730	C1776	SUPPLY/IMPLANTS	"$16,318.00"	Outpatient	"$8,159.00"	Not Applicable	"$8,925.95"	"$10,884.11"	"$6,527.20"	Not Applicable	"$5,711.30"	"$11,422.60"	"$5,711.30"	"$11,422.60"
BSPLT TIB 1 RT CMNT GNSS II TI NPOR 71420176	C1776	SUPPLY/IMPLANTS	"$16,316.00"	Outpatient	"$8,158.00"	Not Applicable	"$8,924.85"	"$10,882.77"	"$6,526.40"	Not Applicable	"$5,710.60"	"$11,421.20"	"$5,710.60"	"$11,421.20"
PLT 145MM 22MM STD XLNG RDS LT VOLR DIST SS 6 HLE/HD 10 HL 02.111.681S	C1713	SUPPLY/IMPLANTS	"$16,316.00"	Outpatient	"$8,158.00"	"$1,365.15"	"$8,924.85"	"$10,882.77"	"$6,526.40"	Not Applicable	"$5,710.60"	"$11,421.20"	"$1,365.15"	"$11,421.20"
HEAD FEM L+5MM 36MM 12/14 TPR ART/EZE BLX D TI HIP TL STAB 1365-36-720	C1776	SUPPLY/IMPLANTS	"$16,315.00"	Outpatient	"$8,157.50"	Not Applicable	"$8,924.31"	"$10,882.11"	"$6,526.00"	Not Applicable	"$5,710.25"	"$11,420.50"	"$5,710.25"	"$11,420.50"
GRAFT SOFT TISSUE ARTHROFLEX FLEXIGRAFT DERMIS L35 MM X W35 AFLEX100	Q4125	PHARMACY	"$16,312.00"	Outpatient	"$8,156.00"	Not Applicable	"$8,922.66"	"$10,880.10"	"$6,524.80"	Not Applicable	"$5,709.20"	"$11,418.40"	"$5,709.20"	"$11,418.40"
CMNT BN HYDROSET BN SUB CA PHOS 10CC INJ 7943910		SUPPLY/IMPLANTS	"$16,301.00"	Outpatient	"$8,150.50"	Not Applicable	"$8,916.65"	"$10,872.77"	"$6,520.40"	Not Applicable	"$5,705.35"	"$11,410.70"	"$5,705.35"	"$11,410.70"
GFT VASC 80CM 6MM GORE THNWL HEP PROPATEN PTFE REM RING HT066080A	C1768	SUPPLY/IMPLANTS	"$16,286.00"	Outpatient	"$8,143.00"	Not Applicable	"$8,908.44"	"$10,862.76"	"$6,514.40"	Not Applicable	"$5,700.10"	"$11,400.20"	"$5,700.10"	"$11,400.20"
KIT FRACTURE IVAS L15 MM OD10 GA STERILE LATEX FREE DISPOSAB 0808-015-800		STERILE SUPPLY	"$16,282.00"	Outpatient	"$8,141.00"	Not Applicable	"$8,906.25"	"$10,860.09"	"$6,512.80"	Not Applicable	"$5,698.70"	"$11,397.40"	"$5,698.70"	"$11,397.40"
KIT FRACTURE IVAS L15 MM OD11 GA STERILE LATEX FREE DISPOSAB 0808-115-800		STERILE SUPPLY	"$16,282.00"	Outpatient	"$8,141.00"	Not Applicable	"$8,906.25"	"$10,860.09"	"$6,512.80"	Not Applicable	"$5,698.70"	"$11,397.40"	"$5,698.70"	"$11,397.40"
HEAD RADL 24MM ALIGN COCR SD LD HBRD DSGN UNQ ALGN ADJ LCK ALN-RHI-240	C1776	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	Not Applicable	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$5,698.00"	"$11,396.00"
CASE INST 3.5/6.5MM PERIART SCR LID 234804500	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 28CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-280	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 30CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-300	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 32CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-320	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 34CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-340	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 36CM 9MM ENTRY VERSANAIL TMX FEM TROCH RT 181409360	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 38CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-380	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 40CM 9MM 5D UNV VERSANAIL TMX FEM TROCH RT 1814-09-400	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 42CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-420	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 44CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-440	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 46CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-460	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 48CM 9MM UNV VERSANAIL TMX FEM TROCH RT 1814-09-480	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 50CM 9MM UNV ANTGRD ENTRY VERSANAIL TMX RT TROCH FEM 1814-09-500	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 28CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-280	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 30CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-300	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 32CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-320	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 34CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-340	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 36CM 11MM UNV VERSANAIL TMX FEM TROCH RT STRL 181411360	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 38CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-380	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 40CM 11MM ENTRY VERSANAIL TMX FEM TROCH RT 181411400	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 42CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-420	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 46CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-460	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 48CM 11MM UNV VERSANAIL TMX FEM TROCH RT 1814-11-480	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 50CM 11MM UNV ANTGRD ENTRY VERSANAIL TMX RT TROCH 1814-11-500	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 28CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-280	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 30CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-300	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 32CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-320	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 34CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-340	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 36CM 13MM UNV ENTRY VERSANAIL TMX FEM TROCH RT 1814-13-360	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 38CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-380	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 42CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-420	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 44CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-440	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 46CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-460	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 48CM 13MM UNV VERSANAIL TMX FEM TROCH RT 1814-13-480	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 50CM 13MM UNV ANTGRD ENTRY VERSANAIL TMX RT TROCH 1814-13-500	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 28CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-280	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 30CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-300	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 32CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-320	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 34CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-340	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 36CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-360	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 38CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-380	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 46CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-460	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 48CM 9MM UNV VERSANAIL TMX FEM TROCH LT 1815-09-480	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 50CM 9MM UNV ANTGRD ENTRY VERSANAIL TMX LT TROCH FEM 1815-09-500	C1713	SUPPLY/IMPLANTS	"$16,280.00"	Outpatient	"$8,140.00"	"$1,365.15"	"$8,905.16"	"$10,858.76"	"$6,512.00"	Not Applicable	"$5,698.00"	"$11,396.00"	"$1,365.15"	"$11,396.00"
NAIL IM 28CM 11MM UNV