{"File Summary":[{"Hospital Name":"St Josephs Hospital - Savannah","Prices Posted And Effective":"1/1/2021 12:00:00 AM","Gross Charge":"This section presents the standard gross charge for items and services.","Discounted Cash Price":"This section presents information regarding discounted cash pricing for those patients who decide to pay without insurance coverage.","Inpatient De-identified Negotiated Charge":"This section presents the de-identified minimum and maximum charge for items, services, and service packages that occur in the inpatient setting.","Inpatient Payer Specific Charge":"This section presents the payer specific negotiated charge for items, services, and service packages that occur in the inpatient setting.","Outpatient De-identified Negotiated Charge":"This section presents the de-identified minimum And maximum charge For items, services, And service packages that occur In the outpatient setting.","Outpatient Payer Specific Charge":"This section presents the payer specific negotiated charge for items, services, and service packages that occur in the outpatient setting."}],"Gross Charges":[{"Itemcode":"65100001","Description":"ED Level 1 Visit","CDM Revenue Code":"450","CDM HCPCS":"99281","Standard Price":271.0},{"Itemcode":"65100003","Description":"ED Levl-Critical Care 30-74MIN","CDM Revenue Code":"450","CDM HCPCS":"99291","Standard Price":2677.0},{"Itemcode":"65100004","Description":"ED Level 3 Visit","CDM Revenue Code":"450","CDM HCPCS":"99283","Standard Price":776.0},{"Itemcode":"65100005","Description":"ED Level 4 Visit","CDM Revenue Code":"450","CDM HCPCS":"99284","Standard Price":1048.0},{"Itemcode":"65100006","Description":"ED Level 5 Visit","CDM Revenue Code":"450","CDM HCPCS":"99285","Standard Price":1847.0},{"Itemcode":"65100096","Description":"ED Level 2 Visit","CDM Revenue Code":"450","CDM HCPCS":"99282","Standard Price":518.0},{"Itemcode":"65100120","Description":"ED Levl-Critical Care Add'l 30","CDM Revenue Code":"450","CDM HCPCS":"99292","Standard Price":1338.0},{"Itemcode":"65100306","Description":"E.D. Discharge for Insurance","CDM Revenue Code":"450","CDM HCPCS":"99281","Standard Price":1.0},{"Itemcode":"0130","Description":"Attempted Stereotactic Bx","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"0511","Description":"CLINIC ESTABLISHED PT LEVEL I","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"0512","Description":"CLINIC ESTABLISHED PT LEVEL V","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"0513","Description":"CLINIC ESTABLISHED PT LEVEL IV","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"0514","Description":"CLINIC ESTABLISHED PT LEVELIII","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"0515","Description":"CLINIC ESTABLISHED PT LEVEL II","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"61552991","Description":"OB Clinic Visit I","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"61552992","Description":"OB Clinic Visit Ii","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"61552993","Description":"OB Clinic Visit Iii","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"61552994","Description":"OB Clinic Visit Iv","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"61552995","Description":"OB Clinic Visit V","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"61555720","Description":"Resuscitation: Neonatal Comp","CDM Revenue Code":"480","CDM HCPCS":"99465","Standard Price":4396.0},{"Itemcode":"63200092","Description":"Caloric Vstbl Tst Rec Bi Bix4","CDM Revenue Code":"471","CDM HCPCS":"92537","Standard Price":876.0},{"Itemcode":"63200093","Description":"Caloric Vstbl Tst Rec Bi Mono2","CDM Revenue Code":"471","CDM HCPCS":"92538","Standard Price":438.0},{"Itemcode":"63200094","Description":"CaloricVstblTst Rec Bi Bi LTD3","CDM Revenue Code":"471","CDM HCPCS":"92537","Standard Price":876.0},{"Itemcode":"63200095","Description":"CaloricVstblTst RecBi MonoLtd1","CDM Revenue Code":"471","CDM HCPCS":"92538","Standard Price":438.0},{"Itemcode":"63600025","Description":"SMOKING CESS INTERMED 3-10MIN","CDM Revenue Code":"942","CDM HCPCS":"99406","Standard Price":85.0},{"Itemcode":"63600026","Description":"SMOKING CESS INTENSIVE >10MIN","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":85.0},{"Itemcode":"63601001","Description":"Palliative Care Clinic Lvl 1","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"63601002","Description":"Palliative Care Clinic Lvl 2","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"63601003","Description":"Palliative Care Clinic Lvl 3","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"63601004","Description":"Palliative Care Clinic Lvl 4","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"63601005","Description":"Palliative Care Clinic Lvl 5","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"63800008","Description":"Smoking Cess w/sympt 3-10MIN","CDM Revenue Code":"942","CDM HCPCS":"99406","Standard Price":63.0},{"Itemcode":"64100190","Description":"Or Clinic Visit V","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"64504740","Description":"Peg Button: Removal","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"64505039","Description":"Cdd Clinic Level 1","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"64557104","Description":"Transplant Clinic Consult Pre","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"64557105","Description":"Transplant Clinic F/Up","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"64600065","Description":"Clinic Visit I","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"64605540","Description":"Tilt Table","CDM Revenue Code":"480","CDM HCPCS":"93660","Standard Price":6947.0},{"Itemcode":"65100024","Description":"Follow Up Visit Ed","CDM Revenue Code":"450","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"68201001","Description":"Genetic Counseling Visit I","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"68201002","Description":"Genetic Counseling Visit Ii","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"68201003","Description":"Genetic Counseling Visit Iii","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"68201004","Description":"Genetic Counseling Visit Iv","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"68201005","Description":"Genetic Counseling Visit V","CDM Revenue Code":"519","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"68300300","Description":"Prostate Seed Plan Visit","CDM Revenue Code":"510","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"71702800","Description":"Special Proc Op Clinic I","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"71705540","Description":"Tilt Table","CDM Revenue Code":"480","CDM HCPCS":"93660","Standard Price":6947.0},{"Itemcode":"72050001","Description":"Clinic Lvl I Est - up to 30min","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"72050002","Description":"Clinic Lvl II Est - 31 - 60Min","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"72050003","Description":"Clinic Lvl III Est > 60 min","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"72050130","Description":"Valve Clinic - Initial Eval","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"72050131","Description":"Valve Clinic- Reconsult","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"72050132","Description":"Valve Clinic-Ini Eval PLUS CC","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"72050140","Description":"Valve Clinic-1 WK F-U VISIT","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"72050150","Description":"Valve Clin-1 MO/1YR F-U VISIT","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"72050160","Description":"Valve Clinic-Hospital Consult","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"72205325","Description":"Intracardiac Echo","CDM Revenue Code":"480","CDM HCPCS":"93662","Standard Price":1684.0},{"Itemcode":"73100511","Description":"RT Clinic I","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"74201001","Description":"Clinic 1","CDM Revenue Code":"510","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"74201002","Description":"Clinic II","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"74201025","Description":"SMOKING CESS W/O SYMP 3-10 MIN","CDM Revenue Code":"942","CDM HCPCS":"99406","Standard Price":76.0},{"Itemcode":"74201026","Description":"SMOKING CESS W/OSYMP >10 MIN","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":70.0},{"Itemcode":"74201027","Description":"Smoking Cess w/ Symp 3-10MN","CDM Revenue Code":"942","CDM HCPCS":"99406","Standard Price":76.0},{"Itemcode":"74201028","Description":"Smoking Cess w/ Symp >10MIN","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":76.0},{"Itemcode":"74201035","Description":"SBG SMOK CES INT>10MIN 1 ON 1","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":70.0},{"Itemcode":"74220025","Description":"Smoking Cess w/o Sym 3-10MIN","CDM Revenue Code":"942","CDM HCPCS":"99406","Standard Price":76.0},{"Itemcode":"74220026","Description":"Smoking Cess w/o Sym >10MIN","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":76.0},{"Itemcode":"74221001","Description":"Anticoag Clinic 1 Bluffton","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"74221002","Description":"Anticoag Clinic Ii Bluffton","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"74221003","Description":"Anticoag Clinic III Bluffton","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":300.0},{"Itemcode":"74221004","Description":"Anticoag Clinic IV Bluffton","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"74221005","Description":"Anticoag Clinic V Bluffton","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"74221027","Description":"Smoking Cess w/sympt 3-10MIN","CDM Revenue Code":"942","CDM HCPCS":"99406","Standard Price":63.0},{"Itemcode":"74221028","Description":"Smoking Cess w/ Symp >10MIN","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":73.0},{"Itemcode":"74221035","Description":"SBG SMOK CES INT>10MIN 1 ON 1","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":66.34},{"Itemcode":"74221036","Description":"SBG SMOK CES INT>10MIN 12WK","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":440.61},{"Itemcode":"74221037","Description":"SBG SMOK CES INT>10MIN 4WK","CDM Revenue Code":"942","CDM HCPCS":"99407","Standard Price":85.61},{"Itemcode":"74401031","Description":"Cit Clinic 1","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"74401035","Description":"Gilenya Clinic/Cit Clinic 5","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"75100016","Description":"Canalith Repositioning","CDM Revenue Code":"420","CDM HCPCS":"95992","Standard Price":104.0},{"Itemcode":"75100052","Description":"Biofeedback Pelvic 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"90912","Standard Price":130.0},{"Itemcode":"75100053","Description":"Biofeedback Pelvic Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"90913","Standard Price":115.0},{"Itemcode":"75102004","Description":"ROM","CDM Revenue Code":"420","CDM HCPCS":"95851","Standard Price":491.0},{"Itemcode":"75102209","Description":"Dressing Change","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"75110052","Description":"Biofeedback Pelvic 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"90912","Standard Price":130.0},{"Itemcode":"75110053","Description":"Biofeedback Pelvic Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"90913","Standard Price":115.0},{"Itemcode":"75112004","Description":"ROM","CDM Revenue Code":"420","CDM HCPCS":"95851","Standard Price":491.0},{"Itemcode":"75140016","Description":"Canalith Repositioning","CDM Revenue Code":"420","CDM HCPCS":"95992","Standard Price":104.0},{"Itemcode":"75142004","Description":"ROM","CDM Revenue Code":"420","CDM HCPCS":"95851","Standard Price":491.0},{"Itemcode":"75142210","Description":"Dressing Change","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"75150052","Description":"Biofeedback Pelvic 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"90912","Standard Price":130.0},{"Itemcode":"75150053","Description":"Biofeedback Pelvic Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"90913","Standard Price":115.0},{"Itemcode":"75152004","Description":"ROM","CDM Revenue Code":"420","CDM HCPCS":"95851","Standard Price":491.0},{"Itemcode":"75160052","Description":"Biofeedback Pelvic 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"90912","Standard Price":130.0},{"Itemcode":"75160053","Description":"Biofeedback Pelvic Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"90913","Standard Price":115.0},{"Itemcode":"75162004","Description":"ROM","CDM Revenue Code":"420","CDM HCPCS":"95851","Standard Price":491.0},{"Itemcode":"75200052","Description":"Biofeedback Pelvic 1st 15 min","CDM Revenue Code":"430","CDM HCPCS":"90912","Standard Price":130.0},{"Itemcode":"75200053","Description":"Biofeedback Pelvic Add 15 min","CDM Revenue Code":"430","CDM HCPCS":"90913","Standard Price":115.0},{"Itemcode":"75202004","Description":"ROM","CDM Revenue Code":"430","CDM HCPCS":"95851","Standard Price":491.0},{"Itemcode":"75202209","Description":"Dressing Change","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"75340001","Description":"SBG SMOK CESS W/OSYMP 3-10 MIN","CDM Revenue Code":"942","CDM HCPCS":"99406","Standard Price":66.0},{"Itemcode":"75375620","Description":"OP Ostomy Clinic","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"75800070","Description":"Chd Cardiac Rehab Phase 2","CDM Revenue Code":"943","CDM HCPCS":"93798","Standard Price":245.0},{"Itemcode":"75800086","Description":"Chd Cardiac Rehab w/o ECG","CDM Revenue Code":"943","CDM HCPCS":"93797","Standard Price":245.0},{"Itemcode":"75800087","Description":"Chd Cardiac Rehab w/o ECG","CDM Revenue Code":"943","CDM HCPCS":"93797","Standard Price":245.0},{"Itemcode":"75800097","Description":"Pulmonary Rehab Each Hour","CDM Revenue Code":"948","CDM HCPCS":"G0424","Standard Price":245.0},{"Itemcode":"75800098","Description":"PAD Rehab Per Session","CDM Revenue Code":"480","CDM HCPCS":"93668","Standard Price":274.0},{"Itemcode":"75800200","Description":"Disease Mgmt Card Rehab Phase2","CDM Revenue Code":"943","CDM HCPCS":"93798","Standard Price":4716.0},{"Itemcode":"76950036","Description":"Cont Ctr Biofeedback","CDM Revenue Code":"940","CDM HCPCS":"90911","Standard Price":176.0},{"Itemcode":"76950039","Description":"Continence Center Management","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"76951053","Description":"Clinic Visit III","CDM Revenue Code":"761","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"76970190","Description":"Established Patient 1","CDM Revenue Code":"510","CDM HCPCS":"G0463","Standard Price":175.0},{"Itemcode":"76970195","Description":"Established Patient 2","CDM Revenue Code":"510","CDM HCPCS":"G0463","Standard Price":250.0},{"Itemcode":"76970200","Description":"Established Patient 3","CDM Revenue Code":"510","CDM HCPCS":"G0463","Standard Price":345.0},{"Itemcode":"76970205","Description":"Established Patient 4","CDM Revenue Code":"510","CDM HCPCS":"G0463","Standard Price":390.0},{"Itemcode":"76970210","Description":"OP Visit Estab Patient Lvl5","CDM Revenue Code":"510","CDM HCPCS":"G0463","Standard Price":480.0},{"Itemcode":"0116","Description":"Digi Mammo Diag Uni RT w/CAD","CDM Revenue Code":"401","CDM HCPCS":"77065","Standard Price":427.0},{"Itemcode":"0129","Description":"Digi Mam Diag Uni LT W/CAD&Mag","CDM Revenue Code":"401","CDM HCPCS":"77065","Standard Price":427.0},{"Itemcode":"0131","Description":"Digi Mam Diag Uni RT W/CAD&Mag","CDM Revenue Code":"401","CDM HCPCS":"77065","Standard Price":427.0},{"Itemcode":"0134","Description":"Digi Mam Diag BI W/CAD&Mag","CDM Revenue Code":"401","CDM HCPCS":"77066","Standard Price":464.0},{"Itemcode":"0138","Description":"SCREEN Mammo Uni LT W/CAD","CDM Revenue Code":"403","CDM HCPCS":"77067","Standard Price":400.0},{"Itemcode":"0139","Description":"SCREEN Mammo Uni RT W/CAD","CDM Revenue Code":"403","CDM HCPCS":"77067","Standard Price":400.0},{"Itemcode":"0143","Description":"SCREEN Mammo BI W/CAD&IMPLANT","CDM Revenue Code":"403","CDM HCPCS":"77067","Standard Price":464.0},{"Itemcode":"0147","Description":"Xray Biopsy Surg Specimen","CDM Revenue Code":"320","CDM HCPCS":"76098","Standard Price":426.0},{"Itemcode":"0163","Description":"SCREEN Mammo BI W/CAD","CDM Revenue Code":"403","CDM HCPCS":"77067","Standard Price":464.0},{"Itemcode":"0212","Description":"Digi Mam Diag BI w/CAD","CDM Revenue Code":"401","CDM HCPCS":"77066","Standard Price":464.0},{"Itemcode":"0221","Description":"Digi Mam Diag Uni RT W/CAD&Mag","CDM Revenue Code":"401","CDM HCPCS":"77065","Standard Price":427.0},{"Itemcode":"0265","Description":"Galactogram","CDM Revenue Code":"320","CDM HCPCS":"77053","Standard Price":750.0},{"Itemcode":"0267","Description":"Galactogram Multi Ducts","CDM Revenue Code":"320","CDM HCPCS":"77054","Standard Price":671.0},{"Itemcode":"2013","Description":"DIAGN BREAST TOMOSYNTHESIS, LT","CDM Revenue Code":"401","CDM HCPCS":"G0279","Standard Price":103.0},{"Itemcode":"2014","Description":"DIAG BREAST TOMOSYNTHESIS, RT","CDM Revenue Code":"401","CDM HCPCS":"G0279","Standard Price":103.0},{"Itemcode":"2015","Description":"DIAGN BREAST TOMOSYNTHESIS, BI","CDM Revenue Code":"401","CDM HCPCS":"G0279","Standard Price":103.0},{"Itemcode":"2115","Description":"Digi Mammo Diag Uni Lt w/CAD","CDM Revenue Code":"401","CDM HCPCS":"77065","Standard Price":427.0},{"Itemcode":"2141","Description":"XR Chest Decubitus/2Vw - Left","CDM Revenue Code":"320","CDM HCPCS":"71046","Standard Price":502.0},{"Itemcode":"2150","Description":"XR Chest Single View","CDM Revenue Code":"320","CDM HCPCS":"71045","Standard Price":475.0},{"Itemcode":"2155","Description":"XR Chest 2V","CDM Revenue Code":"320","CDM HCPCS":"71046","Standard Price":502.0},{"Itemcode":"2156","Description":"XR Chest Decubitus 2Vw - Right","CDM Revenue Code":"320","CDM HCPCS":"71046","Standard Price":502.0},{"Itemcode":"2157","Description":"XR Chest Flouro 2vw Frnt&Latrl","CDM Revenue Code":"320","CDM HCPCS":"71046","Standard Price":502.0},{"Itemcode":"2159","Description":"XR Chest - Lordotic/Sngl Vw","CDM Revenue Code":"320","CDM HCPCS":"71045","Standard Price":475.0},{"Itemcode":"2161","Description":"XR Chest Oblique Projectn 2viw","CDM Revenue Code":"320","CDM HCPCS":"71046","Standard Price":502.0},{"Itemcode":"2162","Description":"XR Chest Portable","CDM Revenue Code":"320","CDM HCPCS":"71045","Standard Price":475.0},{"Itemcode":"6091","Description":"Breast Tomosynthesis Screen-BI","CDM Revenue Code":"403","CDM HCPCS":"77063","Standard Price":63.0},{"Itemcode":"6092","Description":"Breast Tomosynthesis Scrn-Uni","CDM Revenue Code":"403","CDM HCPCS":"77063","Standard Price":54.0},{"Itemcode":"64131617","Description":"Chest Xray - 1 View Frontal","CDM Revenue Code":"320","CDM HCPCS":"71045","Standard Price":475.0},{"Itemcode":"2301","Description":"CT Maxillo Facial W/Contrast","CDM Revenue Code":"351","CDM HCPCS":"70487","Standard Price":2517.0},{"Itemcode":"5070","Description":"CT - Brain W/Contrast","CDM Revenue Code":"351","CDM HCPCS":"70460","Standard Price":2011.0},{"Itemcode":"5075","Description":"CT - Brain W/O Contrast","CDM Revenue Code":"351","CDM HCPCS":"70450","Standard Price":1473.0},{"Itemcode":"5080","Description":"CT - Brain Wo/W Contrast","CDM Revenue Code":"351","CDM HCPCS":"70470","Standard Price":2383.0},{"Itemcode":"5085","Description":"CT Brain Wo Contrast - Stroke","CDM Revenue Code":"351","CDM HCPCS":"70450","Standard Price":1473.0},{"Itemcode":"5086","Description":"CTA Head W/Wo With Ct Head","CDM Revenue Code":"350","CDM HCPCS":"70496","Standard Price":4946.0},{"Itemcode":"5149","Description":"CTA Neck Parathyroid wo/w cont","CDM Revenue Code":"351","CDM HCPCS":"70498","Standard Price":4951.0},{"Itemcode":"5150","Description":"CT Angio Head Wo/W Cont","CDM Revenue Code":"351","CDM HCPCS":"70496","Standard Price":4946.0},{"Itemcode":"5151","Description":"CTA Angio Neck Wo/W Cont","CDM Revenue Code":"351","CDM HCPCS":"70498","Standard Price":4951.0},{"Itemcode":"5235","Description":"CT Spine Cervic Post Myelogram","CDM Revenue Code":"352","CDM HCPCS":"72126","Standard Price":1963.0},{"Itemcode":"5245","Description":"CT maxillofacial w/wo con","CDM Revenue Code":"350","CDM HCPCS":"70488","Standard Price":2598.0},{"Itemcode":"5250","Description":"CT Maxillo Facial W/O Contrast","CDM Revenue Code":"351","CDM HCPCS":"70486","Standard Price":1854.0},{"Itemcode":"5550","Description":"CT Neck W/Contrast","CDM Revenue Code":"351","CDM HCPCS":"70491","Standard Price":2703.0},{"Itemcode":"5555","Description":"CT Neck W/O Contrast","CDM Revenue Code":"351","CDM HCPCS":"70490","Standard Price":1926.0},{"Itemcode":"5560","Description":"CT Neck Wo/W Contrast","CDM Revenue Code":"351","CDM HCPCS":"70492","Standard Price":3072.0},{"Itemcode":"5600","Description":"CT Orbits/Sella/Ear W/Contrast","CDM Revenue Code":"351","CDM HCPCS":"70481","Standard Price":2634.0},{"Itemcode":"5605","Description":"CT-Orbit/Sella/Ear W/OContrast","CDM Revenue Code":"351","CDM HCPCS":"70480","Standard Price":1773.0},{"Itemcode":"5610","Description":"Orbits/Sella/Ear Wo/W Contrast","CDM Revenue Code":"351","CDM HCPCS":"70482","Standard Price":3038.0},{"Itemcode":"5750","Description":"CT Spine Cervical W/Contrast","CDM Revenue Code":"352","CDM HCPCS":"72126","Standard Price":1963.0},{"Itemcode":"5755","Description":"CT Spine Cervical W/O Contrast","CDM Revenue Code":"352","CDM HCPCS":"72125","Standard Price":1526.0},{"Itemcode":"5756","Description":"CT CERVICAL SPINE W/O&W CONTR","CDM Revenue Code":"352","CDM HCPCS":"72127","Standard Price":894.0},{"Itemcode":"0999","Description":"CT Abdomen Kidne Stne W/O C","CDM Revenue Code":"352","CDM HCPCS":"74150","Standard Price":2990.0},{"Itemcode":"2149","Description":"Screening Calcium Scoring","CDM Revenue Code":"350","CDM HCPCS":"75571","Standard Price":184.0},{"Itemcode":"2234","Description":"CT Guid: Needle Place - Head","CDM Revenue Code":"351","CDM HCPCS":"77012","Standard Price":1200.0},{"Itemcode":"2235","Description":"CT Guid Needle Plmnt-Body S&I","CDM Revenue Code":"352","CDM HCPCS":"77012","Standard Price":1200.0},{"Itemcode":"2236","Description":"CT Guid:Needle Place-Extrm S&I","CDM Revenue Code":"350","CDM HCPCS":"77012","Standard Price":1200.0},{"Itemcode":"2250","Description":"Cardiac Ct Gated W/O Contrast","CDM Revenue Code":"350","CDM HCPCS":"75571","Standard Price":1041.0},{"Itemcode":"2700","Description":"CT Heart W/O Dye W/Calc Scorin","CDM Revenue Code":"350","CDM HCPCS":"75571","Standard Price":1041.0},{"Itemcode":"2702","Description":"CCTA W/O Calcium Scoring","CDM Revenue Code":"350","CDM HCPCS":"75574","Standard Price":4728.0},{"Itemcode":"2703","Description":"CCTA W/ Calcium Scoring","CDM Revenue Code":"350","CDM HCPCS":"75574","Standard Price":4728.0},{"Itemcode":"2704","Description":"CCTA Strxr W/O Calcium Scor","CDM Revenue Code":"350","CDM HCPCS":"75574","Standard Price":4728.0},{"Itemcode":"2705","Description":"CCTA Strxr W/Calcium Scor","CDM Revenue Code":"350","CDM HCPCS":"75574","Standard Price":4728.0},{"Itemcode":"2706","Description":"CT Heart Structure/Morphology","CDM Revenue Code":"350","CDM HCPCS":"75572","Standard Price":3095.0},{"Itemcode":"2707","Description":"CCTA W/Contrast","CDM Revenue Code":"350","CDM HCPCS":"75574","Standard Price":4728.0},{"Itemcode":"2708","Description":"CT Chest W/O Super D Protocol","CDM Revenue Code":"350","CDM HCPCS":"76497","Standard Price":1562.0},{"Itemcode":"2709","Description":"CT Chest W/C Super D Protocol","CDM Revenue Code":"350","CDM HCPCS":"76497","Standard Price":1562.0},{"Itemcode":"2764","Description":"CT Abdomen&Pelvis W/O Cont","CDM Revenue Code":"352","CDM HCPCS":"74176","Standard Price":4950.0},{"Itemcode":"2765","Description":"CT Abdomen & Pelvis W Contrast","CDM Revenue Code":"352","CDM HCPCS":"74177","Standard Price":5823.0},{"Itemcode":"2766","Description":"CT Abdomen&Pelvis 1-2 W/WO Con","CDM Revenue Code":"352","CDM HCPCS":"74178","Standard Price":6289.0},{"Itemcode":"3175","Description":"CT -Radiation Tx Planning","CDM Revenue Code":"333","CDM HCPCS":"77014","Standard Price":1761.0},{"Itemcode":"4234","Description":"CT Guidance Tissue Ablation","CDM Revenue Code":"350","CDM HCPCS":"77013","Standard Price":1378.0},{"Itemcode":"5020","Description":"CT Abdomen W/Contrast","CDM Revenue Code":"352","CDM HCPCS":"74160","Standard Price":3025.0},{"Itemcode":"5025","Description":"CT Abdomen W/O Contrast","CDM Revenue Code":"352","CDM HCPCS":"74150","Standard Price":2990.0},{"Itemcode":"5030","Description":"CT Abdomen Wo/W Contrast","CDM Revenue Code":"352","CDM HCPCS":"74170","Standard Price":3361.0},{"Itemcode":"5152","Description":"CT Angio Chest Wo/W Cont","CDM Revenue Code":"352","CDM HCPCS":"71275","Standard Price":4292.0},{"Itemcode":"5153","Description":"CT Angio Pelvis Wo/W Cont","CDM Revenue Code":"352","CDM HCPCS":"72191","Standard Price":4759.0},{"Itemcode":"5154","Description":"CT ANGIO UPR EXTRM W/O&W/DYE L","CDM Revenue Code":"352","CDM HCPCS":"73206","Standard Price":4595.0},{"Itemcode":"5155","Description":"CT Angio Upper Ext Wo/W- Rt","CDM Revenue Code":"352","CDM HCPCS":"73206","Standard Price":4595.0},{"Itemcode":"5157","Description":"CT Angio Lower Ext Wo/W - Lt","CDM Revenue Code":"352","CDM HCPCS":"73706","Standard Price":4156.0},{"Itemcode":"5158","Description":"CT Angio Lower Ext Wo/W - Rt","CDM Revenue Code":"352","CDM HCPCS":"73706","Standard Price":4156.0},{"Itemcode":"5160","Description":"CT Angio Abdomen Wo/W Cont","CDM Revenue Code":"352","CDM HCPCS":"74175","Standard Price":4694.0},{"Itemcode":"5161","Description":"CT Angio Aorta/Bi Iliofem Wo/W","CDM Revenue Code":"352","CDM HCPCS":"75635","Standard Price":5155.0},{"Itemcode":"5162","Description":"CTA Chest Pe Protocol","CDM Revenue Code":"352","CDM HCPCS":"71275","Standard Price":4292.0},{"Itemcode":"5163","Description":"CTA Abdomen & Pelvis W&W/O","CDM Revenue Code":"352","CDM HCPCS":"74174","Standard Price":8463.0},{"Itemcode":"5164","Description":"CTA Chest For Tavr","CDM Revenue Code":"350","CDM HCPCS":"71275","Standard Price":4292.0},{"Itemcode":"5165","Description":"CTA Chest Pulmonary Vein Study","CDM Revenue Code":"350","CDM HCPCS":"71275","Standard Price":4292.0},{"Itemcode":"5166","Description":"CTA CHEST W/CONTRAST","CDM Revenue Code":"350","CDM HCPCS":"71275","Standard Price":4292.0},{"Itemcode":"5167","Description":"CTA ABDOMEN W/CONTRAST","CDM Revenue Code":"350","CDM HCPCS":"74175","Standard Price":4694.0},{"Itemcode":"5168","Description":"CT-Low Dose Lung CA Screen","CDM Revenue Code":"352","CDM HCPCS":"G0297","Standard Price":320.0},{"Itemcode":"5169","Description":"CT-Chest LowDose Lung Followup","CDM Revenue Code":"352","CDM HCPCS":"G0297","Standard Price":320.0},{"Itemcode":"5201","Description":"CT Lower Extrem W/Cont - Rt","CDM Revenue Code":"352","CDM HCPCS":"73701","Standard Price":2324.0},{"Itemcode":"5202","Description":"CT Lower Extrem W/Cont - Bil","CDM Revenue Code":"352","CDM HCPCS":"73701","Standard Price":2556.0},{"Itemcode":"5203","Description":"CT Lower Extrem W/Cont - Lt","CDM Revenue Code":"352","CDM HCPCS":"73701","Standard Price":2324.0},{"Itemcode":"5206","Description":"CT Lower Extrem W/O Cont - Rt","CDM Revenue Code":"352","CDM HCPCS":"73700","Standard Price":1350.0},{"Itemcode":"5207","Description":"CT Lower Extrem W/O Cont - Bil","CDM Revenue Code":"352","CDM HCPCS":"73700","Standard Price":1909.0},{"Itemcode":"5208","Description":"CT Lower Extrem W/O Cont - Lt","CDM Revenue Code":"352","CDM HCPCS":"73700","Standard Price":1350.0},{"Itemcode":"5211","Description":"CT Lower Extrem Wo/W Cont- Rt","CDM Revenue Code":"352","CDM HCPCS":"73702","Standard Price":3634.0},{"Itemcode":"5212","Description":"CT Lower Extrem Wo/W Cont- Bil","CDM Revenue Code":"352","CDM HCPCS":"73702","Standard Price":4867.0},{"Itemcode":"5213","Description":"CT Lower Extrem Wo/W Cont- Lt","CDM Revenue Code":"352","CDM HCPCS":"73702","Standard Price":3634.0},{"Itemcode":"5216","Description":"CT Upper Extrem W/Cont - RT","CDM Revenue Code":"352","CDM HCPCS":"73201","Standard Price":1974.0},{"Itemcode":"5217","Description":"CT Upper Extrem W/Cont - BI","CDM Revenue Code":"352","CDM HCPCS":"73201","Standard Price":3128.0},{"Itemcode":"5218","Description":"CT Upper Extrem W/Cont - LT","CDM Revenue Code":"352","CDM HCPCS":"73201","Standard Price":1974.0},{"Itemcode":"5221","Description":"CT Upper Extrem W/O Cont - Rt","CDM Revenue Code":"352","CDM HCPCS":"73200","Standard Price":1375.0},{"Itemcode":"5222","Description":"CT Upper Extrem W/O Cont - BI","CDM Revenue Code":"352","CDM HCPCS":"73200","Standard Price":1871.0},{"Itemcode":"5223","Description":"CT Upper Extrem W/O Cont - LT","CDM Revenue Code":"352","CDM HCPCS":"73200","Standard Price":1375.0},{"Itemcode":"5226","Description":"CT Upper Extrem Wo/W Cont - RT","CDM Revenue Code":"352","CDM HCPCS":"73202","Standard Price":5444.0},{"Itemcode":"5227","Description":"CT Upper Extrem Wo/W Cont -BI","CDM Revenue Code":"352","CDM HCPCS":"73202","Standard Price":7026.0},{"Itemcode":"5228","Description":"CT Upper Extrem Wo/W Cont - Lt","CDM Revenue Code":"352","CDM HCPCS":"73202","Standard Price":5444.0},{"Itemcode":"5236","Description":"CT Spine Lumbar Post Myelogram","CDM Revenue Code":"352","CDM HCPCS":"72132","Standard Price":2046.0},{"Itemcode":"5237","Description":"CT Spine Thorac Post Myelogram","CDM Revenue Code":"352","CDM HCPCS":"72129","Standard Price":2047.0},{"Itemcode":"5396","Description":"CT Sinus","CDM Revenue Code":"351","CDM HCPCS":"76380","Standard Price":3231.0},{"Itemcode":"5650","Description":"CT Pelvis W/Contrast","CDM Revenue Code":"352","CDM HCPCS":"72193","Standard Price":2573.0},{"Itemcode":"5655","Description":"CT Pelvis W/O Contrast","CDM Revenue Code":"352","CDM HCPCS":"72192","Standard Price":1549.0},{"Itemcode":"5660","Description":"CT Pelvis Wo/W Contrast","CDM Revenue Code":"352","CDM HCPCS":"72194","Standard Price":3266.0},{"Itemcode":"5760","Description":"CT Spine Lumbar Contrast","CDM Revenue Code":"352","CDM HCPCS":"72132","Standard Price":2046.0},{"Itemcode":"5765","Description":"CT Spine Lumbar W/O Contrast","CDM Revenue Code":"352","CDM HCPCS":"72131","Standard Price":1584.0},{"Itemcode":"5770","Description":"CT LUMBAR SPINE W/WO CNTRST","CDM Revenue Code":"352","CDM HCPCS":"72133","Standard Price":3800.0},{"Itemcode":"5775","Description":"CT Spine Thoracic W/Contrast","CDM Revenue Code":"352","CDM HCPCS":"72129","Standard Price":2047.0},{"Itemcode":"5780","Description":"CT Spine Thoracic W/O Contrast","CDM Revenue Code":"352","CDM HCPCS":"72128","Standard Price":1627.0},{"Itemcode":"5785","Description":"CT THORAC SPINE W/O&W CONTR","CDM Revenue Code":"352","CDM HCPCS":"72130","Standard Price":894.0},{"Itemcode":"5800","Description":"Stereotaxis","CDM Revenue Code":"352","CDM HCPCS":"77011","Standard Price":1378.0},{"Itemcode":"5850","Description":"CT Thorax W/Contrast","CDM Revenue Code":"352","CDM HCPCS":"71260","Standard Price":2581.0},{"Itemcode":"5855","Description":"CT-Thorax W/O Contrast","CDM Revenue Code":"352","CDM HCPCS":"71250","Standard Price":1562.0},{"Itemcode":"5860","Description":"CT Thorax Wo/W Contrast","CDM Revenue Code":"352","CDM HCPCS":"71270","Standard Price":3120.0},{"Itemcode":"68300019","Description":"CT Guidance","CDM Revenue Code":"333","CDM HCPCS":"77014","Standard Price":1761.0},{"Itemcode":"68300029","Description":"SRS CT Guidance, Ajnc Code","CDM Revenue Code":"333","CDM HCPCS":"77014","Standard Price":1761.0},{"Itemcode":"68300175","Description":"CT Phys Plcmt Rad Fields","CDM Revenue Code":"333","CDM HCPCS":"77014","Standard Price":1761.0},{"Itemcode":"71500060","Description":"CTA Calcium Scoring - Screen","CDM Revenue Code":"350","CDM HCPCS":"75571","Standard Price":100.0},{"Itemcode":"71555157","Description":"CT Angio Lower Ext Wo/W - Lt","CDM Revenue Code":"352","CDM HCPCS":"73706","Standard Price":4156.0},{"Itemcode":"71555158","Description":"CT Angio Lower Ext Wo/W - Rt","CDM Revenue Code":"352","CDM HCPCS":"73706","Standard Price":4156.0},{"Itemcode":"6200","Description":"Carotid:Bil DuplxXtracan Scan","CDM Revenue Code":"921","CDM HCPCS":"93880","Standard Price":1747.0},{"Itemcode":"6206","Description":"Carotid: Unilat - Rt","CDM Revenue Code":"921","CDM HCPCS":"93882","Standard Price":1306.0},{"Itemcode":"6208","Description":"Carotid: Unilat - Lt","CDM Revenue Code":"921","CDM HCPCS":"93882","Standard Price":1306.0},{"Itemcode":"6910","Description":"US Transcranial Art, Complete","CDM Revenue Code":"921","CDM HCPCS":"93886","Standard Price":1927.0},{"Itemcode":"6911","Description":"XTRACRANL DuplxUNI/LTD Scan","CDM Revenue Code":"921","CDM HCPCS":"93882","Standard Price":1306.0},{"Itemcode":"72102500","Description":"IVUS Ea Addtl Vessel","CDM Revenue Code":"480","CDM HCPCS":"92979","Standard Price":5645.0},{"Itemcode":"72106650","Description":"IVUS","CDM Revenue Code":"480","CDM HCPCS":"92978","Standard Price":11283.0},{"Itemcode":"72300014","Description":"Echocardiogram M Mode","CDM Revenue Code":"480","CDM HCPCS":"93308","Standard Price":829.0},{"Itemcode":"72300015","Description":"Echocardiography (Limited)","CDM Revenue Code":"480","CDM HCPCS":"93308","Standard Price":829.0},{"Itemcode":"72300016","Description":"Echocardiogram M Mode2D","CDM Revenue Code":"483","CDM HCPCS":"93307","Standard Price":985.0},{"Itemcode":"72300017","Description":"Doppler Echo Limited","CDM Revenue Code":"480","CDM HCPCS":"93321","Standard Price":214.0},{"Itemcode":"72300018","Description":"Doppler Echo Complete","CDM Revenue Code":"480","CDM HCPCS":"93320","Standard Price":351.0},{"Itemcode":"72300035","Description":"Echo Transesophageal","CDM Revenue Code":"483","CDM HCPCS":"93312","Standard Price":1614.0},{"Itemcode":"72300036","Description":"Tee Transesopha Echo-Or","CDM Revenue Code":"483","CDM HCPCS":"93312","Standard Price":1614.0},{"Itemcode":"72300040","Description":"Doppler Color Flow","CDM Revenue Code":"480","CDM HCPCS":"93325","Standard Price":359.0},{"Itemcode":"72300044","Description":"Stress Echocardiography","CDM Revenue Code":"483","CDM HCPCS":"93350","Standard Price":3536.0},{"Itemcode":"72300045","Description":"Stress Echo W/ Contin Monitor","CDM Revenue Code":"480","CDM HCPCS":"93351","Standard Price":3704.0},{"Itemcode":"72300048","Description":"Echo M-Mode/Doppler/Color","CDM Revenue Code":"483","CDM HCPCS":"93306","Standard Price":1576.0},{"Itemcode":"72300115","Description":"Echocardiography (Limited) W/C","CDM Revenue Code":"480","CDM HCPCS":"93308","Standard Price":829.0},{"Itemcode":"72300500","Description":"Echocardiogram M Mode2D W/Cont","CDM Revenue Code":"480","CDM HCPCS":"93307","Standard Price":2021.0},{"Itemcode":"72300501","Description":"Echocardiogram M Mode2D W/Bubb","CDM Revenue Code":"480","CDM HCPCS":"93307","Standard Price":2021.0},{"Itemcode":"72306606","Description":"Echo Transthoracic Comp; congn","CDM Revenue Code":"483","CDM HCPCS":"C8921","Standard Price":3020.0},{"Itemcode":"0058","Description":"US Guidance Needle Plcmnt S&I","CDM Revenue Code":"402","CDM HCPCS":"76942","Standard Price":1884.0},{"Itemcode":"0192","Description":"US Extrem Nonvascular Complete","CDM Revenue Code":"402","CDM HCPCS":"76881","Standard Price":912.0},{"Itemcode":"0193","Description":"US Extrem Nonvascular Limited","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"0201","Description":"US Soft Tissue Chest Wall","CDM Revenue Code":"402","CDM HCPCS":"76604","Standard Price":762.0},{"Itemcode":"0202","Description":"US Soft Tissue Upper Back","CDM Revenue Code":"402","CDM HCPCS":"76604","Standard Price":762.0},{"Itemcode":"0203","Description":"US Soft Tissue Lower Back","CDM Revenue Code":"402","CDM HCPCS":"76705","Standard Price":718.0},{"Itemcode":"0204","Description":"US Soft Tissue Abdominal Wall","CDM Revenue Code":"402","CDM HCPCS":"76705","Standard Price":718.0},{"Itemcode":"0205","Description":"US Soft Tiss Pelvic Wall-LTD","CDM Revenue Code":"402","CDM HCPCS":"76857","Standard Price":1030.0},{"Itemcode":"0206","Description":"US Soft Tissue Buttock-LTD","CDM Revenue Code":"402","CDM HCPCS":"76857","Standard Price":1030.0},{"Itemcode":"0207","Description":"US Soft Tissue Neck","CDM Revenue Code":"402","CDM HCPCS":"76536","Standard Price":747.0},{"Itemcode":"0208","Description":"US Retroperitoneal Limited","CDM Revenue Code":"402","CDM HCPCS":"76775","Standard Price":699.0},{"Itemcode":"0209","Description":"US Doppler Transplanted Kidney","CDM Revenue Code":"402","CDM HCPCS":"76776","Standard Price":693.0},{"Itemcode":"0274","Description":"US Breast Complete LFT","CDM Revenue Code":"402","CDM HCPCS":"76641","Standard Price":906.0},{"Itemcode":"0275","Description":"US Breast Complete - RT","CDM Revenue Code":"402","CDM HCPCS":"76641","Standard Price":906.0},{"Itemcode":"0276","Description":"US Breast Complete - BI","CDM Revenue Code":"402","CDM HCPCS":"76641","Standard Price":906.0},{"Itemcode":"0277","Description":"US Breast Limited LT","CDM Revenue Code":"402","CDM HCPCS":"76642","Standard Price":838.0},{"Itemcode":"0278","Description":"US Breast Limited - RT","CDM Revenue Code":"402","CDM HCPCS":"76642","Standard Price":838.0},{"Itemcode":"0279","Description":"US Breast Limited BI","CDM Revenue Code":"402","CDM HCPCS":"76642","Standard Price":838.0},{"Itemcode":"0280","Description":"US Extremity Non-Vasc LTD - LT","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"0281","Description":"US Extremity Non-Vasc LTD - RT","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"2931","Description":"US Transvag: Pregnant Uterus","CDM Revenue Code":"402","CDM HCPCS":"76817","Standard Price":759.0},{"Itemcode":"3450","Description":"US Guidance- Abcess Drainage","CDM Revenue Code":"402","CDM HCPCS":"76942","Standard Price":1884.0},{"Itemcode":"3453","Description":"US Ob Follow Up per Fetus","CDM Revenue Code":"402","CDM HCPCS":"76816","Standard Price":693.0},{"Itemcode":"5259","Description":"US Guidance Non-vascular","CDM Revenue Code":"402","CDM HCPCS":"76942","Standard Price":1884.0},{"Itemcode":"5300","Description":"Duplx Flow Pelvic Vasc-Compl","CDM Revenue Code":"921","CDM HCPCS":"93975","Standard Price":999.0},{"Itemcode":"5302","Description":"Intraop Venous Doppler - L Leg","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"5304","Description":"Intraop Venous Doppler - R Leg","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6010","Description":"US- Abdomen General (Complete)","CDM Revenue Code":"402","CDM HCPCS":"76700","Standard Price":787.0},{"Itemcode":"6020","Description":"US - Abdomen Limited","CDM Revenue Code":"402","CDM HCPCS":"76705","Standard Price":718.0},{"Itemcode":"6030","Description":"DuplxAbdomen Vasc Complete","CDM Revenue Code":"921","CDM HCPCS":"93975","Standard Price":999.0},{"Itemcode":"6031","Description":"US Exam - AAA Screen","CDM Revenue Code":"402","CDM HCPCS":"76706","Standard Price":696.0},{"Itemcode":"6035","Description":"DuplxTesticular Vasc Study","CDM Revenue Code":"921","CDM HCPCS":"93975","Standard Price":999.0},{"Itemcode":"6040","Description":"Aorta: Duplx Scan W/Graft Eval","CDM Revenue Code":"921","CDM HCPCS":"93978","Standard Price":595.0},{"Itemcode":"6050","Description":"US Guided Amniocentesis S&I","CDM Revenue Code":"402","CDM HCPCS":"76946","Standard Price":872.0},{"Itemcode":"6060","Description":"Aorta Abdomen Deep","CDM Revenue Code":"402","CDM HCPCS":"76705","Standard Price":718.0},{"Itemcode":"6070","Description":"US - Appendix","CDM Revenue Code":"402","CDM HCPCS":"76705","Standard Price":718.0},{"Itemcode":"6080","Description":"ART DUPLX BPG UPPER EXTR -BI","CDM Revenue Code":"921","CDM HCPCS":"93930","Standard Price":2113.0},{"Itemcode":"6083","Description":"Art Duplex Upper Extr - LT/LTD","CDM Revenue Code":"921","CDM HCPCS":"93931","Standard Price":1388.0},{"Itemcode":"6084","Description":"Art Duplex BPG Upper Extr - BI","CDM Revenue Code":"921","CDM HCPCS":"93930","Standard Price":2113.0},{"Itemcode":"6086","Description":"Art Duplex Upper Extr - RT/LTD","CDM Revenue Code":"921","CDM HCPCS":"93931","Standard Price":1388.0},{"Itemcode":"6090","Description":"DUPLEX ART LOWER EXT BIL","CDM Revenue Code":"921","CDM HCPCS":"93925","Standard Price":910.0},{"Itemcode":"6096","Description":"ART DUPLEX LOWER EXTR - RT/LTD","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"6098","Description":"ART DUPLEX LOWER EXTR - LT/LTD","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"6220","Description":"US - Chest Localize","CDM Revenue Code":"402","CDM HCPCS":"76604","Standard Price":762.0},{"Itemcode":"6300","Description":"US - Diaphragm","CDM Revenue Code":"402","CDM HCPCS":"76705","Standard Price":718.0},{"Itemcode":"6331","Description":"US Guided Pseudoaneurysm Inje","CDM Revenue Code":"402","CDM HCPCS":"76942","Standard Price":1884.0},{"Itemcode":"6351","Description":"US LTD Non-Vasc Extremity: RT","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"6353","Description":"US LTD NonVasc Extremity: LT","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"6375","Description":"Duplx Art Groin Complt - BI","CDM Revenue Code":"921","CDM HCPCS":"93925","Standard Price":910.0},{"Itemcode":"6376","Description":"ART DPLX BPG Groin - RT","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"6377","Description":"ART DPLX BPG Groin - LT","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"6400","Description":"Head Neonatal","CDM Revenue Code":"402","CDM HCPCS":"76506","Standard Price":803.0},{"Itemcode":"6401","Description":"US Head and Neck - Adult","CDM Revenue Code":"402","CDM HCPCS":"76536","Standard Price":747.0},{"Itemcode":"6420","Description":"US - Hip Baby","CDM Revenue Code":"402","CDM HCPCS":"76885","Standard Price":1052.0},{"Itemcode":"64400150","Description":"US Guidance","CDM Revenue Code":"402","CDM HCPCS":"76942","Standard Price":1884.0},{"Itemcode":"64502029","Description":"RUS","CDM Revenue Code":"402","CDM HCPCS":"76872","Standard Price":515.0},{"Itemcode":"64600058","Description":"US Guidance Non-vascular","CDM Revenue Code":"402","CDM HCPCS":"76942","Standard Price":1884.0},{"Itemcode":"64608905","Description":"ULTRASOUND GUIDANCE VASCULAR","CDM Revenue Code":"402","CDM HCPCS":"76937","Standard Price":493.0},{"Itemcode":"6501","Description":"US Inguinal Canal - Right","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"6503","Description":"US Inguinal Canal - Left","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"6551","Description":"Jugular Vein Doppler Bilateral","CDM Revenue Code":"921","CDM HCPCS":"93970","Standard Price":1048.0},{"Itemcode":"6552","Description":"Jugular Vein Doppler Uni- Rt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6553","Description":"Jugular Vein Doppler Uni- Lt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6575","Description":"US LIVER LOC S&I","CDM Revenue Code":"402","CDM HCPCS":"76942","Standard Price":1884.0},{"Itemcode":"6600","Description":"OB Biophys ProfileW/ONonStress","CDM Revenue Code":"402","CDM HCPCS":"76819","Standard Price":889.0},{"Itemcode":"6605","Description":"OB Doppler","CDM Revenue Code":"402","CDM HCPCS":"76827","Standard Price":549.0},{"Itemcode":"6608","Description":"US OB Singl Gest 1St Trimester","CDM Revenue Code":"402","CDM HCPCS":"76801","Standard Price":849.0},{"Itemcode":"6609","Description":"OB Comp- 1St Tri- Ea Addl Gest","CDM Revenue Code":"402","CDM HCPCS":"76802","Standard Price":788.0},{"Itemcode":"6610","Description":"US OB Singl Gest-2/3 Trimester","CDM Revenue Code":"402","CDM HCPCS":"76805","Standard Price":735.0},{"Itemcode":"6611","Description":"US OB- 2/3 Tri- Ea Addl Gest","CDM Revenue Code":"402","CDM HCPCS":"76810","Standard Price":714.0},{"Itemcode":"6615","Description":"OB Limited/Emergency/Position","CDM Revenue Code":"402","CDM HCPCS":"76815","Standard Price":578.0},{"Itemcode":"6675","Description":"US Pelvic Complete","CDM Revenue Code":"402","CDM HCPCS":"76856","Standard Price":694.0},{"Itemcode":"6676","Description":"Pelvic US Complete- For Driver","CDM Revenue Code":"402","CDM HCPCS":"76856","Standard Price":694.0},{"Itemcode":"6695","Description":"Pelvic Histosonogram","CDM Revenue Code":"402","CDM HCPCS":"76831","Standard Price":1026.0},{"Itemcode":"6750","Description":"Renal Ultrasound","CDM Revenue Code":"402","CDM HCPCS":"76770","Standard Price":942.0},{"Itemcode":"6780","Description":"DuplxRenal Art Doppler Comp","CDM Revenue Code":"921","CDM HCPCS":"93975","Standard Price":999.0},{"Itemcode":"6801","Description":"Venous: Saphenous Mapping - Rt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6802","Description":"Venous: Saphenous Mapping - Lt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6805","Description":"Venous Duplx:Saphenous Map-BI","CDM Revenue Code":"921","CDM HCPCS":"93970","Standard Price":1048.0},{"Itemcode":"6825","Description":"US Spine","CDM Revenue Code":"402","CDM HCPCS":"76800","Standard Price":1054.0},{"Itemcode":"68300246","Description":"US Prostate Vol for Brachy Tmt","CDM Revenue Code":"402","CDM HCPCS":"76873","Standard Price":379.0},{"Itemcode":"6850","Description":"Intraoperative Ultrasound","CDM Revenue Code":"402","CDM HCPCS":"76998","Standard Price":970.0},{"Itemcode":"6851","Description":"Intra Op Us For D&C","CDM Revenue Code":"402","CDM HCPCS":"76998","Standard Price":970.0},{"Itemcode":"6855","Description":"Intraoperative Us: Extended","CDM Revenue Code":"402","CDM HCPCS":"76998","Standard Price":970.0},{"Itemcode":"6860","Description":"Duplx Art Sma Doppler Comp","CDM Revenue Code":"921","CDM HCPCS":"93975","Standard Price":999.0},{"Itemcode":"6875","Description":"US Testicular Scrotum&Contents","CDM Revenue Code":"402","CDM HCPCS":"76870","Standard Price":1168.0},{"Itemcode":"6881","Description":"US EXT Superficial NonVasc RT","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"6883","Description":"US EXT Superficial NonVasc LT","CDM Revenue Code":"402","CDM HCPCS":"76882","Standard Price":659.0},{"Itemcode":"6895","Description":"US - Thyroid","CDM Revenue Code":"402","CDM HCPCS":"76536","Standard Price":747.0},{"Itemcode":"6920","Description":"Transvaginal Non-Ob Us","CDM Revenue Code":"402","CDM HCPCS":"76830","Standard Price":667.0},{"Itemcode":"6925","Description":"US Transvaginal Add Non-OB","CDM Revenue Code":"402","CDM HCPCS":"76830","Standard Price":667.0},{"Itemcode":"6940","Description":"Venous Extrm Duplx Arm - BI","CDM Revenue Code":"921","CDM HCPCS":"93970","Standard Price":1048.0},{"Itemcode":"6941","Description":"Venous Upper & Lower Extrm Bi","CDM Revenue Code":"921","CDM HCPCS":"93970","Standard Price":1048.0},{"Itemcode":"6946","Description":"Venous Arm Unilat - Rt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6947","Description":"Venous Arm Unilat - Lt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6965","Description":"Venous: Upper Extr Mapping-Bi","CDM Revenue Code":"921","CDM HCPCS":"93970","Standard Price":1048.0},{"Itemcode":"6967","Description":"Venous: Upper Extr Mapping-Rt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6968","Description":"Venous: Upper Extr Mapping-Lt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6970","Description":"Venous Doppler Lower Ext - Rt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6971","Description":"Venous Doppler Lower Ext - Lt","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6972","Description":"Venous Doppler Lower Ext - Bil","CDM Revenue Code":"921","CDM HCPCS":"93970","Standard Price":1048.0},{"Itemcode":"6973","Description":"US Duplex/Reflux Extrem - RT","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"6985","Description":"Venous Doppler Reflux Study-BI","CDM Revenue Code":"921","CDM HCPCS":"93970","Standard Price":2113.0},{"Itemcode":"7052","Description":"Arterial Lower Extre Dig-Rt","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"7053","Description":"Duplx Art LwXtr Dig Compl-BI","CDM Revenue Code":"921","CDM HCPCS":"93925","Standard Price":910.0},{"Itemcode":"7056","Description":"Art Bypass Grft Upper Extr -Rt","CDM Revenue Code":"921","CDM HCPCS":"93931","Standard Price":1388.0},{"Itemcode":"7058","Description":"Arterial Lower Extre Dig-Lt","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"7060","Description":"Art Bypass Grft Upper Extr -LT","CDM Revenue Code":"921","CDM HCPCS":"93931","Standard Price":1388.0},{"Itemcode":"7065","Description":"Art Duplx BPG Lower Extr -Rt","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"7066","Description":"Art Bypass Grft Lower Extr -LT","CDM Revenue Code":"921","CDM HCPCS":"93926","Standard Price":781.0},{"Itemcode":"7067","Description":"Duplx Art Bypas Grf Lwr Ext-Bi","CDM Revenue Code":"921","CDM HCPCS":"93925","Standard Price":910.0},{"Itemcode":"7080","Description":"Arterial Upper Extr Digits -Rt","CDM Revenue Code":"921","CDM HCPCS":"93931","Standard Price":1388.0},{"Itemcode":"7081","Description":"Arterial Upper Extr Digits -Lt","CDM Revenue Code":"921","CDM HCPCS":"93931","Standard Price":1388.0},{"Itemcode":"7098","Description":"US Guidance Vascular Access","CDM Revenue Code":"402","CDM HCPCS":"76937","Standard Price":493.0},{"Itemcode":"7103","Description":"US Duplex/Reflux Extrem - LT","CDM Revenue Code":"921","CDM HCPCS":"93971","Standard Price":833.0},{"Itemcode":"72300046","Description":"Echo TEE for Guidance","CDM Revenue Code":"483","CDM HCPCS":"93355","Standard Price":3200.0},{"Itemcode":"72306506","Description":"Fetal Echocardiogram (M-Mode)","CDM Revenue Code":"402","CDM HCPCS":"76825","Standard Price":1524.0},{"Itemcode":"72306605","Description":"Fetal Echo-Doppler Complete","CDM Revenue Code":"402","CDM HCPCS":"76827","Standard Price":549.0},{"Itemcode":"8905","Description":"ULTRASOUND GUIDANCE VASCULAR","CDM Revenue Code":"402","CDM HCPCS":"76937","Standard Price":493.0},{"Itemcode":"0001","Description":"MRI Brain/Brain Stem Wo/W Con","CDM Revenue Code":"611","CDM HCPCS":"70553","Standard Price":5288.0},{"Itemcode":"0008","Description":"MRI Brain/Brain Stem W/Contr","CDM Revenue Code":"611","CDM HCPCS":"70552","Standard Price":2542.0},{"Itemcode":"0009","Description":"MRI Cervical Spine W/O Cont","CDM Revenue Code":"612","CDM HCPCS":"72141","Standard Price":2295.0},{"Itemcode":"0010","Description":"MRI Spine Cervical W/Contrast","CDM Revenue Code":"612","CDM HCPCS":"72142","Standard Price":4107.0},{"Itemcode":"0024","Description":"MRI Brain/Brain Stem W/O Contr","CDM Revenue Code":"611","CDM HCPCS":"70551","Standard Price":2487.0},{"Itemcode":"0047","Description":"MRI Cervical Spine Wo/W Contr","CDM Revenue Code":"610","CDM HCPCS":"72156","Standard Price":5480.0},{"Itemcode":"0061","Description":"MRI Iacs Wo/W Contrast","CDM Revenue Code":"611","CDM HCPCS":"70553","Standard Price":5288.0},{"Itemcode":"0062","Description":"MRI Pituitary Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"70553","Standard Price":5288.0},{"Itemcode":"0067","Description":"MRI Orbit/Face &/Or Neck W/Wo","CDM Revenue Code":"610","CDM HCPCS":"70543","Standard Price":6439.0},{"Itemcode":"0124","Description":"MRI ORBITS/FACE &OR nECK W/O","CDM Revenue Code":"610","CDM HCPCS":"70540","Standard Price":3167.0},{"Itemcode":"0146","Description":"MRI Orbits/Face &Or Neck W/C","CDM Revenue Code":"610","CDM HCPCS":"70542","Standard Price":3697.0},{"Itemcode":"0160","Description":"MRA Neck W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"70547","Standard Price":1967.0},{"Itemcode":"0161","Description":"MRA Neck W/Contrast","CDM Revenue Code":"610","CDM HCPCS":"70548","Standard Price":4038.0},{"Itemcode":"0162","Description":"MRA Neck Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"70549","Standard Price":4198.0},{"Itemcode":"0164","Description":"MRA Head W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"70544","Standard Price":2022.0},{"Itemcode":"0165","Description":"MRA Head W/Contrast","CDM Revenue Code":"610","CDM HCPCS":"70545","Standard Price":2701.0},{"Itemcode":"0166","Description":"MRA Head Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"70546","Standard Price":4208.0},{"Itemcode":"0006","Description":"MRI Abdomen W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"74181","Standard Price":3550.0},{"Itemcode":"0011","Description":"MRI Chest W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"71550","Standard Price":3539.0},{"Itemcode":"0012","Description":"MRI Lower Ext Jnt Wo/W Cont-Rt","CDM Revenue Code":"610","CDM HCPCS":"73720","Standard Price":5358.0},{"Itemcode":"0014","Description":"MRI Lumbar Spine W/O Cont","CDM Revenue Code":"612","CDM HCPCS":"72148","Standard Price":2339.0},{"Itemcode":"0015","Description":"MRI Lumbar Spine W/Cont","CDM Revenue Code":"612","CDM HCPCS":"72149","Standard Price":3825.0},{"Itemcode":"0016","Description":"MRI Lower Ext Jnt Wo/W Cont-Lt","CDM Revenue Code":"610","CDM HCPCS":"73720","Standard Price":5358.0},{"Itemcode":"0018","Description":"MRI Pelvis W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"72195","Standard Price":3023.0},{"Itemcode":"0020","Description":"MRI Thoracic Spine W/O Cont","CDM Revenue Code":"612","CDM HCPCS":"72146","Standard Price":2521.0},{"Itemcode":"0021","Description":"MRI Thoracic Spine W/Cont","CDM Revenue Code":"612","CDM HCPCS":"72147","Standard Price":5083.0},{"Itemcode":"0022","Description":"MRI Upper Ext W/O Cont -Lt","CDM Revenue Code":"610","CDM HCPCS":"73218","Standard Price":2273.0},{"Itemcode":"0023","Description":"MRI Upper Ext Jnt W/O Cont -Lt","CDM Revenue Code":"610","CDM HCPCS":"73221","Standard Price":2818.0},{"Itemcode":"0030","Description":"MRI Lumbar Spine Wo/W Cont","CDM Revenue Code":"612","CDM HCPCS":"72158","Standard Price":4633.0},{"Itemcode":"0033","Description":"MRI Abdomen Ltd W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"74181","Standard Price":3550.0},{"Itemcode":"0044","Description":"MRA Abdomen Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8902","Standard Price":5753.0},{"Itemcode":"0045","Description":"MRA Chest Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8911","Standard Price":5201.0},{"Itemcode":"0048","Description":"MRI Thoracic Spine Wo/W Contr","CDM Revenue Code":"610","CDM HCPCS":"72157","Standard Price":5480.0},{"Itemcode":"0056","Description":"MRI Temporomandibular Joint","CDM Revenue Code":"610","CDM HCPCS":"70336","Standard Price":4649.0},{"Itemcode":"0070","Description":"MRI Upper Ext Jnt Wo/W Cont-Lt","CDM Revenue Code":"610","CDM HCPCS":"73223","Standard Price":5158.0},{"Itemcode":"0075","Description":"MRI Pelvis Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"72197","Standard Price":6148.0},{"Itemcode":"0076","Description":"MRA Abdomen W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8901","Standard Price":2903.0},{"Itemcode":"0077","Description":"MRI Lower Ext W/O Cont - Lt","CDM Revenue Code":"610","CDM HCPCS":"73718","Standard Price":2892.0},{"Itemcode":"0080","Description":"MRI Upper Ext Wo/W Cont -LT","CDM Revenue Code":"610","CDM HCPCS":"73220","Standard Price":4074.0},{"Itemcode":"0087","Description":"MRA Upper Ext Wo/W Cont - Lt","CDM Revenue Code":"610","CDM HCPCS":"C8936","Standard Price":6171.0},{"Itemcode":"0106","Description":"MRI Lower Ext W/O Cont - Rt","CDM Revenue Code":"610","CDM HCPCS":"73718","Standard Price":2892.0},{"Itemcode":"0107","Description":"MRI Lower Ext W/O Cont - Bi","CDM Revenue Code":"610","CDM HCPCS":"73718","Standard Price":3181.0},{"Itemcode":"0109","Description":"MRI Lower Ext Jnt Wo/W Cont-Bi","CDM Revenue Code":"610","CDM HCPCS":"73720","Standard Price":5894.0},{"Itemcode":"0135","Description":"MRA Upper Extremity W/Cont -Bi","CDM Revenue Code":"610","CDM HCPCS":"C8934","Standard Price":4220.0},{"Itemcode":"0136","Description":"MRA Upper Ext W/Cont - LT","CDM Revenue Code":"610","CDM HCPCS":"C8934","Standard Price":2110.0},{"Itemcode":"0137","Description":"MRA Upper Ext W/Cont - Rt","CDM Revenue Code":"610","CDM HCPCS":"C8934","Standard Price":2110.0},{"Itemcode":"0144","Description":"MRA Chest W/Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8909","Standard Price":4200.0},{"Itemcode":"0145","Description":"MRA Abdomen W/Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8900","Standard Price":3676.0},{"Itemcode":"0148","Description":"MRA CHEST W/O Contrast","CDM Revenue Code":"618","CDM HCPCS":"C8910","Standard Price":3721.0},{"Itemcode":"0170","Description":"MRI Breast Wo/W Cont - Bilat","CDM Revenue Code":"610","CDM HCPCS":"C8908","Standard Price":8000.0},{"Itemcode":"0176","Description":"MRI Breast W/O Cont - Bilat","CDM Revenue Code":"610","CDM HCPCS":"77047","Standard Price":6511.0},{"Itemcode":"0181","Description":"C MRI W/O CONTRAST, MORPH","CDM Revenue Code":"610","CDM HCPCS":"75557","Standard Price":2397.0},{"Itemcode":"0183","Description":"CMRI W/O Con W/Stress Imaging","CDM Revenue Code":"610","CDM HCPCS":"75559","Standard Price":3383.0},{"Itemcode":"0184","Description":"C MRI Morph W/Wo Contrast","CDM Revenue Code":"610","CDM HCPCS":"75561","Standard Price":3353.0},{"Itemcode":"0186","Description":"CMRI W/Wo Con W/Stress Imaging","CDM Revenue Code":"610","CDM HCPCS":"75563","Standard Price":4046.0},{"Itemcode":"0188","Description":"C MRI Velocity Flow Mapping","CDM Revenue Code":"610","CDM HCPCS":"75565","Standard Price":1662.0},{"Itemcode":"0190","Description":"MRI Spectroscopy","CDM Revenue Code":"610","CDM HCPCS":"76390","Standard Price":5364.0},{"Itemcode":"1011","Description":"MRI CHEST W/CONTRAST","CDM Revenue Code":"610","CDM HCPCS":"71551","Standard Price":1577.0},{"Itemcode":"1012","Description":"MRI Chest Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"71552","Standard Price":6223.0},{"Itemcode":"1015","Description":"MRI ABDOMEN LTD W/CON","CDM Revenue Code":"610","CDM HCPCS":"74182","Standard Price":3989.0},{"Itemcode":"1016","Description":"MRI Abdomen Wo/W Contrast","CDM Revenue Code":"610","CDM HCPCS":"74183","Standard Price":6106.0},{"Itemcode":"1017","Description":"MRI Abdomen W/Contrast","CDM Revenue Code":"610","CDM HCPCS":"74182","Standard Price":3989.0},{"Itemcode":"1200","Description":"MRI LWER EXT NOT JNT W/CON LT","CDM Revenue Code":"610","CDM HCPCS":"73719","Standard Price":1630.0},{"Itemcode":"1201","Description":"MRI LWER EXT NOT JNT W/CON RT","CDM Revenue Code":"610","CDM HCPCS":"73719","Standard Price":1630.0},{"Itemcode":"1202","Description":"MRI LWER EXT NOT JNT W/CON BI","CDM Revenue Code":"610","CDM HCPCS":"73719","Standard Price":3258.0},{"Itemcode":"1300","Description":"MRI Lower Ext Jnt W/Cont - LT","CDM Revenue Code":"610","CDM HCPCS":"73722","Standard Price":5223.0},{"Itemcode":"1301","Description":"MRI Lower Ext Jnt W/Cont - Rt","CDM Revenue Code":"610","CDM HCPCS":"73722","Standard Price":5223.0},{"Itemcode":"1302","Description":"MRI Lower Ext Jnt W/Cont - BI","CDM Revenue Code":"610","CDM HCPCS":"73722","Standard Price":6500.0},{"Itemcode":"1303","Description":"MRI Lower Ext Jnt W/O Cont -LT","CDM Revenue Code":"610","CDM HCPCS":"73721","Standard Price":3108.0},{"Itemcode":"1304","Description":"MRI Lower Ext Jnt W/O Cont -RT","CDM Revenue Code":"610","CDM HCPCS":"73721","Standard Price":3108.0},{"Itemcode":"1305","Description":"MRI Lower Ext Jnt W/O Cont -Bi","CDM Revenue Code":"610","CDM HCPCS":"73721","Standard Price":5111.0},{"Itemcode":"1306","Description":"MRI Lower Ext Jnt Wo/W Cont-Lt","CDM Revenue Code":"610","CDM HCPCS":"73723","Standard Price":5662.0},{"Itemcode":"1307","Description":"MRI Lower Ext Jnt Wo/W Cont-Rt","CDM Revenue Code":"610","CDM HCPCS":"73723","Standard Price":5662.0},{"Itemcode":"1308","Description":"MRI Lower Ext Jnt Wo/W Cont-Bi","CDM Revenue Code":"610","CDM HCPCS":"73723","Standard Price":7000.0},{"Itemcode":"1309","Description":"MRA Lower Ext W/O Cont - Lt","CDM Revenue Code":"610","CDM HCPCS":"C8913","Standard Price":5111.0},{"Itemcode":"1310","Description":"MRA Lower Ext W/O Cont - Rt","CDM Revenue Code":"610","CDM HCPCS":"C8913","Standard Price":5111.0},{"Itemcode":"1311","Description":"MRA Lower Ext W/O Cont - Bi","CDM Revenue Code":"610","CDM HCPCS":"C8913","Standard Price":6600.0},{"Itemcode":"1312","Description":"MRA Lower Ext Wo/W Cont - Lt","CDM Revenue Code":"610","CDM HCPCS":"C8914","Standard Price":12186.0},{"Itemcode":"1313","Description":"MRA Lower Ext Wo/W Cont - Rt","CDM Revenue Code":"610","CDM HCPCS":"C8914","Standard Price":12186.0},{"Itemcode":"1314","Description":"MRA Lower Ext Wo/W Cont - BI","CDM Revenue Code":"610","CDM HCPCS":"C8914","Standard Price":13600.0},{"Itemcode":"1315","Description":"MRA Pelvis W/O","CDM Revenue Code":"610","CDM HCPCS":"C8919","Standard Price":2686.0},{"Itemcode":"1316","Description":"MRI Pelvis Ltd W/Contrast","CDM Revenue Code":"610","CDM HCPCS":"72196","Standard Price":5037.0},{"Itemcode":"1317","Description":"MRA Pelvis With Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8918","Standard Price":3846.0},{"Itemcode":"1318","Description":"MRI Abdomen W/O Cont W/Mrcp","CDM Revenue Code":"610","CDM HCPCS":"74181","Standard Price":5365.0},{"Itemcode":"1319","Description":"MRA Pelvis W & W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8920","Standard Price":4231.0},{"Itemcode":"1900","Description":"MRI Upper Ext W/O Cont - RT","CDM Revenue Code":"610","CDM HCPCS":"73218","Standard Price":2273.0},{"Itemcode":"1901","Description":"MRI Upper Ext W/O Cont - Bi","CDM Revenue Code":"610","CDM HCPCS":"73218","Standard Price":2875.0},{"Itemcode":"1902","Description":"MRI UPPR EXT NOT JNT W/CON LT","CDM Revenue Code":"610","CDM HCPCS":"73219","Standard Price":1630.0},{"Itemcode":"1903","Description":"MRI UPPR EXT NOT JNT W/CON RT","CDM Revenue Code":"610","CDM HCPCS":"73219","Standard Price":1630.0},{"Itemcode":"1904","Description":"MRI UPPR EXT NOT JNT W/CON BI","CDM Revenue Code":"610","CDM HCPCS":"73219","Standard Price":3258.0},{"Itemcode":"1905","Description":"MRI Upper Ext Wo/W Cont - Rt","CDM Revenue Code":"610","CDM HCPCS":"73220","Standard Price":4074.0},{"Itemcode":"1906","Description":"MRI Up Ext Nt Jt Wo/WCont - Bi","CDM Revenue Code":"610","CDM HCPCS":"73220","Standard Price":5800.0},{"Itemcode":"1907","Description":"MRI Upper Ext Jnt W/O Cont -Rt","CDM Revenue Code":"610","CDM HCPCS":"73221","Standard Price":2818.0},{"Itemcode":"1908","Description":"MRI Upper Ext Jnt W/O Cont -Bi","CDM Revenue Code":"610","CDM HCPCS":"73221","Standard Price":3200.0},{"Itemcode":"1909","Description":"MRI Upper Ext Jnt W/Cont - Lt","CDM Revenue Code":"610","CDM HCPCS":"73222","Standard Price":4140.0},{"Itemcode":"1910","Description":"MRI Upper Ext Jnt W/Cont - RT","CDM Revenue Code":"610","CDM HCPCS":"73222","Standard Price":4140.0},{"Itemcode":"1911","Description":"MRI Upper Ext Jnt W/Cont - Bi","CDM Revenue Code":"610","CDM HCPCS":"73222","Standard Price":4140.0},{"Itemcode":"1912","Description":"MRI Upper Ext Jnt Wo/W Cont-Rt","CDM Revenue Code":"610","CDM HCPCS":"73223","Standard Price":5158.0},{"Itemcode":"1915","Description":"MRI BREAST UNI W/O CON LT","CDM Revenue Code":"610","CDM HCPCS":"77046","Standard Price":3256.0},{"Itemcode":"1916","Description":"MRI BREAST UNI W/O CON RT","CDM Revenue Code":"610","CDM HCPCS":"77046","Standard Price":3256.0},{"Itemcode":"1917","Description":"MRI BREAST UNI W&W/O CON LT","CDM Revenue Code":"610","CDM HCPCS":"C8905","Standard Price":4000.0},{"Itemcode":"1918","Description":"MRI BREAST UNI W&W/O CON RT","CDM Revenue Code":"610","CDM HCPCS":"C8905","Standard Price":4000.0},{"Itemcode":"2655","Description":"MRI Guided Breast Biopsy S&I","CDM Revenue Code":"610","CDM HCPCS":"77021","Standard Price":1200.0},{"Itemcode":"2659","Description":"MRA Spinal Cord w/Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8931","Standard Price":987.0},{"Itemcode":"2660","Description":"MRA Spinal Cord w/o Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8932","Standard Price":662.0},{"Itemcode":"2662","Description":"MRA Spinal Cord w&w/o Contrast","CDM Revenue Code":"610","CDM HCPCS":"C8933","Standard Price":1116.0},{"Itemcode":"71600180","Description":"Cardiac MRI-Morph W/O Contrast","CDM Revenue Code":"610","CDM HCPCS":"75557","Standard Price":2397.0},{"Itemcode":"0057","Description":"Dexa Bone Density Study","CDM Revenue Code":"320","CDM HCPCS":"77080","Standard Price":173.0},{"Itemcode":"0140","Description":"POST OP HIP 1 VIEW","CDM Revenue Code":"320","CDM HCPCS":"73501","Standard Price":642.0},{"Itemcode":"0142","Description":"XR POST OP PELVIS 1-2 V","CDM Revenue Code":"320","CDM HCPCS":"72170","Standard Price":627.0},{"Itemcode":"0151","Description":"Dexa Bone Dens -Forearm","CDM Revenue Code":"320","CDM HCPCS":"77081","Standard Price":204.0},{"Itemcode":"0199","Description":"Cephalometrics","CDM Revenue Code":"320","CDM HCPCS":"70140","Standard Price":317.0},{"Itemcode":"0766","Description":"Arthrogram Ankle - Lt","CDM Revenue Code":"320","CDM HCPCS":"73615","Standard Price":723.0},{"Itemcode":"0769","Description":"Arthrogram Ankle - Rt","CDM Revenue Code":"320","CDM HCPCS":"73615","Standard Price":723.0},{"Itemcode":"0778","Description":"Arthrogram Knee - Lt","CDM Revenue Code":"320","CDM HCPCS":"73580","Standard Price":1039.0},{"Itemcode":"0781","Description":"Arthrogram Knee - Rt","CDM Revenue Code":"320","CDM HCPCS":"73580","Standard Price":1039.0},{"Itemcode":"0790","Description":"Arthrogram Wrist - Lt","CDM Revenue Code":"320","CDM HCPCS":"73115","Standard Price":332.0},{"Itemcode":"0793","Description":"Arthrogram Wrist - Rt","CDM Revenue Code":"320","CDM HCPCS":"73115","Standard Price":332.0},{"Itemcode":"1211","Description":"XR HIP UNI W/PELVIS 1VIEW","CDM Revenue Code":"320","CDM HCPCS":"73501","Standard Price":642.0},{"Itemcode":"1212","Description":"XR HIP LT W/PELVIS 2-3 VIEWS","CDM Revenue Code":"320","CDM HCPCS":"73502","Standard Price":661.0},{"Itemcode":"1213","Description":"XR HIP UNI W/PELVIS MIN 4VWS","CDM Revenue Code":"320","CDM HCPCS":"73503","Standard Price":717.0},{"Itemcode":"1215","Description":"XR HIPS BI W/PELVIS 3-4 VIEWS","CDM Revenue Code":"320","CDM HCPCS":"73522","Standard Price":1080.0},{"Itemcode":"1216","Description":"XR HIPS BI W/PELVIS MIN5VWS","CDM Revenue Code":"320","CDM HCPCS":"73523","Standard Price":1171.0},{"Itemcode":"1217","Description":"XR HIP RT W/PELVIS 2-3 VIEWS","CDM Revenue Code":"320","CDM HCPCS":"73502","Standard Price":661.0},{"Itemcode":"2035","Description":"AC Joints","CDM Revenue Code":"320","CDM HCPCS":"73050","Standard Price":399.0},{"Itemcode":"2046","Description":"XR Ankle 2 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73600","Standard Price":620.0},{"Itemcode":"2048","Description":"XR Ankle 2 View - Lt","CDM Revenue Code":"320","CDM HCPCS":"73600","Standard Price":620.0},{"Itemcode":"2051","Description":"XR Ankle >=3 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73610","Standard Price":602.0},{"Itemcode":"2053","Description":"XR Ankle >=3 View - Lt","CDM Revenue Code":"320","CDM HCPCS":"73610","Standard Price":602.0},{"Itemcode":"2055","Description":"Arthritis Survey 10 Joints","CDM Revenue Code":"320","CDM HCPCS":"77077","Standard Price":704.0},{"Itemcode":"2120","Description":"Bone Age Survey Studies","CDM Revenue Code":"320","CDM HCPCS":"77072","Standard Price":407.0},{"Itemcode":"2125","Description":"XR Bone Length Studies","CDM Revenue Code":"320","CDM HCPCS":"77073","Standard Price":528.0},{"Itemcode":"2129","Description":"XR Bone Survey Complete","CDM Revenue Code":"320","CDM HCPCS":"77075","Standard Price":1109.0},{"Itemcode":"2166","Description":"XR Chest Ribs >= 3 View - RT","CDM Revenue Code":"320","CDM HCPCS":"71101","Standard Price":648.0},{"Itemcode":"2169","Description":"Chest Ribs Unilat - Lt","CDM Revenue Code":"320","CDM HCPCS":"71101","Standard Price":648.0},{"Itemcode":"2186","Description":"XR - Clavicle: Rt","CDM Revenue Code":"320","CDM HCPCS":"73000","Standard Price":540.0},{"Itemcode":"2188","Description":"XR Clavicle: Lt","CDM Revenue Code":"320","CDM HCPCS":"73000","Standard Price":540.0},{"Itemcode":"2245","Description":"Elbow 2 Views - Rt","CDM Revenue Code":"320","CDM HCPCS":"73070","Standard Price":632.0},{"Itemcode":"2246","Description":"XR Elbow 2 Views - Lt","CDM Revenue Code":"320","CDM HCPCS":"73070","Standard Price":632.0},{"Itemcode":"2310","Description":"XR Extremity Upper Infant RT","CDM Revenue Code":"320","CDM HCPCS":"73092","Standard Price":487.0},{"Itemcode":"2313","Description":"XR Extremity Upper Infant - Lt","CDM Revenue Code":"320","CDM HCPCS":"73092","Standard Price":487.0},{"Itemcode":"2327","Description":"XR Finger(S)/Thumb>=2Views-Rt","CDM Revenue Code":"320","CDM HCPCS":"73140","Standard Price":504.0},{"Itemcode":"2328","Description":"XR Finger(S)/Thumb >=2Views-Lt","CDM Revenue Code":"320","CDM HCPCS":"73140","Standard Price":504.0},{"Itemcode":"2335","Description":"Facial Bones Complete","CDM Revenue Code":"320","CDM HCPCS":"70150","Standard Price":596.0},{"Itemcode":"2344","Description":"XR FEMUR 1 VIEW","CDM Revenue Code":"320","CDM HCPCS":"73551","Standard Price":563.0},{"Itemcode":"2345","Description":"XR FEMUR MIN 2 VIEWS - LT","CDM Revenue Code":"320","CDM HCPCS":"73552","Standard Price":592.0},{"Itemcode":"2346","Description":"XR FEMUR MIN 2 VIEWS - RT","CDM Revenue Code":"320","CDM HCPCS":"73552","Standard Price":592.0},{"Itemcode":"2347","Description":"XR FEMUR MIN 2 VIEWS - BI","CDM Revenue Code":"320","CDM HCPCS":"73552","Standard Price":688.0},{"Itemcode":"2371","Description":"XR Foot 2 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73620","Standard Price":633.0},{"Itemcode":"2373","Description":"XR Foot 2 View Lt","CDM Revenue Code":"320","CDM HCPCS":"73620","Standard Price":633.0},{"Itemcode":"2376","Description":"XR Foot >=3 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73630","Standard Price":667.0},{"Itemcode":"2378","Description":"XR Foot >=3.0 Views Lt","CDM Revenue Code":"320","CDM HCPCS":"73630","Standard Price":667.0},{"Itemcode":"2381","Description":"XR Forearm 2 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73090","Standard Price":570.0},{"Itemcode":"2383","Description":"XR Forearm 2 View - Lt","CDM Revenue Code":"320","CDM HCPCS":"73090","Standard Price":570.0},{"Itemcode":"2401","Description":"XR Hand >=3 Views - Rt","CDM Revenue Code":"320","CDM HCPCS":"73130","Standard Price":559.0},{"Itemcode":"2403","Description":"XR Hand >=3 Views - Lt","CDM Revenue Code":"320","CDM HCPCS":"73130","Standard Price":559.0},{"Itemcode":"2407","Description":"XR HIPS W/PELVIS BI 2 VIEWS","CDM Revenue Code":"320","CDM HCPCS":"73521","Standard Price":963.0},{"Itemcode":"2409","Description":"XR HIPS W/PELVIS BI 3-4 VIEWS","CDM Revenue Code":"320","CDM HCPCS":"73522","Standard Price":1080.0},{"Itemcode":"2426","Description":"XR Humerus >= 2 VIEWS- Rt","CDM Revenue Code":"320","CDM HCPCS":"73060","Standard Price":613.0},{"Itemcode":"2428","Description":"XR Humerus >=2 VIEWS - Lt","CDM Revenue Code":"320","CDM HCPCS":"73060","Standard Price":613.0},{"Itemcode":"2476","Description":"XR Knee 1 Or 2 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73560","Standard Price":558.0},{"Itemcode":"2477","Description":"XR Knee 1 Or 2 View - BI","CDM Revenue Code":"320","CDM HCPCS":"73560","Standard Price":837.0},{"Itemcode":"2478","Description":"XR Knee 1 Or 2 View - LT","CDM Revenue Code":"320","CDM HCPCS":"73560","Standard Price":558.0},{"Itemcode":"2481","Description":"XR Knee 3 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73562","Standard Price":532.0},{"Itemcode":"2483","Description":"XR Knee 3 View - Lt","CDM Revenue Code":"320","CDM HCPCS":"73562","Standard Price":532.0},{"Itemcode":"2485","Description":"XR Knee BI Stnding Ap(Wght Bea","CDM Revenue Code":"320","CDM HCPCS":"73565","Standard Price":661.0},{"Itemcode":"2486","Description":"XR Knee 3 View - BI","CDM Revenue Code":"320","CDM HCPCS":"73562","Standard Price":1087.0},{"Itemcode":"2505","Description":"XR Knee 4 View Min - LT","CDM Revenue Code":"320","CDM HCPCS":"73564","Standard Price":657.0},{"Itemcode":"2506","Description":"XR Knee 4 View Min - RT","CDM Revenue Code":"320","CDM HCPCS":"73564","Standard Price":657.0},{"Itemcode":"2508","Description":"Spine Cervical - 4 View Min","CDM Revenue Code":"320","CDM HCPCS":"72050","Standard Price":544.0},{"Itemcode":"2550","Description":"Mandible Complete","CDM Revenue Code":"320","CDM HCPCS":"70110","Standard Price":584.0},{"Itemcode":"2600","Description":"Nasal Bones Complete","CDM Revenue Code":"320","CDM HCPCS":"70160","Standard Price":407.0},{"Itemcode":"2652","Description":"Orbits Complete - Bilat","CDM Revenue Code":"320","CDM HCPCS":"70200","Standard Price":623.0},{"Itemcode":"2661","Description":"XR Heel >=2 Views- Rt","CDM Revenue Code":"320","CDM HCPCS":"73650","Standard Price":643.0},{"Itemcode":"2663","Description":"XR Heel >= 2.0 Views - LT","CDM Revenue Code":"320","CDM HCPCS":"73650","Standard Price":643.0},{"Itemcode":"2665","Description":"Panorex","CDM Revenue Code":"320","CDM HCPCS":"70355","Standard Price":557.0},{"Itemcode":"2671","Description":"XR Patella 4 View- Rt","CDM Revenue Code":"320","CDM HCPCS":"73564","Standard Price":657.0},{"Itemcode":"2673","Description":"XR Patella - Lt","CDM Revenue Code":"320","CDM HCPCS":"73564","Standard Price":657.0},{"Itemcode":"2675","Description":"XR Pelvis: Ap","CDM Revenue Code":"320","CDM HCPCS":"72170","Standard Price":627.0},{"Itemcode":"2690","Description":"Ribs: Bilateral 3 Views","CDM Revenue Code":"320","CDM HCPCS":"71110","Standard Price":639.0},{"Itemcode":"2696","Description":"Ribs: Unilateral - Rt","CDM Revenue Code":"320","CDM HCPCS":"71100","Standard Price":648.0},{"Itemcode":"2697","Description":"Ribs: Unilateral - Lt","CDM Revenue Code":"320","CDM HCPCS":"71100","Standard Price":648.0},{"Itemcode":"2710","Description":"Sacroiliac Joints","CDM Revenue Code":"320","CDM HCPCS":"72202","Standard Price":533.0},{"Itemcode":"2715","Description":"XR Sacrum-Coccyx","CDM Revenue Code":"320","CDM HCPCS":"72220","Standard Price":657.0},{"Itemcode":"2726","Description":"XR Scapula - Rt","CDM Revenue Code":"320","CDM HCPCS":"73010","Standard Price":575.0},{"Itemcode":"2728","Description":"XR Scapula - Lt","CDM Revenue Code":"320","CDM HCPCS":"73010","Standard Price":575.0},{"Itemcode":"2730","Description":"X-R SternoClaviclar Jnts 3+Vws","CDM Revenue Code":"320","CDM HCPCS":"71130","Standard Price":136.0},{"Itemcode":"2746","Description":"XR Shoulder 2 View Min -Rt","CDM Revenue Code":"320","CDM HCPCS":"73030","Standard Price":544.0},{"Itemcode":"2748","Description":"XR Shoulder 2 View Min -Lt","CDM Revenue Code":"320","CDM HCPCS":"73030","Standard Price":544.0},{"Itemcode":"2749","Description":"XR Shoulder 2 View Min -BI","CDM Revenue Code":"320","CDM HCPCS":"73030","Standard Price":1064.0},{"Itemcode":"2751","Description":"XR Shoulder - Rt, Single View","CDM Revenue Code":"320","CDM HCPCS":"73020","Standard Price":357.0},{"Itemcode":"2753","Description":"XR Shoulder - Lt, Single View","CDM Revenue Code":"320","CDM HCPCS":"73020","Standard Price":357.0},{"Itemcode":"2770","Description":"Sinuses Paranasal Complete","CDM Revenue Code":"320","CDM HCPCS":"70220","Standard Price":717.0},{"Itemcode":"2780","Description":"Skull Complete","CDM Revenue Code":"320","CDM HCPCS":"70260","Standard Price":639.0},{"Itemcode":"2785","Description":"Skull Limited","CDM Revenue Code":"320","CDM HCPCS":"70250","Standard Price":607.0},{"Itemcode":"2800","Description":"Spine Cerv Complete","CDM Revenue Code":"320","CDM HCPCS":"72052","Standard Price":699.0},{"Itemcode":"2805","Description":"Spine Cervical - 2 Or 3 Views","CDM Revenue Code":"320","CDM HCPCS":"72040","Standard Price":571.0},{"Itemcode":"2807","Description":"XR Spine Cervical 1 Vw","CDM Revenue Code":"320","CDM HCPCS":"72020","Standard Price":368.0},{"Itemcode":"2811","Description":"XR SPI ENTIRE SCOLI EVAL)2/3VW","CDM Revenue Code":"320","CDM HCPCS":"72082","Standard Price":730.0},{"Itemcode":"2815","Description":"Spine Lumbar - 2 Or 3 Views","CDM Revenue Code":"320","CDM HCPCS":"72100","Standard Price":722.0},{"Itemcode":"2820","Description":"Spine Lumbar 4 View Minimum","CDM Revenue Code":"320","CDM HCPCS":"72110","Standard Price":608.0},{"Itemcode":"2828","Description":"XR Spine Thoracic 1 View","CDM Revenue Code":"320","CDM HCPCS":"72020","Standard Price":368.0},{"Itemcode":"2830","Description":"Spine Thoracic 2 View","CDM Revenue Code":"320","CDM HCPCS":"72070","Standard Price":684.0},{"Itemcode":"2831","Description":"Spine Thoracolumbar - 2 Views","CDM Revenue Code":"320","CDM HCPCS":"72080","Standard Price":740.0},{"Itemcode":"2840","Description":"X-Ray Sternum min 2views","CDM Revenue Code":"320","CDM HCPCS":"71120","Standard Price":663.0},{"Itemcode":"2852","Description":"XR Toe(S) Lt Foot >=2Views- LT","CDM Revenue Code":"320","CDM HCPCS":"73660","Standard Price":527.0},{"Itemcode":"2857","Description":"XR Toe(S) Rt Foot >=2Views-RT","CDM Revenue Code":"320","CDM HCPCS":"73660","Standard Price":527.0},{"Itemcode":"2875","Description":"XR Tibia&Fibula 2vews - RT","CDM Revenue Code":"320","CDM HCPCS":"73590","Standard Price":616.0},{"Itemcode":"2877","Description":"XR Tibia&Fibula 2Vews- LT","CDM Revenue Code":"320","CDM HCPCS":"73590","Standard Price":616.0},{"Itemcode":"2878","Description":"X-ray Tibia&Fibula 2Vws- BI","CDM Revenue Code":"320","CDM HCPCS":"73590","Standard Price":918.0},{"Itemcode":"2880","Description":"XR TMJ Joint BI","CDM Revenue Code":"320","CDM HCPCS":"70330","Standard Price":803.0},{"Itemcode":"2976","Description":"XR Wrist >=3 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73110","Standard Price":539.0},{"Itemcode":"2978","Description":"XR Wrist >=3 View - Lt","CDM Revenue Code":"320","CDM HCPCS":"73110","Standard Price":539.0},{"Itemcode":"2981","Description":"XR Wrist 2 View - Rt","CDM Revenue Code":"320","CDM HCPCS":"73100","Standard Price":619.0},{"Itemcode":"2983","Description":"XR Wrist 2 View - Lt","CDM Revenue Code":"320","CDM HCPCS":"73100","Standard Price":619.0},{"Itemcode":"3505","Description":"Ribs:Bilat W/Pa Chest Min 4 Vw","CDM Revenue Code":"320","CDM HCPCS":"71111","Standard Price":651.0},{"Itemcode":"3860","Description":"XR TMJ Joint RT","CDM Revenue Code":"320","CDM HCPCS":"70328","Standard Price":746.0},{"Itemcode":"3861","Description":"XR TMJ Joint LT","CDM Revenue Code":"320","CDM HCPCS":"70328","Standard Price":746.0},{"Itemcode":"64100612","Description":"Post Op Skull No Charge","CDM Revenue Code":"320","CDM HCPCS":"70250","Standard Price":0.0},{"Itemcode":"64101140","Description":"Mandible","CDM Revenue Code":"320","CDM HCPCS":"70100","Standard Price":705.0},{"Itemcode":"64608300","Description":"Diskography: Lumbar S&I","CDM Revenue Code":"320","CDM HCPCS":"72295","Standard Price":5581.0},{"Itemcode":"8300","Description":"Diskography: Lumbar S&I","CDM Revenue Code":"320","CDM HCPCS":"72295","Standard Price":5581.0},{"Itemcode":"8301","Description":"DISCOGRAPHY CER/T EA LEVEL S&I","CDM Revenue Code":"320","CDM HCPCS":"72285","Standard Price":3720.0},{"Itemcode":"8447","Description":"Spine Thoracic 3 View","CDM Revenue Code":"320","CDM HCPCS":"72072","Standard Price":688.0},{"Itemcode":"8448","Description":"Spine Lumbar Comp W/ Bending","CDM Revenue Code":"320","CDM HCPCS":"72114","Standard Price":680.0},{"Itemcode":"8449","Description":"XR Elbow >=3 Views - LT","CDM Revenue Code":"320","CDM HCPCS":"73080","Standard Price":654.0},{"Itemcode":"8471","Description":"XR Elbow >=3 Views - Rt","CDM Revenue Code":"320","CDM HCPCS":"73080","Standard Price":654.0},{"Itemcode":"8475","Description":"XR Hand 2 Views - RT","CDM Revenue Code":"320","CDM HCPCS":"73120","Standard Price":545.0},{"Itemcode":"8481","Description":"XR Extremity Lower Infant - Rt","CDM Revenue Code":"320","CDM HCPCS":"73592","Standard Price":618.0},{"Itemcode":"8482","Description":"XR Extremity Lower Infant - BI","CDM Revenue Code":"320","CDM HCPCS":"73592","Standard Price":918.0},{"Itemcode":"8501","Description":"XR Hand 2 Views - Lt","CDM Revenue Code":"320","CDM HCPCS":"73120","Standard Price":545.0},{"Itemcode":"8502","Description":"XR Extremity Lower Infant - Lt","CDM Revenue Code":"320","CDM HCPCS":"73592","Standard Price":618.0},{"Itemcode":"0004","Description":"Brain Imaging <4V W/Vasc Flow","CDM Revenue Code":"340","CDM HCPCS":"78601","Standard Price":2293.0},{"Itemcode":"0073","Description":"NM - Lymphoscintigraphy","CDM Revenue Code":"341","CDM HCPCS":"78195","Standard Price":2258.0},{"Itemcode":"0102","Description":"Liver Imaging Static Only","CDM Revenue Code":"340","CDM HCPCS":"78201","Standard Price":944.0},{"Itemcode":"0103","Description":"Liver Spect","CDM Revenue Code":"341","CDM HCPCS":"78205","Standard Price":3824.0},{"Itemcode":"0178","Description":"Theraputic Administation","CDM Revenue Code":"342","CDM HCPCS":"79101","Standard Price":817.0},{"Itemcode":"0196","Description":"Implanted Pump Injection Scan","CDM Revenue Code":"340","CDM HCPCS":"78499","Standard Price":3602.0},{"Itemcode":"3003","Description":"PET/CT Limited Initial","CDM Revenue Code":"404","CDM HCPCS":"78814","Standard Price":7475.0},{"Itemcode":"3005","Description":"PET/CT Limited Subsequent","CDM Revenue Code":"404","CDM HCPCS":"78814","Standard Price":7475.0},{"Itemcode":"3009","Description":"PET/CT Skull-Thigh Initial","CDM Revenue Code":"404","CDM HCPCS":"78815","Standard Price":7870.0},{"Itemcode":"3011","Description":"PET/CT Skull-Thigh Sub","CDM Revenue Code":"404","CDM HCPCS":"78815","Standard Price":7870.0},{"Itemcode":"3013","Description":"PET/CT Whole Body Initial","CDM Revenue Code":"404","CDM HCPCS":"78816","Standard Price":8306.0},{"Itemcode":"3014","Description":"PET/CT Whole Body Subsequent","CDM Revenue Code":"404","CDM HCPCS":"78816","Standard Price":8306.0},{"Itemcode":"3017","Description":"PET/CT Dementia /Alzheimer'S","CDM Revenue Code":"404","CDM HCPCS":"78608","Standard Price":14096.0},{"Itemcode":"3022","Description":"PET Limited Initial","CDM Revenue Code":"404","CDM HCPCS":"78811","Standard Price":4795.0},{"Itemcode":"3024","Description":"PET Limited Subsequent","CDM Revenue Code":"404","CDM HCPCS":"78811","Standard Price":4795.0},{"Itemcode":"3026","Description":"PET Skull Base -Thigh Initial","CDM Revenue Code":"404","CDM HCPCS":"78812","Standard Price":3628.0},{"Itemcode":"3028","Description":"PET Skull Base-Thigh Subsequnt","CDM Revenue Code":"404","CDM HCPCS":"78812","Standard Price":3628.0},{"Itemcode":"3030","Description":"PET Full Body Initial","CDM Revenue Code":"404","CDM HCPCS":"78813","Standard Price":3628.0},{"Itemcode":"3032","Description":"PET Full Body Subsequent","CDM Revenue Code":"404","CDM HCPCS":"78813","Standard Price":3628.0},{"Itemcode":"3061","Description":"Radioactive Inj Non Imgaging","CDM Revenue Code":"340","CDM HCPCS":"78808","Standard Price":2840.0},{"Itemcode":"3101","Description":"I131 Migb Scan","CDM Revenue Code":"341","CDM HCPCS":"78075","Standard Price":19151.0},{"Itemcode":"4020","Description":"NM - Abscess Loc Limited","CDM Revenue Code":"341","CDM HCPCS":"78805","Standard Price":2553.0},{"Itemcode":"4025","Description":"Abscess Loc Spect","CDM Revenue Code":"341","CDM HCPCS":"78807","Standard Price":1087.0},{"Itemcode":"4030","Description":"NM - Abscess L0C Wb","CDM Revenue Code":"341","CDM HCPCS":"78806","Standard Price":1774.0},{"Itemcode":"4050","Description":"NM - Bone Image Limited","CDM Revenue Code":"341","CDM HCPCS":"78300","Standard Price":1360.0},{"Itemcode":"4055","Description":"NM - Bone Image Spect","CDM Revenue Code":"341","CDM HCPCS":"78320","Standard Price":2823.0},{"Itemcode":"4060","Description":"NM - Bone Image Three Phase","CDM Revenue Code":"341","CDM HCPCS":"78315","Standard Price":2804.0},{"Itemcode":"4065","Description":"NM - Bone Scan Wb","CDM Revenue Code":"341","CDM HCPCS":"78306","Standard Price":1441.0},{"Itemcode":"4095","Description":"Brain: Image Spect","CDM Revenue Code":"341","CDM HCPCS":"78607","Standard Price":2082.0},{"Itemcode":"4125","Description":"NM - HIDA (Hepatobiliary Scan)","CDM Revenue Code":"341","CDM HCPCS":"78226","Standard Price":3134.0},{"Itemcode":"4135","Description":"Cisternogram","CDM Revenue Code":"341","CDM HCPCS":"78630","Standard Price":10887.0},{"Itemcode":"4150","Description":"CSF Leakage","CDM Revenue Code":"341","CDM HCPCS":"78650","Standard Price":1575.0},{"Itemcode":"4155","Description":"CSF Shunt Evaluation","CDM Revenue Code":"341","CDM HCPCS":"78645","Standard Price":2456.0},{"Itemcode":"4175","Description":"Cystogram Vcu","CDM Revenue Code":"341","CDM HCPCS":"78740","Standard Price":1804.0},{"Itemcode":"4270","Description":"NM - Gastric Emptying","CDM Revenue Code":"341","CDM HCPCS":"78264","Standard Price":2867.0},{"Itemcode":"4280","Description":"NM - Abdominal Rbc Scan","CDM Revenue Code":"341","CDM HCPCS":"78278","Standard Price":3636.0},{"Itemcode":"4295","Description":"NM - HIDA Scan (Quantitative)","CDM Revenue Code":"341","CDM HCPCS":"78227","Standard Price":3134.0},{"Itemcode":"4300","Description":"NM - Hyperthyroidism Therapy","CDM Revenue Code":"342","CDM HCPCS":"79005","Standard Price":2621.0},{"Itemcode":"4360","Description":"NM - Kidney: Triple Renal","CDM Revenue Code":"341","CDM HCPCS":"78707","Standard Price":2426.0},{"Itemcode":"4400","Description":"NM - Liver/Spleen Scan","CDM Revenue Code":"341","CDM HCPCS":"78215","Standard Price":1387.0},{"Itemcode":"4415","Description":"Hemangioma Scan","CDM Revenue Code":"341","CDM HCPCS":"78206","Standard Price":4449.0},{"Itemcode":"4440","Description":"NM - Lung Perfusion","CDM Revenue Code":"341","CDM HCPCS":"78580","Standard Price":966.0},{"Itemcode":"4445","Description":"NM - Lung Perfusion/Vent","CDM Revenue Code":"341","CDM HCPCS":"78582","Standard Price":2031.0},{"Itemcode":"4500","Description":"Meckels Diverticulum","CDM Revenue Code":"341","CDM HCPCS":"78290","Standard Price":3833.0},{"Itemcode":"4540","Description":"NM - MUGA","CDM Revenue Code":"341","CDM HCPCS":"78453","Standard Price":2809.0},{"Itemcode":"4545","Description":"NM - Myocardial Spect Single","CDM Revenue Code":"341","CDM HCPCS":"78451","Standard Price":7161.0},{"Itemcode":"4551","Description":"NM - Myocardial Spect Multiple","CDM Revenue Code":"341","CDM HCPCS":"78452","Standard Price":7170.0},{"Itemcode":"4600","Description":"NM - Parathyroid Planar","CDM Revenue Code":"341","CDM HCPCS":"78070","Standard Price":2790.0},{"Itemcode":"4625","Description":"NM - Pulmonary Quant Function","CDM Revenue Code":"341","CDM HCPCS":"78598","Standard Price":1644.0},{"Itemcode":"4770","Description":"NM - Thyroid Ablation","CDM Revenue Code":"342","CDM HCPCS":"79005","Standard Price":2621.0},{"Itemcode":"4780","Description":"NM - S Iodine Whole Body Scan","CDM Revenue Code":"341","CDM HCPCS":"78018","Standard Price":3257.0},{"Itemcode":"4785","Description":"NM - Thyroid Scan Only","CDM Revenue Code":"341","CDM HCPCS":"78013","Standard Price":1090.0},{"Itemcode":"4795","Description":"NM - Thyroid Uptake Scan","CDM Revenue Code":"341","CDM HCPCS":"78014","Standard Price":1446.0},{"Itemcode":"4800","Description":"Thyroid Uptake Single","CDM Revenue Code":"341","CDM HCPCS":"78012","Standard Price":5332.0},{"Itemcode":"4810","Description":"NM Trpl Renal-SglStud W/WoDrug","CDM Revenue Code":"341","CDM HCPCS":"78708","Standard Price":2329.0},{"Itemcode":"4811","Description":"Renal Scan Static","CDM Revenue Code":"341","CDM HCPCS":"78700","Standard Price":3617.0},{"Itemcode":"4825","Description":"Tumor: Localization Limited","CDM Revenue Code":"341","CDM HCPCS":"78800","Standard Price":1539.0},{"Itemcode":"4830","Description":"NM - Tumor: Localization Spect","CDM Revenue Code":"341","CDM HCPCS":"78803","Standard Price":1524.0},{"Itemcode":"4835","Description":"NM-Tumor Loc Whole Body-2+ Dys","CDM Revenue Code":"341","CDM HCPCS":"78804","Standard Price":4096.0},{"Itemcode":"4836","Description":"Tumor Loc Whole Bdy-Single Day","CDM Revenue Code":"341","CDM HCPCS":"78802","Standard Price":3489.0},{"Itemcode":"4955","Description":"NM -Gated Blood Pool Stdy-Rest","CDM Revenue Code":"341","CDM HCPCS":"78472","Standard Price":2213.0},{"Itemcode":"6052","Description":"Bone Scan - Multiple Areas","CDM Revenue Code":"341","CDM HCPCS":"78305","Standard Price":5304.0},{"Itemcode":"6053","Description":"NM - IMAGING CARDIAC SHUNT","CDM Revenue Code":"341","CDM HCPCS":"78428","Standard Price":2180.0},{"Itemcode":"6054","Description":"NM - IMAGING LUNG VENTILATION","CDM Revenue Code":"341","CDM HCPCS":"78579","Standard Price":1230.0},{"Itemcode":"71401015","Description":"Radiopharm Tx Intra-Arterial","CDM Revenue Code":"342","CDM HCPCS":"79445","Standard Price":11335.0},{"Itemcode":"3000","Description":"PET/CT Fdg Dose","CDM Revenue Code":"343","CDM HCPCS":"A9552","Standard Price":2013.0},{"Itemcode":"3001","Description":"F-18 Study Dose Up To 30Mci","CDM Revenue Code":"343","CDM HCPCS":"A9580","Standard Price":993.0},{"Itemcode":"71400070","Description":"TC99M Sulfur Colloid<=20.00mci","CDM Revenue Code":"343","CDM HCPCS":"A9541","Standard Price":2508.0},{"Itemcode":"71402100","Description":"Cold Pyp LbldRBC TC-99m<=30mci","CDM Revenue Code":"343","CDM HCPCS":"A9560","Standard Price":2429.0},{"Itemcode":"71402200","Description":"GA-67 Citrate 6Mci","CDM Revenue Code":"343","CDM HCPCS":"A9556","Standard Price":6051.0},{"Itemcode":"71402300","Description":"I-123 Cap: 200 Microcuries","CDM Revenue Code":"343","CDM HCPCS":"A9516","Standard Price":1985.0},{"Itemcode":"71402301","Description":"I-123 Cap:100 Microcuries","CDM Revenue Code":"343","CDM HCPCS":"A9516","Standard Price":1985.0},{"Itemcode":"71402302","Description":"XOFIGO per MicroCurie","CDM Revenue Code":"344","CDM HCPCS":"A9606","Standard Price":613.0},{"Itemcode":"71402304","Description":"TC99M-LYMPHOSEEK <=0.5mci","CDM Revenue Code":"343","CDM HCPCS":"A9520","Standard Price":2839.0},{"Itemcode":"71402320","Description":"Indium-111 Dtpa Per 0.5 Mci","CDM Revenue Code":"343","CDM HCPCS":"A9548","Standard Price":28807.0},{"Itemcode":"71402330","Description":"Octreoscan Up To 6 Mci","CDM Revenue Code":"343","CDM HCPCS":"A9572","Standard Price":61787.0},{"Itemcode":"71402340","Description":"Indium 111 AUTOWbc Per 0.5 Mci","CDM Revenue Code":"343","CDM HCPCS":"A9570","Standard Price":23688.0},{"Itemcode":"71402750","Description":"TC99M Sestamibi / Study Dose","CDM Revenue Code":"343","CDM HCPCS":"A9500","Standard Price":2131.0},{"Itemcode":"71402765","Description":"TC 99M Ceretec","CDM Revenue Code":"343","CDM HCPCS":"A9569","Standard Price":32103.0},{"Itemcode":"71402775","Description":"TC99M Choletec","CDM Revenue Code":"343","CDM HCPCS":"A9537","Standard Price":1141.0},{"Itemcode":"71402810","Description":"TC 99M Hmpao Wbc","CDM Revenue Code":"343","CDM HCPCS":"A9569","Standard Price":32103.0},{"Itemcode":"71402830","Description":"TC99M Maa Per Study Dose 10Mci","CDM Revenue Code":"343","CDM HCPCS":"A9540","Standard Price":598.0},{"Itemcode":"71402840","Description":"TC99M Mag-3 /Study Dose 10Mci","CDM Revenue Code":"343","CDM HCPCS":"A9562","Standard Price":5542.0},{"Itemcode":"71402850","Description":"TC99M Mdp Up To 30 Mci","CDM Revenue Code":"343","CDM HCPCS":"A9503","Standard Price":630.0},{"Itemcode":"71402875","Description":"TC99M Na TC04 Per Mci","CDM Revenue Code":"343","CDM HCPCS":"A9512","Standard Price":201.0},{"Itemcode":"71402885","Description":"TC99M Pyp Per Study Dose 25Mci","CDM Revenue Code":"343","CDM HCPCS":"A9538","Standard Price":1582.0},{"Itemcode":"71402930","Description":"TC99M Sulfur Colloid-Lymphocen","CDM Revenue Code":"343","CDM HCPCS":"A9541","Standard Price":2508.0},{"Itemcode":"71402975","Description":"XE-133 20Mci","CDM Revenue Code":"343","CDM HCPCS":"A9558","Standard Price":2570.0},{"Itemcode":"71404837","Description":"Prostascint Up To 10 Mci","CDM Revenue Code":"343","CDM HCPCS":"A9507","Standard Price":55784.0},{"Itemcode":"71404939","Description":"Ultratag LbldRBC TC-99m<=30mci","CDM Revenue Code":"343","CDM HCPCS":"A9560","Standard Price":2429.0},{"Itemcode":"71405340","Description":"Quadramet Per 150 Mci","CDM Revenue Code":"344","CDM HCPCS":"A9604","Standard Price":141931.0},{"Itemcode":"71406000","Description":"Thallium Tl-201 Cl Ea Mci","CDM Revenue Code":"343","CDM HCPCS":"A9505","Standard Price":645.0},{"Itemcode":"71407070","Description":"I 131 Cap Per Mci, Theraputic","CDM Revenue Code":"344","CDM HCPCS":"A9517","Standard Price":425.0},{"Itemcode":"71407071","Description":"I 131 Cap Per Mci, Diagnostic","CDM Revenue Code":"343","CDM HCPCS":"A9509","Standard Price":873.0},{"Itemcode":"0013","Description":"Perc Plcmnt- Enteroclysis Tube","CDM Revenue Code":"320","CDM HCPCS":"74355","Standard Price":2238.0},{"Itemcode":"0105","Description":"FL RETROGRADE PYELOGRAM","CDM Revenue Code":"320","CDM HCPCS":"74420","Standard Price":816.0},{"Itemcode":"0167","Description":"KUB","CDM Revenue Code":"320","CDM HCPCS":"74018","Standard Price":478.0},{"Itemcode":"0189","Description":"Sm Bow W/ Enterovu","CDM Revenue Code":"320","CDM HCPCS":"74250","Standard Price":3210.0},{"Itemcode":"0197","Description":"Peritoneal Shuntogram S&I","CDM Revenue Code":"320","CDM HCPCS":"75809","Standard Price":773.0},{"Itemcode":"0367","Description":"XR Shunt: Series S&I","CDM Revenue Code":"320","CDM HCPCS":"75809","Standard Price":773.0},{"Itemcode":"1600","Description":"INTRA OP CHOLANGIOGRAM S&I","CDM Revenue Code":"320","CDM HCPCS":"74300","Standard Price":503.0},{"Itemcode":"2020","Description":"Abdomen 1 View","CDM Revenue Code":"320","CDM HCPCS":"74018","Standard Price":478.0},{"Itemcode":"2025","Description":"XR Abdomen 2 View","CDM Revenue Code":"320","CDM HCPCS":"74019","Standard Price":660.0},{"Itemcode":"2030","Description":"XR Abdomen Complete/KUB","CDM Revenue Code":"320","CDM HCPCS":"74018","Standard Price":728.0},{"Itemcode":"2031","Description":"Abdomen Obstruc Series W/Pa","CDM Revenue Code":"320","CDM HCPCS":"74022","Standard Price":784.0},{"Itemcode":"2090","Description":"XR Babygram for FB 1View","CDM Revenue Code":"320","CDM HCPCS":"76010","Standard Price":431.0},{"Itemcode":"2100","Description":"Barium Swallow Mod/Video","CDM Revenue Code":"320","CDM HCPCS":"74230","Standard Price":700.0},{"Itemcode":"2101","Description":"Esophagus W/Mod Barium Swallow","CDM Revenue Code":"320","CDM HCPCS":"74230","Standard Price":700.0},{"Itemcode":"2200","Description":"Cystogram >= 3Views","CDM Revenue Code":"320","CDM HCPCS":"74430","Standard Price":1221.0},{"Itemcode":"2260","Description":"Enema: Barium","CDM Revenue Code":"320","CDM HCPCS":"74270","Standard Price":1124.0},{"Itemcode":"2265","Description":"XR Barium Air Contrast","CDM Revenue Code":"320","CDM HCPCS":"74280","Standard Price":1068.0},{"Itemcode":"2270","Description":"Enema: Barium Thru Colostomy","CDM Revenue Code":"320","CDM HCPCS":"74270","Standard Price":1124.0},{"Itemcode":"2290","Description":"ERCP Pancreatic Ductal S&I","CDM Revenue Code":"320","CDM HCPCS":"74329","Standard Price":813.0},{"Itemcode":"2300","Description":"XR Esophagus","CDM Revenue Code":"320","CDM HCPCS":"74220","Standard Price":516.0},{"Itemcode":"2355","Description":"Fistula Tract Stdy (Non Dial)","CDM Revenue Code":"320","CDM HCPCS":"76080","Standard Price":763.0},{"Itemcode":"2356","Description":"SINUS TRACT STUDY","CDM Revenue Code":"320","CDM HCPCS":"76080","Standard Price":763.0},{"Itemcode":"2440","Description":"Hysterosalpingogram","CDM Revenue Code":"320","CDM HCPCS":"74740","Standard Price":758.0},{"Itemcode":"2450","Description":"IVP","CDM Revenue Code":"320","CDM HCPCS":"74400","Standard Price":1316.0},{"Itemcode":"2460","Description":"IVP Pedi","CDM Revenue Code":"320","CDM HCPCS":"74400","Standard Price":1316.0},{"Itemcode":"2500","Description":"Loopogram","CDM Revenue Code":"320","CDM HCPCS":"74425","Standard Price":4661.0},{"Itemcode":"2620","Description":"XR -Neck Soft Tissue","CDM Revenue Code":"320","CDM HCPCS":"70360","Standard Price":417.0},{"Itemcode":"2630","Description":"XR Nephrostogram, Antegrade","CDM Revenue Code":"320","CDM HCPCS":"74425","Standard Price":4661.0},{"Itemcode":"2761","Description":"Sialogram Parotid - Rt","CDM Revenue Code":"320","CDM HCPCS":"70390","Standard Price":1263.0},{"Itemcode":"2763","Description":"Sialogram Parotid - Lt","CDM Revenue Code":"320","CDM HCPCS":"70390","Standard Price":1263.0},{"Itemcode":"2795","Description":"XR Small Bowel Series","CDM Revenue Code":"320","CDM HCPCS":"74250","Standard Price":3210.0},{"Itemcode":"2915","Description":"XR UGI W/Kub","CDM Revenue Code":"320","CDM HCPCS":"74241","Standard Price":603.0},{"Itemcode":"2920","Description":"UGI Single Contrast","CDM Revenue Code":"320","CDM HCPCS":"74241","Standard Price":603.0},{"Itemcode":"2922","Description":"Barium Swallow/Ugi W/Air Cont","CDM Revenue Code":"320","CDM HCPCS":"74247","Standard Price":603.0},{"Itemcode":"2923","Description":"Barium Swallow W/Ugi","CDM Revenue Code":"320","CDM HCPCS":"74240","Standard Price":606.0},{"Itemcode":"2925","Description":"XR UGI Air Contrast","CDM Revenue Code":"320","CDM HCPCS":"74246","Standard Price":600.0},{"Itemcode":"2926","Description":"UGI Small Bowel Single","CDM Revenue Code":"320","CDM HCPCS":"74245","Standard Price":3205.0},{"Itemcode":"4827","Description":"Renal Cyst Aspir/Scler W/CONTR","CDM Revenue Code":"320","CDM HCPCS":"74470","Standard Price":7853.0},{"Itemcode":"5130","Description":"CT Drainage Cath Guidance","CDM Revenue Code":"350","CDM HCPCS":"75989","Standard Price":1344.0},{"Itemcode":"5246","Description":"Peritoneogram Aft Air/Cont S&I","CDM Revenue Code":"320","CDM HCPCS":"74190","Standard Price":1777.0},{"Itemcode":"5258","Description":"Transcatheter Biopsy","CDM Revenue Code":"320","CDM HCPCS":"75970","Standard Price":5975.0},{"Itemcode":"64100094","Description":"ERCP Pancreatic Duct S&I","CDM Revenue Code":"320","CDM HCPCS":"74329","Standard Price":813.0},{"Itemcode":"64100101","Description":"Cystography 3++ Views","CDM Revenue Code":"320","CDM HCPCS":"74430","Standard Price":1221.0},{"Itemcode":"64101130","Description":"Hysterosalpingography S&I","CDM Revenue Code":"320","CDM HCPCS":"74740","Standard Price":758.0},{"Itemcode":"64139947","Description":"Embolization Transcath-S&I","CDM Revenue Code":"320","CDM HCPCS":"75894","Standard Price":11262.0},{"Itemcode":"64139959","Description":"Antegrade Pyelogram","CDM Revenue Code":"320","CDM HCPCS":"74425","Standard Price":4661.0},{"Itemcode":"64600197","Description":"Peritoneal Shuntogram S&I","CDM Revenue Code":"320","CDM HCPCS":"75809","Standard Price":773.0},{"Itemcode":"64604827","Description":"Renal Cyst Aspir/Scler W/CONTR","CDM Revenue Code":"320","CDM HCPCS":"74470","Standard Price":7853.0},{"Itemcode":"64605258","Description":"Transcatheter Biopsy","CDM Revenue Code":"320","CDM HCPCS":"75970","Standard Price":5975.0},{"Itemcode":"64608266","Description":"Perc Drain W/Cath Plcmt-Guide","CDM Revenue Code":"320","CDM HCPCS":"75989","Standard Price":1344.0},{"Itemcode":"64608294","Description":"Antegrade Pyelogram","CDM Revenue Code":"320","CDM HCPCS":"74425","Standard Price":4661.0},{"Itemcode":"64608350","Description":"Embolization Transcath, S&I","CDM Revenue Code":"320","CDM HCPCS":"75894","Standard Price":11262.0},{"Itemcode":"64608468","Description":"Biliary Dilation- Guidance S&I","CDM Revenue Code":"320","CDM HCPCS":"74363","Standard Price":7212.0},{"Itemcode":"64608825","Description":"PercutaneusTube Chng XR Contrl","CDM Revenue Code":"320","CDM HCPCS":"75984","Standard Price":4679.0},{"Itemcode":"64608845","Description":"Ureteral Dilation-Guidance S&I","CDM Revenue Code":"320","CDM HCPCS":"74485","Standard Price":2722.0},{"Itemcode":"71106100","Description":"UGI w/Air Double Follow Thru","CDM Revenue Code":"320","CDM HCPCS":"74246","Standard Price":600.0},{"Itemcode":"71106101","Description":"Hypotonic Duodenography","CDM Revenue Code":"320","CDM HCPCS":"74251","Standard Price":600.0},{"Itemcode":"71106103","Description":"Barium Swallow with Air","CDM Revenue Code":"320","CDM HCPCS":"74221","Standard Price":603.0},{"Itemcode":"71106104","Description":"Small Bowel follow thru Study","CDM Revenue Code":"320","CDM HCPCS":"74248","Standard Price":603.0},{"Itemcode":"71106105","Description":"UGI Small Bowel Double","CDM Revenue Code":"320","CDM HCPCS":"74240","Standard Price":606.0},{"Itemcode":"8266","Description":"Perc Drain W/Cath Plcmt-Guide","CDM Revenue Code":"320","CDM HCPCS":"75989","Standard Price":1344.0},{"Itemcode":"8292","Description":"Biliary Duct PTHD Stent Placem","CDM Revenue Code":"320","CDM HCPCS":"74363","Standard Price":7212.0},{"Itemcode":"8294","Description":"Antegrade Pyelogram","CDM Revenue Code":"320","CDM HCPCS":"74425","Standard Price":4661.0},{"Itemcode":"8309","Description":"FLUORO GUIDANCE DRAIN W/CATH","CDM Revenue Code":"320","CDM HCPCS":"75989","Standard Price":1344.0},{"Itemcode":"8350","Description":"Embolization Transcath, S&I","CDM Revenue Code":"320","CDM HCPCS":"75894","Standard Price":11262.0},{"Itemcode":"8457","Description":"ERCP BILIARY S&I","CDM Revenue Code":"320","CDM HCPCS":"74328","Standard Price":1325.0},{"Itemcode":"8458","Description":"ERCP CombBiliary/PancreaticS&I","CDM Revenue Code":"320","CDM HCPCS":"74330","Standard Price":1187.0},{"Itemcode":"8461","Description":"Esophageal Dilatation","CDM Revenue Code":"320","CDM HCPCS":"74360","Standard Price":663.0},{"Itemcode":"8463","Description":"Urography Retrograde S&I","CDM Revenue Code":"320","CDM HCPCS":"74450","Standard Price":763.0},{"Itemcode":"8464","Description":"Urethrocystography Voiding","CDM Revenue Code":"320","CDM HCPCS":"74455","Standard Price":763.0},{"Itemcode":"8468","Description":"Biliary Dilation- Guidance S&I","CDM Revenue Code":"320","CDM HCPCS":"74363","Standard Price":7212.0},{"Itemcode":"8825","Description":"PercutaneusTube Chng XR Contrl","CDM Revenue Code":"320","CDM HCPCS":"75984","Standard Price":4679.0},{"Itemcode":"8845","Description":"Ureteral Dilation-Guidance S&I","CDM Revenue Code":"320","CDM HCPCS":"74485","Standard Price":2722.0},{"Itemcode":"0150","Description":"Angio Post Embolization Periph","CDM Revenue Code":"320","CDM HCPCS":"75898","Standard Price":3621.0},{"Itemcode":"0152","Description":"Transcath Embolization F/Up","CDM Revenue Code":"320","CDM HCPCS":"75898","Standard Price":3621.0},{"Itemcode":"0153","Description":"Lumbar Punct -Fluoro Guidance","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"0182","Description":"Fluoro Guided Spinal Injection","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"0238","Description":"Breast Tomography, DX Radiogra","CDM Revenue Code":"320","CDM HCPCS":"76499","Standard Price":274.0},{"Itemcode":"0441","Description":"HYSTEROSALPINGOGRAM INJECT","CDM Revenue Code":"361","CDM HCPCS":"58340","Standard Price":78.0},{"Itemcode":"0767","Description":"Inject Proc Arthro Ankle - Lt","CDM Revenue Code":"361","CDM HCPCS":"27648","Standard Price":414.0},{"Itemcode":"0770","Description":"Inject Proc Arthro Ankle - Rt","CDM Revenue Code":"361","CDM HCPCS":"27648","Standard Price":414.0},{"Itemcode":"0772","Description":"Arthrogram Hip - LT","CDM Revenue Code":"320","CDM HCPCS":"73525","Standard Price":987.0},{"Itemcode":"0773","Description":"Inj HIP Arthrogram w/Anest -Lt","CDM Revenue Code":"361","CDM HCPCS":"27095","Standard Price":55.0},{"Itemcode":"0775","Description":"XR Arthrogram Hip - RT","CDM Revenue Code":"320","CDM HCPCS":"73525","Standard Price":987.0},{"Itemcode":"0776","Description":"Inj HIP Arthrogram w/Anest -Rt","CDM Revenue Code":"361","CDM HCPCS":"27095","Standard Price":55.0},{"Itemcode":"0784","Description":"Arthrogram Shoulder - LT","CDM Revenue Code":"320","CDM HCPCS":"73040","Standard Price":991.0},{"Itemcode":"0785","Description":"Inject Proc Arthro Shoulder-Lt","CDM Revenue Code":"361","CDM HCPCS":"23350","Standard Price":56.0},{"Itemcode":"0787","Description":"Arthrogram Shoulder - Rt","CDM Revenue Code":"320","CDM HCPCS":"73040","Standard Price":991.0},{"Itemcode":"0788","Description":"Inject Proc Arthro Shoulder-Rt","CDM Revenue Code":"361","CDM HCPCS":"23350","Standard Price":56.0},{"Itemcode":"0791","Description":"Inject Proc Arthrogrm Wrist-Lt","CDM Revenue Code":"361","CDM HCPCS":"25246","Standard Price":1016.0},{"Itemcode":"0794","Description":"Inject Proc Arthrogrm Wrist-Rt","CDM Revenue Code":"361","CDM HCPCS":"25246","Standard Price":1016.0},{"Itemcode":"0796","Description":"Arthrogram Elbow Injection","CDM Revenue Code":"361","CDM HCPCS":"24220","Standard Price":208.0},{"Itemcode":"0797","Description":"Arthrogram Elbow","CDM Revenue Code":"320","CDM HCPCS":"73085","Standard Price":350.0},{"Itemcode":"0947","Description":"Therapeutic Enema Rad","CDM Revenue Code":"320","CDM HCPCS":"74283","Standard Price":661.0},{"Itemcode":"2201","Description":"CYSTOGRAM INJECTION","CDM Revenue Code":"361","CDM HCPCS":"51600","Standard Price":47.0},{"Itemcode":"2238","Description":"CT 3D Rendering","CDM Revenue Code":"350","CDM HCPCS":"76377","Standard Price":548.0},{"Itemcode":"2360","Description":"Fluoroscopy Up To 1 Hour","CDM Revenue Code":"320","CDM HCPCS":"76000","Standard Price":2127.0},{"Itemcode":"2361","Description":"Fluoro: Needle Placemnt-Biopsy","CDM Revenue Code":"320","CDM HCPCS":"77002","Standard Price":1189.0},{"Itemcode":"2362","Description":"Fluoro: Needle/Cath Tip-Spine","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"2510","Description":"Jugular Venogram S&I","CDM Revenue Code":"320","CDM HCPCS":"75860","Standard Price":674.0},{"Itemcode":"2560","Description":"Myelogram: Cervical S&I","CDM Revenue Code":"320","CDM HCPCS":"72240","Standard Price":5254.0},{"Itemcode":"2565","Description":"XR Myelogram: Complete","CDM Revenue Code":"320","CDM HCPCS":"72270","Standard Price":5687.0},{"Itemcode":"2570","Description":"Myelogram: Lumbar S&I","CDM Revenue Code":"320","CDM HCPCS":"72265","Standard Price":5225.0},{"Itemcode":"2575","Description":"Myelogram: Thoracic S&I","CDM Revenue Code":"320","CDM HCPCS":"72255","Standard Price":5296.0},{"Itemcode":"2612","Description":"Therapeutic Enema","CDM Revenue Code":"320","CDM HCPCS":"74283","Standard Price":661.0},{"Itemcode":"2640","Description":"Nerve Root Injection","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"3501","Description":"Fluoro LOC Ndl Plcmnt Aspiratn","CDM Revenue Code":"320","CDM HCPCS":"77002","Standard Price":1189.0},{"Itemcode":"3502","Description":"INJ PROC CHOLANGIOGRAM THRU CA","CDM Revenue Code":"361","CDM HCPCS":"47531","Standard Price":971.0},{"Itemcode":"3503","Description":"INJ PROC LOOPOGRAM","CDM Revenue Code":"361","CDM HCPCS":"50690","Standard Price":124.0},{"Itemcode":"4550","Description":"CT 3D W/O Post Processing","CDM Revenue Code":"350","CDM HCPCS":"76376","Standard Price":261.0},{"Itemcode":"4826","Description":"Fluoro Guided Abscess Drainage","CDM Revenue Code":"320","CDM HCPCS":"77002","Standard Price":1189.0},{"Itemcode":"5238","Description":"Angio: Spinal Selective S&I","CDM Revenue Code":"320","CDM HCPCS":"75705","Standard Price":5434.0},{"Itemcode":"5252","Description":"Tips Proc W/O Hemodyn Eval S&I","CDM Revenue Code":"320","CDM HCPCS":"75887","Standard Price":1409.0},{"Itemcode":"5254","Description":"Mech Rmvl Pericath Mtrl Cvad","CDM Revenue Code":"320","CDM HCPCS":"75901","Standard Price":5589.0},{"Itemcode":"5256","Description":"REM CVD Intralum Obst Mtrl S&I","CDM Revenue Code":"320","CDM HCPCS":"75902","Standard Price":8385.0},{"Itemcode":"6330","Description":"Pseudo-Aneurysm Compression","CDM Revenue Code":"402","CDM HCPCS":"76936","Standard Price":1080.0},{"Itemcode":"64107814","Description":"Stent Taa & L Subclavian Origi","CDM Revenue Code":"320","CDM HCPCS":"75956","Standard Price":7122.0},{"Itemcode":"64107815","Description":"Stent Taa S&I","CDM Revenue Code":"320","CDM HCPCS":"75957","Standard Price":2461.0},{"Itemcode":"64107816","Description":"Endoleak Prox Thoracic Aorta","CDM Revenue Code":"320","CDM HCPCS":"75958","Standard Price":10695.0},{"Itemcode":"64107817","Description":"Endoleak Dist Thoracic Aorta","CDM Revenue Code":"320","CDM HCPCS":"75959","Standard Price":5725.0},{"Itemcode":"64139936","Description":"Thrombolytic Declot Cv Cath","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"64139938","Description":"Mech Rmv Pericath Mtrl CVD S&I","CDM Revenue Code":"320","CDM HCPCS":"75901","Standard Price":5589.0},{"Itemcode":"64139972","Description":"Angio: Existing Cath (F/U)","CDM Revenue Code":"320","CDM HCPCS":"75898","Standard Price":3621.0},{"Itemcode":"64139976","Description":"Angio: Spinal Selective S&I","CDM Revenue Code":"320","CDM HCPCS":"75705","Standard Price":5434.0},{"Itemcode":"64139984","Description":"Angio: Pulmonary Nonselect S&I","CDM Revenue Code":"320","CDM HCPCS":"75746","Standard Price":1279.0},{"Itemcode":"64601152","Description":"F-U Angio, Embolization","CDM Revenue Code":"320","CDM HCPCS":"75898","Standard Price":3621.0},{"Itemcode":"64602360","Description":"Fluoroscopy Up To 1 Hour","CDM Revenue Code":"320","CDM HCPCS":"76000","Standard Price":2127.0},{"Itemcode":"64602362","Description":"Fluoroguide for Spine Injectn","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"64602510","Description":"Jugular Venogram S&I","CDM Revenue Code":"320","CDM HCPCS":"75860","Standard Price":674.0},{"Itemcode":"64604826","Description":"Fluoro Guided Needle Localiza","CDM Revenue Code":"320","CDM HCPCS":"77002","Standard Price":1189.0},{"Itemcode":"64605238","Description":"Angio: Spinal Selective S&I","CDM Revenue Code":"320","CDM HCPCS":"75705","Standard Price":5434.0},{"Itemcode":"64605254","Description":"Mech Rmvl Pericath Mtrl Cvad","CDM Revenue Code":"320","CDM HCPCS":"75901","Standard Price":5589.0},{"Itemcode":"64605256","Description":"REM CVD Intralum Obst Mtrl S&I","CDM Revenue Code":"320","CDM HCPCS":"75902","Standard Price":8385.0},{"Itemcode":"64608080","Description":"Angio: Extremity Bilateral S&I","CDM Revenue Code":"320","CDM HCPCS":"75716","Standard Price":5594.0},{"Itemcode":"64608090","Description":"Angio: Extremity RT S&I","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"64608100","Description":"Angio:Pulmonary Select BI S&I","CDM Revenue Code":"320","CDM HCPCS":"75743","Standard Price":5794.0},{"Itemcode":"64608120","Description":"Angio: Thoracic S&I","CDM Revenue Code":"320","CDM HCPCS":"75605","Standard Price":3024.0},{"Itemcode":"64608220","Description":"Aortogram: Iliac Femoral/Ro","CDM Revenue Code":"320","CDM HCPCS":"75630","Standard Price":5211.0},{"Itemcode":"64608221","Description":"Aortogram: Abdominal","CDM Revenue Code":"320","CDM HCPCS":"75625","Standard Price":5292.0},{"Itemcode":"64608230","Description":"Angio:Pelvic Select/Supra1 S&I","CDM Revenue Code":"320","CDM HCPCS":"75736","Standard Price":4856.0},{"Itemcode":"64608236","Description":"Angio Pelvic Selct/Supra 2 S&I","CDM Revenue Code":"320","CDM HCPCS":"75736","Standard Price":4856.0},{"Itemcode":"64608260","Description":"Angio Viscrl Select/Supra1 S&I","CDM Revenue Code":"320","CDM HCPCS":"75726","Standard Price":6734.0},{"Itemcode":"64608261","Description":"Angio Viscerl Selec/Supra2 S&I","CDM Revenue Code":"320","CDM HCPCS":"75726","Standard Price":6734.0},{"Itemcode":"64608262","Description":"Angio Viscrl SelEct/Supra3 S&I","CDM Revenue Code":"320","CDM HCPCS":"75726","Standard Price":6734.0},{"Itemcode":"64608306","Description":"Portography W/Hemodynamics S&I","CDM Revenue Code":"320","CDM HCPCS":"75885","Standard Price":9664.0},{"Itemcode":"64608307","Description":"Venogram Hepatic W/Hemodyn S&I","CDM Revenue Code":"320","CDM HCPCS":"75889","Standard Price":2970.0},{"Itemcode":"64608308","Description":"Venogram Hepatic W/OHemodynS&I","CDM Revenue Code":"320","CDM HCPCS":"75891","Standard Price":3624.0},{"Itemcode":"64608314","Description":"Fluroguidance for Vein Device","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"64608506","Description":"Angio: Extremity S&I LT","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"64608523","Description":"Angio Pulmonary Select S&I LT","CDM Revenue Code":"320","CDM HCPCS":"75741","Standard Price":9061.0},{"Itemcode":"64608524","Description":"Angio: Pulmonary Select S&I RT","CDM Revenue Code":"320","CDM HCPCS":"75741","Standard Price":9061.0},{"Itemcode":"64608891","Description":"Venogram: Vena Cava Superior","CDM Revenue Code":"320","CDM HCPCS":"75827","Standard Price":3812.0},{"Itemcode":"64608910","Description":"Venogram: Extremity S&I BI","CDM Revenue Code":"320","CDM HCPCS":"75822","Standard Price":4361.0},{"Itemcode":"64608915","Description":"Venogram: Extremity S&I RT","CDM Revenue Code":"320","CDM HCPCS":"75820","Standard Price":2600.0},{"Itemcode":"64608917","Description":"Venogram: Extremity Left","CDM Revenue Code":"320","CDM HCPCS":"75820","Standard Price":2600.0},{"Itemcode":"64608918","Description":"VENOGRAM: VENA CAVA INFERIOR","CDM Revenue Code":"320","CDM HCPCS":"75825","Standard Price":3706.0},{"Itemcode":"64608935","Description":"Venogram Renal Select S&I RT","CDM Revenue Code":"320","CDM HCPCS":"75831","Standard Price":6805.0},{"Itemcode":"64608938","Description":"Venogram: Renal Select Lt","CDM Revenue Code":"320","CDM HCPCS":"75831","Standard Price":6805.0},{"Itemcode":"64608975","Description":"Renin Venous Sampling S&I","CDM Revenue Code":"320","CDM HCPCS":"75893","Standard Price":2898.0},{"Itemcode":"64609995","Description":"ANGIO S&I BRACHIAL RETROGRADE","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"6696","Description":"HYSTROSONOGRAM INFUSION","CDM Revenue Code":"361","CDM HCPCS":"58340","Standard Price":78.0},{"Itemcode":"6751","Description":"US- UMBILICAL ARTERY DOPPLER","CDM Revenue Code":"402","CDM HCPCS":"76820","Standard Price":305.0},{"Itemcode":"68300027","Description":"Guidance for Radia Tx Deliver","CDM Revenue Code":"333","CDM HCPCS":"G6002","Standard Price":1429.0},{"Itemcode":"71400074","Description":"Injection Id Sntl Node:Non Img","CDM Revenue Code":"341","CDM HCPCS":"38792","Standard Price":919.0},{"Itemcode":"71600153","Description":"Lumbar Punct -Fluoro Guidance","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"71708302","Description":"Angio: Select Ea Addl Vessel","CDM Revenue Code":"320","CDM HCPCS":"75774","Standard Price":685.0},{"Itemcode":"72100210","Description":"Flouro Up To 1 Hour","CDM Revenue Code":"320","CDM HCPCS":"76000","Standard Price":2127.0},{"Itemcode":"72101175","Description":"Venogram VenaCava Inferior S&I","CDM Revenue Code":"320","CDM HCPCS":"75825","Standard Price":3706.0},{"Itemcode":"72101176","Description":"Venogram Extrem Iliac S&I Uni","CDM Revenue Code":"320","CDM HCPCS":"75820","Standard Price":2600.0},{"Itemcode":"72102300","Description":"Abd AortogrmW/CC NonSelect S&I","CDM Revenue Code":"320","CDM HCPCS":"75625","Standard Price":5292.0},{"Itemcode":"72102301","Description":"BI Run-Off W/Cc NonSelect S&I","CDM Revenue Code":"320","CDM HCPCS":"G0278","Standard Price":5594.0},{"Itemcode":"72102304","Description":"Angio: Select Ea Addl Vessel","CDM Revenue Code":"320","CDM HCPCS":"75774","Standard Price":685.0},{"Itemcode":"72106110","Description":"Angiogram: Extrem S&I BI","CDM Revenue Code":"320","CDM HCPCS":"75716","Standard Price":5594.0},{"Itemcode":"72106116","Description":"Angiogram: Extrem Uni S&I -RT","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"72106117","Description":"Angiogram: Extrem UnI S&I -LT","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"72106125","Description":"Aortogram Abd","CDM Revenue Code":"320","CDM HCPCS":"75625","Standard Price":5292.0},{"Itemcode":"72106130","Description":"Aortogram Abd Run-Off BI S&I","CDM Revenue Code":"320","CDM HCPCS":"75630","Standard Price":5211.0},{"Itemcode":"72106960","Description":"Transcath Infusion F-Up Cor","CDM Revenue Code":"320","CDM HCPCS":"75898","Standard Price":3621.0},{"Itemcode":"72108120","Description":"Angio: Thoracic Aorta","CDM Revenue Code":"320","CDM HCPCS":"75605","Standard Price":3024.0},{"Itemcode":"72208891","Description":"Venogram: Vena Cava Superior","CDM Revenue Code":"320","CDM HCPCS":"75827","Standard Price":3812.0},{"Itemcode":"72300033","Description":"3D Reconstruction For Tee","CDM Revenue Code":"350","CDM HCPCS":"76376","Standard Price":261.0},{"Itemcode":"76953000","Description":"Needle Loc Lesion Axill - RT","CDM Revenue Code":"361","CDM HCPCS":"10035","Standard Price":1500.0},{"Itemcode":"76953001","Description":"Needle Loc Lesion Axill - LT","CDM Revenue Code":"361","CDM HCPCS":"10035","Standard Price":1500.0},{"Itemcode":"8080","Description":"Angio: Extremity Bilateral S&I","CDM Revenue Code":"320","CDM HCPCS":"75716","Standard Price":5594.0},{"Itemcode":"8090","Description":"Angio: Extremity RT S&I","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"8100","Description":"Angio:Pulmonary Select BI S&I","CDM Revenue Code":"320","CDM HCPCS":"75743","Standard Price":5794.0},{"Itemcode":"8120","Description":"Angio: Thoracic S&I","CDM Revenue Code":"320","CDM HCPCS":"75605","Standard Price":3024.0},{"Itemcode":"8171","Description":"Implantable Port Removal","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"8220","Description":"Aortogram: Iliac Femoral/Ro","CDM Revenue Code":"320","CDM HCPCS":"75630","Standard Price":5211.0},{"Itemcode":"8221","Description":"Aortogram: Abdominal","CDM Revenue Code":"320","CDM HCPCS":"75625","Standard Price":5292.0},{"Itemcode":"8222","Description":"CV Catheter Repair","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"8223","Description":"CV Catheter Replacement","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"8230","Description":"Angio:Pelvic Select/Supra1 S&I","CDM Revenue Code":"320","CDM HCPCS":"75736","Standard Price":4856.0},{"Itemcode":"8236","Description":"Angio Pelvic Selct/Supra 2 S&I","CDM Revenue Code":"320","CDM HCPCS":"75736","Standard Price":4856.0},{"Itemcode":"8260","Description":"Angio Viscrl Select/Supra1 S&I","CDM Revenue Code":"320","CDM HCPCS":"75726","Standard Price":6734.0},{"Itemcode":"8261","Description":"Angio Viscerl Selec/Supra2 S&I","CDM Revenue Code":"320","CDM HCPCS":"75726","Standard Price":6734.0},{"Itemcode":"8262","Description":"Angio Viscrl SelEct/Supra3 S&I","CDM Revenue Code":"320","CDM HCPCS":"75726","Standard Price":6734.0},{"Itemcode":"8302","Description":"Angio: Select Ea Addl Vessel","CDM Revenue Code":"320","CDM HCPCS":"75774","Standard Price":685.0},{"Itemcode":"8303","Description":"FLUORO GUIDANCE EPIDURAL INJ","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"8304","Description":"FLURO GUIDNC NEEDL PLCMNT LOC","CDM Revenue Code":"320","CDM HCPCS":"77002","Standard Price":1189.0},{"Itemcode":"8306","Description":"Portography W/Hemodynamics S&I","CDM Revenue Code":"320","CDM HCPCS":"75885","Standard Price":9664.0},{"Itemcode":"8307","Description":"Venogram: Hepatic W/Hemodyn","CDM Revenue Code":"320","CDM HCPCS":"75889","Standard Price":2970.0},{"Itemcode":"8308","Description":"Venogram: Hepatic W/O Hemodyn","CDM Revenue Code":"320","CDM HCPCS":"75891","Standard Price":3624.0},{"Itemcode":"8314","Description":"Fluroguidance for Vein Device","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"8441","Description":"INJECTION FOR MYELOGRAM","CDM Revenue Code":"361","CDM HCPCS":"62284","Standard Price":58.0},{"Itemcode":"8450","Description":"Defecogram","CDM Revenue Code":"320","CDM HCPCS":"76499","Standard Price":274.0},{"Itemcode":"8486","Description":"INJECT PROC SIALOGRAPHY -RT","CDM Revenue Code":"361","CDM HCPCS":"42550","Standard Price":46.0},{"Itemcode":"8496","Description":"INJECT PROC SIALOGRAPHY -LT","CDM Revenue Code":"361","CDM HCPCS":"42550","Standard Price":46.0},{"Itemcode":"8506","Description":"Angio: Extremity S&I LT","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"8523","Description":"Angio Pulmonary Select S&I LT","CDM Revenue Code":"320","CDM HCPCS":"75741","Standard Price":9061.0},{"Itemcode":"8524","Description":"Angio: Pulmonary Select S&I RT","CDM Revenue Code":"320","CDM HCPCS":"75741","Standard Price":9061.0},{"Itemcode":"8610","Description":"IR NEUROSTIMULATOR IMPLANT","CDM Revenue Code":"320","CDM HCPCS":"77003","Standard Price":4626.0},{"Itemcode":"8854","Description":"Catheter Removal: Tunneled","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"8891","Description":"Venogram: Vena Cava Superior","CDM Revenue Code":"320","CDM HCPCS":"75827","Standard Price":3812.0},{"Itemcode":"8910","Description":"Venogram: Extremity S&I BI","CDM Revenue Code":"320","CDM HCPCS":"75822","Standard Price":4361.0},{"Itemcode":"8915","Description":"Venogram: Extremity S&I RT","CDM Revenue Code":"320","CDM HCPCS":"75820","Standard Price":2600.0},{"Itemcode":"8917","Description":"Venogram: Extremity Left","CDM Revenue Code":"320","CDM HCPCS":"75820","Standard Price":2600.0},{"Itemcode":"8918","Description":"VENOGRAM: VENA CAVA INFERIOR","CDM Revenue Code":"320","CDM HCPCS":"75825","Standard Price":3706.0},{"Itemcode":"8920","Description":"Fluoroscopy for Injection","CDM Revenue Code":"320","CDM HCPCS":"77002","Standard Price":1189.0},{"Itemcode":"8935","Description":"Venogram Renal Select S&I RT","CDM Revenue Code":"320","CDM HCPCS":"75831","Standard Price":6805.0},{"Itemcode":"8937","Description":"Venogram Renal Select S&I BI","CDM Revenue Code":"320","CDM HCPCS":"75833","Standard Price":7261.0},{"Itemcode":"8938","Description":"Venogram: Renal Select Lt","CDM Revenue Code":"320","CDM HCPCS":"75831","Standard Price":6805.0},{"Itemcode":"8950","Description":"CV Catheter Placement External","CDM Revenue Code":"320","CDM HCPCS":"77001","Standard Price":3787.0},{"Itemcode":"8975","Description":"Renin Venous Sampling S&I","CDM Revenue Code":"320","CDM HCPCS":"75893","Standard Price":2898.0},{"Itemcode":"9970","Description":"ANGIO: EXTREMITY BILATERAL S&I","CDM Revenue Code":"320","CDM HCPCS":"75716","Standard Price":5594.0},{"Itemcode":"9995","Description":"ANGIO S&I BRACHIAL RETROGRADE","CDM Revenue Code":"320","CDM HCPCS":"75710","Standard Price":4936.0},{"Itemcode":"64101901","Description":"STAT - Surgical Profile - D","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":66.0},{"Itemcode":"64101902","Description":"Glucose","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":66.0},{"Itemcode":"64101904","Description":"Calcium: Ionized","CDM Revenue Code":"300","CDM HCPCS":"82330","Standard Price":170.0},{"Itemcode":"64101905","Description":"Blood Gases","CDM Revenue Code":"300","CDM HCPCS":"82803","Standard Price":320.0},{"Itemcode":"64504480","Description":"Hemocult Analysis Feces","CDM Revenue Code":"300","CDM HCPCS":"82270","Standard Price":233.0},{"Itemcode":"68269721","Description":"Creatinine, Blood","CDM Revenue Code":"300","CDM HCPCS":"82565","Standard Price":85.0},{"Itemcode":"70100008","Description":"Occult Blood: Stool","CDM Revenue Code":"300","CDM HCPCS":"82272","Standard Price":88.0},{"Itemcode":"70100021","Description":"Total Protein: Serum","CDM Revenue Code":"300","CDM HCPCS":"84155","Standard Price":114.0},{"Itemcode":"70100022","Description":"Albumin-Serum,Plasma,orWholeBl","CDM Revenue Code":"300","CDM HCPCS":"82040","Standard Price":93.0},{"Itemcode":"70100023","Description":"Calcium Total","CDM Revenue Code":"300","CDM HCPCS":"82310","Standard Price":70.0},{"Itemcode":"70100024","Description":"Phosphorus","CDM Revenue Code":"300","CDM HCPCS":"84100","Standard Price":100.0},{"Itemcode":"70100025","Description":"Cholesterol","CDM Revenue Code":"300","CDM HCPCS":"82465","Standard Price":95.0},{"Itemcode":"70100026","Description":"Uric Acid: Blood","CDM Revenue Code":"300","CDM HCPCS":"84550","Standard Price":94.0},{"Itemcode":"70100027","Description":"Bilirubin: Total","CDM Revenue Code":"300","CDM HCPCS":"82247","Standard Price":106.0},{"Itemcode":"70100029","Description":"SGOT","CDM Revenue Code":"300","CDM HCPCS":"84450","Standard Price":80.0},{"Itemcode":"70100031","Description":"BUN - QUANT","CDM Revenue Code":"300","CDM HCPCS":"84520","Standard Price":80.0},{"Itemcode":"70100032","Description":"Sodium: Serum","CDM Revenue Code":"300","CDM HCPCS":"84295","Standard Price":88.0},{"Itemcode":"70100033","Description":"Potassium: Serum","CDM Revenue Code":"300","CDM HCPCS":"84132","Standard Price":84.0},{"Itemcode":"70100034","Description":"Chloride Blood","CDM Revenue Code":"300","CDM HCPCS":"82435","Standard Price":89.0},{"Itemcode":"70100035","Description":"CO2","CDM Revenue Code":"300","CDM HCPCS":"82374","Standard Price":132.0},{"Itemcode":"70100036","Description":"Glucose","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":76.0},{"Itemcode":"70100037","Description":"Creatinine - Blood","CDM Revenue Code":"300","CDM HCPCS":"82565","Standard Price":93.0},{"Itemcode":"70100038","Description":"Glyco Hemoglobin","CDM Revenue Code":"300","CDM HCPCS":"83036","Standard Price":53.0},{"Itemcode":"70100039","Description":"Carbohydrate Deficient Trans","CDM Revenue Code":"300","CDM HCPCS":"82373","Standard Price":554.0},{"Itemcode":"70100050","Description":"Alkaline Phosphatase","CDM Revenue Code":"300","CDM HCPCS":"84075","Standard Price":100.0},{"Itemcode":"70100051","Description":"Cpk Total","CDM Revenue Code":"300","CDM HCPCS":"82550","Standard Price":100.0},{"Itemcode":"70100052","Description":"LDH","CDM Revenue Code":"300","CDM HCPCS":"83615","Standard Price":105.0},{"Itemcode":"70100056","Description":"SGPT","CDM Revenue Code":"300","CDM HCPCS":"84460","Standard Price":80.0},{"Itemcode":"70100057","Description":"Glucose 1Hr No Fastng Specimen","CDM Revenue Code":"300","CDM HCPCS":"82950","Standard Price":153.0},{"Itemcode":"70100058","Description":"Protein Electrophoresis","CDM Revenue Code":"300","CDM HCPCS":"84165","Standard Price":476.0},{"Itemcode":"70100059","Description":"H Pylori (C-13) Breath Test","CDM Revenue Code":"300","CDM HCPCS":"83013","Standard Price":375.0},{"Itemcode":"70100060","Description":"Vitamin B2 Riboflavin","CDM Revenue Code":"300","CDM HCPCS":"84252","Standard Price":238.0},{"Itemcode":"70100068","Description":"Glucose 2Hr Pp","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":76.0},{"Itemcode":"70100069","Description":"HCG: Qualitative","CDM Revenue Code":"300","CDM HCPCS":"84703","Standard Price":132.0},{"Itemcode":"70100076","Description":"Lipase","CDM Revenue Code":"300","CDM HCPCS":"83690","Standard Price":122.0},{"Itemcode":"70100077","Description":"Triglycerides","CDM Revenue Code":"300","CDM HCPCS":"84478","Standard Price":132.0},{"Itemcode":"70100078","Description":"Amylase","CDM Revenue Code":"300","CDM HCPCS":"82150","Standard Price":104.0},{"Itemcode":"70100086","Description":"Gamma Gt","CDM Revenue Code":"300","CDM HCPCS":"82977","Standard Price":159.0},{"Itemcode":"70100096","Description":"Oligoclonal Banding","CDM Revenue Code":"300","CDM HCPCS":"83916","Standard Price":388.0},{"Itemcode":"70100101","Description":"Fetal Lung Maturity","CDM Revenue Code":"300","CDM HCPCS":"83663","Standard Price":494.0},{"Itemcode":"70100106","Description":"Acylcarnitines; Quant","CDM Revenue Code":"300","CDM HCPCS":"82017","Standard Price":1227.0},{"Itemcode":"70100123","Description":"Antigliadin Iga Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":505.0},{"Itemcode":"70100124","Description":"Antigliadin Igg Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":505.0},{"Itemcode":"70100144","Description":"Hyaluronic Acid Elisa Quant","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":908.0},{"Itemcode":"70100145","Description":"Timp-1 Elisa Quant","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":668.0},{"Itemcode":"70100173","Description":"Anti-Ompc Elisa Iga","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":274.0},{"Itemcode":"70100174","Description":"Anti Cbir1 Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":274.0},{"Itemcode":"70100177","Description":"Salivary Hormone Assay","CDM Revenue Code":"300","CDM HCPCS":"84144","Standard Price":1356.0},{"Itemcode":"70100200","Description":"Estrogens Fractionated","CDM Revenue Code":"300","CDM HCPCS":"82671","Standard Price":268.0},{"Itemcode":"70100205","Description":"IGG","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70100206","Description":"IGA","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70100207","Description":"IGM","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70100208","Description":"Haptoglobin","CDM Revenue Code":"300","CDM HCPCS":"83010","Standard Price":226.0},{"Itemcode":"70100209","Description":"Alpha 1 Antitrypsin","CDM Revenue Code":"300","CDM HCPCS":"82103","Standard Price":271.0},{"Itemcode":"70100211","Description":"Luteinizing Hormone","CDM Revenue Code":"300","CDM HCPCS":"83002","Standard Price":160.0},{"Itemcode":"70100214","Description":"IGA Total By Nephmtry (Celiac)","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70100217","Description":"IGG For Immunoglobin Profile","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70100221","Description":"Lactoferrin Fecal Qual","CDM Revenue Code":"300","CDM HCPCS":"83630","Standard Price":1704.0},{"Itemcode":"70100223","Description":"Prostaglandin Ea","CDM Revenue Code":"300","CDM HCPCS":"84150","Standard Price":2296.0},{"Itemcode":"70100224","Description":"Tissue Tgab Iga","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":982.0},{"Itemcode":"70100236","Description":"FSH","CDM Revenue Code":"300","CDM HCPCS":"83001","Standard Price":153.0},{"Itemcode":"70100251","Description":"HDL Cholesterol","CDM Revenue Code":"300","CDM HCPCS":"83718","Standard Price":399.0},{"Itemcode":"70100259","Description":"Pregnenolone","CDM Revenue Code":"300","CDM HCPCS":"84140","Standard Price":355.0},{"Itemcode":"70100260","Description":"Deoxycorticosterone","CDM Revenue Code":"300","CDM HCPCS":"82633","Standard Price":2849.0},{"Itemcode":"70100263","Description":"Iron","CDM Revenue Code":"300","CDM HCPCS":"83540","Standard Price":93.0},{"Itemcode":"70100265","Description":"Iron Binding Capacity-T (TIBC)","CDM Revenue Code":"300","CDM HCPCS":"83550","Standard Price":106.0},{"Itemcode":"70100266","Description":"Prolactin","CDM Revenue Code":"300","CDM HCPCS":"84146","Standard Price":191.0},{"Itemcode":"70100279","Description":"Magnesium -Quest Cathartic Lax","CDM Revenue Code":"300","CDM HCPCS":"83735","Standard Price":140.0},{"Itemcode":"70100280","Description":"Phosphorus -Quest Cathartic Lx","CDM Revenue Code":"300","CDM HCPCS":"84100","Standard Price":145.0},{"Itemcode":"70100303","Description":"Glucose Tolerance 1St Hr","CDM Revenue Code":"300","CDM HCPCS":"82951","Standard Price":179.0},{"Itemcode":"70100314","Description":"Magnesium","CDM Revenue Code":"300","CDM HCPCS":"83735","Standard Price":85.0},{"Itemcode":"70100325","Description":"Amnisure Test","CDM Revenue Code":"300","CDM HCPCS":"84112","Standard Price":474.0},{"Itemcode":"70100335","Description":"Vanillylmandelic Acid -Quest","CDM Revenue Code":"300","CDM HCPCS":"84585","Standard Price":119.0},{"Itemcode":"70100336","Description":"Creatinine Random Urine-Quest","CDM Revenue Code":"300","CDM HCPCS":"82570","Standard Price":93.0},{"Itemcode":"70100363","Description":"Interleukin-6,Highly Sensitive","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70100368","Description":"Phosphatase Alkaline -Quest","CDM Revenue Code":"300","CDM HCPCS":"84075","Standard Price":190.0},{"Itemcode":"70100399","Description":"Prealbumin","CDM Revenue Code":"300","CDM HCPCS":"84134","Standard Price":110.0},{"Itemcode":"70100400","Description":"Oxcarbazepine -Quest","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":449.0},{"Itemcode":"70100401","Description":"Risperidone -Quest","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":554.0},{"Itemcode":"70100402","Description":"T-4 Total","CDM Revenue Code":"300","CDM HCPCS":"84436","Standard Price":76.0},{"Itemcode":"70100404","Description":"Tsh:Thyroid Stimulate Hormon","CDM Revenue Code":"300","CDM HCPCS":"84443","Standard Price":91.0},{"Itemcode":"70100408","Description":"Galactose-1-Phosphate Rbc Mayo","CDM Revenue Code":"300","CDM HCPCS":"84378","Standard Price":1061.0},{"Itemcode":"70100409","Description":"Galactose P Mayo","CDM Revenue Code":"300","CDM HCPCS":"82760","Standard Price":1031.0},{"Itemcode":"70100410","Description":"Metanephrines Frac Pl -Quest","CDM Revenue Code":"300","CDM HCPCS":"83835","Standard Price":1097.0},{"Itemcode":"70100411","Description":"T3: Uptake","CDM Revenue Code":"300","CDM HCPCS":"84479","Standard Price":70.0},{"Itemcode":"70100414","Description":"Cea: Carcinoembryonic Antigen","CDM Revenue Code":"300","CDM HCPCS":"82378","Standard Price":102.0},{"Itemcode":"70100415","Description":"Cortisol:Serum Or Plasma Total","CDM Revenue Code":"300","CDM HCPCS":"82533","Standard Price":174.0},{"Itemcode":"70100416","Description":"Cortisol: Salivary","CDM Revenue Code":"300","CDM HCPCS":"82533","Standard Price":537.0},{"Itemcode":"70100421","Description":"Free PSA Quest","CDM Revenue Code":"300","CDM HCPCS":"84154","Standard Price":352.0},{"Itemcode":"70100430","Description":"Osmolality: Blood","CDM Revenue Code":"300","CDM HCPCS":"83930","Standard Price":263.0},{"Itemcode":"70100431","Description":"Osmolality:Urine","CDM Revenue Code":"300","CDM HCPCS":"83935","Standard Price":264.0},{"Itemcode":"70100435","Description":"Ferritin","CDM Revenue Code":"300","CDM HCPCS":"82728","Standard Price":101.0},{"Itemcode":"70100436","Description":"Pancreatic Elastase-1 Qst14693","CDM Revenue Code":"300","CDM HCPCS":"82656","Standard Price":982.0},{"Itemcode":"70100438","Description":"Mucopolysaccharides Qn Ur Qst","CDM Revenue Code":"300","CDM HCPCS":"83864","Standard Price":1834.0},{"Itemcode":"70100442","Description":"Spice Test Qst-Nms 4281U","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":554.0},{"Itemcode":"70100443","Description":"Hydroxyproline P Qst","CDM Revenue Code":"300","CDM HCPCS":"83500","Standard Price":531.0},{"Itemcode":"70100469","Description":"HCG: Quantitative","CDM Revenue Code":"300","CDM HCPCS":"84702","Standard Price":52.0},{"Itemcode":"70100479","Description":"Folate Serum","CDM Revenue Code":"300","CDM HCPCS":"82746","Standard Price":154.0},{"Itemcode":"70100480","Description":"Vitamin B-12 Level","CDM Revenue Code":"300","CDM HCPCS":"82607","Standard Price":116.0},{"Itemcode":"70100482","Description":"Folic Acid Rbc 82747","CDM Revenue Code":"300","CDM HCPCS":"82747","Standard Price":204.0},{"Itemcode":"70100502","Description":"LDH Isoenzymes","CDM Revenue Code":"300","CDM HCPCS":"83625","Standard Price":183.0},{"Itemcode":"70100503","Description":"HCG Quantitative -Quest","CDM Revenue Code":"300","CDM HCPCS":"84702","Standard Price":77.0},{"Itemcode":"70100504","Description":"AFP - Quest Triple Test","CDM Revenue Code":"300","CDM HCPCS":"82105","Standard Price":121.0},{"Itemcode":"70100506","Description":"Stool Lactoferrin Quant Qst","CDM Revenue Code":"300","CDM HCPCS":"83631","Standard Price":609.0},{"Itemcode":"70100525","Description":"HSP-70 Ab (Anti 68 Kd Ag) Qst","CDM Revenue Code":"300","CDM HCPCS":"84181","Standard Price":844.0},{"Itemcode":"70100527","Description":"Lamellar Bodies","CDM Revenue Code":"300","CDM HCPCS":"83664","Standard Price":397.0},{"Itemcode":"70100528","Description":"L/S Ratio","CDM Revenue Code":"300","CDM HCPCS":"83661","Standard Price":452.0},{"Itemcode":"70100622","Description":"Cryoglobulins","CDM Revenue Code":"300","CDM HCPCS":"82595","Standard Price":211.0},{"Itemcode":"70100659","Description":"N Telopeptide(Ntx),Random Ur","CDM Revenue Code":"300","CDM HCPCS":"82523","Standard Price":366.0},{"Itemcode":"70100665","Description":"G6PD Screen","CDM Revenue Code":"300","CDM HCPCS":"82955","Standard Price":208.0},{"Itemcode":"70100672","Description":"Selenium Serum -Quest","CDM Revenue Code":"300","CDM HCPCS":"84255","Standard Price":342.0},{"Itemcode":"70100673","Description":"Selenium Blood -Quest","CDM Revenue Code":"300","CDM HCPCS":"84255","Standard Price":819.0},{"Itemcode":"70100676","Description":"Vitamin B1 Plasma -Quest","CDM Revenue Code":"300","CDM HCPCS":"84425","Standard Price":386.0},{"Itemcode":"70100677","Description":"Vitamin B1 Whole Blood -Quest","CDM Revenue Code":"300","CDM HCPCS":"84425","Standard Price":386.0},{"Itemcode":"70100678","Description":"ACHR Modulating Ab -Quest","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1143.0},{"Itemcode":"70100679","Description":"ACHR Blocking Ab -Quest","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70100680","Description":"ACHR Binding Ab -Quest","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":400.0},{"Itemcode":"70100689","Description":"Bile Acids, Total","CDM Revenue Code":"300","CDM HCPCS":"82239","Standard Price":330.0},{"Itemcode":"70100721","Description":"Protein: Urine","CDM Revenue Code":"300","CDM HCPCS":"84156","Standard Price":130.0},{"Itemcode":"70100723","Description":"Calcium Urine","CDM Revenue Code":"300","CDM HCPCS":"82340","Standard Price":194.0},{"Itemcode":"70100724","Description":"Phosphorus: Urine","CDM Revenue Code":"300","CDM HCPCS":"84105","Standard Price":194.0},{"Itemcode":"70100726","Description":"Uric Acid: Other Source","CDM Revenue Code":"300","CDM HCPCS":"84560","Standard Price":74.0},{"Itemcode":"70100731","Description":"Urea Nitrogen: Urine","CDM Revenue Code":"300","CDM HCPCS":"84540","Standard Price":208.0},{"Itemcode":"70100732","Description":"Sodium: Urine 24Hr","CDM Revenue Code":"300","CDM HCPCS":"84300","Standard Price":83.0},{"Itemcode":"70100733","Description":"Potassium: Urine","CDM Revenue Code":"300","CDM HCPCS":"84133","Standard Price":93.0},{"Itemcode":"70100750","Description":"Anti Mullerian Hormone -Repros","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":353.0},{"Itemcode":"70100755","Description":"Estrone 2-Alphahydrox (Quest)","CDM Revenue Code":"300","CDM HCPCS":"82679","Standard Price":1420.0},{"Itemcode":"70100756","Description":"Estrone 16-Alphahydrox (Quest)","CDM Revenue Code":"300","CDM HCPCS":"82679","Standard Price":1420.0},{"Itemcode":"70100757","Description":"Creatinine (Estronex) (Quest)","CDM Revenue Code":"300","CDM HCPCS":"82570","Standard Price":93.0},{"Itemcode":"70100758","Description":"Protein Elect-Urine","CDM Revenue Code":"300","CDM HCPCS":"84166","Standard Price":645.0},{"Itemcode":"70100772","Description":"IA Multiple Step Method","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":632.0},{"Itemcode":"70100777","Description":"Somatostatin (Quest)","CDM Revenue Code":"300","CDM HCPCS":"84307","Standard Price":949.0},{"Itemcode":"70100779","Description":"Acetone","CDM Revenue Code":"300","CDM HCPCS":"82009","Standard Price":95.0},{"Itemcode":"70100780","Description":"Acetone Titer","CDM Revenue Code":"300","CDM HCPCS":"82010","Standard Price":313.0},{"Itemcode":"70100781","Description":"Triglycerides -Quest Vap","CDM Revenue Code":"300","CDM HCPCS":"84478","Standard Price":300.0},{"Itemcode":"70100801","Description":"Ribosomal Antibodies -Quest","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":341.0},{"Itemcode":"70100803","Description":"Ph -Stool Quest","CDM Revenue Code":"300","CDM HCPCS":"83986","Standard Price":272.0},{"Itemcode":"70100815","Description":"Fatty Acid Peroxisomal-Quest","CDM Revenue Code":"300","CDM HCPCS":"82726","Standard Price":554.0},{"Itemcode":"70100818","Description":"Lactic Acid","CDM Revenue Code":"300","CDM HCPCS":"83605","Standard Price":145.0},{"Itemcode":"70100819","Description":"Lactic Acid-Arterial","CDM Revenue Code":"300","CDM HCPCS":"83605","Standard Price":145.0},{"Itemcode":"70100821","Description":"Total Protein Oth Src: Fluid","CDM Revenue Code":"300","CDM HCPCS":"84157","Standard Price":190.0},{"Itemcode":"70100823","Description":"Fetal Hgb Qst 513","CDM Revenue Code":"300","CDM HCPCS":"83021","Standard Price":53.0},{"Itemcode":"70100824","Description":"Free Hemoglobin Plasma Qst 514","CDM Revenue Code":"300","CDM HCPCS":"83051","Standard Price":113.0},{"Itemcode":"70100829","Description":"Pinworm Ova Prep","CDM Revenue Code":"300","CDM HCPCS":"Q0113","Standard Price":116.0},{"Itemcode":"70100830","Description":"Osmolality-Stool","CDM Revenue Code":"300","CDM HCPCS":"84999","Standard Price":271.0},{"Itemcode":"70100832","Description":"Sodium: Stool","CDM Revenue Code":"300","CDM HCPCS":"84302","Standard Price":261.0},{"Itemcode":"70100833","Description":"Potassium: Stool","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":195.0},{"Itemcode":"70100839","Description":"IGA1 (Qst 31488)","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":147.0},{"Itemcode":"70100840","Description":"IGA2 (Qst 31488)","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":147.0},{"Itemcode":"70100841","Description":"Total Iga (Qst 31488)","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70100845","Description":"Beta-Hydroxybutyrate Qst 37054","CDM Revenue Code":"300","CDM HCPCS":"82010","Standard Price":313.0},{"Itemcode":"70100849","Description":"Tissue Ttg Antibody Igg","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":391.0},{"Itemcode":"70100850","Description":"Tissue Ttg Antibody Iga","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":391.0},{"Itemcode":"70100853","Description":"Sugars, Qual Single Sp-Stool","CDM Revenue Code":"300","CDM HCPCS":"84376","Standard Price":92.0},{"Itemcode":"70100878","Description":"Amylase-Fluid","CDM Revenue Code":"300","CDM HCPCS":"82150","Standard Price":104.0},{"Itemcode":"70100879","Description":"Oxygen Dissociation P50","CDM Revenue Code":"300","CDM HCPCS":"82820","Standard Price":920.0},{"Itemcode":"70100885","Description":"HU Antibody Western Blot Qst","CDM Revenue Code":"300","CDM HCPCS":"84181","Standard Price":143.0},{"Itemcode":"70100888","Description":"RI Antibody Western Blot","CDM Revenue Code":"300","CDM HCPCS":"84181","Standard Price":328.0},{"Itemcode":"70100892","Description":"Thallium Blood","CDM Revenue Code":"300","CDM HCPCS":"83018","Standard Price":254.0},{"Itemcode":"70100897","Description":"Bile Acids Fract/Total Qst","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":741.0},{"Itemcode":"70100900","Description":"Calcium Ionized Qst","CDM Revenue Code":"300","CDM HCPCS":"82330","Standard Price":170.0},{"Itemcode":"70100901","Description":"Ammonia","CDM Revenue Code":"300","CDM HCPCS":"82140","Standard Price":235.0},{"Itemcode":"70100902","Description":"Ammonia: Arterial","CDM Revenue Code":"300","CDM HCPCS":"82140","Standard Price":235.0},{"Itemcode":"70100912","Description":"11-Deoxycortisol Lc/Ms/Ms Qst","CDM Revenue Code":"300","CDM HCPCS":"82634","Standard Price":299.0},{"Itemcode":"70100915","Description":"Fungitell (1-3)-B-D-Glucan Qst","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":645.0},{"Itemcode":"70100917","Description":"Fatty Acid Profile Comp -Qst","CDM Revenue Code":"300","CDM HCPCS":"82554","Standard Price":1094.0},{"Itemcode":"70100921","Description":"Protein Total: CSF","CDM Revenue Code":"300","CDM HCPCS":"84157","Standard Price":190.0},{"Itemcode":"70100933","Description":"Kappa Light Chain Ur Qst","CDM Revenue Code":"300","CDM HCPCS":"83883","Standard Price":507.0},{"Itemcode":"70100935","Description":"Lambda Light Chain Ur Qst","CDM Revenue Code":"300","CDM HCPCS":"83883","Standard Price":507.0},{"Itemcode":"70100936","Description":"Glucose Body Fluid: Not Blood","CDM Revenue Code":"300","CDM HCPCS":"82945","Standard Price":232.0},{"Itemcode":"70100958","Description":"Protein Elec Urine/Csf","CDM Revenue Code":"300","CDM HCPCS":"84166","Standard Price":645.0},{"Itemcode":"70100996","Description":"IGG:Csf","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70101079","Description":"Chloride CSF","CDM Revenue Code":"300","CDM HCPCS":"82438","Standard Price":38.0},{"Itemcode":"70101248","Description":"Anti-Mag Ab Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1077.0},{"Itemcode":"70101249","Description":"Anti-Sgpg Ab Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1077.0},{"Itemcode":"70101250","Description":"Anti-Gm1 Ab Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1077.0},{"Itemcode":"70101251","Description":"Anti-Gd1B Ab Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1077.0},{"Itemcode":"70101252","Description":"Anti-Asialo Gm1 Ab Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1077.0},{"Itemcode":"70101253","Description":"Anti-Gq1B Ab Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1077.0},{"Itemcode":"70101254","Description":"Anti-Sulfatide Ab Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1077.0},{"Itemcode":"70101255","Description":"Anti-Hu Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":982.0},{"Itemcode":"70101257","Description":"Phosphorylated-Tau","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70101258","Description":"Total Tau","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70101259","Description":"AB42","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70101318","Description":"Glycomark","CDM Revenue Code":"300","CDM HCPCS":"84378","Standard Price":603.0},{"Itemcode":"70101319","Description":"Phenylalanine Qst","CDM Revenue Code":"300","CDM HCPCS":"84030","Standard Price":507.0},{"Itemcode":"70101320","Description":"Tyrosine Qst","CDM Revenue Code":"300","CDM HCPCS":"84510","Standard Price":607.0},{"Itemcode":"70101339","Description":"Procalcitonin","CDM Revenue Code":"300","CDM HCPCS":"84145","Standard Price":473.0},{"Itemcode":"70101367","Description":"Iron Liver Tissue Mayo","CDM Revenue Code":"300","CDM HCPCS":"83540","Standard Price":597.0},{"Itemcode":"70101407","Description":"Cv2 Antibody Test Athena","CDM Revenue Code":"300","CDM HCPCS":"84182","Standard Price":1656.0},{"Itemcode":"70101409","Description":"VWF Collagen Binding Assay Qs","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":622.0},{"Itemcode":"70101412","Description":"Lead Serum/Plasma - Nms","CDM Revenue Code":"300","CDM HCPCS":"83655","Standard Price":882.0},{"Itemcode":"70101413","Description":"Phenolphthalein Stool/Feces","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":241.0},{"Itemcode":"70101416","Description":"Citrate 24 Hr Urine","CDM Revenue Code":"300","CDM HCPCS":"82507","Standard Price":81.0},{"Itemcode":"70101421","Description":"Fatty Acid Prof Mayo","CDM Revenue Code":"300","CDM HCPCS":"82726","Standard Price":554.0},{"Itemcode":"70101423","Description":"PSA Total Quest","CDM Revenue Code":"300","CDM HCPCS":"84153","Standard Price":69.0},{"Itemcode":"70101441","Description":"Neuronal V-G K+ Channel Ab S","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":594.0},{"Itemcode":"70101442","Description":"Ach Receptor (Mcsl) Bind Ab","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":594.0},{"Itemcode":"70101443","Description":"Striational (Stri Mscl) Ab S","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":569.0},{"Itemcode":"70101444","Description":"N-Type Calcium Channel Ab","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":594.0},{"Itemcode":"70101445","Description":"P/Q Type Calcium Channel Ab","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":594.0},{"Itemcode":"70101450","Description":"ACHR Ganglionic Neuronal Ab S","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":711.0},{"Itemcode":"70101465","Description":"Corticosterone Lc/Ms/Ms Qst","CDM Revenue Code":"300","CDM HCPCS":"82528","Standard Price":140.0},{"Itemcode":"70101602","Description":"Ethylene Glycol","CDM Revenue Code":"300","CDM HCPCS":"82693","Standard Price":352.0},{"Itemcode":"70101603","Description":"Amino Acids: Quant","CDM Revenue Code":"300","CDM HCPCS":"82139","Standard Price":1358.0},{"Itemcode":"70101620","Description":"17-Hydroxypregnenolone","CDM Revenue Code":"300","CDM HCPCS":"84143","Standard Price":325.0},{"Itemcode":"70101622","Description":"Homovanillic Acid (Hva)","CDM Revenue Code":"300","CDM HCPCS":"83150","Standard Price":1781.0},{"Itemcode":"70101664","Description":"Chromatography Quant","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":2481.0},{"Itemcode":"70101670","Description":"Pyruvate","CDM Revenue Code":"300","CDM HCPCS":"84210","Standard Price":360.0},{"Itemcode":"70101673","Description":"Volatiles","CDM Revenue Code":"300","CDM HCPCS":"84600","Standard Price":1270.0},{"Itemcode":"70101674","Description":"Kappa Light Chain - Serum","CDM Revenue Code":"300","CDM HCPCS":"83883","Standard Price":132.0},{"Itemcode":"70101675","Description":"Lambda Light Chain - Serum","CDM Revenue Code":"300","CDM HCPCS":"83883","Standard Price":132.0},{"Itemcode":"70101703","Description":"Ph Urine","CDM Revenue Code":"300","CDM HCPCS":"83986","Standard Price":113.0},{"Itemcode":"70101724","Description":"Protein-Urine","CDM Revenue Code":"300","CDM HCPCS":"84156","Standard Price":130.0},{"Itemcode":"70101725","Description":"Glucose: Urine","CDM Revenue Code":"300","CDM HCPCS":"82945","Standard Price":232.0},{"Itemcode":"70101817","Description":"Cystatin C","CDM Revenue Code":"300","CDM HCPCS":"82610","Standard Price":182.0},{"Itemcode":"70101818","Description":"AssayMyeloperoxidase CardioIQ","CDM Revenue Code":"300","CDM HCPCS":"83876","Standard Price":174.0},{"Itemcode":"70101819","Description":"Assay Lipoprotein PLA2/PLAC Q","CDM Revenue Code":"301","CDM HCPCS":"83698","Standard Price":330.0},{"Itemcode":"70102037","Description":"Gtt Each Additional Hour 1","CDM Revenue Code":"300","CDM HCPCS":"82952","Standard Price":57.0},{"Itemcode":"70102038","Description":"Gtt Each Additional Hour 2","CDM Revenue Code":"300","CDM HCPCS":"82952","Standard Price":57.0},{"Itemcode":"70102039","Description":"Gtt Each Additional Hour 3","CDM Revenue Code":"300","CDM HCPCS":"82952","Standard Price":57.0},{"Itemcode":"70102041","Description":"Trypsin","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":388.0},{"Itemcode":"70102092","Description":"Mass Spec Nes; Quant","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":554.0},{"Itemcode":"70102093","Description":"Biotinidase, Adult","CDM Revenue Code":"300","CDM HCPCS":"82261","Standard Price":239.0},{"Itemcode":"70102380","Description":"Fetal Hgb,Qual By Copper Sulfa","CDM Revenue Code":"300","CDM HCPCS":"83033","Standard Price":550.0},{"Itemcode":"70102381","Description":"Cholinesterase; RBC","CDM Revenue Code":"300","CDM HCPCS":"82482","Standard Price":699.0},{"Itemcode":"70102565","Description":"Cholesterol, Body Fluid","CDM Revenue Code":"300","CDM HCPCS":"84999","Standard Price":95.0},{"Itemcode":"70102702","Description":"Bilirubin: Direct","CDM Revenue Code":"300","CDM HCPCS":"82248","Standard Price":88.0},{"Itemcode":"70102804","Description":"IGF Binding Protein-1","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70102805","Description":"IGF Binding Protein-2","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70102806","Description":"Insulin-Like Growth Factor-Ii","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":677.0},{"Itemcode":"70102807","Description":"Luteinizing Releasing Factor","CDM Revenue Code":"300","CDM HCPCS":"83727","Standard Price":1584.0},{"Itemcode":"70102850","Description":"Glucagon","CDM Revenue Code":"300","CDM HCPCS":"82943","Standard Price":316.0},{"Itemcode":"70103100","Description":"Lipoprotein (a)","CDM Revenue Code":"300","CDM HCPCS":"83695","Standard Price":204.0},{"Itemcode":"70103308","Description":"Calcium: Ionized","CDM Revenue Code":"300","CDM HCPCS":"82330","Standard Price":170.0},{"Itemcode":"70103600","Description":"Glucose: Blood By Monitor Dev","CDM Revenue Code":"300","CDM HCPCS":"82962","Standard Price":34.0},{"Itemcode":"70103655","Description":"Angiotensin Ii","CDM Revenue Code":"300","CDM HCPCS":"82163","Standard Price":522.0},{"Itemcode":"70104001","Description":"Acetylchol Recept Ab","CDM Revenue Code":"300","CDM HCPCS":"84238","Standard Price":2708.0},{"Itemcode":"70104003","Description":"ACTH","CDM Revenue Code":"300","CDM HCPCS":"82024","Standard Price":494.0},{"Itemcode":"70104004","Description":"Aldolase","CDM Revenue Code":"300","CDM HCPCS":"82085","Standard Price":150.0},{"Itemcode":"70104006","Description":"Aldosterone","CDM Revenue Code":"300","CDM HCPCS":"82088","Standard Price":232.0},{"Itemcode":"70104008","Description":"AFP Serum Tumor Marker","CDM Revenue Code":"300","CDM HCPCS":"82105","Standard Price":227.0},{"Itemcode":"70104010","Description":"Alkaline Phos Isoenzymes","CDM Revenue Code":"300","CDM HCPCS":"84080","Standard Price":384.0},{"Itemcode":"70104013","Description":"Amino Acids Quantitative","CDM Revenue Code":"300","CDM HCPCS":"82139","Standard Price":711.0},{"Itemcode":"70104017","Description":"Amino Levulinic-Ur24","CDM Revenue Code":"300","CDM HCPCS":"82135","Standard Price":427.0},{"Itemcode":"70104023","Description":"Androstenedione","CDM Revenue Code":"300","CDM HCPCS":"82157","Standard Price":371.0},{"Itemcode":"70104024","Description":"Angiotensin Converting Enzy","CDM Revenue Code":"300","CDM HCPCS":"82164","Standard Price":809.0},{"Itemcode":"70104035","Description":"Arsenic","CDM Revenue Code":"300","CDM HCPCS":"82175","Standard Price":332.0},{"Itemcode":"70104049","Description":"Oxalate","CDM Revenue Code":"300","CDM HCPCS":"83945","Standard Price":686.0},{"Itemcode":"70104054","Description":"C-Peptide","CDM Revenue Code":"300","CDM HCPCS":"84681","Standard Price":323.0},{"Itemcode":"70104056","Description":"Calcitonin","CDM Revenue Code":"300","CDM HCPCS":"82308","Standard Price":578.0},{"Itemcode":"70104061","Description":"Carotene","CDM Revenue Code":"300","CDM HCPCS":"82380","Standard Price":183.0},{"Itemcode":"70104062","Description":"Catechol: Fra-Urn 24Hr","CDM Revenue Code":"300","CDM HCPCS":"82384","Standard Price":500.0},{"Itemcode":"70104065","Description":"Catecholamines:Fractionated","CDM Revenue Code":"300","CDM HCPCS":"82384","Standard Price":450.0},{"Itemcode":"70104074","Description":"FR T4 By Equilibrium Dialysis","CDM Revenue Code":"300","CDM HCPCS":"84439","Standard Price":164.0},{"Itemcode":"70104081","Description":"PTH - Parathyroid Hormone","CDM Revenue Code":"300","CDM HCPCS":"83970","Standard Price":302.0},{"Itemcode":"70104091","Description":"Copper","CDM Revenue Code":"300","CDM HCPCS":"82525","Standard Price":235.0},{"Itemcode":"70104095","Description":"Cortisol Free","CDM Revenue Code":"300","CDM HCPCS":"82530","Standard Price":557.0},{"Itemcode":"70104097","Description":"Tsh Receptor Antibody","CDM Revenue Code":"300","CDM HCPCS":"82397","Standard Price":274.0},{"Itemcode":"70104101","Description":"Erythropoietin","CDM Revenue Code":"300","CDM HCPCS":"82668","Standard Price":408.0},{"Itemcode":"70104105","Description":"Cyanide","CDM Revenue Code":"300","CDM HCPCS":"82600","Standard Price":246.0},{"Itemcode":"70104106","Description":"Lipid Associated Sialic Acid","CDM Revenue Code":"300","CDM HCPCS":"84275","Standard Price":1237.0},{"Itemcode":"70104108","Description":"Cystine-Urn 24Hr","CDM Revenue Code":"300","CDM HCPCS":"82131","Standard Price":937.0},{"Itemcode":"70104114","Description":"Dhea","CDM Revenue Code":"300","CDM HCPCS":"82626","Standard Price":523.0},{"Itemcode":"70104115","Description":"Dhea Sulfate","CDM Revenue Code":"300","CDM HCPCS":"82627","Standard Price":237.0},{"Itemcode":"70104123","Description":"Estradiol","CDM Revenue Code":"300","CDM HCPCS":"82670","Standard Price":208.0},{"Itemcode":"70104134","Description":"Quantitative Fat","CDM Revenue Code":"300","CDM HCPCS":"82710","Standard Price":694.0},{"Itemcode":"70104141","Description":"Gastrin","CDM Revenue Code":"300","CDM HCPCS":"82941","Standard Price":261.0},{"Itemcode":"70104143","Description":"Hemoglobin, Glycated","CDM Revenue Code":"300","CDM HCPCS":"83036","Standard Price":74.0},{"Itemcode":"70104144","Description":"Aluminum","CDM Revenue Code":"300","CDM HCPCS":"82108","Standard Price":140.0},{"Itemcode":"70104145","Description":"Growth Hormone","CDM Revenue Code":"300","CDM HCPCS":"83003","Standard Price":258.0},{"Itemcode":"70104149","Description":"Histamine","CDM Revenue Code":"300","CDM HCPCS":"83088","Standard Price":392.0},{"Itemcode":"70104152","Description":"Fructosamine","CDM Revenue Code":"300","CDM HCPCS":"82985","Standard Price":156.0},{"Itemcode":"70104169","Description":"Amino Acids Each Quant","CDM Revenue Code":"300","CDM HCPCS":"82131","Standard Price":937.0},{"Itemcode":"70104173","Description":"Beta 2 - Microglobulin","CDM Revenue Code":"300","CDM HCPCS":"82232","Standard Price":278.0},{"Itemcode":"70104181","Description":"Anti Histone Antibodies","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":130.0},{"Itemcode":"70104182","Description":"Hydroxypro Total-U24","CDM Revenue Code":"300","CDM HCPCS":"83505","Standard Price":518.0},{"Itemcode":"70104185","Description":"IGD","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70104191","Description":"Insulin: Assay Total","CDM Revenue Code":"300","CDM HCPCS":"83525","Standard Price":150.0},{"Itemcode":"70104195","Description":"Ketogenicsteroids: 17","CDM Revenue Code":"300","CDM HCPCS":"83586","Standard Price":374.0},{"Itemcode":"70104201","Description":"Lead","CDM Revenue Code":"300","CDM HCPCS":"83655","Standard Price":85.0},{"Itemcode":"70104217","Description":"Mercury","CDM Revenue Code":"300","CDM HCPCS":"83825","Standard Price":1223.0},{"Itemcode":"70104223","Description":"Metanephrines","CDM Revenue Code":"300","CDM HCPCS":"83835","Standard Price":507.0},{"Itemcode":"70104224","Description":"Metanephrines:Tot U2","CDM Revenue Code":"300","CDM HCPCS":"83835","Standard Price":1559.0},{"Itemcode":"70104233","Description":"Myelin Basic Protein: Csf","CDM Revenue Code":"300","CDM HCPCS":"83873","Standard Price":296.0},{"Itemcode":"70104234","Description":"Myoglobin","CDM Revenue Code":"300","CDM HCPCS":"83874","Standard Price":388.0},{"Itemcode":"70104248","Description":"5-Nucleotidase","CDM Revenue Code":"300","CDM HCPCS":"83915","Standard Price":140.0},{"Itemcode":"70104259","Description":"Porphobilinogen-Quan","CDM Revenue Code":"300","CDM HCPCS":"84110","Standard Price":507.0},{"Itemcode":"70104260","Description":"Porphyrins-Quant","CDM Revenue Code":"300","CDM HCPCS":"84120","Standard Price":278.0},{"Itemcode":"70104265","Description":"Progesterone","CDM Revenue Code":"300","CDM HCPCS":"84144","Standard Price":153.0},{"Itemcode":"70104268","Description":"Parathormone","CDM Revenue Code":"300","CDM HCPCS":"83970","Standard Price":1083.0},{"Itemcode":"70104276","Description":"Renin","CDM Revenue Code":"300","CDM HCPCS":"84244","Standard Price":204.0},{"Itemcode":"70104290","Description":"Hemoglobin Electrophoresis","CDM Revenue Code":"300","CDM HCPCS":"83020","Standard Price":300.0},{"Itemcode":"70104291","Description":"Serotonin","CDM Revenue Code":"300","CDM HCPCS":"84260","Standard Price":1578.0},{"Itemcode":"70104294","Description":"Somatomedin-C","CDM Revenue Code":"300","CDM HCPCS":"84305","Standard Price":400.0},{"Itemcode":"70104296","Description":"Stone Analysis","CDM Revenue Code":"300","CDM HCPCS":"82365","Standard Price":630.0},{"Itemcode":"70104299","Description":"Lipoprotein-Blood; By Nmr","CDM Revenue Code":"300","CDM HCPCS":"83704","Standard Price":711.0},{"Itemcode":"70104300","Description":"IGE Gammaglobulin","CDM Revenue Code":"300","CDM HCPCS":"82785","Standard Price":90.0},{"Itemcode":"70104303","Description":"T03: Total-Triiodothyronine","CDM Revenue Code":"300","CDM HCPCS":"84480","Standard Price":183.0},{"Itemcode":"70104304","Description":"T-4: Free","CDM Revenue Code":"300","CDM HCPCS":"84439","Standard Price":164.0},{"Itemcode":"70104306","Description":"Testosterone: Total","CDM Revenue Code":"300","CDM HCPCS":"84403","Standard Price":173.0},{"Itemcode":"70104313","Description":"Thyroxine Bind Glob","CDM Revenue Code":"300","CDM HCPCS":"84442","Standard Price":578.0},{"Itemcode":"70104321","Description":"Transferrin","CDM Revenue Code":"300","CDM HCPCS":"84466","Standard Price":196.0},{"Itemcode":"70104332","Description":"Vasoactive Intestinal Peptide","CDM Revenue Code":"300","CDM HCPCS":"84586","Standard Price":900.0},{"Itemcode":"70104336","Description":"Vitamin A","CDM Revenue Code":"300","CDM HCPCS":"84590","Standard Price":303.0},{"Itemcode":"70104337","Description":"Vitamin C Asc Acid Level","CDM Revenue Code":"300","CDM HCPCS":"82180","Standard Price":222.0},{"Itemcode":"70104341","Description":"Vitamin D 1-25-Dihydroxy","CDM Revenue Code":"300","CDM HCPCS":"82652","Standard Price":167.0},{"Itemcode":"70104342","Description":"Vitamin D-25 Hydroxy","CDM Revenue Code":"300","CDM HCPCS":"82306","Standard Price":154.0},{"Itemcode":"70104343","Description":"Vitamin E","CDM Revenue Code":"300","CDM HCPCS":"84446","Standard Price":168.0},{"Itemcode":"70104344","Description":"VMA","CDM Revenue Code":"300","CDM HCPCS":"84585","Standard Price":278.0},{"Itemcode":"70104350","Description":"Anti Gbm (Glomer Base Mem)","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":458.0},{"Itemcode":"70104351","Description":"Xylose Tolerance","CDM Revenue Code":"300","CDM HCPCS":"84620","Standard Price":982.0},{"Itemcode":"70104356","Description":"Zinc","CDM Revenue Code":"300","CDM HCPCS":"84630","Standard Price":229.0},{"Itemcode":"70104406","Description":"Troponin T","CDM Revenue Code":"300","CDM HCPCS":"84484","Standard Price":168.0},{"Itemcode":"70104466","Description":"Ceruloplasmin","CDM Revenue Code":"300","CDM HCPCS":"82390","Standard Price":183.0},{"Itemcode":"70104478","Description":"Hydroxyprogesterone 17D","CDM Revenue Code":"300","CDM HCPCS":"83498","Standard Price":362.0},{"Itemcode":"70104515","Description":"Prostatic Acid Phosphatase","CDM Revenue Code":"300","CDM HCPCS":"84066","Standard Price":90.0},{"Itemcode":"70104710","Description":"Microalbumin","CDM Revenue Code":"300","CDM HCPCS":"82043","Standard Price":106.0},{"Itemcode":"70104743","Description":"Porphyrins:Qualitative:Urine","CDM Revenue Code":"300","CDM HCPCS":"84120","Standard Price":524.0},{"Itemcode":"70104754","Description":"Myoglobin-Urine","CDM Revenue Code":"300","CDM HCPCS":"83874","Standard Price":388.0},{"Itemcode":"70104803","Description":"Cholinesterase: Pseudo","CDM Revenue Code":"300","CDM HCPCS":"82480","Standard Price":301.0},{"Itemcode":"70104804","Description":"Dibucaine -Quest","CDM Revenue Code":"300","CDM HCPCS":"82638","Standard Price":89.0},{"Itemcode":"70104805","Description":"Cholinesterase Serum -Quest","CDM Revenue Code":"300","CDM HCPCS":"82480","Standard Price":66.0},{"Itemcode":"70104989","Description":"T3: Reverse","CDM Revenue Code":"300","CDM HCPCS":"84482","Standard Price":303.0},{"Itemcode":"70104990","Description":"Organic Acids, Urine","CDM Revenue Code":"300","CDM HCPCS":"83918","Standard Price":976.0},{"Itemcode":"70105014","Description":"Cpk Mb","CDM Revenue Code":"300","CDM HCPCS":"82553","Standard Price":129.0},{"Itemcode":"70105079","Description":"Hemosiderin Qualitative","CDM Revenue Code":"300","CDM HCPCS":"83070","Standard Price":239.0},{"Itemcode":"70105152","Description":"LDH With Isos If Ele","CDM Revenue Code":"300","CDM HCPCS":"83615","Standard Price":308.0},{"Itemcode":"70105153","Description":"Cpk With Ckmb If Ele","CDM Revenue Code":"300","CDM HCPCS":"82550","Standard Price":100.0},{"Itemcode":"70105550","Description":"Spe Western Blot: Bld/Fld Prob","CDM Revenue Code":"300","CDM HCPCS":"84182","Standard Price":1656.0},{"Itemcode":"70106342","Description":"Mass Spectrometry Nes Qualnbsc","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":60.0},{"Itemcode":"70106343","Description":"Biotinidase, Nb Screen","CDM Revenue Code":"300","CDM HCPCS":"82261","Standard Price":97.0},{"Itemcode":"70106344","Description":"Hydroxyprogesterone 17D, Nbsc","CDM Revenue Code":"300","CDM HCPCS":"83498","Standard Price":362.0},{"Itemcode":"70106345","Description":"G6PD, NB Screen","CDM Revenue Code":"300","CDM HCPCS":"82960","Standard Price":254.0},{"Itemcode":"70106346","Description":"IA CF; Cystic Fibrosis Nb Sc","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":195.0},{"Itemcode":"70106435","Description":"Apolipoprotein","CDM Revenue Code":"300","CDM HCPCS":"82172","Standard Price":179.0},{"Itemcode":"70106500","Description":"Gases Blood Ph Only","CDM Revenue Code":"300","CDM HCPCS":"82800","Standard Price":63.0},{"Itemcode":"70106501","Description":"Insulin Free","CDM Revenue Code":"300","CDM HCPCS":"83527","Standard Price":1194.0},{"Itemcode":"70106502","Description":"Carboxyhemoglobin","CDM Revenue Code":"300","CDM HCPCS":"82375","Standard Price":267.0},{"Itemcode":"70106503","Description":"Osteocalcin (Bone Gla Protein)","CDM Revenue Code":"300","CDM HCPCS":"83937","Standard Price":428.0},{"Itemcode":"70106721","Description":"Preg-Assoc Plasma Protein-A","CDM Revenue Code":"300","CDM HCPCS":"84163","Standard Price":592.0},{"Itemcode":"70107078","Description":"Amylase Urine","CDM Revenue Code":"300","CDM HCPCS":"82150","Standard Price":104.0},{"Itemcode":"70107310","Description":"Urea Nitrogen Clearance","CDM Revenue Code":"300","CDM HCPCS":"84545","Standard Price":195.0},{"Itemcode":"70107370","Description":"Creatinine Clearance","CDM Revenue Code":"300","CDM HCPCS":"82575","Standard Price":180.0},{"Itemcode":"70107721","Description":"Protein: Ur Quan Ran","CDM Revenue Code":"300","CDM HCPCS":"84156","Standard Price":130.0},{"Itemcode":"70107726","Description":"Uric Acid-Urine Rand","CDM Revenue Code":"300","CDM HCPCS":"84560","Standard Price":226.0},{"Itemcode":"70107732","Description":"Sodium: Urine","CDM Revenue Code":"300","CDM HCPCS":"84300","Standard Price":83.0},{"Itemcode":"70107733","Description":"Potassium-Urn Rand","CDM Revenue Code":"300","CDM HCPCS":"84133","Standard Price":93.0},{"Itemcode":"70107734","Description":"Chloride Urine","CDM Revenue Code":"300","CDM HCPCS":"82436","Standard Price":129.0},{"Itemcode":"70107737","Description":"Creatinine Oth Src- Urine","CDM Revenue Code":"300","CDM HCPCS":"82570","Standard Price":69.0},{"Itemcode":"70107780","Description":"Thyroglobulin","CDM Revenue Code":"300","CDM HCPCS":"84432","Standard Price":313.0},{"Itemcode":"70108012","Description":"PTH-Related Protein","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70108020","Description":"GAD 65 Decarboxylase","CDM Revenue Code":"301","CDM HCPCS":"83519","Standard Price":263.0},{"Itemcode":"70108025","Description":"Immunoassay Quant Nos","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":622.0},{"Itemcode":"70108026","Description":"IGF Binding Protein-3","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70108028","Description":"Beta Glucosidase: Leukocytes","CDM Revenue Code":"300","CDM HCPCS":"82963","Standard Price":1978.0},{"Itemcode":"70108051","Description":"LDH -Fluid","CDM Revenue Code":"300","CDM HCPCS":"83615","Standard Price":105.0},{"Itemcode":"70108171","Description":"Ph Body Fld - Not Blood","CDM Revenue Code":"300","CDM HCPCS":"83986","Standard Price":214.0},{"Itemcode":"70108496","Description":"Phosphorous Inorg-QstCathrtics","CDM Revenue Code":"300","CDM HCPCS":"84100","Standard Price":341.0},{"Itemcode":"70108497","Description":"Magnesium - Quest Cathartics","CDM Revenue Code":"300","CDM HCPCS":"83735","Standard Price":140.0},{"Itemcode":"70108498","Description":"Chromatography, Thin Layer Nes","CDM Revenue Code":"300","CDM HCPCS":"84999","Standard Price":302.0},{"Itemcode":"70108557","Description":"Fluoride","CDM Revenue Code":"300","CDM HCPCS":"82735","Standard Price":1547.0},{"Itemcode":"70108558","Description":"Mass Spectrometry Nes Qual","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":110.0},{"Itemcode":"70108559","Description":"Cadmium","CDM Revenue Code":"300","CDM HCPCS":"82300","Standard Price":1541.0},{"Itemcode":"70108560","Description":"Chromium","CDM Revenue Code":"300","CDM HCPCS":"82495","Standard Price":193.0},{"Itemcode":"70108561","Description":"Spectrometry Nos 2","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":308.0},{"Itemcode":"70108563","Description":"Manganese","CDM Revenue Code":"300","CDM HCPCS":"83785","Standard Price":256.0},{"Itemcode":"70108564","Description":"Fatty Acids: Nonesterfied","CDM Revenue Code":"300","CDM HCPCS":"82725","Standard Price":959.0},{"Itemcode":"70108702","Description":"Specific Gravity-Fld","CDM Revenue Code":"300","CDM HCPCS":"84315","Standard Price":43.0},{"Itemcode":"70109023","Description":"Antiendomysial Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":982.0},{"Itemcode":"70109026","Description":"5HIAA 24 Hour Urine","CDM Revenue Code":"300","CDM HCPCS":"83497","Standard Price":229.0},{"Itemcode":"70109027","Description":"5HIAA: Random Urine","CDM Revenue Code":"300","CDM HCPCS":"83497","Standard Price":204.0},{"Itemcode":"70109035","Description":"Creatinine Ur Quest","CDM Revenue Code":"300","CDM HCPCS":"82570","Standard Price":93.0},{"Itemcode":"70109200","Description":"Drug Quantitation Nos","CDM Revenue Code":"300","CDM HCPCS":"83789","Standard Price":554.0},{"Itemcode":"70109202","Description":"Vit B12 Binding Capacity","CDM Revenue Code":"300","CDM HCPCS":"82608","Standard Price":223.0},{"Itemcode":"70109204","Description":"Soluble Transferrin Receptor","CDM Revenue Code":"300","CDM HCPCS":"84238","Standard Price":656.0},{"Itemcode":"70109208","Description":"Nephelometry Ea Analyte Nos","CDM Revenue Code":"300","CDM HCPCS":"83883","Standard Price":989.0},{"Itemcode":"70109226","Description":"Autoantibody Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":502.0},{"Itemcode":"70109239","Description":"HPLC Quant For 6-Mmpn","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":554.0},{"Itemcode":"70109264","Description":"TPMT Enz Activity Rbc Promet","CDM Revenue Code":"300","CDM HCPCS":"82657","Standard Price":554.0},{"Itemcode":"70109265","Description":"HPLC Quant 6-Mthyl-Thioguanine","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":554.0},{"Itemcode":"70109266","Description":"Amg By Nephelometry Prometheus","CDM Revenue Code":"300","CDM HCPCS":"83883","Standard Price":989.0},{"Itemcode":"70109268","Description":"Anca Elisa Igg","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":274.0},{"Itemcode":"70109269","Description":"Anti-A4-Fla2 Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":274.0},{"Itemcode":"70109270","Description":"Anti-Fla-X Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":274.0},{"Itemcode":"70109271","Description":"VEGF Elisa","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":274.0},{"Itemcode":"70109272","Description":"Icam Chemiluminescent Assay","CDM Revenue Code":"300","CDM HCPCS":"82397","Standard Price":274.0},{"Itemcode":"70109273","Description":"Vcam Chemilluminescent Assay","CDM Revenue Code":"300","CDM HCPCS":"82397","Standard Price":274.0},{"Itemcode":"70109274","Description":"SAA Chemiluminescent Assay","CDM Revenue Code":"300","CDM HCPCS":"82397","Standard Price":274.0},{"Itemcode":"70109282","Description":"HPLC Quant For 6-Tgn","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":554.0},{"Itemcode":"70109283","Description":"Hu-Ttg Elisa Iga Recombinant","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":505.0},{"Itemcode":"70109284","Description":"Prometheus Anser Ifx","CDM Revenue Code":"300","CDM HCPCS":"84999","Standard Price":2483.0},{"Itemcode":"70109600","Description":"IGG Index","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70109721","Description":"Estriol: Unconj","CDM Revenue Code":"300","CDM HCPCS":"82677","Standard Price":272.0},{"Itemcode":"70109804","Description":"Antigliadin Ab:Igg","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":111.0},{"Itemcode":"70109807","Description":"Antigliadin Ab:Iga","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":111.0},{"Itemcode":"70109818","Description":"Estriol","CDM Revenue Code":"300","CDM HCPCS":"82677","Standard Price":408.0},{"Itemcode":"70109819","Description":"Estrogens;Total","CDM Revenue Code":"300","CDM HCPCS":"82672","Standard Price":410.0},{"Itemcode":"70109820","Description":"Estrone","CDM Revenue Code":"300","CDM HCPCS":"82679","Standard Price":477.0},{"Itemcode":"70109822","Description":"17-Ketosteroid Fractionation","CDM Revenue Code":"300","CDM HCPCS":"83593","Standard Price":1337.0},{"Itemcode":"70109823","Description":"Adh Anti Diuretic Hormone","CDM Revenue Code":"300","CDM HCPCS":"84588","Standard Price":296.0},{"Itemcode":"70109825","Description":"Free T3","CDM Revenue Code":"300","CDM HCPCS":"84481","Standard Price":170.0},{"Itemcode":"70109830","Description":"Thiocyanate","CDM Revenue Code":"300","CDM HCPCS":"84430","Standard Price":81.0},{"Itemcode":"70109832","Description":"Gtt Each Additional Hour 5","CDM Revenue Code":"300","CDM HCPCS":"82952","Standard Price":57.0},{"Itemcode":"70109834","Description":"Thyroid Stimulating Immunogl","CDM Revenue Code":"300","CDM HCPCS":"84445","Standard Price":412.0},{"Itemcode":"70109840","Description":"Heavy Metals Screen","CDM Revenue Code":"300","CDM HCPCS":"83015","Standard Price":861.0},{"Itemcode":"70109841","Description":"Estrogen Receptor Assay","CDM Revenue Code":"300","CDM HCPCS":"84233","Standard Price":3691.0},{"Itemcode":"70109844","Description":"Cpk Isoenzyme","CDM Revenue Code":"300","CDM HCPCS":"82552","Standard Price":227.0},{"Itemcode":"70109846","Description":"Progesterone Receptor Assay","CDM Revenue Code":"300","CDM HCPCS":"84234","Standard Price":4808.0},{"Itemcode":"70109852","Description":"17-Hydroxycorticosteroids","CDM Revenue Code":"300","CDM HCPCS":"83491","Standard Price":225.0},{"Itemcode":"70109853","Description":"Gastroccult For Ph/Hb","CDM Revenue Code":"300","CDM HCPCS":"82271","Standard Price":95.0},{"Itemcode":"70109863","Description":"Pg (Phosphatidylglycerol)","CDM Revenue Code":"300","CDM HCPCS":"84081","Standard Price":1018.0},{"Itemcode":"70109866","Description":"Methylamalonic Acid","CDM Revenue Code":"300","CDM HCPCS":"83921","Standard Price":664.0},{"Itemcode":"70109867","Description":"Chemiluminescent Assay","CDM Revenue Code":"300","CDM HCPCS":"82397","Standard Price":274.0},{"Itemcode":"70109868","Description":"Blood Gases","CDM Revenue Code":"300","CDM HCPCS":"82803","Standard Price":320.0},{"Itemcode":"70109900","Description":"IGG","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70109912","Description":"LDL Subparticles","CDM Revenue Code":"300","CDM HCPCS":"82664","Standard Price":1394.0},{"Itemcode":"70109915","Description":"Cea: Fluid","CDM Revenue Code":"300","CDM HCPCS":"82378","Standard Price":215.0},{"Itemcode":"70109932","Description":"Albumin -Quest","CDM Revenue Code":"300","CDM HCPCS":"82040","Standard Price":93.0},{"Itemcode":"70109934","Description":"LDL Cholesterol Direct","CDM Revenue Code":"300","CDM HCPCS":"83721","Standard Price":121.0},{"Itemcode":"70109938","Description":"Sex Hormone Binding Globulin","CDM Revenue Code":"300","CDM HCPCS":"84270","Standard Price":111.0},{"Itemcode":"70109940","Description":"Testoserone Total-Quest","CDM Revenue Code":"300","CDM HCPCS":"84403","Standard Price":674.0},{"Itemcode":"70109955","Description":"Testosterone Free -Quest","CDM Revenue Code":"300","CDM HCPCS":"84402","Standard Price":290.0},{"Itemcode":"70109956","Description":"Testoserone Total Profile","CDM Revenue Code":"300","CDM HCPCS":"84403","Standard Price":253.0},{"Itemcode":"70109959","Description":"Total PSA Screening","CDM Revenue Code":"300","CDM HCPCS":"G0103","Standard Price":97.0},{"Itemcode":"70109999","Description":"PSA Total","CDM Revenue Code":"300","CDM HCPCS":"84153","Standard Price":97.0},{"Itemcode":"70110014","Description":"Citrate 24Hr Urine","CDM Revenue Code":"300","CDM HCPCS":"82507","Standard Price":713.0},{"Itemcode":"70110015","Description":"TRH - Thyrotropin Rel Hormone","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70110035","Description":"Albumin Urine Or Other","CDM Revenue Code":"300","CDM HCPCS":"82042","Standard Price":94.0},{"Itemcode":"70110041","Description":"N-Telopeptide (Ntx)","CDM Revenue Code":"300","CDM HCPCS":"82523","Standard Price":589.0},{"Itemcode":"70110060","Description":"Thyrotropin Blocking Ab","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70110090","Description":"Homocysteine","CDM Revenue Code":"300","CDM HCPCS":"83090","Standard Price":294.0},{"Itemcode":"70110135","Description":"Fibronectin: Fetal","CDM Revenue Code":"300","CDM HCPCS":"82731","Standard Price":809.0},{"Itemcode":"70110166","Description":"Vitamin B6","CDM Revenue Code":"300","CDM HCPCS":"84207","Standard Price":374.0},{"Itemcode":"70110167","Description":"Proinsulin","CDM Revenue Code":"300","CDM HCPCS":"84206","Standard Price":334.0},{"Itemcode":"70110168","Description":"Niacin","CDM Revenue Code":"300","CDM HCPCS":"84591","Standard Price":613.0},{"Itemcode":"70110190","Description":"Selenium","CDM Revenue Code":"300","CDM HCPCS":"84255","Standard Price":2061.0},{"Itemcode":"70110195","Description":"Zinc Protoporphyrin","CDM Revenue Code":"300","CDM HCPCS":"84202","Standard Price":384.0},{"Itemcode":"70110200","Description":"Thiamine (Vitamin B1)","CDM Revenue Code":"300","CDM HCPCS":"84425","Standard Price":349.0},{"Itemcode":"70110220","Description":"Alpha 1 Antitrypsin - Pheno","CDM Revenue Code":"300","CDM HCPCS":"82104","Standard Price":286.0},{"Itemcode":"70110221","Description":"PL-7 Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":727.0},{"Itemcode":"70110222","Description":"PL-12 Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":727.0},{"Itemcode":"70110224","Description":"KU Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":727.0},{"Itemcode":"70110225","Description":"Ej Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":727.0},{"Itemcode":"70110226","Description":"OJ Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":727.0},{"Itemcode":"70110230","Description":"Sulfate: Urine","CDM Revenue Code":"300","CDM HCPCS":"84392","Standard Price":141.0},{"Itemcode":"70110332","Description":"Tissue Tgab Iga","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":411.0},{"Itemcode":"70110340","Description":"IGG Subclass 1","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":147.0},{"Itemcode":"70110341","Description":"IGG Subclass 2","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":147.0},{"Itemcode":"70110342","Description":"IGG Subclass 3","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":147.0},{"Itemcode":"70110343","Description":"IGG Subclass 4","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":147.0},{"Itemcode":"70110344","Description":"Total Igg -Qst","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":211.0},{"Itemcode":"70110363","Description":"Phospholipid Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70110364","Description":"Phospholipid Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1176.0},{"Itemcode":"70110365","Description":"Phospholipid Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1176.0},{"Itemcode":"70110366","Description":"Phospholipid Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1176.0},{"Itemcode":"70110367","Description":"Phospholipid Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70110368","Description":"Phospholipid Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1057.0},{"Itemcode":"70110369","Description":"Phospholipid Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1057.0},{"Itemcode":"70110370","Description":"Phospholipid Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1057.0},{"Itemcode":"70110371","Description":"Phospholipid Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1057.0},{"Itemcode":"70110372","Description":"Phospholipid Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70110373","Description":"Phospholipid Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70110374","Description":"Phospholipid Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70110375","Description":"Phospholipid Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70110376","Description":"Phospholipid Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1176.0},{"Itemcode":"70110377","Description":"Phospholipid Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1192.0},{"Itemcode":"70110402","Description":"Benzene","CDM Revenue Code":"300","CDM HCPCS":"84600","Standard Price":1479.0},{"Itemcode":"70110405","Description":"Immunoassay: Quantitative","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1244.0},{"Itemcode":"70110406","Description":"Bnp (Pro-B Type Natriuretic) P","CDM Revenue Code":"300","CDM HCPCS":"83880","Standard Price":423.0},{"Itemcode":"70110435","Description":"Chlorinated Hydrocarbon:Screen","CDM Revenue Code":"300","CDM HCPCS":"82441","Standard Price":554.0},{"Itemcode":"70112010","Description":"Carnitine; Quant 1Specimen","CDM Revenue Code":"300","CDM HCPCS":"82379","Standard Price":296.0},{"Itemcode":"70115011","Description":"Spectrophotometry Nos","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":645.0},{"Itemcode":"70115012","Description":"Hemoglobin, Urine","CDM Revenue Code":"300","CDM HCPCS":"83069","Standard Price":365.0},{"Itemcode":"70115019","Description":"Lipoprotein High Resolution","CDM Revenue Code":"300","CDM HCPCS":"83701","Standard Price":347.0},{"Itemcode":"70115056","Description":"Pyruvate Kinase","CDM Revenue Code":"300","CDM HCPCS":"84220","Standard Price":869.0},{"Itemcode":"70115717","Description":"Anti-HMGCR Ab (EIA)","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":903.0},{"Itemcode":"70115740","Description":"NT5C1A IgG - WUSM","CDM Revenue Code":"300","CDM HCPCS":"84182","Standard Price":797.0},{"Itemcode":"70115773","Description":"Mitochondrial Antibody IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":93.0},{"Itemcode":"70115774","Description":"Anti-GBM Antibody","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":185.0},{"Itemcode":"70115775","Description":"Serine Protease3,IgG (C-ANCA)","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":130.0},{"Itemcode":"70115776","Description":"Myeloperoxidase Ab (P-ANCA)","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":130.0},{"Itemcode":"70115778","Description":"PTH-Related Peptide (PTH-RP)","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":463.0},{"Itemcode":"70115781","Description":"Inhibin B","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":451.0},{"Itemcode":"70115790","Description":"5-HIAA","CDM Revenue Code":"300","CDM HCPCS":"83497","Standard Price":123.0},{"Itemcode":"70115795","Description":"PL-12 Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":159.0},{"Itemcode":"70115796","Description":"PL-7 Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":159.0},{"Itemcode":"70115797","Description":"OJ Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":159.0},{"Itemcode":"70115798","Description":"EJ Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":159.0},{"Itemcode":"70115799","Description":"SRP Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":159.0},{"Itemcode":"70115811","Description":"Parietal Cell Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":148.0},{"Itemcode":"70115812","Description":"Centromere Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":111.0},{"Itemcode":"70115814","Description":"Cobalt","CDM Revenue Code":"300","CDM HCPCS":"83018","Standard Price":204.0},{"Itemcode":"70115815","Description":"Iodine, Serum","CDM Revenue Code":"300","CDM HCPCS":"83018","Standard Price":494.0},{"Itemcode":"70115838","Description":"Thyroglobulin, S/P (CIA)","CDM Revenue Code":"300","CDM HCPCS":"84432","Standard Price":185.0},{"Itemcode":"70115839","Description":"Thyroglobulin, S/P (LC-MS/MS)","CDM Revenue Code":"300","CDM HCPCS":"84432","Standard Price":494.0},{"Itemcode":"70115859","Description":"Calcium, Urine","CDM Revenue Code":"300","CDM HCPCS":"82340","Standard Price":83.0},{"Itemcode":"70115860","Description":"Chloride, Urine","CDM Revenue Code":"300","CDM HCPCS":"82436","Standard Price":83.0},{"Itemcode":"70115861","Description":"Citrate","CDM Revenue Code":"300","CDM HCPCS":"82507","Standard Price":130.0},{"Itemcode":"70115862","Description":"Uric Acid, other source","CDM Revenue Code":"300","CDM HCPCS":"84560","Standard Price":83.0},{"Itemcode":"70115863","Description":"Magnesium","CDM Revenue Code":"300","CDM HCPCS":"83735","Standard Price":83.0},{"Itemcode":"70115864","Description":"Oxalate","CDM Revenue Code":"300","CDM HCPCS":"83945","Standard Price":83.0},{"Itemcode":"70115865","Description":"Phosphorus, Urine","CDM Revenue Code":"300","CDM HCPCS":"84105","Standard Price":83.0},{"Itemcode":"70115866","Description":"Potassium, Urine","CDM Revenue Code":"300","CDM HCPCS":"84133","Standard Price":83.0},{"Itemcode":"70115867","Description":"Sodium, Urine","CDM Revenue Code":"300","CDM HCPCS":"84300","Standard Price":83.0},{"Itemcode":"70115868","Description":"Sulfate, Urine","CDM Revenue Code":"300","CDM HCPCS":"84392","Standard Price":83.0},{"Itemcode":"70115869","Description":"pH; body fluid, NOS","CDM Revenue Code":"300","CDM HCPCS":"83986","Standard Price":83.0},{"Itemcode":"70115871","Description":"Acetylcholine Recep Block Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":352.0},{"Itemcode":"70115872","Description":"Acetylcholine Modulat Block Ab","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":417.0},{"Itemcode":"70115892","Description":"Maternal Serum Screen AFP","CDM Revenue Code":"300","CDM HCPCS":"82105","Standard Price":140.0},{"Itemcode":"70115911","Description":"Free PSA","CDM Revenue Code":"300","CDM HCPCS":"84154","Standard Price":140.0},{"Itemcode":"70115921","Description":"Hgb Evaluation w/ Reflex","CDM Revenue Code":"300","CDM HCPCS":"83021","Standard Price":278.0},{"Itemcode":"70115985","Description":"Hemoglobin-SF","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":104.0},{"Itemcode":"70115986","Description":"Alpha Defensins-SF","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":104.0},{"Itemcode":"70115994","Description":"RNA Polymerase III Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":649.0},{"Itemcode":"70115996","Description":"Chromatin Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":463.0},{"Itemcode":"70116001","Description":"Celiac Dis Dual Ag Screen","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":463.0},{"Itemcode":"70116002","Description":"DGP Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":111.0},{"Itemcode":"70116003","Description":"DGP Antibody, IgA","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":111.0},{"Itemcode":"70116004","Description":"tTG Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":232.0},{"Itemcode":"70116005","Description":"tTG Ab, IgA","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":93.0},{"Itemcode":"70116007","Description":"Immunglobulin A","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":84.0},{"Itemcode":"70116015","Description":"Neuronal Ab (Amphiphysin)","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":356.0},{"Itemcode":"70116018","Description":"Neuronal Nuclear Abs IgG, IB","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":741.0},{"Itemcode":"70116080","Description":"Serum Protein Electrophoresis","CDM Revenue Code":"300","CDM HCPCS":"84165","Standard Price":74.0},{"Itemcode":"70116081","Description":"Prot,total,by refract,any src","CDM Revenue Code":"300","CDM HCPCS":"84160","Standard Price":74.0},{"Itemcode":"70116082","Description":"Total Protein Other Specimen","CDM Revenue Code":"300","CDM HCPCS":"84157","Standard Price":111.0},{"Itemcode":"70116083","Description":"Protein E-Phoresis/Urine/CSF","CDM Revenue Code":"300","CDM HCPCS":"84166","Standard Price":111.0},{"Itemcode":"70116088","Description":"Adalimumab Neutralizing Ab","CDM Revenue Code":"300","CDM HCPCS":"82397","Standard Price":1569.0},{"Itemcode":"70116090","Description":"Thiopur Methyltransferase,RBC","CDM Revenue Code":"300","CDM HCPCS":"82657","Standard Price":926.0},{"Itemcode":"70116094","Description":"Infliximab Neutralizing Ab","CDM Revenue Code":"300","CDM HCPCS":"82397","Standard Price":1569.0},{"Itemcode":"70116095","Description":"Muscle-Specific Kinase(MuSK)Ab","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":692.0},{"Itemcode":"70116102","Description":"Vasoactive Intestinal Peptide","CDM Revenue Code":"300","CDM HCPCS":"84586","Standard Price":371.0},{"Itemcode":"70116103","Description":"Pancreatic Polypeptide","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":649.0},{"Itemcode":"70116107","Description":"Pancreatic Elastase, Fecal","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":865.0},{"Itemcode":"70116178","Description":"Insulin-Like Growth Factor 2","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":677.0},{"Itemcode":"70116205","Description":"Vitamin B2 Riboflavin","CDM Revenue Code":"300","CDM HCPCS":"84252","Standard Price":463.0},{"Itemcode":"70116210","Description":"Adenoise Deaminase, RBC","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":494.0},{"Itemcode":"70116211","Description":"Adenoise Deaminase,Pleural Fld","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":371.0},{"Itemcode":"70116213","Description":"Arsenic","CDM Revenue Code":"300","CDM HCPCS":"82175","Standard Price":140.0},{"Itemcode":"70116214","Description":"Lead","CDM Revenue Code":"300","CDM HCPCS":"83655","Standard Price":140.0},{"Itemcode":"70116215","Description":"Mercury, quantitative","CDM Revenue Code":"300","CDM HCPCS":"83825","Standard Price":140.0},{"Itemcode":"70116216","Description":"Arsenic","CDM Revenue Code":"300","CDM HCPCS":"82175","Standard Price":570.0},{"Itemcode":"70116221","Description":"Estriol","CDM Revenue Code":"300","CDM HCPCS":"82677","Standard Price":140.0},{"Itemcode":"70116222","Description":"Fecal Fat, Quant Random","CDM Revenue Code":"300","CDM HCPCS":"82710","Standard Price":278.0},{"Itemcode":"70116223","Description":"Fecal Fat, Quant 24-hr","CDM Revenue Code":"300","CDM HCPCS":"82710","Standard Price":371.0},{"Itemcode":"70116224","Description":"Fecal Fat, Quant 48-hr","CDM Revenue Code":"300","CDM HCPCS":"82710","Standard Price":556.0},{"Itemcode":"70116225","Description":"Fecal Fat, Quant 72-hr","CDM Revenue Code":"300","CDM HCPCS":"82710","Standard Price":463.0},{"Itemcode":"70116231","Description":"Immunglobulin A","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":179.0},{"Itemcode":"70116232","Description":"Immunglobulin A Subclass 1","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":179.0},{"Itemcode":"70116233","Description":"Immunglobulin A Subclass 2","CDM Revenue Code":"300","CDM HCPCS":"82787","Standard Price":179.0},{"Itemcode":"70116241","Description":"Anti-Mullerian Hormone","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":367.0},{"Itemcode":"70116245","Description":"ACE, CSF","CDM Revenue Code":"300","CDM HCPCS":"82164","Standard Price":278.0},{"Itemcode":"70116248","Description":"AQP4 ELISA","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":1545.0},{"Itemcode":"70116261","Description":"Coenzyme Q10, Total","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":494.0},{"Itemcode":"70116267","Description":"Mannose Binding Lectin","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":677.0},{"Itemcode":"70116293","Description":"Bismuth, Blood","CDM Revenue Code":"300","CDM HCPCS":"83018","Standard Price":278.0},{"Itemcode":"70116294","Description":"Androstenedione","CDM Revenue Code":"300","CDM HCPCS":"82157","Standard Price":194.0},{"Itemcode":"70116295","Description":"Dehydroepiandrosterone (DHEA)","CDM Revenue Code":"300","CDM HCPCS":"83498","Standard Price":194.0},{"Itemcode":"70116296","Description":"Testosterone; total","CDM Revenue Code":"300","CDM HCPCS":"84403","Standard Price":194.0},{"Itemcode":"70116297","Description":"17-Hydroxyprogesterone","CDM Revenue Code":"300","CDM HCPCS":"82634","Standard Price":194.0},{"Itemcode":"70116298","Description":"11-Deoxycortisol, HPLC-MS/MS","CDM Revenue Code":"300","CDM HCPCS":"82626","Standard Price":194.0},{"Itemcode":"70116301","Description":"Vitamin B12 Binding Capacity","CDM Revenue Code":"300","CDM HCPCS":"82608","Standard Price":232.0},{"Itemcode":"70116314","Description":"ADAMTS13 Antibody","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":1402.0},{"Itemcode":"70116317","Description":"Myelin Assoc Glycoprotein, IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":214.0},{"Itemcode":"70116318","Description":"GM1 Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":185.0},{"Itemcode":"70116319","Description":"GM1 Antibody, IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":185.0},{"Itemcode":"70116320","Description":"GD1b Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":185.0},{"Itemcode":"70116321","Description":"GD1b Antibody, IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":185.0},{"Itemcode":"70116322","Description":"GQ1b Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":185.0},{"Itemcode":"70116323","Description":"GQ1b Antibody, IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":185.0},{"Itemcode":"70116324","Description":"VGKC Antibody","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1030.0},{"Itemcode":"70116325","Description":"Aquaporin-4 Receptor Antibody","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":1030.0},{"Itemcode":"70116335","Description":"Ph, Fecal","CDM Revenue Code":"300","CDM HCPCS":"83986","Standard Price":111.0},{"Itemcode":"70116336","Description":"Potassium, Stool","CDM Revenue Code":"300","CDM HCPCS":"84999","Standard Price":130.0},{"Itemcode":"70116337","Description":"Sodium, Stool","CDM Revenue Code":"300","CDM HCPCS":"84302","Standard Price":130.0},{"Itemcode":"70116338","Description":"Chloride, Stool","CDM Revenue Code":"300","CDM HCPCS":"82438","Standard Price":130.0},{"Itemcode":"70116341","Description":"PAPP-A","CDM Revenue Code":"300","CDM HCPCS":"84163","Standard Price":335.0},{"Itemcode":"70116342","Description":"VGCC Antibody","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":1030.0},{"Itemcode":"70116343","Description":"Titin Antibody","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":803.0},{"Itemcode":"70116344","Description":"Melanocyte Stim Hormone,Alpha","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":856.0},{"Itemcode":"70116359","Description":"AST, FibroMeter","CDM Revenue Code":"300","CDM HCPCS":"84450","Standard Price":167.0},{"Itemcode":"70116360","Description":"ALT, FibroMeter","CDM Revenue Code":"300","CDM HCPCS":"84460","Standard Price":167.0},{"Itemcode":"70116361","Description":"Ferritin, FibroMeter","CDM Revenue Code":"300","CDM HCPCS":"82728","Standard Price":167.0},{"Itemcode":"70116362","Description":"Glucose, FibroMeter","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":167.0},{"Itemcode":"70116375","Description":"SGPG Antibody, IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":274.0},{"Itemcode":"70116382","Description":"Insulin, Total","CDM Revenue Code":"300","CDM HCPCS":"83525","Standard Price":77.0},{"Itemcode":"70116383","Description":"Insulin, Free","CDM Revenue Code":"300","CDM HCPCS":"83527","Standard Price":77.0},{"Itemcode":"70116399","Description":"Vitamin B7 (Biotin)","CDM Revenue Code":"300","CDM HCPCS":"84591","Standard Price":499.0},{"Itemcode":"70116421","Description":"Dihydrotestosterone (DHT)","CDM Revenue Code":"300","CDM HCPCS":"82642","Standard Price":209.0},{"Itemcode":"70116455","Description":"F-Actin Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":50.0},{"Itemcode":"70116456","Description":"14-3-3 eta Protein","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":645.0},{"Itemcode":"70116457","Description":"Acylglycines, Quant, Ur","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":692.0},{"Itemcode":"70116459","Description":"Porphyrins, Total, Pl or Ser","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":120.0},{"Itemcode":"70116479","Description":"Fat, Fecal Qualitative","CDM Revenue Code":"300","CDM HCPCS":"82705","Standard Price":112.0},{"Itemcode":"70116490","Description":"Magnesium, RBC","CDM Revenue Code":"300","CDM HCPCS":"83735","Standard Price":229.0},{"Itemcode":"70116493","Description":"Thyroglobulin, FNA","CDM Revenue Code":"300","CDM HCPCS":"84432","Standard Price":175.0},{"Itemcode":"70116497","Description":"Phencyclidine (PCP),S/P,Quant","CDM Revenue Code":"300","CDM HCPCS":"83992","Standard Price":426.0},{"Itemcode":"70116501","Description":"Immunglobulin A","CDM Revenue Code":"300","CDM HCPCS":"82784","Standard Price":84.0},{"Itemcode":"70116502","Description":"Heavy Metal Quant","CDM Revenue Code":"300","CDM HCPCS":"83018","Standard Price":1658.0},{"Itemcode":"70116503","Description":"Vitamin K","CDM Revenue Code":"300","CDM HCPCS":"84597","Standard Price":487.0},{"Itemcode":"70116504","Description":"SGPG Antibody, IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":89.0},{"Itemcode":"70116505","Description":"MAG Antibody, IgM Elisa","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":89.0},{"Itemcode":"70116506","Description":"Asialo-GM1 Antibodies, IgG/IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":89.0},{"Itemcode":"70116507","Description":"GM1 Antibodies, IgG/IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":89.0},{"Itemcode":"70116508","Description":"GD1a Antibodies, IgG/IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":89.0},{"Itemcode":"70116509","Description":"GD1b Antibodies, IgG/IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":89.0},{"Itemcode":"70116510","Description":"GQ1b Antibodies, IgG/IgM","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":89.0},{"Itemcode":"70116515","Description":"Alpha-1-antitrypsin; phenotype","CDM Revenue Code":"300","CDM HCPCS":"82104","Standard Price":179.0},{"Itemcode":"70116536","Description":"Hydroxycorticosteroids,17,Ur","CDM Revenue Code":"300","CDM HCPCS":"83491","Standard Price":315.0},{"Itemcode":"70116539","Description":"Copper Level Urine","CDM Revenue Code":"300","CDM HCPCS":"82525","Standard Price":71.0},{"Itemcode":"70116540","Description":"Creatinine Body Fluid","CDM Revenue Code":"300","CDM HCPCS":"82570","Standard Price":50.0},{"Itemcode":"70116548","Description":"Oxalate, Total, Urine","CDM Revenue Code":"300","CDM HCPCS":"83945","Standard Price":128.0},{"Itemcode":"70116549","Description":"Thyroxine binding globulin","CDM Revenue Code":"300","CDM HCPCS":"84442","Standard Price":101.0},{"Itemcode":"70116550","Description":"Bullous Pemphigoid Ag 180, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":383.0},{"Itemcode":"70116551","Description":"Bullous Pemphigoid Ag 230, IgG","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":383.0},{"Itemcode":"70116552","Description":"Lead, Urine","CDM Revenue Code":"300","CDM HCPCS":"83655","Standard Price":64.0},{"Itemcode":"70116553","Description":"Carboxyhemoglobin;quantitative","CDM Revenue Code":"300","CDM HCPCS":"82375","Standard Price":508.0},{"Itemcode":"70116560","Description":"21-Hydroxylase Antibody","CDM Revenue Code":"300","CDM HCPCS":"83519","Standard Price":326.0},{"Itemcode":"70116568","Description":"Porphyrins Total, Plasma","CDM Revenue Code":"300","CDM HCPCS":"84311","Standard Price":664.0},{"Itemcode":"70116569","Description":"Porphyrins, Fractionation,Plas","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":920.0},{"Itemcode":"70116581","Description":"Leptin Quant by CIA","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":373.0},{"Itemcode":"70116599","Description":"Pompe (GAA),Enz Act Leukocytes","CDM Revenue Code":"300","CDM HCPCS":"82657","Standard Price":621.0},{"Itemcode":"70116600","Description":"F-Actin (Smooth Muscle) Ab,IgA","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":395.0},{"Itemcode":"70116604","Description":"SAE1 Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116605","Description":"NXP2 Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116606","Description":"MDA5 Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116607","Description":"TIF-1 gamma Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116608","Description":"Mi-2 Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116609","Description":"P155/140 Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116610","Description":"PL-12 Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116611","Description":"PL-7 Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116612","Description":"OJ Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116613","Description":"EJ Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116614","Description":"SRP Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116615","Description":"Ku Ab-EMP","CDM Revenue Code":"300","CDM HCPCS":"83516","Standard Price":91.0},{"Itemcode":"70116627","Description":"IGF Binding Protein-3","CDM Revenue Code":"301","CDM HCPCS":"82397","Standard Price":114.0},{"Itemcode":"70116630","Description":"Interleukin 5","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":528.0},{"Itemcode":"70116631","Description":"Chylomicron Screen, Body Fluid","CDM Revenue Code":"300","CDM HCPCS":"82664","Standard Price":212.0},{"Itemcode":"70116632","Description":"Glucose, Urine","CDM Revenue Code":"301","CDM HCPCS":"82945","Standard Price":98.0},{"Itemcode":"70116638","Description":"Uric Acid, Urine","CDM Revenue Code":"301","CDM HCPCS":"84560","Standard Price":46.0},{"Itemcode":"70116639","Description":"Insulin, Fasting","CDM Revenue Code":"301","CDM HCPCS":"83525","Standard Price":58.0},{"Itemcode":"70116644","Description":"Immunoglobulin E","CDM Revenue Code":"301","CDM HCPCS":"82785","Standard Price":50.0},{"Itemcode":"70116646","Description":"Alpha Fetoprotein Tumor Marker","CDM Revenue Code":"301","CDM HCPCS":"82105","Standard Price":82.0},{"Itemcode":"70116648","Description":"Homocysteine, Total","CDM Revenue Code":"300","CDM HCPCS":"83090","Standard Price":127.0},{"Itemcode":"70116651","Description":"Chromium, RBC","CDM Revenue Code":"301","CDM HCPCS":"82495","Standard Price":647.0},{"Itemcode":"70116652","Description":"Alpha Galactosidase, Serum","CDM Revenue Code":"301","CDM HCPCS":"82657","Standard Price":1468.0},{"Itemcode":"70116653","Description":"IgA","CDM Revenue Code":"301","CDM HCPCS":"82784","Standard Price":60.0},{"Itemcode":"70116654","Description":"IgG","CDM Revenue Code":"301","CDM HCPCS":"82784","Standard Price":60.0},{"Itemcode":"70116655","Description":"IgM","CDM Revenue Code":"301","CDM HCPCS":"82784","Standard Price":60.0},{"Itemcode":"70116656","Description":"Total Protein","CDM Revenue Code":"301","CDM HCPCS":"84155","Standard Price":60.0},{"Itemcode":"70116657","Description":"SPE","CDM Revenue Code":"300","CDM HCPCS":"84165","Standard Price":60.0},{"Itemcode":"70116673","Description":"Pyruvate kinase","CDM Revenue Code":"301","CDM HCPCS":"84220","Standard Price":325.0},{"Itemcode":"70116674","Description":"Total PSA","CDM Revenue Code":"301","CDM HCPCS":"84153","Standard Price":484.0},{"Itemcode":"70116675","Description":"Free PSA","CDM Revenue Code":"301","CDM HCPCS":"84154","Standard Price":621.0},{"Itemcode":"70116681","Description":"Methemoglobin Reductase, Bld","CDM Revenue Code":"300","CDM HCPCS":"82657","Standard Price":1300.0},{"Itemcode":"70116683","Description":"Interferon gamma","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":529.0},{"Itemcode":"70116684","Description":"Cholinesterase, RBC","CDM Revenue Code":"300","CDM HCPCS":"82482","Standard Price":106.0},{"Itemcode":"70116731","Description":"Immunoassay Quant Nos 4","CDM Revenue Code":"301","CDM HCPCS":"83520","Standard Price":44.0},{"Itemcode":"70116732","Description":"Immunoassay Quant Nos 5","CDM Revenue Code":"301","CDM HCPCS":"83520","Standard Price":44.0},{"Itemcode":"70118028","Description":"Very Long Chain Fatty Acids","CDM Revenue Code":"300","CDM HCPCS":"82726","Standard Price":554.0},{"Itemcode":"70118029","Description":"Enzyme: Radioactive Substrate","CDM Revenue Code":"300","CDM HCPCS":"82658","Standard Price":554.0},{"Itemcode":"70118468","Description":"Column Chromatography/Ms Quani","CDM Revenue Code":"300","CDM HCPCS":"82542","Standard Price":554.0},{"Itemcode":"70118489","Description":"Immunoassay Quant Nos 3","CDM Revenue Code":"300","CDM HCPCS":"83520","Standard Price":592.0},{"Itemcode":"70118494","Description":"Arsenic: Nail","CDM Revenue Code":"300","CDM HCPCS":"82175","Standard Price":861.0},{"Itemcode":"70119500","Description":"Nags:Hexosam. A & Total Serum","CDM Revenue Code":"300","CDM HCPCS":"83080","Standard Price":1389.0},{"Itemcode":"70124320","Description":"Electrophoresis, Nes","CDM Revenue Code":"300","CDM HCPCS":"82664","Standard Price":1176.0},{"Itemcode":"73100003","Description":"Blood Gases","CDM Revenue Code":"300","CDM HCPCS":"82803","Standard Price":320.0},{"Itemcode":"73100110","Description":"Calcium Ionized","CDM Revenue Code":"300","CDM HCPCS":"82330","Standard Price":170.0},{"Itemcode":"73100111","Description":"Lactate","CDM Revenue Code":"300","CDM HCPCS":"83605","Standard Price":145.0},{"Itemcode":"73100114","Description":"Sodium: Serum","CDM Revenue Code":"300","CDM HCPCS":"84295","Standard Price":88.0},{"Itemcode":"73100115","Description":"Potassium: Serum","CDM Revenue Code":"300","CDM HCPCS":"84132","Standard Price":84.0},{"Itemcode":"73100116","Description":"Chloride Blood","CDM Revenue Code":"300","CDM HCPCS":"82435","Standard Price":89.0},{"Itemcode":"73100117","Description":"Glucose; Blood, Quant","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":76.0},{"Itemcode":"73100221","Description":"BG W/ POC ELECTROLYTES","CDM Revenue Code":"300","CDM HCPCS":"82803","Standard Price":334.0},{"Itemcode":"73100222","Description":"BG W/ POC ELECTROLW/GLU","CDM Revenue Code":"300","CDM HCPCS":"82803","Standard Price":347.0},{"Itemcode":"74201024","Description":"Glucose","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":70.0},{"Itemcode":"74221019","Description":"AST - Med Mgmt","CDM Revenue Code":"300","CDM HCPCS":"84450","Standard Price":80.0},{"Itemcode":"74221020","Description":"Alt - Med Mgmt","CDM Revenue Code":"300","CDM HCPCS":"84460","Standard Price":80.0},{"Itemcode":"74221021","Description":"Creatinine, Blood","CDM Revenue Code":"300","CDM HCPCS":"82565","Standard Price":93.0},{"Itemcode":"74221022","Description":"BUN - QUANT","CDM Revenue Code":"300","CDM HCPCS":"84520","Standard Price":80.0},{"Itemcode":"74221024","Description":"Glucose","CDM Revenue Code":"300","CDM HCPCS":"82947","Standard Price":70.0},{"Itemcode":"74221025","Description":"A1C","CDM Revenue Code":"300","CDM HCPCS":"83036","Standard Price":74.0},{"Itemcode":"75452025","Description":"Go Strong Fasting Glucose","CDM Revenue Code":"300","CDM HCPCS":"82962","Standard Price":9.0},{"Itemcode":"75452026","Description":"Go Strong Hgba1C","CDM Revenue Code":"300","CDM HCPCS":"83036","Standard Price":15.0},{"Itemcode":"70100215","Description":"Clozapine (Clozaril) Qst","CDM Revenue Code":"300","CDM HCPCS":"80159","Standard Price":583.0},{"Itemcode":"70100645","Description":"Acetaminophen Assay","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":174.0},{"Itemcode":"70100740","Description":"Salicylate Assay","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":153.0},{"Itemcode":"70100751","Description":"Alcohol Ethyl","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":217.0},{"Itemcode":"70100842","Description":"Fentanyl Drug Screen","CDM Revenue Code":"300","CDM HCPCS":"G0659","Standard Price":204.0},{"Itemcode":"70100843","Description":"Fentanyl Drug Confirmation","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":441.0},{"Itemcode":"70101019","Description":"Methadone","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":290.0},{"Itemcode":"70101099","Description":"Drug Screen ADOS KIMS CEDIA EI","CDM Revenue Code":"300","CDM HCPCS":"80307","Standard Price":844.0},{"Itemcode":"70101310","Description":"Drug Screen B Single;Ea Proc","CDM Revenue Code":"300","CDM HCPCS":"G0659","Standard Price":249.0},{"Itemcode":"70101663","Description":"Zonisamide","CDM Revenue Code":"300","CDM HCPCS":"80203","Standard Price":250.0},{"Itemcode":"70104247","Description":"Nortriptyline,1-2 Definitive","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":396.0},{"Itemcode":"70106234","Description":"Amitriptylin/ElavilAntidepTric","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":310.0},{"Itemcode":"70109024","Description":"Gabapentin Level","CDM Revenue Code":"300","CDM HCPCS":"80171","Standard Price":106.0},{"Itemcode":"70109889","Description":"SedrugscrTricyclic, 3-5Antidep","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":141.0},{"Itemcode":"70110008","Description":"Drug Confirmation: Amphet","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":417.0},{"Itemcode":"70110009","Description":"Drug Confirmation:Opiates >=1","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":441.0},{"Itemcode":"70110010","Description":"Drug Confirmation: Benzo","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":389.0},{"Itemcode":"70110011","Description":"Drug Confirmation: Cocaine","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":363.0},{"Itemcode":"70110033","Description":"Lamotrigine","CDM Revenue Code":"300","CDM HCPCS":"80175","Standard Price":537.0},{"Itemcode":"70110145","Description":"Oxycodone","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":1636.0},{"Itemcode":"70110350","Description":"Drug Confirmation:Barbiturates","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":208.0},{"Itemcode":"70115014","Description":"Dihydrotestosterone (Dht)","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":740.0},{"Itemcode":"70115505","Description":"Nicotine, Assay","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":428.0},{"Itemcode":"70115611","Description":"Tricyclic Antidepres Eval -QST","CDM Revenue Code":"301","CDM HCPCS":"G0480","Standard Price":267.0},{"Itemcode":"70115631","Description":"Drug Test Presumptive","CDM Revenue Code":"300","CDM HCPCS":"G0659","Standard Price":578.0},{"Itemcode":"70115632","Description":"Drug Test Def 22++ - LabCorp","CDM Revenue Code":"300","CDM HCPCS":"G0483","Standard Price":578.0},{"Itemcode":"70115754","Description":"Drug Screen Amphetamines","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":141.0},{"Itemcode":"70115755","Description":"Drug Screen Barbiturates","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":141.0},{"Itemcode":"70115756","Description":"Drug Screen Benzodiazepines","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":141.0},{"Itemcode":"70115757","Description":"Drug Screen Cannabinoids","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":141.0},{"Itemcode":"70115758","Description":"Drug Screen Cocaine","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":141.0},{"Itemcode":"70115759","Description":"Drug Screen Opiates","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":141.0},{"Itemcode":"70115764","Description":"Drug Screening Buprenorphine","CDM Revenue Code":"301","CDM HCPCS":"G0480","Standard Price":158.0},{"Itemcode":"70115771","Description":"Drug Test Prsmv Chem Analyzr","CDM Revenue Code":"300","CDM HCPCS":"80307","Standard Price":447.0},{"Itemcode":"70115783","Description":"TSH Receptor Ab (ARUP)","CDM Revenue Code":"300","CDM HCPCS":"80353","Standard Price":192.0},{"Itemcode":"70115877","Description":"Methanol","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":195.0},{"Itemcode":"70115882","Description":"Oxcarbazepine","CDM Revenue Code":"300","CDM HCPCS":"80183","Standard Price":151.0},{"Itemcode":"70115901","Description":"Drug Pan 9,Se/Pl,Scr Rflx Conf","CDM Revenue Code":"300","CDM HCPCS":"80307","Standard Price":491.0},{"Itemcode":"70115902","Description":"Amphetamines, Se/Pl, Quant","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":546.0},{"Itemcode":"70115903","Description":"Barbiturates, Se/Pl, Quant","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":416.0},{"Itemcode":"70115904","Description":"Benzodiazepines, Se/Pl, Quant","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":416.0},{"Itemcode":"70115905","Description":"THC Metabolite, Se/Pl, Quant","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":546.0},{"Itemcode":"70115906","Description":"Cocaine Metabolite, Se/Pl, Qnt","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":468.0},{"Itemcode":"70115907","Description":"Methadone and Metab, Se/Pl, Qt","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":546.0},{"Itemcode":"70115908","Description":"Opiates, Se/Pl, Quant","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":546.0},{"Itemcode":"70115909","Description":"Buprenorphine & Metab,Se/Pl,Qt","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":546.0},{"Itemcode":"70115910","Description":"Phencyclidine (PCP), Se/Pl, Qt","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":416.0},{"Itemcode":"70115912","Description":"Amphetmines, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":806.0},{"Itemcode":"70115913","Description":"Barbiturates, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":806.0},{"Itemcode":"70115914","Description":"Benzodiazepines, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":780.0},{"Itemcode":"70115915","Description":"Buprenorphine,Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":580.0},{"Itemcode":"70115916","Description":"Cannabinoids, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":624.0},{"Itemcode":"70115917","Description":"Cocaine, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":624.0},{"Itemcode":"70115918","Description":"Methadone, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":624.0},{"Itemcode":"70115919","Description":"Opiates, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":624.0},{"Itemcode":"70115920","Description":"Phencyclidine, Confirm, Mec","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":780.0},{"Itemcode":"70115971","Description":"Drug Panel 9,U,Scr w/Rflx Conf","CDM Revenue Code":"300","CDM HCPCS":"80307","Standard Price":226.0},{"Itemcode":"70115972","Description":"Amphetamines Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"80324","Standard Price":176.0},{"Itemcode":"70115973","Description":"MDMA, Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":176.0},{"Itemcode":"70115974","Description":"Barbiturates Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":546.0},{"Itemcode":"70115975","Description":"Benzodiazepines Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":351.0},{"Itemcode":"70115976","Description":"THC Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":312.0},{"Itemcode":"70115977","Description":"Cocaine Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":312.0},{"Itemcode":"70115978","Description":"Methadone Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":351.0},{"Itemcode":"70115979","Description":"Opiates Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":137.0},{"Itemcode":"70115980","Description":"Oxycodone Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":137.0},{"Itemcode":"70115981","Description":"Propoxyphene Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":416.0},{"Itemcode":"70115982","Description":"PCP, Confirm, Ur","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":416.0},{"Itemcode":"70116105","Description":"Ethyl Glucoronide/Sulfate,U,Qt","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":328.0},{"Itemcode":"70116212","Description":"Hypoglycemia Pan,Sylfonylureas","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":390.0},{"Itemcode":"70116251","Description":"Phosphatidylethanol (PEth)","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":580.0},{"Itemcode":"70116494","Description":"Amphetamines/Methamphetamines","CDM Revenue Code":"300","CDM HCPCS":"80324","Standard Price":167.0},{"Itemcode":"70116495","Description":"MDA, MDEA, MDMA","CDM Revenue Code":"300","CDM HCPCS":"80359","Standard Price":167.0},{"Itemcode":"70116496","Description":"Alcohol, Urine, Quant","CDM Revenue Code":"300","CDM HCPCS":"80320","Standard Price":128.0},{"Itemcode":"70116498","Description":"Propoxyphene & Met, S/P, Quant","CDM Revenue Code":"300","CDM HCPCS":"80367","Standard Price":439.0},{"Itemcode":"70116499","Description":"Fluoxetine & Met, S/P","CDM Revenue Code":"300","CDM HCPCS":"80332","Standard Price":540.0},{"Itemcode":"70116574","Description":"Clobazam Quantitative, S/P","CDM Revenue Code":"300","CDM HCPCS":"80339","Standard Price":504.0},{"Itemcode":"70116583","Description":"Drug Screen (Nonforensic), Ser","CDM Revenue Code":"300","CDM HCPCS":"80307","Standard Price":410.0},{"Itemcode":"70116597","Description":"Lacosamide, Serum or Plasma","CDM Revenue Code":"300","CDM HCPCS":"80339","Standard Price":570.0},{"Itemcode":"70116678","Description":"Amitriptyline/Nortriptyline","CDM Revenue Code":"300","CDM HCPCS":"G0480","Standard Price":170.0},{"Itemcode":"70118460","Description":"Levetiracetam","CDM Revenue Code":"300","CDM HCPCS":"80177","Standard Price":638.0},{"Itemcode":"70121000","Description":"Mycophenolic Acid","CDM Revenue Code":"300","CDM HCPCS":"80180","Standard Price":400.0},{"Itemcode":"61700154","Description":"Activated Clotting Time","CDM Revenue Code":"300","CDM HCPCS":"85347","Standard Price":359.0},{"Itemcode":"61800080","Description":"Activated Clotting Time","CDM Revenue Code":"300","CDM HCPCS":"85347","Standard Price":359.0},{"Itemcode":"68269753","Description":"CBC, AUTO, DIFF PLTLTS","CDM Revenue Code":"300","CDM HCPCS":"85025","Standard Price":47.0},{"Itemcode":"70100016","Description":"Sedimentation Rate","CDM Revenue Code":"300","CDM HCPCS":"85651","Standard Price":119.0},{"Itemcode":"70100018","Description":"Platelet Count","CDM Revenue Code":"300","CDM HCPCS":"85049","Standard Price":95.0},{"Itemcode":"70100041","Description":"Protime","CDM Revenue Code":"300","CDM HCPCS":"85610","Standard Price":79.0},{"Itemcode":"70100042","Description":"PTT","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":109.0},{"Itemcode":"70100071","Description":"CBC Without DIFF-AUTOM PLTLT","CDM Revenue Code":"300","CDM HCPCS":"85027","Standard Price":35.0},{"Itemcode":"70100072","Description":"Differential: Manual","CDM Revenue Code":"300","CDM HCPCS":"85007","Standard Price":21.0},{"Itemcode":"70100098","Description":"D-Dimer","CDM Revenue Code":"300","CDM HCPCS":"85379","Standard Price":282.0},{"Itemcode":"70100198","Description":"Fibrinogen","CDM Revenue Code":"300","CDM HCPCS":"85384","Standard Price":212.0},{"Itemcode":"70100434","Description":"Factor II Activity - Qst","CDM Revenue Code":"300","CDM HCPCS":"85210","Standard Price":355.0},{"Itemcode":"70100517","Description":"Fibrin Split Products","CDM Revenue Code":"300","CDM HCPCS":"85362","Standard Price":297.0},{"Itemcode":"70100518","Description":"Thrombin Time","CDM Revenue Code":"300","CDM HCPCS":"85670","Standard Price":127.0},{"Itemcode":"70100608","Description":"VWF Protease Activity","CDM Revenue Code":"300","CDM HCPCS":"85397","Standard Price":624.0},{"Itemcode":"70100609","Description":"VWF Protease Inhibitor","CDM Revenue Code":"300","CDM HCPCS":"85335","Standard Price":760.0},{"Itemcode":"70100646","Description":"Kleihauer-Betke","CDM Revenue Code":"300","CDM HCPCS":"85460","Standard Price":229.0},{"Itemcode":"70100660","Description":"Sickle Cell Prep","CDM Revenue Code":"300","CDM HCPCS":"85660","Standard Price":222.0},{"Itemcode":"70100663","Description":"Leuk Alk Phos","CDM Revenue Code":"300","CDM HCPCS":"85540","Standard Price":339.0},{"Itemcode":"70100711","Description":"WBC - Automated","CDM Revenue Code":"300","CDM HCPCS":"85048","Standard Price":129.0},{"Itemcode":"70100713","Description":"Hemoglobin","CDM Revenue Code":"300","CDM HCPCS":"85018","Standard Price":78.0},{"Itemcode":"70100714","Description":"Hematocrit","CDM Revenue Code":"300","CDM HCPCS":"85014","Standard Price":78.0},{"Itemcode":"70100715","Description":"Reticulocyte Count - Auto","CDM Revenue Code":"300","CDM HCPCS":"85045","Standard Price":116.0},{"Itemcode":"70100825","Description":"WBC Stool","CDM Revenue Code":"300","CDM HCPCS":"89055","Standard Price":173.0},{"Itemcode":"70100861","Description":"PTT Mixing 1","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":109.0},{"Itemcode":"70100862","Description":"PTT Mixing 2","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":109.0},{"Itemcode":"70101029","Description":"PTT La Screen Qs","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":55.0},{"Itemcode":"70101030","Description":"PTT La Hexagonal Phase Confir","CDM Revenue Code":"300","CDM HCPCS":"85598","Standard Price":274.0},{"Itemcode":"70101295","Description":"Fibrinogen Antigen Neph -Quest","CDM Revenue Code":"300","CDM HCPCS":"85385","Standard Price":112.0},{"Itemcode":"70101368","Description":"Euglobulin Clot Lysis Time Qst","CDM Revenue Code":"300","CDM HCPCS":"85360","Standard Price":432.0},{"Itemcode":"70101405","Description":"PTT -La (Lupus Panel Quest)","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":109.0},{"Itemcode":"70101406","Description":"Drvvt For Lupus Panel Quest","CDM Revenue Code":"300","CDM HCPCS":"85613","Standard Price":330.0},{"Itemcode":"70101408","Description":"PTT Vw Panel Quest 15540","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":109.0},{"Itemcode":"70101422","Description":"Protein S Free Quest","CDM Revenue Code":"300","CDM HCPCS":"85306","Standard Price":131.0},{"Itemcode":"70101468","Description":"FETOMATERNAL HEMORRHAGE ROSETT","CDM Revenue Code":"300","CDM HCPCS":"85461","Standard Price":365.0},{"Itemcode":"70101604","Description":"Factor V Activity Clotting","CDM Revenue Code":"300","CDM HCPCS":"85220","Standard Price":203.0},{"Itemcode":"70102018","Description":"WBC (DIFF)","CDM Revenue Code":"300","CDM HCPCS":"85004","Standard Price":306.0},{"Itemcode":"70102382","Description":"Nijmegen Assay","CDM Revenue Code":"300","CDM HCPCS":"85335","Standard Price":1213.0},{"Itemcode":"70104033","Description":"Anti Thrombin III, Activ Assay","CDM Revenue Code":"300","CDM HCPCS":"85300","Standard Price":485.0},{"Itemcode":"70104063","Description":"Viscosity","CDM Revenue Code":"300","CDM HCPCS":"85810","Standard Price":94.0},{"Itemcode":"70104209","Description":"Lupus Anticoagulant","CDM Revenue Code":"300","CDM HCPCS":"85300","Standard Price":1118.0},{"Itemcode":"70104214","Description":"Lysozyme(Muramidase)","CDM Revenue Code":"300","CDM HCPCS":"85549","Standard Price":156.0},{"Itemcode":"70104239","Description":"Protein C","CDM Revenue Code":"300","CDM HCPCS":"85302","Standard Price":593.0},{"Itemcode":"70104240","Description":"Protein S","CDM Revenue Code":"300","CDM HCPCS":"85305","Standard Price":670.0},{"Itemcode":"70104289","Description":"Factor VIII Assay","CDM Revenue Code":"300","CDM HCPCS":"85240","Standard Price":686.0},{"Itemcode":"70106790","Description":"Hemolysin: Acid","CDM Revenue Code":"300","CDM HCPCS":"85475","Standard Price":492.0},{"Itemcode":"70108027","Description":"Factor X Activity Clotting","CDM Revenue Code":"300","CDM HCPCS":"85260","Standard Price":234.0},{"Itemcode":"70109025","Description":"Osmotic Fragility: Rbc","CDM Revenue Code":"300","CDM HCPCS":"85557","Standard Price":1260.0},{"Itemcode":"70109749","Description":"Russell Viper Venom","CDM Revenue Code":"300","CDM HCPCS":"85613","Standard Price":330.0},{"Itemcode":"70109752","Description":"Factor Inhibitor Test","CDM Revenue Code":"300","CDM HCPCS":"85335","Standard Price":670.0},{"Itemcode":"70109753","Description":"CBC, AUTO, DIFF PLTLTS","CDM Revenue Code":"300","CDM HCPCS":"85025","Standard Price":43.0},{"Itemcode":"70109755","Description":"Von Willebrand Factor","CDM Revenue Code":"300","CDM HCPCS":"85246","Standard Price":1353.0},{"Itemcode":"70109757","Description":"Factor IX Assay","CDM Revenue Code":"300","CDM HCPCS":"85250","Standard Price":437.0},{"Itemcode":"70109910","Description":"Reticulocyte Count Manual","CDM Revenue Code":"300","CDM HCPCS":"85044","Standard Price":281.0},{"Itemcode":"70110045","Description":"Factor VII","CDM Revenue Code":"300","CDM HCPCS":"85230","Standard Price":250.0},{"Itemcode":"70110050","Description":"Factor XI Activity","CDM Revenue Code":"300","CDM HCPCS":"85270","Standard Price":413.0},{"Itemcode":"70110051","Description":"Factor XII Activity","CDM Revenue Code":"300","CDM HCPCS":"85280","Standard Price":390.0},{"Itemcode":"70110055","Description":"Factor XIII","CDM Revenue Code":"300","CDM HCPCS":"85290","Standard Price":777.0},{"Itemcode":"70110075","Description":"Protein S Functional","CDM Revenue Code":"300","CDM HCPCS":"85306","Standard Price":512.0},{"Itemcode":"70110076","Description":"Protein C Functional","CDM Revenue Code":"300","CDM HCPCS":"85303","Standard Price":486.0},{"Itemcode":"70110160","Description":"Protime - Capillary","CDM Revenue Code":"300","CDM HCPCS":"85610","Standard Price":175.0},{"Itemcode":"70110180","Description":"Ristocetin Cofactor","CDM Revenue Code":"300","CDM HCPCS":"85245","Standard Price":257.0},{"Itemcode":"70110185","Description":"Von Willebrand Factor Antigen","CDM Revenue Code":"300","CDM HCPCS":"85246","Standard Price":380.0},{"Itemcode":"70110186","Description":"Von Willebrand Ag: Multimeric","CDM Revenue Code":"300","CDM HCPCS":"85247","Standard Price":546.0},{"Itemcode":"70110192","Description":"Platelet Functn InVitro 1 Epi","CDM Revenue Code":"300","CDM HCPCS":"85576","Standard Price":245.0},{"Itemcode":"70110193","Description":"Platelet Function 2 Adp","CDM Revenue Code":"300","CDM HCPCS":"85576","Standard Price":245.0},{"Itemcode":"70110400","Description":"Heparin Assay","CDM Revenue Code":"300","CDM HCPCS":"85520","Standard Price":321.0},{"Itemcode":"70115022","Description":"Fletcher Factor Assay","CDM Revenue Code":"300","CDM HCPCS":"85292","Standard Price":1784.0},{"Itemcode":"70115030","Description":"Platelet Neutralization","CDM Revenue Code":"300","CDM HCPCS":"85597","Standard Price":1693.0},{"Itemcode":"70115741","Description":"K (Kinetics) TEG","CDM Revenue Code":"305","CDM HCPCS":"85384","Standard Price":16.0},{"Itemcode":"70115742","Description":"Angle TEG","CDM Revenue Code":"305","CDM HCPCS":"85384","Standard Price":16.0},{"Itemcode":"70115743","Description":"Fibrinogen Functional TEG","CDM Revenue Code":"305","CDM HCPCS":"85384","Standard Price":16.0},{"Itemcode":"70115744","Description":"MA (Max Clot) TEG","CDM Revenue Code":"305","CDM HCPCS":"85576","Standard Price":40.0},{"Itemcode":"70115745","Description":"MA (Max Clot) Rapid TEG","CDM Revenue Code":"305","CDM HCPCS":"85576","Standard Price":40.0},{"Itemcode":"70115746","Description":"MA HKH TEG","CDM Revenue Code":"305","CDM HCPCS":"85576","Standard Price":40.0},{"Itemcode":"70115747","Description":"MA ADP TEG","CDM Revenue Code":"305","CDM HCPCS":"85576","Standard Price":40.0},{"Itemcode":"70115748","Description":"MA Act F TEG","CDM Revenue Code":"305","CDM HCPCS":"85576","Standard Price":40.0},{"Itemcode":"70115749","Description":"%% Inhibition ADP TEG","CDM Revenue Code":"305","CDM HCPCS":"85576","Standard Price":40.0},{"Itemcode":"70115750","Description":"R (Reaction) TEG","CDM Revenue Code":"305","CDM HCPCS":"85347","Standard Price":16.0},{"Itemcode":"70115751","Description":"R (Reaction) TEG w/ Hep","CDM Revenue Code":"305","CDM HCPCS":"85347","Standard Price":16.0},{"Itemcode":"70115752","Description":"Fibrinogen Level TEG","CDM Revenue Code":"305","CDM HCPCS":"85370","Standard Price":42.0},{"Itemcode":"70115782","Description":"VWFactor Collagen Binding","CDM Revenue Code":"300","CDM HCPCS":"85246","Standard Price":692.0},{"Itemcode":"70115883","Description":"Protein S Ag, Free","CDM Revenue Code":"300","CDM HCPCS":"85306","Standard Price":468.0},{"Itemcode":"70115959","Description":"PT- ARUP","CDM Revenue Code":"300","CDM HCPCS":"85610","Standard Price":99.0},{"Itemcode":"70115960","Description":"aPTT- ARUP","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":99.0},{"Itemcode":"70115961","Description":"dRVVT - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85613","Standard Price":99.0},{"Itemcode":"70115962","Description":"TT - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85670","Standard Price":125.0},{"Itemcode":"70115963","Description":"Reptilase Time - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85635","Standard Price":234.0},{"Itemcode":"70115964","Description":"PTT - D - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85730","Standard Price":176.0},{"Itemcode":"70115965","Description":"Heparin neutralization - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85525","Standard Price":176.0},{"Itemcode":"70115966","Description":"aPTT-D 1:1 Mix - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85732","Standard Price":101.0},{"Itemcode":"70115967","Description":"Plt Neutralization - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85597","Standard Price":273.0},{"Itemcode":"70115968","Description":"dRVVT 1:1 Mix - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85613","Standard Price":101.0},{"Itemcode":"70115969","Description":"dRVVT Confrim - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85613","Standard Price":187.0},{"Itemcode":"70115970","Description":"Hex Phos - ARUP","CDM Revenue Code":"300","CDM HCPCS":"85598","Standard Price":416.0},{"Itemcode":"70116129","Description":"Antithrombin Iii Antigenic","CDM Revenue Code":"300","CDM HCPCS":"85301","Standard Price":1020.0},{"Itemcode":"70116174","Description":"Fibrinogen Antigen","CDM Revenue Code":"300","CDM HCPCS":"85385","Standard Price":413.0},{"Itemcode":"70116243","Description":"Osmotic Fragility Erythrocyte","CDM Revenue Code":"300","CDM HCPCS":"85555","Standard Price":585.0},{"Itemcode":"70116244","Description":"Ureaplasma and Mycoplasma PCR","CDM Revenue Code":"300","CDM HCPCS":"85555","Standard Price":860.0},{"Itemcode":"70116299","Description":"Heparin Cofactor II, Plasma","CDM Revenue Code":"300","CDM HCPCS":"85130","Standard Price":560.0},{"Itemcode":"70116576","Description":"Factor IX, Activity","CDM Revenue Code":"300","CDM HCPCS":"85250","Standard Price":213.0},{"Itemcode":"70116577","Description":"Factor VIII, Activity","CDM Revenue Code":"300","CDM HCPCS":"85240","Standard Price":134.0},{"Itemcode":"70116640","Description":"Protein C, Functional","CDM Revenue Code":"300","CDM HCPCS":"85303","Standard Price":152.0},{"Itemcode":"70116641","Description":"Protein S, Functional","CDM Revenue Code":"305","CDM HCPCS":"85306","Standard Price":217.0},{"Itemcode":"70118476","Description":"Activated Protein Resistance","CDM Revenue Code":"300","CDM HCPCS":"85307","Standard Price":302.0},{"Itemcode":"70118478","Description":"Plasminogen Activator Inhibito","CDM Revenue Code":"300","CDM HCPCS":"85415","Standard Price":1619.0},{"Itemcode":"70118480","Description":"Functional Plasminogen","CDM Revenue Code":"300","CDM HCPCS":"85420","Standard Price":616.0},{"Itemcode":"70118490","Description":"High Molecular Wt. Kininogen","CDM Revenue Code":"300","CDM HCPCS":"85293","Standard Price":1784.0},{"Itemcode":"71700365","Description":"Activated Clotting Time","CDM Revenue Code":"300","CDM HCPCS":"85347","Standard Price":359.0},{"Itemcode":"72106025","Description":"Activated Clotting Time","CDM Revenue Code":"300","CDM HCPCS":"85347","Standard Price":359.0},{"Itemcode":"72205100","Description":"Activated Clotting Time","CDM Revenue Code":"300","CDM HCPCS":"85347","Standard Price":359.0},{"Itemcode":"74201006","Description":"INR","CDM Revenue Code":"300","CDM HCPCS":"85610","Standard Price":46.0},{"Itemcode":"74221006","Description":"INR","CDM Revenue Code":"300","CDM HCPCS":"85610","Standard Price":46.0},{"Itemcode":"70100001","Description":"RPR; non-treponemal Qual","CDM Revenue Code":"300","CDM HCPCS":"86592","Standard Price":41.0},{"Itemcode":"70100074","Description":"Cryptococcus Ab","CDM Revenue Code":"300","CDM HCPCS":"86641","Standard Price":496.0},{"Itemcode":"70100075","Description":"Mono","CDM Revenue Code":"300","CDM HCPCS":"86308","Standard Price":128.0},{"Itemcode":"70100083","Description":"Immunoelectrophoresis;Serum","CDM Revenue Code":"300","CDM HCPCS":"86320","Standard Price":608.0},{"Itemcode":"70100087","Description":"Rotavirus","CDM Revenue Code":"300","CDM HCPCS":"86759","Standard Price":281.0},{"Itemcode":"70100112","Description":"Stronglyoides Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"86682","Standard Price":390.0},{"Itemcode":"70100163","Description":"Immunofixation Electrophoresis","CDM Revenue Code":"300","CDM HCPCS":"86334","Standard Price":605.0},{"Itemcode":"70100180","Description":"Cryptococcal Ag","CDM Revenue Code":"300","CDM HCPCS":"86403","Standard Price":174.0},{"Itemcode":"70100203","Description":"Complement: C3","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":98.0},{"Itemcode":"70100204","Description":"Complement: C4","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":98.0},{"Itemcode":"70100226","Description":"RMSF Igm By Ifa -Quest","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":156.0},{"Itemcode":"70100227","Description":"RMSF Igg By Ifa -Quest","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":156.0},{"Itemcode":"70100254","Description":"Mitogen Induced Blastogen 1","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":462.0},{"Itemcode":"70100255","Description":"Mitogen Induced Blastogen 2","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":955.0},{"Itemcode":"70100256","Description":"Mitogen Induced Blastogen 3","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":1051.0},{"Itemcode":"70100258","Description":"B Cells Total Count","CDM Revenue Code":"300","CDM HCPCS":"86355","Standard Price":1321.0},{"Itemcode":"70100272","Description":"ASO","CDM Revenue Code":"300","CDM HCPCS":"86063","Standard Price":193.0},{"Itemcode":"70100276","Description":"HIV 1/2 Rapid","CDM Revenue Code":"300","CDM HCPCS":"86701","Standard Price":167.0},{"Itemcode":"70100307","Description":"Serotype 56 (18C)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":142.0},{"Itemcode":"70100308","Description":"Serotype 68(9V)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":72.0},{"Itemcode":"70100326","Description":"RA Quantitative","CDM Revenue Code":"300","CDM HCPCS":"86431","Standard Price":99.0},{"Itemcode":"70100340","Description":"CMV Anbibody IgG Elisa","CDM Revenue Code":"300","CDM HCPCS":"86644","Standard Price":169.0},{"Itemcode":"70100341","Description":"California Encephalitis Virus","CDM Revenue Code":"300","CDM HCPCS":"86651","Standard Price":110.0},{"Itemcode":"70100342","Description":"Encephalitis Eastern Equine","CDM Revenue Code":"300","CDM HCPCS":"86652","Standard Price":89.0},{"Itemcode":"70100343","Description":"Encephalitis St Louis","CDM Revenue Code":"300","CDM HCPCS":"86653","Standard Price":110.0},{"Itemcode":"70100344","Description":"Encephalitis Western Equine","CDM Revenue Code":"300","CDM HCPCS":"86654","Standard Price":72.0},{"Itemcode":"70100345","Description":"Enterovirus","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":326.0},{"Itemcode":"70100346","Description":"HSV Type 1","CDM Revenue Code":"300","CDM HCPCS":"86695","Standard Price":109.0},{"Itemcode":"70100347","Description":"HSV Type 2","CDM Revenue Code":"300","CDM HCPCS":"86696","Standard Price":108.0},{"Itemcode":"70100348","Description":"Influenza Ab","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":167.0},{"Itemcode":"70100349","Description":"Lymphocytic Choriomeningitis","CDM Revenue Code":"300","CDM HCPCS":"86727","Standard Price":70.0},{"Itemcode":"70100350","Description":"Mumps","CDM Revenue Code":"300","CDM HCPCS":"86735","Standard Price":422.0},{"Itemcode":"70100351","Description":"Measles","CDM Revenue Code":"300","CDM HCPCS":"86765","Standard Price":114.0},{"Itemcode":"70100352","Description":"Varicella Zoster","CDM Revenue Code":"300","CDM HCPCS":"86787","Standard Price":117.0},{"Itemcode":"70100353","Description":"Adenovirus","CDM Revenue Code":"300","CDM HCPCS":"86603","Standard Price":92.0},{"Itemcode":"70100355","Description":"C-Reactive Protein","CDM Revenue Code":"300","CDM HCPCS":"86140","Standard Price":75.0},{"Itemcode":"70100364","Description":"NSE - Neuron Specific Enolase","CDM Revenue Code":"300","CDM HCPCS":"86316","Standard Price":323.0},{"Itemcode":"70100365","Description":"R.Typhi Igg -Quest","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":314.0},{"Itemcode":"70100366","Description":"R.Typhi Igm -Quest","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":314.0},{"Itemcode":"70100369","Description":"Brucella Ab Igg -Quest","CDM Revenue Code":"300","CDM HCPCS":"86622","Standard Price":218.0},{"Itemcode":"70100370","Description":"Brucella Ab Igm -Quest","CDM Revenue Code":"300","CDM HCPCS":"86622","Standard Price":218.0},{"Itemcode":"70100432","Description":"M Pneumo Igg Ab -Quest","CDM Revenue Code":"300","CDM HCPCS":"86738","Standard Price":156.0},{"Itemcode":"70100439","Description":"Lactoferrin Quant Stool Qst","CDM Revenue Code":"300","CDM HCPCS":"86361","Standard Price":623.0},{"Itemcode":"70100444","Description":"Smooth Muscle Antibody Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":102.0},{"Itemcode":"70100468","Description":"Neutrophil Ab Fcl -Quest","CDM Revenue Code":"300","CDM HCPCS":"86021","Standard Price":806.0},{"Itemcode":"70100507","Description":"Cysticercus Ab Elisa Serum Qst","CDM Revenue Code":"300","CDM HCPCS":"86682","Standard Price":477.0},{"Itemcode":"70100618","Description":"Post Transfusion Reaction","CDM Revenue Code":"300","CDM HCPCS":"86078","Standard Price":284.0},{"Itemcode":"70100623","Description":"Cold Agglutinins","CDM Revenue Code":"300","CDM HCPCS":"86157","Standard Price":221.0},{"Itemcode":"70100644","Description":"RF Fluid Titer Qst","CDM Revenue Code":"300","CDM HCPCS":"86431","Standard Price":138.0},{"Itemcode":"70100656","Description":"Jo-1 Antibody -Quest","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":94.0},{"Itemcode":"70100657","Description":"HTLV Antibody I/Ii -Quest","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":213.0},{"Itemcode":"70100658","Description":"Dengue Fever Igg -Quest","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":748.0},{"Itemcode":"70100666","Description":"Rabies Titer Response Qst","CDM Revenue Code":"300","CDM HCPCS":"86382","Standard Price":581.0},{"Itemcode":"70100667","Description":"Fluorescent Antibody Titer Ea","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":407.0},{"Itemcode":"70100674","Description":"Heparin-Induced Platelet Ab","CDM Revenue Code":"300","CDM HCPCS":"86022","Standard Price":1189.0},{"Itemcode":"70100675","Description":"Serotonin Release Assay -Qst","CDM Revenue Code":"300","CDM HCPCS":"86022","Standard Price":1366.0},{"Itemcode":"70100682","Description":"West Nile Virus Ab Igm Csf","CDM Revenue Code":"300","CDM HCPCS":"86788","Standard Price":280.0},{"Itemcode":"70100683","Description":"West Nile Virus Ab Igg Csf","CDM Revenue Code":"300","CDM HCPCS":"86789","Standard Price":280.0},{"Itemcode":"70100686","Description":"Nuclear Matrix Proteins -Quest","CDM Revenue Code":"300","CDM HCPCS":"86316","Standard Price":1479.0},{"Itemcode":"70100695","Description":"N.Meningitidis Igg Serogrp A","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":66.0},{"Itemcode":"70100696","Description":"N.Meningitidis Igg Serogrp C","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":66.0},{"Itemcode":"70100697","Description":"N.Meningitidis Igg Serogrp Y","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":66.0},{"Itemcode":"70100698","Description":"N.Meningitidis Igg Serogrpw135","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":66.0},{"Itemcode":"70100716","Description":"T Cells Total Count -Quest","CDM Revenue Code":"300","CDM HCPCS":"86359","Standard Price":160.0},{"Itemcode":"70100717","Description":"T Cells Cd4:Cd8 Quest Lym Pnl","CDM Revenue Code":"300","CDM HCPCS":"86360","Standard Price":246.0},{"Itemcode":"70100746","Description":"Giardia Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"86674","Standard Price":292.0},{"Itemcode":"70100747","Description":"Giardia Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"86674","Standard Price":292.0},{"Itemcode":"70100748","Description":"Giardia Ab Agm","CDM Revenue Code":"300","CDM HCPCS":"86674","Standard Price":292.0},{"Itemcode":"70100752","Description":"Whole Egg (IgG) Eia - Quest","CDM Revenue Code":"300","CDM HCPCS":"86001","Standard Price":328.0},{"Itemcode":"70100774","Description":"Poliovirus Antibody Type1","CDM Revenue Code":"300","CDM HCPCS":"86382","Standard Price":249.0},{"Itemcode":"70100775","Description":"Poliovirus Antibody Type 2","CDM Revenue Code":"300","CDM HCPCS":"86382","Standard Price":167.0},{"Itemcode":"70100776","Description":"Poliovirus Antibody Type 3","CDM Revenue Code":"300","CDM HCPCS":"86382","Standard Price":249.0},{"Itemcode":"70100783","Description":"Immunoelec-Other Fluids(Conc)","CDM Revenue Code":"300","CDM HCPCS":"86335","Standard Price":262.0},{"Itemcode":"70100804","Description":"H.Pylori Ab IgA","CDM Revenue Code":"300","CDM HCPCS":"86677","Standard Price":366.0},{"Itemcode":"70100805","Description":"H.Pylori Ab Igg -Quest","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":173.0},{"Itemcode":"70100806","Description":"H.Pylori Ab IgM","CDM Revenue Code":"300","CDM HCPCS":"86677","Standard Price":366.0},{"Itemcode":"70100807","Description":"Hep B Ab Quant Liver Trans","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":180.0},{"Itemcode":"70100808","Description":"Hep B Surface Ab Quant -Quest","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":84.0},{"Itemcode":"70100809","Description":"Hep B Core Ab Igm -Quest","CDM Revenue Code":"300","CDM HCPCS":"86705","Standard Price":119.0},{"Itemcode":"70100810","Description":"Ca 27.29 Immunoassay Quant","CDM Revenue Code":"300","CDM HCPCS":"86300","Standard Price":218.0},{"Itemcode":"70100812","Description":"IMMUNO ELPHORS, OTHER FLUIDS","CDM Revenue Code":"300","CDM HCPCS":"86335","Standard Price":1339.0},{"Itemcode":"70100847","Description":"Rnp Antibody Qst 19887","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":120.0},{"Itemcode":"70100851","Description":"Chromatin Nucleosomal Antibody","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":262.0},{"Itemcode":"70100856","Description":"C4 Binding Protein Plasma","CDM Revenue Code":"300","CDM HCPCS":"86329","Standard Price":349.0},{"Itemcode":"70100864","Description":"Herpesvirus 8 Igg Antibody Ifa","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":291.0},{"Itemcode":"70100866","Description":"Echovirus 4 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":54.0},{"Itemcode":"70100867","Description":"Echovirus 7 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":54.0},{"Itemcode":"70100868","Description":"Echovirus 9 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":54.0},{"Itemcode":"70100869","Description":"Echovirus 11 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":54.0},{"Itemcode":"70100870","Description":"Echovirus 30 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":54.0},{"Itemcode":"70100873","Description":"L.Pneumophila Serogrp 1","CDM Revenue Code":"300","CDM HCPCS":"86713","Standard Price":215.0},{"Itemcode":"70100874","Description":"L.Pneumophila Serogrp 2-6,8","CDM Revenue Code":"300","CDM HCPCS":"86713","Standard Price":215.0},{"Itemcode":"70100875","Description":"American Cockroach IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":160.0},{"Itemcode":"70100877","Description":"S.Pneumoniae Igg Maid 23 Serot","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":893.0},{"Itemcode":"70100886","Description":"HU Antibody Titer Qst","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":71.0},{"Itemcode":"70100887","Description":"Neuronal Nuclear Ri Ab Screen","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":480.0},{"Itemcode":"70100889","Description":"RI Antibody Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":120.0},{"Itemcode":"70100924","Description":"L Donovani Igg","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100925","Description":"L Donovani Igm","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100926","Description":"L Braziliensis Igg","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100927","Description":"L Braziliensis Igm","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100928","Description":"L Mexicana Igg","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100929","Description":"L Mexicana Igm","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100930","Description":"L Tropicalis Igg","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100931","Description":"L Tropicalis Igm","CDM Revenue Code":"300","CDM HCPCS":"86717","Standard Price":145.0},{"Itemcode":"70100938","Description":"Natural Killer Cells Total Qst","CDM Revenue Code":"300","CDM HCPCS":"86357","Standard Price":497.0},{"Itemcode":"70101000","Description":"RPR Titer QN, non Treponemal","CDM Revenue Code":"300","CDM HCPCS":"86593","Standard Price":109.0},{"Itemcode":"70101007","Description":"Neuronal Nuc Ab Hu Scrn -Quest","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":732.0},{"Itemcode":"70101008","Description":"Quantiferon Tb Gold - Quest","CDM Revenue Code":"300","CDM HCPCS":"86480","Standard Price":1030.0},{"Itemcode":"70101049","Description":"Jcv Antibody Qst","CDM Revenue Code":"300","CDM HCPCS":"86711","Standard Price":865.0},{"Itemcode":"70101078","Description":"Jcv Ab Inhibition Assay Qst","CDM Revenue Code":"300","CDM HCPCS":"86711","Standard Price":865.0},{"Itemcode":"70101311","Description":"DSDNA Screen","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":101.0},{"Itemcode":"70101312","Description":"Fluorescent AB - DsDNA Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":160.0},{"Itemcode":"70101314","Description":"Platelet Antibody ID 2B/3A","CDM Revenue Code":"300","CDM HCPCS":"86022","Standard Price":226.0},{"Itemcode":"70101371","Description":"Influenza A Ab Qst","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":31.0},{"Itemcode":"70101372","Description":"Influenza Type B Ab Qst","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":31.0},{"Itemcode":"70101373","Description":"C. Pneumoniae Igm","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":28.0},{"Itemcode":"70101374","Description":"C. Pneumoniae Igg","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":28.0},{"Itemcode":"70101376","Description":"C. Pneumoniae Iga","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":28.0},{"Itemcode":"70101377","Description":"Coxsackie B Type 1","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101378","Description":"Coxsackie B Type 2","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101379","Description":"Coxsackie B Type 3","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101380","Description":"Coxsackie B Type 4","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101381","Description":"Coxsackie B Type 5","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101382","Description":"Coxsackie B Type 6","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101383","Description":"Echovirus Serotype 4","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101384","Description":"Echovirus Serotype 7","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101385","Description":"Echovirus Serotype 9","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101386","Description":"Echovirus Serotype 11","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101387","Description":"Echovirus Serotype 30","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":29.0},{"Itemcode":"70101392","Description":"Circulating Tumor Cells","CDM Revenue Code":"300","CDM HCPCS":"86152","Standard Price":3270.0},{"Itemcode":"70101419","Description":"Immunofixation For Kappa Lt Ch","CDM Revenue Code":"300","CDM HCPCS":"86334","Standard Price":272.0},{"Itemcode":"70101433","Description":"Neuromyelitis Optica Mayo","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":1530.0},{"Itemcode":"70101446","Description":"Purkinje Cell Cyto Ab Type Tr","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101447","Description":"Crmp-5-IgG","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101448","Description":"Anti-Neuronal Ab Type 3","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101449","Description":"Purkinje Cell Cyto Ab Type 2","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101451","Description":"Anti-Neuronal Nuclear Ab Type1","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101452","Description":"Anti-Neuronal Nuclear Ab Type2","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101453","Description":"Purkinje Cell Cyto Ab Type 1","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101454","Description":"Amphyiphysin Ab","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101455","Description":"Anti-Glial Nuclear Ab Type 1","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":388.0},{"Itemcode":"70101467","Description":"HISTAMINE RELEASE (CU)","CDM Revenue Code":"300","CDM HCPCS":"86343","Standard Price":535.0},{"Itemcode":"70101524","Description":"Ampiphysin Ab MAYO","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":1661.0},{"Itemcode":"70101525","Description":"CRMP-5 IgG MAYO","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":1661.0},{"Itemcode":"70101641","Description":"INF AGENT AB QNT Serotype 1","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":126.0},{"Itemcode":"70101642","Description":"IA INF AGENT AB QNT Serotype 3","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":126.0},{"Itemcode":"70101643","Description":"IA INF AGENT AB QNT Serotype 4","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":126.0},{"Itemcode":"70101644","Description":"IA INF AGENT AB QNT Serotype 5","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":122.0},{"Itemcode":"70101645","Description":"IA INF AGENT AB QNT Serotype 8","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":126.0},{"Itemcode":"70101646","Description":"Serotype (9) 9N","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":126.0},{"Itemcode":"70101647","Description":"IA INFAGNT AB QNT Sero 12(12F)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":122.0},{"Itemcode":"70101648","Description":"IA INF AGNT AB QNT Serotype 14","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":122.0},{"Itemcode":"70101649","Description":"IA INFAGNT AB QNT Sero 19(19F)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":122.0},{"Itemcode":"70101650","Description":"IA INFAGNT AB QNT Sero 23(23F)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":122.0},{"Itemcode":"70101661","Description":"Immunoassay For Tumor Ag Qual","CDM Revenue Code":"300","CDM HCPCS":"86316","Standard Price":919.0},{"Itemcode":"70101666","Description":"Beta 2 Glycoprotein 1 Ea- Ab 1","CDM Revenue Code":"300","CDM HCPCS":"86146","Standard Price":271.0},{"Itemcode":"70101667","Description":"Beta 2 Glycoprotein 1 Ea- Ab 2","CDM Revenue Code":"300","CDM HCPCS":"86146","Standard Price":271.0},{"Itemcode":"70101668","Description":"Beta 2 Glycoprotein 1 Ea- Ab 3","CDM Revenue Code":"300","CDM HCPCS":"86146","Standard Price":271.0},{"Itemcode":"70101800","Description":"Cryptococcal Ag Titr","CDM Revenue Code":"300","CDM HCPCS":"86406","Standard Price":216.0},{"Itemcode":"70102001","Description":"Virus Ab-Not Elsewhere Spec","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":328.0},{"Itemcode":"70102009","Description":"Chlamydia Serology","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":249.0},{"Itemcode":"70102012","Description":"IA INFAGNT AB QNT Sero 26(6B)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":126.0},{"Itemcode":"70102013","Description":"IA INFAGNT AB QNT Sero 51(7F)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":124.0},{"Itemcode":"70102015","Description":"Antibody: Parvovirus","CDM Revenue Code":"300","CDM HCPCS":"86747","Standard Price":196.0},{"Itemcode":"70102016","Description":"Antibody: Parvovirus","CDM Revenue Code":"300","CDM HCPCS":"86747","Standard Price":196.0},{"Itemcode":"70102019","Description":"T Cells - Cd4:Cd8","CDM Revenue Code":"300","CDM HCPCS":"86360","Standard Price":589.0},{"Itemcode":"70102024","Description":"Fluorescent Antibody 2","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":438.0},{"Itemcode":"70102025","Description":"Fluorescent Antibody 3","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":479.0},{"Itemcode":"70102027","Description":"Coxiella Brunetii 1","CDM Revenue Code":"300","CDM HCPCS":"86638","Standard Price":177.0},{"Itemcode":"70102028","Description":"Coxiella Brunetii 2","CDM Revenue Code":"300","CDM HCPCS":"86638","Standard Price":177.0},{"Itemcode":"70102029","Description":"Coxiella Brunetii 3","CDM Revenue Code":"300","CDM HCPCS":"86638","Standard Price":177.0},{"Itemcode":"70102030","Description":"Coxiella Brunetii0 4","CDM Revenue Code":"300","CDM HCPCS":"86638","Standard Price":177.0},{"Itemcode":"70102643","Description":"Cyclic Citrullinated Peptide","CDM Revenue Code":"300","CDM HCPCS":"86200","Standard Price":397.0},{"Itemcode":"70102675","Description":"Endomysial Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":425.0},{"Itemcode":"70102720","Description":"ASO Titer","CDM Revenue Code":"300","CDM HCPCS":"86060","Standard Price":148.0},{"Itemcode":"70103016","Description":"RAST Bahia Grass","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103017","Description":"RAST Birch Tree","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103018","Description":"RAST Tree, Mountain Cedar, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103019","Description":"RAST Mouse Urine Proteins,IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103021","Description":"RAST,Tree Pecan/Hickory IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103022","Description":"RAST, Penicillium notatum IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103023","Description":"RAST SheepSorrel Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103024","Description":"RAST, Nettle,Allergen IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70103813","Description":"Antibody; Hepatitis, Delta","CDM Revenue Code":"300","CDM HCPCS":"86692","Standard Price":168.0},{"Itemcode":"70103816","Description":"Bordetella Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":433.0},{"Itemcode":"70103817","Description":"Bordetella Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":433.0},{"Itemcode":"70103818","Description":"Bordetella Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":433.0},{"Itemcode":"70103819","Description":"Bordetella Ab FHA IgG","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":433.0},{"Itemcode":"70103821","Description":"Bordetella Ab FHA IGA","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":433.0},{"Itemcode":"70104000","Description":"Rast Soybean IgE Qnt/SmiQnt","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":116.0},{"Itemcode":"70104002","Description":"Adenovirus Serology","CDM Revenue Code":"300","CDM HCPCS":"86603","Standard Price":300.0},{"Itemcode":"70104007","Description":"Rast Egg White","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":114.0},{"Itemcode":"70104015","Description":"Rast Milk","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":117.0},{"Itemcode":"70104016","Description":"Rast Wheat","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":116.0},{"Itemcode":"70104018","Description":"Amoeba Antibody","CDM Revenue Code":"300","CDM HCPCS":"86753","Standard Price":347.0},{"Itemcode":"70104019","Description":"Rast Peanut","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":117.0},{"Itemcode":"70104020","Description":"Rast Shrimp","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":118.0},{"Itemcode":"70104021","Description":"Rast Tomato","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":76.0},{"Itemcode":"70104022","Description":"Rast Pork","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":185.0},{"Itemcode":"70104025","Description":"Rast Corn","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":116.0},{"Itemcode":"70104026","Description":"Antimyeloperoxidase Ab","CDM Revenue Code":"300","CDM HCPCS":"86021","Standard Price":247.0},{"Itemcode":"70104027","Description":"Anti Centromere Ab","CDM Revenue Code":"300","CDM HCPCS":"86038","Standard Price":142.0},{"Itemcode":"70104029","Description":"Rast Beef","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":116.0},{"Itemcode":"70104030","Description":"Rast Potato","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":140.0},{"Itemcode":"70104031","Description":"Anti Mitochondrial Antibody","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":258.0},{"Itemcode":"70104032","Description":"Anti Smooth Muscle Ab","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":227.0},{"Itemcode":"70104041","Description":"Rast Onion","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":168.0},{"Itemcode":"70104043","Description":"Blastomycoses Serology","CDM Revenue Code":"300","CDM HCPCS":"86612","Standard Price":235.0},{"Itemcode":"70104045","Description":"Brucella Serology -D Quest","CDM Revenue Code":"300","CDM HCPCS":"86622","Standard Price":0.0},{"Itemcode":"70104046","Description":"Rast Flounder","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":153.0},{"Itemcode":"70104047","Description":"Rast Egg Yolk","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":114.0},{"Itemcode":"70104048","Description":"Ca 15-3 (Ca 27.29)","CDM Revenue Code":"300","CDM HCPCS":"86300","Standard Price":218.0},{"Itemcode":"70104050","Description":"Rast Oat","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70104053","Description":"Immune Complex C1Q Binding","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":530.0},{"Itemcode":"70104059","Description":"Anti Dna","CDM Revenue Code":"300","CDM HCPCS":"86225","Standard Price":152.0},{"Itemcode":"70104060","Description":"Rast Cockroach, Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70104069","Description":"Ca-125","CDM Revenue Code":"300","CDM HCPCS":"86304","Standard Price":103.0},{"Itemcode":"70104070","Description":"Anti DNA By Farr","CDM Revenue Code":"300","CDM HCPCS":"86225","Standard Price":152.0},{"Itemcode":"70104072","Description":"Rast Scallop","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70104073","Description":"Rast Clam","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70104075","Description":"Rast Walnut","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70104076","Description":"Rast Codfish","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70104085","Description":"Coccidiodes Serology","CDM Revenue Code":"300","CDM HCPCS":"86635","Standard Price":102.0},{"Itemcode":"70104088","Description":"Complement: Tot Ch50","CDM Revenue Code":"300","CDM HCPCS":"86162","Standard Price":201.0},{"Itemcode":"70104093","Description":"Rast Sesame Seed","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70104109","Description":"Diptheria Antibody","CDM Revenue Code":"300","CDM HCPCS":"86648","Standard Price":688.0},{"Itemcode":"70104129","Description":"Anti Ena","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":225.0},{"Itemcode":"70104138","Description":"FTA(ABS); Pallidum,Treponema","CDM Revenue Code":"300","CDM HCPCS":"86780","Standard Price":130.0},{"Itemcode":"70104148","Description":"Hepatitis B Core AB IgM","CDM Revenue Code":"300","CDM HCPCS":"86705","Standard Price":341.0},{"Itemcode":"70104150","Description":"C-1 Esterase Inhibitor","CDM Revenue Code":"300","CDM HCPCS":"86161","Standard Price":255.0},{"Itemcode":"70104155","Description":"Platelet Antibodies","CDM Revenue Code":"300","CDM HCPCS":"86023","Standard Price":663.0},{"Itemcode":"70104156","Description":"Hepatitis A Ab - Total","CDM Revenue Code":"300","CDM HCPCS":"86708","Standard Price":265.0},{"Itemcode":"70104157","Description":"Hepatitis A Ab-Igm","CDM Revenue Code":"300","CDM HCPCS":"86709","Standard Price":198.0},{"Itemcode":"70104158","Description":"Anti Islet Cell (Pancreatic)","CDM Revenue Code":"300","CDM HCPCS":"86341","Standard Price":353.0},{"Itemcode":"70104161","Description":"Hepatitis B Core Ab Total","CDM Revenue Code":"300","CDM HCPCS":"86704","Standard Price":166.0},{"Itemcode":"70104163","Description":"Hepatitis B Surf Ab (Hbsab)","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":63.0},{"Itemcode":"70104165","Description":"Hepatitis Be Ab","CDM Revenue Code":"300","CDM HCPCS":"86707","Standard Price":146.0},{"Itemcode":"70104171","Description":"HSV 1 Igm, Ifa Quest 17369","CDM Revenue Code":"300","CDM HCPCS":"86695","Standard Price":71.0},{"Itemcode":"70104172","Description":"HSV 2 Igm, Ifa Quest 17369","CDM Revenue Code":"300","CDM HCPCS":"86696","Standard Price":100.0},{"Itemcode":"70104174","Description":"Histoplasma Serology","CDM Revenue Code":"300","CDM HCPCS":"86698","Standard Price":190.0},{"Itemcode":"70104175","Description":"HLA B 27","CDM Revenue Code":"300","CDM HCPCS":"86812","Standard Price":366.0},{"Itemcode":"70104176","Description":"Antibody; HIV - 1","CDM Revenue Code":"300","CDM HCPCS":"86701","Standard Price":100.0},{"Itemcode":"70104179","Description":"HIV or HTLV Ab Confirmation","CDM Revenue Code":"300","CDM HCPCS":"86689","Standard Price":229.0},{"Itemcode":"70104186","Description":"Influenza Virus Ab","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":167.0},{"Itemcode":"70104192","Description":"Insulin Antibodies - Titer","CDM Revenue Code":"300","CDM HCPCS":"86337","Standard Price":946.0},{"Itemcode":"70104197","Description":"Hepatitis C Antibody","CDM Revenue Code":"300","CDM HCPCS":"86803","Standard Price":155.0},{"Itemcode":"70104200","Description":"Antibody; HIV - 2","CDM Revenue Code":"300","CDM HCPCS":"86702","Standard Price":137.0},{"Itemcode":"70104203","Description":"Legionella Titer","CDM Revenue Code":"300","CDM HCPCS":"86713","Standard Price":215.0},{"Itemcode":"70104204","Description":"Leptospira Serology","CDM Revenue Code":"300","CDM HCPCS":"86720","Standard Price":396.0},{"Itemcode":"70104218","Description":"Rubeola","CDM Revenue Code":"300","CDM HCPCS":"86765","Standard Price":132.0},{"Itemcode":"70104231","Description":"Mumps Serology","CDM Revenue Code":"300","CDM HCPCS":"86735","Standard Price":422.0},{"Itemcode":"70104237","Description":"Mycoplasma","CDM Revenue Code":"300","CDM HCPCS":"86738","Standard Price":412.0},{"Itemcode":"70104238","Description":"Ca 19-9","CDM Revenue Code":"300","CDM HCPCS":"86301","Standard Price":184.0},{"Itemcode":"70104252","Description":"Anti Parietal Ab","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":421.0},{"Itemcode":"70104269","Description":"Parvovirus Ab","CDM Revenue Code":"300","CDM HCPCS":"86747","Standard Price":196.0},{"Itemcode":"70104271","Description":"Immune Complex-Raji Cell","CDM Revenue Code":"300","CDM HCPCS":"86332","Standard Price":1868.0},{"Itemcode":"70104274","Description":"Rast Other","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":110.0},{"Itemcode":"70104281","Description":"RSV Serology","CDM Revenue Code":"300","CDM HCPCS":"86756","Standard Price":759.0},{"Itemcode":"70104284","Description":"Rubella Antibody-Igm","CDM Revenue Code":"300","CDM HCPCS":"86762","Standard Price":131.0},{"Itemcode":"70104311","Description":"Tetanus Ab","CDM Revenue Code":"300","CDM HCPCS":"86774","Standard Price":547.0},{"Itemcode":"70104312","Description":"Thyroglobulin Antibody","CDM Revenue Code":"300","CDM HCPCS":"86800","Standard Price":144.0},{"Itemcode":"70104322","Description":"Trichinella Serology","CDM Revenue Code":"309","CDM HCPCS":"86784","Standard Price":259.0},{"Itemcode":"70104328","Description":"Toxoplasma","CDM Revenue Code":"300","CDM HCPCS":"86777","Standard Price":324.0},{"Itemcode":"70104330","Description":"Toxoplasma Igm-Ab","CDM Revenue Code":"300","CDM HCPCS":"86778","Standard Price":159.0},{"Itemcode":"70104331","Description":"Varicella Zoster Ab","CDM Revenue Code":"300","CDM HCPCS":"86787","Standard Price":117.0},{"Itemcode":"70104334","Description":"VDRL-CSF Non-treponemal, Qual","CDM Revenue Code":"300","CDM HCPCS":"86592","Standard Price":51.0},{"Itemcode":"70104355","Description":"CMV Antibody Serology","CDM Revenue Code":"300","CDM HCPCS":"86644","Standard Price":190.0},{"Itemcode":"70104358","Description":"Lyme Disease Antibodies","CDM Revenue Code":"300","CDM HCPCS":"86618","Standard Price":479.0},{"Itemcode":"70104360","Description":"H. Pylori IgG Antibody","CDM Revenue Code":"300","CDM HCPCS":"86677","Standard Price":126.0},{"Itemcode":"70104431","Description":"Varicilla Zoster Igm","CDM Revenue Code":"300","CDM HCPCS":"86787","Standard Price":155.0},{"Itemcode":"70104469","Description":"Anti Scleroderma Ab","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":233.0},{"Itemcode":"70104470","Description":"SmAntibody (Smith AB) ENA Qst","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":44.0},{"Itemcode":"70104471","Description":"Sm RNP ENA Qst","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":44.0},{"Itemcode":"70104477","Description":"Intrinsic Factor Antibody","CDM Revenue Code":"300","CDM HCPCS":"86340","Standard Price":415.0},{"Itemcode":"70104483","Description":"CMV IgM Antibody","CDM Revenue Code":"300","CDM HCPCS":"86645","Standard Price":184.0},{"Itemcode":"70104551","Description":"Ana Titer","CDM Revenue Code":"300","CDM HCPCS":"86039","Standard Price":92.0},{"Itemcode":"70104985","Description":"Rubella","CDM Revenue Code":"300","CDM HCPCS":"86762","Standard Price":100.0},{"Itemcode":"70105070","Description":"Antireticulin Ab: Iga","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":606.0},{"Itemcode":"70106054","Description":"Rast Penicillin G","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":117.0},{"Itemcode":"70106055","Description":"Rast Penicillin V","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":114.0},{"Itemcode":"70106056","Description":"Bermuda Grass, Allergen IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106057","Description":"Meadow Fescue","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106058","Description":"Perrenial Rye Grass","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106059","Description":"Timothy Grass, Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106060","Description":"June Grass","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70106061","Description":"Common Ragweed, Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106062","Description":"Giant Ragweed","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106063","Description":"Lambs Quarter Ea Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106064","Description":"Goldenrod","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106065","Description":"Maple Tree, Allergen IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106066","Description":"Beech Tree","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106067","Description":"Oak Tree, Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106068","Description":"Elm Tree, Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106069","Description":"Cat Epithilium, Allergen IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106070","Description":"Horse Dander","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106071","Description":"Dog Dander, Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106072","Description":"Allergen IgE Penicillum","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106073","Description":"Cladosporium, Allergen IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106074","Description":"Aspergillus, Allergen IgE ea","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106075","Description":"Mucor","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106076","Description":"Alternaria, Allergen IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106077","Description":"Greer House Dust","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106078","Description":"Hollister Stier","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106080","Description":"DPteronyssinMite,Allergen,IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106081","Description":"D Farinae Mite, Allergen, IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106082","Description":"English Plaintain","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":349.0},{"Itemcode":"70106083","Description":"RAST Rough Pigweed,AllergenIgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70106123","Description":"Antithyroid Peroxidase Ab-D","CDM Revenue Code":"300","CDM HCPCS":"86376","Standard Price":267.0},{"Itemcode":"70106124","Description":"Liver-Kidney Microsomal Ab","CDM Revenue Code":"300","CDM HCPCS":"86376","Standard Price":267.0},{"Itemcode":"70106204","Description":"Fungus Ab, Nos","CDM Revenue Code":"300","CDM HCPCS":"86671","Standard Price":911.0},{"Itemcode":"70106281","Description":"Histoplasma Ab","CDM Revenue Code":"300","CDM HCPCS":"86698","Standard Price":190.0},{"Itemcode":"70106334","Description":"Coxsackie A2 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":44.0},{"Itemcode":"70106335","Description":"Coxsackie A4 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":44.0},{"Itemcode":"70106336","Description":"Coxsackie A7 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":44.0},{"Itemcode":"70106337","Description":"Coxsackie A9 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":44.0},{"Itemcode":"70106338","Description":"Coxsackie A10 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":44.0},{"Itemcode":"70106339","Description":"Coxsackie A16 Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":44.0},{"Itemcode":"70108010","Description":"Antibody To Pm-1","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":276.0},{"Itemcode":"70108011","Description":"HCV Riba","CDM Revenue Code":"300","CDM HCPCS":"86804","Standard Price":448.0},{"Itemcode":"70108013","Description":"Complement C2","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":183.0},{"Itemcode":"70109206","Description":"Asca Elisa Iga","CDM Revenue Code":"300","CDM HCPCS":"86671","Standard Price":349.0},{"Itemcode":"70109207","Description":"Asca Elisa Igg","CDM Revenue Code":"300","CDM HCPCS":"86671","Standard Price":349.0},{"Itemcode":"70109223","Description":"HSV Igm Ab Screen","CDM Revenue Code":"300","CDM HCPCS":"86694","Standard Price":153.0},{"Itemcode":"70109224","Description":"HSV Igm Titer","CDM Revenue Code":"300","CDM HCPCS":"86694","Standard Price":164.0},{"Itemcode":"70109225","Description":"DNA Antibody Single Stranded","CDM Revenue Code":"300","CDM HCPCS":"86226","Standard Price":900.0},{"Itemcode":"70109275","Description":"Crp","CDM Revenue Code":"300","CDM HCPCS":"86140","Standard Price":75.0},{"Itemcode":"70109300","Description":"Rast, Carrot","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70109301","Description":"Rast, Pea","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70109302","Description":"Rast, White Bean","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":109.0},{"Itemcode":"70109762","Description":"Ana","CDM Revenue Code":"300","CDM HCPCS":"86038","Standard Price":60.0},{"Itemcode":"70109784","Description":"Fluorescent Antibody 1","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":480.0},{"Itemcode":"70109790","Description":"HIV 1/2 Antibodies/Ag IMASY","CDM Revenue Code":"300","CDM HCPCS":"G0475","Standard Price":73.0},{"Itemcode":"70109793","Description":"Toxoplasma Igm","CDM Revenue Code":"300","CDM HCPCS":"86778","Standard Price":642.0},{"Itemcode":"70109795","Description":"SSA","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":244.0},{"Itemcode":"70109797","Description":"SSB","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":244.0},{"Itemcode":"70109798","Description":"RMSF -Igm","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":238.0},{"Itemcode":"70109800","Description":"RMSF -Igg","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":238.0},{"Itemcode":"70109801","Description":"Ehrilichia Chaffensis Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"86666","Standard Price":310.0},{"Itemcode":"70109802","Description":"Ehrilichia Chaffensis Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"86666","Standard Price":310.0},{"Itemcode":"70109803","Description":"Chlamydia: Igg","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":293.0},{"Itemcode":"70109805","Description":"Cardiolipin Ig Class Ea Ab","CDM Revenue Code":"300","CDM HCPCS":"86147","Standard Price":134.0},{"Itemcode":"70109806","Description":"ImmuneGlobulin Cardiolipin IgM","CDM Revenue Code":"300","CDM HCPCS":"86147","Standard Price":134.0},{"Itemcode":"70109809","Description":"EBV VCA, IgG","CDM Revenue Code":"300","CDM HCPCS":"86665","Standard Price":66.0},{"Itemcode":"70109810","Description":"Q Fever","CDM Revenue Code":"300","CDM HCPCS":"86638","Standard Price":326.0},{"Itemcode":"70109811","Description":"Epstein Barr Early Ag (Ea)","CDM Revenue Code":"300","CDM HCPCS":"86663","Standard Price":66.0},{"Itemcode":"70109812","Description":"Herpes Type Ii","CDM Revenue Code":"300","CDM HCPCS":"86696","Standard Price":116.0},{"Itemcode":"70109813","Description":"Epstein Barr Nuclear Ag(Ebna)","CDM Revenue Code":"300","CDM HCPCS":"86664","Standard Price":66.0},{"Itemcode":"70109814","Description":"Chlamydia: Igm","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":288.0},{"Itemcode":"70109815","Description":"Herpes Type I","CDM Revenue Code":"300","CDM HCPCS":"86695","Standard Price":116.0},{"Itemcode":"70109817","Description":"Chlamydia: Iga","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":290.0},{"Itemcode":"70109902","Description":"Typhus Fever Ab","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":238.0},{"Itemcode":"70109903","Description":"Typhus Fever Ab","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":238.0},{"Itemcode":"70109914","Description":"Chlamydia Trachomatis","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":609.0},{"Itemcode":"70109916","Description":"RA - Fluid","CDM Revenue Code":"300","CDM HCPCS":"86430","Standard Price":102.0},{"Itemcode":"70109922","Description":"B. Hensalae Igg","CDM Revenue Code":"300","CDM HCPCS":"86611","Standard Price":138.0},{"Itemcode":"70109923","Description":"B. Hensalae Igm","CDM Revenue Code":"300","CDM HCPCS":"86611","Standard Price":138.0},{"Itemcode":"70109924","Description":"B.Quintana Igg","CDM Revenue Code":"300","CDM HCPCS":"86611","Standard Price":138.0},{"Itemcode":"70109925","Description":"B Quintana Igm","CDM Revenue Code":"300","CDM HCPCS":"86611","Standard Price":138.0},{"Itemcode":"70109949","Description":"Lymphocytic Choriomeningitis A","CDM Revenue Code":"300","CDM HCPCS":"86727","Standard Price":70.0},{"Itemcode":"70109950","Description":"Encephalitis Ab-Eastern Equine","CDM Revenue Code":"300","CDM HCPCS":"86652","Standard Price":89.0},{"Itemcode":"70109951","Description":"Encephalits Ab (California)","CDM Revenue Code":"300","CDM HCPCS":"86651","Standard Price":110.0},{"Itemcode":"70109952","Description":"Encephalitis Ab (St Louis)","CDM Revenue Code":"300","CDM HCPCS":"86653","Standard Price":124.0},{"Itemcode":"70109953","Description":"Encephalitis Ab","CDM Revenue Code":"300","CDM HCPCS":"86654","Standard Price":147.0},{"Itemcode":"70109960","Description":"Coxsackie Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":169.0},{"Itemcode":"70109961","Description":"Coxsackie Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":169.0},{"Itemcode":"70109962","Description":"Coxsackie Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":169.0},{"Itemcode":"70109963","Description":"Coxsackie Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":169.0},{"Itemcode":"70109964","Description":"Coxsackie Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":169.0},{"Itemcode":"70109965","Description":"Coxsackie Ab","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":157.0},{"Itemcode":"70109966","Description":"Virus Ab-Not Elsewhere Spec","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":226.0},{"Itemcode":"70109967","Description":"Mumps Serology","CDM Revenue Code":"300","CDM HCPCS":"86735","Standard Price":422.0},{"Itemcode":"70109970","Description":"A Fumagatus","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":82.0},{"Itemcode":"70109971","Description":"M Faeni","CDM Revenue Code":"300","CDM HCPCS":"86609","Standard Price":107.0},{"Itemcode":"70109972","Description":"S Viridis","CDM Revenue Code":"300","CDM HCPCS":"86609","Standard Price":107.0},{"Itemcode":"70109973","Description":"Encephalitis Ab-Western Equine","CDM Revenue Code":"300","CDM HCPCS":"86654","Standard Price":70.0},{"Itemcode":"70109985","Description":"Aspergillus Niger","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":82.0},{"Itemcode":"70109986","Description":"Aspergillus Fla Vus","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":82.0},{"Itemcode":"70109987","Description":"Casa (Cancer Assoc Serum Ag)","CDM Revenue Code":"300","CDM HCPCS":"86316","Standard Price":1548.0},{"Itemcode":"70109988","Description":"Aspergillus Fumagatus","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":82.0},{"Itemcode":"70109992","Description":"Tularemia Ab","CDM Revenue Code":"300","CDM HCPCS":"86668","Standard Price":632.0},{"Itemcode":"70109994","Description":"Nocardia Ab","CDM Revenue Code":"300","CDM HCPCS":"86744","Standard Price":112.0},{"Itemcode":"70109995","Description":"Pigeon Serum","CDM Revenue Code":"300","CDM HCPCS":"86331","Standard Price":140.0},{"Itemcode":"70109996","Description":"T Candidus","CDM Revenue Code":"300","CDM HCPCS":"86609","Standard Price":140.0},{"Itemcode":"70109997","Description":"Therm Sacchari","CDM Revenue Code":"300","CDM HCPCS":"86331","Standard Price":389.0},{"Itemcode":"70109998","Description":"T Vulgaris","CDM Revenue Code":"300","CDM HCPCS":"86609","Standard Price":140.0},{"Itemcode":"70110012","Description":"C-Reactive Protein (Cardio)","CDM Revenue Code":"300","CDM HCPCS":"86141","Standard Price":92.0},{"Itemcode":"70110013","Description":"Narcolepsy (Dr/Dq)","CDM Revenue Code":"300","CDM HCPCS":"86817","Standard Price":1575.0},{"Itemcode":"70110018","Description":"C6 Lyme Peptide Elisa","CDM Revenue Code":"300","CDM HCPCS":"86618","Standard Price":888.0},{"Itemcode":"70110082","Description":"West Nile Virus: Igm","CDM Revenue Code":"300","CDM HCPCS":"86788","Standard Price":161.0},{"Itemcode":"70110083","Description":"West Nile Virus: Igg","CDM Revenue Code":"300","CDM HCPCS":"86789","Standard Price":161.0},{"Itemcode":"70110085","Description":"Salmonella Antibody","CDM Revenue Code":"300","CDM HCPCS":"86768","Standard Price":338.0},{"Itemcode":"70110091","Description":"Cd4 Absolute Count","CDM Revenue Code":"300","CDM HCPCS":"86361","Standard Price":1037.0},{"Itemcode":"70110101","Description":"Lyme Igg: Western Blot","CDM Revenue Code":"300","CDM HCPCS":"86617","Standard Price":302.0},{"Itemcode":"70110102","Description":"Lyme Igm: Western Blot","CDM Revenue Code":"300","CDM HCPCS":"86617","Standard Price":302.0},{"Itemcode":"70110115","Description":"Inhibin A","CDM Revenue Code":"300","CDM HCPCS":"86336","Standard Price":323.0},{"Itemcode":"70110130","Description":"Dnase Bab","CDM Revenue Code":"300","CDM HCPCS":"86215","Standard Price":102.0},{"Itemcode":"70110205","Description":"Reproductive Immunophenotype","CDM Revenue Code":"300","CDM HCPCS":"86357","Standard Price":588.0},{"Itemcode":"70110223","Description":"MI-2 Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":525.0},{"Itemcode":"70110227","Description":"SRP Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":597.0},{"Itemcode":"70110228","Description":"U2 Snrnp Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":114.0},{"Itemcode":"70110229","Description":"Jo-1 Auto Abs","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":534.0},{"Itemcode":"70110236","Description":"HPV: Amp Probe (High Risk)","CDM Revenue Code":"300","CDM HCPCS":"G0476","Standard Price":472.0},{"Itemcode":"70110295","Description":"Insulin Antibodies Rflx Titer","CDM Revenue Code":"300","CDM HCPCS":"86337","Standard Price":54.0},{"Itemcode":"70110325","Description":"Proteinase 3 Ab","CDM Revenue Code":"300","CDM HCPCS":"86021","Standard Price":243.0},{"Itemcode":"70110360","Description":"Cardiolipin AB - IgM","CDM Revenue Code":"300","CDM HCPCS":"86147","Standard Price":134.0},{"Itemcode":"70110361","Description":"Cardiolipin AB IgG","CDM Revenue Code":"300","CDM HCPCS":"86147","Standard Price":134.0},{"Itemcode":"70110362","Description":"Cardiolipin AB IgA","CDM Revenue Code":"300","CDM HCPCS":"86147","Standard Price":134.0},{"Itemcode":"70110398","Description":"Influenza Virus Ab","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":167.0},{"Itemcode":"70110399","Description":"Mycoplasma","CDM Revenue Code":"300","CDM HCPCS":"86738","Standard Price":173.0},{"Itemcode":"70110401","Description":"Anti Cardiolipin Screen","CDM Revenue Code":"300","CDM HCPCS":"86147","Standard Price":134.0},{"Itemcode":"70112827","Description":"Mumps IgG","CDM Revenue Code":"300","CDM HCPCS":"86735","Standard Price":170.0},{"Itemcode":"70115032","Description":"Candida Antibody","CDM Revenue Code":"300","CDM HCPCS":"86628","Standard Price":522.0},{"Itemcode":"70115714","Description":"Fecal Globin - Quest","CDM Revenue Code":"300","CDM HCPCS":"G0328","Standard Price":235.0},{"Itemcode":"70115718","Description":"Johnson Grass, Allergen IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70115726","Description":"Brazil Nut Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70115727","Description":"Hazelnut Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70115728","Description":"Macadamia Nut Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":29.0},{"Itemcode":"70115730","Description":"Peanut-Ara h 2 Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":33.0},{"Itemcode":"70115731","Description":"Peanut-Ara h 1 Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":33.0},{"Itemcode":"70115732","Description":"Peanut-Ara h 3 Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":33.0},{"Itemcode":"70115733","Description":"Peanut-Ara h 9 Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":33.0},{"Itemcode":"70115734","Description":"Peanut-Ara h 8 Quant IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":33.0},{"Itemcode":"70115779","Description":"Plt Abs Direct,IgG","CDM Revenue Code":"300","CDM HCPCS":"86023","Standard Price":187.0},{"Itemcode":"70115780","Description":"Plt Abs Direct,IgM","CDM Revenue Code":"300","CDM HCPCS":"86023","Standard Price":187.0},{"Itemcode":"70115784","Description":"A.fumigatus #1 Ab Precipitin","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":39.0},{"Itemcode":"70115785","Description":"A.fumigatus #6 Ab Precipitin","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":39.0},{"Itemcode":"70115786","Description":"A.pullulans Ab, Precipitin","CDM Revenue Code":"300","CDM HCPCS":"86331","Standard Price":39.0},{"Itemcode":"70115787","Description":"Pigeon Serum Ab, Precipitin","CDM Revenue Code":"300","CDM HCPCS":"86331","Standard Price":39.0},{"Itemcode":"70115788","Description":"M.faeni Ab, Precipitin","CDM Revenue Code":"300","CDM HCPCS":"86331","Standard Price":39.0},{"Itemcode":"70115789","Description":"T.vulgaris #1 Ab, Precipitin","CDM Revenue Code":"300","CDM HCPCS":"86331","Standard Price":39.0},{"Itemcode":"70115791","Description":"Tetanus Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":102.0},{"Itemcode":"70115792","Description":"Immunofix electroph,Other Flds","CDM Revenue Code":"300","CDM HCPCS":"86335","Standard Price":262.0},{"Itemcode":"70115794","Description":"Jo-1 Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":146.0},{"Itemcode":"70115813","Description":"Platelet Antibody Indirect","CDM Revenue Code":"300","CDM HCPCS":"86022","Standard Price":623.0},{"Itemcode":"70115816","Description":"Echovirus Antibody Type 6","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":159.0},{"Itemcode":"70115817","Description":"Echovirus Antibody Type 7","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":159.0},{"Itemcode":"70115818","Description":"Echovirus Antibody Type 9","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":159.0},{"Itemcode":"70115819","Description":"Echovirus Antibody Type 11","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":159.0},{"Itemcode":"70115820","Description":"Echovirus Antibody Type 30","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":159.0},{"Itemcode":"70115822","Description":"HSV 1,2 Ab Screen IgG, CSF","CDM Revenue Code":"300","CDM HCPCS":"86694","Standard Price":187.0},{"Itemcode":"70115823","Description":"Influenza A Virus Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":94.0},{"Itemcode":"70115824","Description":"Influenza A Virus Ab IgM","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":94.0},{"Itemcode":"70115825","Description":"Influenza B Virus Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":94.0},{"Itemcode":"70115826","Description":"Influenza B Virus Ab IgM","CDM Revenue Code":"300","CDM HCPCS":"86710","Standard Price":94.0},{"Itemcode":"70115827","Description":"Varicella Zoster Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86787","Standard Price":153.0},{"Itemcode":"70115828","Description":"Mumps IgM","CDM Revenue Code":"300","CDM HCPCS":"86735","Standard Price":170.0},{"Itemcode":"70115830","Description":"Varicella Zoster Ab IgM","CDM Revenue Code":"300","CDM HCPCS":"86787","Standard Price":153.0},{"Itemcode":"70115831","Description":"Measles (Rubeola) IgG","CDM Revenue Code":"300","CDM HCPCS":"86765","Standard Price":170.0},{"Itemcode":"70115832","Description":"HSV Type 1 Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86695","Standard Price":255.0},{"Itemcode":"70115833","Description":"LCM Virus Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86727","Standard Price":187.0},{"Itemcode":"70115834","Description":"LCM Virus Ab, IgM","CDM Revenue Code":"300","CDM HCPCS":"86727","Standard Price":187.0},{"Itemcode":"70115835","Description":"Measles (Rubeola) IgM","CDM Revenue Code":"300","CDM HCPCS":"86765","Standard Price":213.0},{"Itemcode":"70115836","Description":"HSV Type 2 Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86696","Standard Price":255.0},{"Itemcode":"70115843","Description":"Pneumo Serotype 1 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115844","Description":"Pneumo Serotype 2 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115845","Description":"Pneumo Serotype 4 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115846","Description":"Pneumo Serotype 5 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115847","Description":"Pneumo Serotype 6B IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115848","Description":"Pneumo Serotype 7F IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115849","Description":"Pneumo Serotype 8 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115850","Description":"Pneumo Serotype 9N IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115851","Description":"Pneumo Serotype 9V IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115852","Description":"Pneumo Serotype 12F IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115853","Description":"Pneumo Serotype 14 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115854","Description":"Pneumo Serotype 18C IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115855","Description":"Pneumo Serotype 19F IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115856","Description":"Pneumo Serotype 23F IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":24.0},{"Itemcode":"70115858","Description":"Antibody, Aspergillus","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":102.0},{"Itemcode":"70115873","Description":"C1-Esterase Inhibitor","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":128.0},{"Itemcode":"70115874","Description":"Parvovirus B19 Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86747","Standard Price":128.0},{"Itemcode":"70115875","Description":"Parvovirus B19 Ab IgM","CDM Revenue Code":"300","CDM HCPCS":"86747","Standard Price":128.0},{"Itemcode":"70115879","Description":"Insulin Antibody","CDM Revenue Code":"300","CDM HCPCS":"86337","Standard Price":383.0},{"Itemcode":"70115880","Description":"Mycoplasma pneumoniae Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86738","Standard Price":102.0},{"Itemcode":"70115881","Description":"Mycoplasma pneumoniae Ab IgM","CDM Revenue Code":"300","CDM HCPCS":"86738","Standard Price":102.0},{"Itemcode":"70115885","Description":"Peanut IgE","CDM Revenue Code":"302","CDM HCPCS":"86003","Standard Price":143.0},{"Itemcode":"70115886","Description":"Peanut Sev Ara h 1","CDM Revenue Code":"302","CDM HCPCS":"86008","Standard Price":143.0},{"Itemcode":"70115887","Description":"Peanut Sev Ara h 2","CDM Revenue Code":"302","CDM HCPCS":"86008","Standard Price":143.0},{"Itemcode":"70115888","Description":"Peanut Sev Ara h 3","CDM Revenue Code":"302","CDM HCPCS":"86008","Standard Price":143.0},{"Itemcode":"70115889","Description":"Peanut Sev Ara h 9","CDM Revenue Code":"302","CDM HCPCS":"86008","Standard Price":143.0},{"Itemcode":"70115890","Description":"Peanut Mild Ara h 8","CDM Revenue Code":"302","CDM HCPCS":"86008","Standard Price":143.0},{"Itemcode":"70115896","Description":"HTLV I/II Antibodies by ELISA","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":113.0},{"Itemcode":"70115897","Description":"HTLV I/II Antibodies, WB","CDM Revenue Code":"300","CDM HCPCS":"86689","Standard Price":471.0},{"Itemcode":"70115898","Description":"Borrelia burgdorferi Abs","CDM Revenue Code":"300","CDM HCPCS":"86618","Standard Price":94.0},{"Itemcode":"70115899","Description":"Borrelia burgdorferi IgG, WB","CDM Revenue Code":"300","CDM HCPCS":"86617","Standard Price":170.0},{"Itemcode":"70115900","Description":"Borrelia burgdorferi IgM, WB","CDM Revenue Code":"300","CDM HCPCS":"86617","Standard Price":170.0},{"Itemcode":"70115922","Description":"VDRL with reflex to titer","CDM Revenue Code":"300","CDM HCPCS":"86592","Standard Price":68.0},{"Itemcode":"70115923","Description":"VDRL titer","CDM Revenue Code":"300","CDM HCPCS":"86593","Standard Price":213.0},{"Itemcode":"70115929","Description":"Peanut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115930","Description":"Lobster IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115931","Description":"Crab IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115932","Description":"Egg Yolk IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115933","Description":"Egg White IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115934","Description":"D farinae IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115935","Description":"Scallop IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115936","Description":"Milk (Cow's) IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115937","Description":"Codfish IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115938","Description":"Pecan IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115939","Description":"Oyster IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115940","Description":"Dog Dander IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115941","Description":"Alternaria alternata IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115942","Description":"Soybean IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115943","Description":"Tomato IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115944","Description":"Pistachio IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115945","Description":"Walnut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115956","Description":"Shrimp IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70115957","Description":"HIV-1 Antibody","CDM Revenue Code":"300","CDM HCPCS":"86701","Standard Price":218.0},{"Itemcode":"70115984","Description":"CRP-SF","CDM Revenue Code":"300","CDM HCPCS":"86140","Standard Price":95.0},{"Itemcode":"70115987","Description":"ANA","CDM Revenue Code":"300","CDM HCPCS":"86039","Standard Price":136.0},{"Itemcode":"70115988","Description":"Smith (ENA) Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":128.0},{"Itemcode":"70115989","Description":"dsDNA Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86225","Standard Price":110.0},{"Itemcode":"70115990","Description":"dsDNA (Crithidia) Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":255.0},{"Itemcode":"70115991","Description":"Ribonucleic Protein Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":128.0},{"Itemcode":"70115992","Description":"Scl-70 Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":128.0},{"Itemcode":"70115993","Description":"SSB (La) (ENA) Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":128.0},{"Itemcode":"70115995","Description":"PM/Scl 100 Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":458.0},{"Itemcode":"70115997","Description":"SSA-52 (Ro52) Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":128.0},{"Itemcode":"70115998","Description":"SSA-60 (Ro60) Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":128.0},{"Itemcode":"70115999","Description":"Fibrillarin (U3 RNP) Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":523.0},{"Itemcode":"70116006","Description":"Endomysial Ab, IgA","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":255.0},{"Itemcode":"70116008","Description":"ANCA","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":213.0},{"Itemcode":"70116009","Description":"ANCA Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":358.0},{"Itemcode":"70116013","Description":"CV2.1 Antibody IgG, Screen","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":327.0},{"Itemcode":"70116014","Description":"PCCA/ANNA IgG Screen","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":327.0},{"Itemcode":"70116016","Description":"Neuronal Nuclear Ab Ttr, IgG","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":680.0},{"Itemcode":"70116017","Description":"Purkinje Cell Antibody Ttr IgG","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":567.0},{"Itemcode":"70116019","Description":"CV2.1 Antibody Titer, IgG","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":1526.0},{"Itemcode":"70116098","Description":"B. pertussis Ab, IgA by ELISA","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":128.0},{"Itemcode":"70116099","Description":"B. pertussis Ab, IgG by ELISA","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":128.0},{"Itemcode":"70116100","Description":"B. pertussis Ab, IgA by IB","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":272.0},{"Itemcode":"70116101","Description":"B. pertussis Ab, IgG by IB","CDM Revenue Code":"300","CDM HCPCS":"86615","Standard Price":272.0},{"Itemcode":"70116108","Description":"Tuna IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116109","Description":"Almond IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116110","Description":"Brazil Nut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116111","Description":"Cashew IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116112","Description":"Hazelnut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116113","Description":"Chestnut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116114","Description":"Whole Egg IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116115","Description":"Alpha-lactalbumin IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":53.0},{"Itemcode":"70116116","Description":"Bahia Grass IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116117","Description":"Barley IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116118","Description":"Beef IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116119","Description":"Bermuda Grass IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116120","Description":"Beta-lactoglobulin IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":53.0},{"Itemcode":"70116121","Description":"Birch Tree IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116122","Description":"Black Pepper IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116123","Description":"Blue Mussel IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116124","Description":"Casein IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":53.0},{"Itemcode":"70116125","Description":"Cat Dander IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116126","Description":"Chili Pepper IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116127","Description":"Clam IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116128","Description":"German Cockroach IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116130","Description":"Coconut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116131","Description":"Common/Short Ragweed IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116132","Description":"Corn IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116133","Description":"D. pteronyssinus IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116134","Description":"Yellow Dock IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116135","Description":"English Plantain IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116136","Description":"Fire Ant IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116137","Description":"Garlic IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116138","Description":"Gluten IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116139","Description":"Honey Bee Venom IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116140","Description":"Latex IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116141","Description":"Macadamia Nut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116142","Description":"Box Elder/Maple Tree IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116143","Description":"Oak Tree IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116144","Description":"Onion IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116145","Description":"Orange IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116146","Description":"Paper Wasp IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116147","Description":"Bell Pepper IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116148","Description":"Penicillin G IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116149","Description":"Penicillin V IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116150","Description":"White Pine Tree IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116151","Description":"Pineapple IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116152","Description":"Pigweed IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116153","Description":"Sesame Seed IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116154","Description":"Sheep Sorrell IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116155","Description":"Oat IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116156","Description":"Strawberry IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116157","Description":"A. alternata IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116158","Description":"C. albicans IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116159","Description":"Hormodendrum IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116160","Description":"Meadow Fescue IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116161","Description":"A. fumigatus IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116162","Description":"P. notatum IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116163","Description":"Houst Dust Greer IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116164","Description":"Trout IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116165","Description":"Tuna IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116166","Description":"Wheat IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116167","Description":"Whey IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116168","Description":"White-faced Hornet IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116169","Description":"Baker/Brewer's Yeast IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116170","Description":"YellowFaced Hornet IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116171","Description":"Yellow Jacket Venom IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116172","Description":"Chocolate Ige","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116175","Description":"Herpesvirus 6 Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":436.0},{"Itemcode":"70116176","Description":"Herpesvirus 6 Antibody, IgM","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":638.0},{"Itemcode":"70116177","Description":"Herpesvirus 6 Ab, IgM Titer","CDM Revenue Code":"300","CDM HCPCS":"86790","Standard Price":589.0},{"Itemcode":"70116179","Description":"June/Kentucky Blue Grass IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116180","Description":"Johnson Grass IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116181","Description":"Chicken IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116182","Description":"Cheddar Cheese IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116183","Description":"Gulf Flounder IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116184","Description":"Lamb's Quarters IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116185","Description":"House Dust Stier IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116186","Description":"Amoxicillin IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116187","Description":"Banana IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116188","Description":"Carrot IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116189","Description":"Oregano IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116190","Description":"Perennial Rye Grass IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116191","Description":"Potato IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116192","Description":"Pork IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116193","Description":"Ampicillin IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116194","Description":"Horse Hair/Dander IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116195","Description":"Pea IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116196","Description":"Lima Bean/White Bean IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116197","Description":"Rice IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":53.0},{"Itemcode":"70116198","Description":"Feather Mix IgE","CDM Revenue Code":"300","CDM HCPCS":"86005","Standard Price":76.0},{"Itemcode":"70116199","Description":"Striated Muscle Abs","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":145.0},{"Itemcode":"70116200","Description":"Striated Muscle Abs IgG Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":425.0},{"Itemcode":"70116201","Description":"Adenovirus Antibody, Serum","CDM Revenue Code":"300","CDM HCPCS":"86603","Standard Price":517.0},{"Itemcode":"70116202","Description":"Beta-2 Transferrin","CDM Revenue Code":"300","CDM HCPCS":"86335","Standard Price":482.0},{"Itemcode":"70116206","Description":"T cells;total counts - LSP 3","CDM Revenue Code":"300","CDM HCPCS":"86359","Standard Price":161.0},{"Itemcode":"70116207","Description":"T cells; Abs CD4 and CD8-LSP3","CDM Revenue Code":"300","CDM HCPCS":"86360","Standard Price":161.0},{"Itemcode":"70116208","Description":"T cells;total counts-LSP4","CDM Revenue Code":"300","CDM HCPCS":"86359","Standard Price":255.0},{"Itemcode":"70116209","Description":"T cells; Abs CD4 and CD8-LSP4","CDM Revenue Code":"300","CDM HCPCS":"86360","Standard Price":255.0},{"Itemcode":"70116217","Description":"Myocardial Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":170.0},{"Itemcode":"70116218","Description":"Myocardial Ab IgG Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":553.0},{"Itemcode":"70116226","Description":"Complement Component 2","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":323.0},{"Itemcode":"70116227","Description":"Histoplasma Mycelia, CF","CDM Revenue Code":"300","CDM HCPCS":"86698","Standard Price":105.0},{"Itemcode":"70116228","Description":"Histoplasma yeast, CF","CDM Revenue Code":"300","CDM HCPCS":"86698","Standard Price":105.0},{"Itemcode":"70116229","Description":"Histoplasma spp.Abs,Precipitin","CDM Revenue Code":"300","CDM HCPCS":"86698","Standard Price":105.0},{"Itemcode":"70116242","Description":"Raji Cell Immune Complex Assay","CDM Revenue Code":"300","CDM HCPCS":"86332","Standard Price":609.0},{"Itemcode":"70116247","Description":"Diphtheria Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":153.0},{"Itemcode":"70116249","Description":"AQP4, IgG by IFA","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":1003.0},{"Itemcode":"70116250","Description":"AQP4, IgG by IFA, Serum Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":741.0},{"Itemcode":"70116255","Description":"C. pneumoniae IgM Titer","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":85.0},{"Itemcode":"70116256","Description":"C. trachomatis IgM Titer","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":85.0},{"Itemcode":"70116257","Description":"C. psittaci IgM Titer","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":85.0},{"Itemcode":"70116258","Description":"C. pneumoniae IgG Titer","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":85.0},{"Itemcode":"70116259","Description":"C. trachomatis IgG Titer","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":85.0},{"Itemcode":"70116260","Description":"C. psittaci IgG Titer","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":85.0},{"Itemcode":"70116262","Description":"Toxoplasma gondii Ab, IgG CSF","CDM Revenue Code":"300","CDM HCPCS":"86777","Standard Price":623.0},{"Itemcode":"70116263","Description":"Neutrophil Oxidative Burst","CDM Revenue Code":"300","CDM HCPCS":"86352","Standard Price":828.0},{"Itemcode":"70116268","Description":"B cells, total count","CDM Revenue Code":"300","CDM HCPCS":"86355","Standard Price":107.0},{"Itemcode":"70116269","Description":"NK cells, total count","CDM Revenue Code":"300","CDM HCPCS":"86357","Standard Price":107.0},{"Itemcode":"70116270","Description":"T cells; total count","CDM Revenue Code":"300","CDM HCPCS":"86359","Standard Price":107.0},{"Itemcode":"70116271","Description":"T Cells; Absol CD4 and CD8","CDM Revenue Code":"300","CDM HCPCS":"86360","Standard Price":107.0},{"Itemcode":"70116272","Description":"Mononuclear cell ag 1, qt","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":107.0},{"Itemcode":"70116273","Description":"Mononuclear cell ag 2, qt","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":107.0},{"Itemcode":"70116274","Description":"Mononuclear cell ag 3, qt","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":107.0},{"Itemcode":"70116275","Description":"Mononuclear cell ag 4, qt","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":107.0},{"Itemcode":"70116276","Description":"Lymph Response to Candida","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":541.0},{"Itemcode":"70116277","Description":"Lymph Response to Tetanus","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":541.0},{"Itemcode":"70116278","Description":"Lymph Response to PHA","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":541.0},{"Itemcode":"70116279","Description":"Lymph Response to Con A","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":541.0},{"Itemcode":"70116280","Description":"Lymph Response to PWM","CDM Revenue Code":"300","CDM HCPCS":"86353","Standard Price":541.0},{"Itemcode":"70116281","Description":"C.Trachomatis (L1) IgG","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116282","Description":"C.Trachomatis (L1) IgA","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116283","Description":"C. trachomatis (D-K) IgG","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116284","Description":"C. trachomatis (D-K) IgA","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116285","Description":"C. pneumoniae IgG","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116286","Description":"C. pneumoniae IgA","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116287","Description":"C. psittaci IgG","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116288","Description":"C. psittaci IgA","CDM Revenue Code":"300","CDM HCPCS":"86631","Standard Price":38.0},{"Itemcode":"70116289","Description":"C.Trachomatis (L1) IgM","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":38.0},{"Itemcode":"70116290","Description":"C. trachomatis (D-K) IgM","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":38.0},{"Itemcode":"70116291","Description":"C. pneumoniae IgM","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":38.0},{"Itemcode":"70116292","Description":"C. psittaci IgM","CDM Revenue Code":"300","CDM HCPCS":"86632","Standard Price":38.0},{"Itemcode":"70116302","Description":"Neisseria gonorrhoea Abs,Total","CDM Revenue Code":"300","CDM HCPCS":"86609","Standard Price":373.0},{"Itemcode":"70116305","Description":"Filaria Ab IgG4 by ELISA,Serum","CDM Revenue Code":"300","CDM HCPCS":"86682","Standard Price":541.0},{"Itemcode":"70116312","Description":"Poliovirus Ab Type 1","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":255.0},{"Itemcode":"70116313","Description":"Poliovirus Ab Type 3","CDM Revenue Code":"300","CDM HCPCS":"86658","Standard Price":255.0},{"Itemcode":"70116326","Description":"NMDA Receptor Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":945.0},{"Itemcode":"70116327","Description":"GAD Antibody","CDM Revenue Code":"300","CDM HCPCS":"86341","Standard Price":945.0},{"Itemcode":"70116328","Description":"LGI1 Ab IgG Screen by IFA","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":680.0},{"Itemcode":"70116329","Description":"CASPR2 Ab IgG Screen by IFA","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":680.0},{"Itemcode":"70116330","Description":"LGI1 Ab IgG Titer by IFA","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":1417.0},{"Itemcode":"70116331","Description":"CASPR2 Ab IgG Titer by IFA","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":1275.0},{"Itemcode":"70116332","Description":"NMDA Receptor Ab, IgGTiter","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":850.0},{"Itemcode":"70116333","Description":"NMO/AQP4-IgG, Serum","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":1003.0},{"Itemcode":"70116334","Description":"NMO/AQP4-IgG, Titer Serum","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":741.0},{"Itemcode":"70116345","Description":"Pneumo Serotype 3 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116346","Description":"Pneumo Serotype 10A IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116347","Description":"Pneumo Serotype 11A IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116348","Description":"Pneumo Serotype 15B IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116349","Description":"Pneumo Serotype 17F IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116350","Description":"Pneumo Serotype 19A IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116351","Description":"Pneumo Serotype 20 IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116352","Description":"Pneumo Serotype 22F IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116353","Description":"Pneumo Serotype 33F IgG","CDM Revenue Code":"300","CDM HCPCS":"86317","Standard Price":34.0},{"Itemcode":"70116354","Description":"Brucella Ab by Agglutination","CDM Revenue Code":"300","CDM HCPCS":"86622","Standard Price":119.0},{"Itemcode":"70116365","Description":"Aspergillus fumigatus Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86606","Standard Price":425.0},{"Itemcode":"70116373","Description":"Typhus Fever Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":106.0},{"Itemcode":"70116374","Description":"Typhus Fever Antibody, IgM","CDM Revenue Code":"300","CDM HCPCS":"86757","Standard Price":106.0},{"Itemcode":"70116379","Description":"S. cerevisiae Ab, IgA","CDM Revenue Code":"300","CDM HCPCS":"86671","Standard Price":140.0},{"Itemcode":"70116380","Description":"S. cerevisiae Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86671","Standard Price":140.0},{"Itemcode":"70116381","Description":"ANCA, IgG","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":140.0},{"Itemcode":"70116397","Description":"Peach IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":32.0},{"Itemcode":"70116398","Description":"Tilapia IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":32.0},{"Itemcode":"70116400","Description":"Mouse Epithelium IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":32.0},{"Itemcode":"70116401","Description":"M. racemosus IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":32.0},{"Itemcode":"70116403","Description":"Mackerel IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":32.0},{"Itemcode":"70116404","Description":"Halibut IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":32.0},{"Itemcode":"70116405","Description":"Salmon IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":32.0},{"Itemcode":"70116408","Description":"EBV VCA, IgM","CDM Revenue Code":"300","CDM HCPCS":"86665","Standard Price":66.0},{"Itemcode":"70116411","Description":"Echinococcus Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86682","Standard Price":129.0},{"Itemcode":"70116414","Description":"Complement Component 5","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":177.0},{"Itemcode":"70116415","Description":"Complement Component 7","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":554.0},{"Itemcode":"70116416","Description":"Complement Component 9","CDM Revenue Code":"300","CDM HCPCS":"86160","Standard Price":554.0},{"Itemcode":"70116419","Description":"C1q Binding Assay","CDM Revenue Code":"300","CDM HCPCS":"86332","Standard Price":114.0},{"Itemcode":"70116452","Description":"MOG IgG Antibody","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":807.0},{"Itemcode":"70116453","Description":"MOG IgG Antibody Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":1177.0},{"Itemcode":"70116458","Description":"Apple IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116472","Description":"Babesia microti IgG","CDM Revenue Code":"300","CDM HCPCS":"86753","Standard Price":100.0},{"Itemcode":"70116473","Description":"Babesia microti IgM","CDM Revenue Code":"300","CDM HCPCS":"86753","Standard Price":100.0},{"Itemcode":"70116474","Description":"A. Phagocytophilum Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86666","Standard Price":198.0},{"Itemcode":"70116475","Description":"A. Phagocytophilum Ab, IgM","CDM Revenue Code":"300","CDM HCPCS":"86666","Standard Price":198.0},{"Itemcode":"70116476","Description":"Cinnamon IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116477","Description":"Trichinella Antibody, IgG","CDM Revenue Code":"300","CDM HCPCS":"86784","Standard Price":640.0},{"Itemcode":"70116484","Description":"Francisella tularensis Ab IgG","CDM Revenue Code":"300","CDM HCPCS":"86668","Standard Price":161.0},{"Itemcode":"70116485","Description":"Francisella tularensis Ab IgM","CDM Revenue Code":"300","CDM HCPCS":"86668","Standard Price":161.0},{"Itemcode":"70116487","Description":"Ehrlichia chaffeensis Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86666","Standard Price":88.0},{"Itemcode":"70116488","Description":"Ehrlichia chaffeensis Ab, IgM","CDM Revenue Code":"300","CDM HCPCS":"86666","Standard Price":88.0},{"Itemcode":"70116491","Description":"Ovomucoid IgE","CDM Revenue Code":"300","CDM HCPCS":"86008","Standard Price":31.0},{"Itemcode":"70116492","Description":"Apricot IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116511","Description":"Purk Cell/Neur Nuc IgG Scrn","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":89.0},{"Itemcode":"70116512","Description":"HSV 1 Glyco G-Specific, IgG","CDM Revenue Code":"300","CDM HCPCS":"86695","Standard Price":128.0},{"Itemcode":"70116513","Description":"HSV 2 Glyco G-Specific, IgG","CDM Revenue Code":"300","CDM HCPCS":"86696","Standard Price":128.0},{"Itemcode":"70116516","Description":"E. histolytica Ab, IgG","CDM Revenue Code":"300","CDM HCPCS":"86753","Standard Price":71.0},{"Itemcode":"70116525","Description":"Western Ragweed IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116526","Description":"Sycamore Tree IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116527","Description":"Russian Thistle IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116528","Description":"Mugwort IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116529","Description":"Goldenrod IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116530","Description":"Kochia/Firebush IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116531","Description":"Eucalyptus Tree IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116532","Description":"White Ash Tree IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116538","Description":"Fungi/Mold, C. albicans IgG","CDM Revenue Code":"300","CDM HCPCS":"86001","Standard Price":110.0},{"Itemcode":"70116541","Description":"Giardia lamblia IgG","CDM Revenue Code":"300","CDM HCPCS":"86674","Standard Price":187.0},{"Itemcode":"70116542","Description":"Giardia lamblia IgM","CDM Revenue Code":"300","CDM HCPCS":"86674","Standard Price":187.0},{"Itemcode":"70116543","Description":"Giardia lamblia IgA","CDM Revenue Code":"300","CDM HCPCS":"86674","Standard Price":187.0},{"Itemcode":"70116544","Description":"N.meningitidis Type A IgG","CDM Revenue Code":"300","CDM HCPCS":"86741","Standard Price":222.0},{"Itemcode":"70116545","Description":"N.meningitidis Type C IgG","CDM Revenue Code":"300","CDM HCPCS":"86741","Standard Price":222.0},{"Itemcode":"70116546","Description":"N.meningitidis Type Y IgG","CDM Revenue Code":"300","CDM HCPCS":"86741","Standard Price":222.0},{"Itemcode":"70116547","Description":"N.meningitidis Type W-135 IgG","CDM Revenue Code":"300","CDM HCPCS":"86741","Standard Price":222.0},{"Itemcode":"70116554","Description":"B cells, total count","CDM Revenue Code":"300","CDM HCPCS":"86355","Standard Price":134.0},{"Itemcode":"70116555","Description":"Natural killer cells,tot ct","CDM Revenue Code":"300","CDM HCPCS":"86357","Standard Price":134.0},{"Itemcode":"70116556","Description":"T cells; total count","CDM Revenue Code":"300","CDM HCPCS":"86359","Standard Price":134.0},{"Itemcode":"70116557","Description":"T cells;abs CD4&CD8 ct,inc rat","CDM Revenue Code":"300","CDM HCPCS":"86360","Standard Price":134.0},{"Itemcode":"70116559","Description":"NK cells Enumeration","CDM Revenue Code":"300","CDM HCPCS":"86357","Standard Price":498.0},{"Itemcode":"70116561","Description":"Mononuclear cell antigen 1","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":228.0},{"Itemcode":"70116562","Description":"Mononuclear cell antigen 2","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":228.0},{"Itemcode":"70116563","Description":"Mononuclear cell antigen 3","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":228.0},{"Itemcode":"70116564","Description":"Mononuclear cell antigen 4","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":228.0},{"Itemcode":"70116565","Description":"Mononuclear cell antigen 5","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":228.0},{"Itemcode":"70116566","Description":"Mononuclear cell antigen 6","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":228.0},{"Itemcode":"70116567","Description":"Mononuclear cell antigen 7","CDM Revenue Code":"300","CDM HCPCS":"86356","Standard Price":228.0},{"Itemcode":"70116570","Description":"Candida Antibody IgA","CDM Revenue Code":"300","CDM HCPCS":"86628","Standard Price":99.0},{"Itemcode":"70116571","Description":"Candida Antibody IgG","CDM Revenue Code":"300","CDM HCPCS":"86628","Standard Price":99.0},{"Itemcode":"70116572","Description":"Candida Antibody IgM","CDM Revenue Code":"300","CDM HCPCS":"86628","Standard Price":99.0},{"Itemcode":"70116580","Description":"Alpha Fetoprotein, Body Fluid","CDM Revenue Code":"300","CDM HCPCS":"86316","Standard Price":82.0},{"Itemcode":"70116616","Description":"Jo-1 Ab IgG-EMP","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":91.0},{"Itemcode":"70116617","Description":"Smith/RNP (ENA) Ab IgG-EMP","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":91.0},{"Itemcode":"70116618","Description":"PM/Scl 100 Ab IgG-EMP","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":91.0},{"Itemcode":"70116619","Description":"SSA-52 (Ro52) (ENA) Ab IgG-EMP","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":91.0},{"Itemcode":"70116620","Description":"SSA-60 (Ro60) (ENA) Ab IgG-EMP","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":91.0},{"Itemcode":"70116621","Description":"Fibrillarin Ab IgG-EMP","CDM Revenue Code":"300","CDM HCPCS":"86235","Standard Price":91.0},{"Itemcode":"70116622","Description":"Sunflower Seed IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116623","Description":"Avocado IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116629","Description":"NMP22, Urine","CDM Revenue Code":"300","CDM HCPCS":"86316","Standard Price":463.0},{"Itemcode":"70116633","Description":"HSV 1/2 Ab, IgG","CDM Revenue Code":"302","CDM HCPCS":"86694","Standard Price":90.0},{"Itemcode":"70116634","Description":"HSV 1, IgG","CDM Revenue Code":"302","CDM HCPCS":"86695","Standard Price":133.0},{"Itemcode":"70116635","Description":"HSV 2, IgG","CDM Revenue Code":"302","CDM HCPCS":"86696","Standard Price":124.0},{"Itemcode":"70116637","Description":"Antistreptolysin O Screen","CDM Revenue Code":"302","CDM HCPCS":"86060","Standard Price":69.0},{"Itemcode":"70116642","Description":"Hepatitis A Virus Abs,Total","CDM Revenue Code":"302","CDM HCPCS":"86708","Standard Price":78.0},{"Itemcode":"70116643","Description":"Thyroid Peroxidase (TPO) Ab","CDM Revenue Code":"302","CDM HCPCS":"86376","Standard Price":58.0},{"Itemcode":"70116647","Description":"Varicella-Zoster Virus Ab, IgG","CDM Revenue Code":"302","CDM HCPCS":"86787","Standard Price":70.0},{"Itemcode":"70116650","Description":"Timothy Grass IgE","CDM Revenue Code":"302","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116658","Description":"IFE","CDM Revenue Code":"300","CDM HCPCS":"86334","Standard Price":60.0},{"Itemcode":"70116662","Description":"CMV Antibody IgM","CDM Revenue Code":"300","CDM HCPCS":"86645","Standard Price":73.0},{"Itemcode":"70116663","Description":"HSV 1 and/or 2 Abs,IgM ELISA","CDM Revenue Code":"302","CDM HCPCS":"86694","Standard Price":73.0},{"Itemcode":"70116664","Description":"Rubella Antibody IgM","CDM Revenue Code":"302","CDM HCPCS":"86762","Standard Price":73.0},{"Itemcode":"70116665","Description":"Toxoplasma gondii Ab, IgM","CDM Revenue Code":"302","CDM HCPCS":"86778","Standard Price":73.0},{"Itemcode":"70116666","Description":"CMV Antibody IgG","CDM Revenue Code":"300","CDM HCPCS":"86644","Standard Price":75.0},{"Itemcode":"70116667","Description":"HSV Type 1/2 Combined Ab, IgG","CDM Revenue Code":"302","CDM HCPCS":"86694","Standard Price":75.0},{"Itemcode":"70116668","Description":"Rubella Antibody IgG","CDM Revenue Code":"302","CDM HCPCS":"86762","Standard Price":75.0},{"Itemcode":"70116669","Description":"Toxoplasma gondii Ab, IgG","CDM Revenue Code":"302","CDM HCPCS":"86777","Standard Price":75.0},{"Itemcode":"70116670","Description":"Blastomyces Ab","CDM Revenue Code":"302","CDM HCPCS":"86612","Standard Price":85.0},{"Itemcode":"70116671","Description":"Blastomyces Abs Immunodifsn","CDM Revenue Code":"302","CDM HCPCS":"86612","Standard Price":76.0},{"Itemcode":"70116676","Description":"p2PSA","CDM Revenue Code":"302","CDM HCPCS":"86316","Standard Price":621.0},{"Itemcode":"70116679","Description":"Lemon IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116680","Description":"Cucumber IgE","CDM Revenue Code":"300","CDM HCPCS":"86003","Standard Price":31.0},{"Itemcode":"70116682","Description":"GBM Ab, IgG by IFA","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":374.0},{"Itemcode":"70116722","Description":"Urticaria-Inducing Activity","CDM Revenue Code":"302","CDM HCPCS":"86352","Standard Price":571.0},{"Itemcode":"70116723","Description":"T-Spot TB","CDM Revenue Code":"302","CDM HCPCS":"86481","Standard Price":392.0},{"Itemcode":"70116724","Description":"Chikungunya Antibodies, IgG","CDM Revenue Code":"302","CDM HCPCS":"86790","Standard Price":281.0},{"Itemcode":"70116725","Description":"Chikungunya Antibodies, IgM","CDM Revenue Code":"302","CDM HCPCS":"86790","Standard Price":281.0},{"Itemcode":"70116726","Description":"Dengue Fever Virus Ab, IgG","CDM Revenue Code":"302","CDM HCPCS":"86790","Standard Price":118.0},{"Itemcode":"70116727","Description":"Dengue Fever Virus Ab, IgM","CDM Revenue Code":"302","CDM HCPCS":"86790","Standard Price":118.0},{"Itemcode":"70116728","Description":"PLA2R Antibody","CDM Revenue Code":"300","CDM HCPCS":"86255","Standard Price":580.0},{"Itemcode":"70116729","Description":"PLA2R Antibody Titer","CDM Revenue Code":"300","CDM HCPCS":"86256","Standard Price":580.0},{"Itemcode":"70116730","Description":"Peanut Sev Ara h 6","CDM Revenue Code":"302","CDM HCPCS":"86008","Standard Price":143.0},{"Itemcode":"70118484","Description":"Phosphatidylserine Ab Igg","CDM Revenue Code":"300","CDM HCPCS":"86148","Standard Price":276.0},{"Itemcode":"70118486","Description":"Phosphatidylserine Ab Iga","CDM Revenue Code":"300","CDM HCPCS":"86148","Standard Price":276.0},{"Itemcode":"70118488","Description":"Phosphatidylserine Ab Igm","CDM Revenue Code":"300","CDM HCPCS":"86148","Standard Price":276.0},{"Itemcode":"70202000","Description":"HLA Ab Screening","CDM Revenue Code":"302","CDM HCPCS":"86828","Standard Price":1574.0},{"Itemcode":"70202001","Description":"HLA Ab ID, Class I","CDM Revenue Code":"302","CDM HCPCS":"86830","Standard Price":985.0},{"Itemcode":"70202002","Description":"HLA Molecular Ab Typing","CDM Revenue Code":"302","CDM HCPCS":"86832","Standard Price":4722.0},{"Itemcode":"70206177","Description":"CMV Negative Blood Prod Test","CDM Revenue Code":"300","CDM HCPCS":"86644","Standard Price":231.0},{"Itemcode":"70100010","Description":"Culture Aerobic: Blood","CDM Revenue Code":"300","CDM HCPCS":"87040","Standard Price":258.0},{"Itemcode":"70100011","Description":"Culture: Urine Colony Count","CDM Revenue Code":"300","CDM HCPCS":"87086","Standard Price":59.0},{"Itemcode":"70100088","Description":"Culture Aerobic: Stool","CDM Revenue Code":"300","CDM HCPCS":"87045","Standard Price":103.0},{"Itemcode":"70100089","Description":"Ova & Parasites","CDM Revenue Code":"300","CDM HCPCS":"87177","Standard Price":103.0},{"Itemcode":"70100090","Description":"H.Pylori Interp-GastTiss-Scrn","CDM Revenue Code":"300","CDM HCPCS":"87081","Standard Price":124.0},{"Itemcode":"70100105","Description":"RSV Antigen -Respiratory Syncy","CDM Revenue Code":"300","CDM HCPCS":"87807","Standard Price":360.0},{"Itemcode":"70100113","Description":"Gram Stain","CDM Revenue Code":"300","CDM HCPCS":"87205","Standard Price":56.0},{"Itemcode":"70100117","Description":"Culture ID -AEROBIC ADDL","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":53.0},{"Itemcode":"70100126","Description":"Beta Strp Scrn-Grp A","CDM Revenue Code":"300","CDM HCPCS":"87430","Standard Price":145.0},{"Itemcode":"70100141","Description":"Concentration For Infect Agent","CDM Revenue Code":"300","CDM HCPCS":"87015","Standard Price":81.0},{"Itemcode":"70100151","Description":"Fungal Culture:Body Fluid","CDM Revenue Code":"300","CDM HCPCS":"87102","Standard Price":410.0},{"Itemcode":"70100152","Description":"Fungus Culture Blood","CDM Revenue Code":"300","CDM HCPCS":"87103","Standard Price":445.0},{"Itemcode":"70100154","Description":"Culture Fungi: Skin-Hair-Nails","CDM Revenue Code":"300","CDM HCPCS":"87101","Standard Price":731.0},{"Itemcode":"70100156","Description":"Beta Strp Scrn-Grp B","CDM Revenue Code":"300","CDM HCPCS":"87802","Standard Price":726.0},{"Itemcode":"70100158","Description":"Culture: Strep Grp B-Oth Src","CDM Revenue Code":"300","CDM HCPCS":"87070","Standard Price":103.0},{"Itemcode":"70100164","Description":"HepatitisB SurfAg EIA (HBSAG)","CDM Revenue Code":"300","CDM HCPCS":"87340","Standard Price":170.0},{"Itemcode":"70100165","Description":"India Ink","CDM Revenue Code":"300","CDM HCPCS":"87210","Standard Price":238.0},{"Itemcode":"70100175","Description":"GDH Antigen","CDM Revenue Code":"300","CDM HCPCS":"87449","Standard Price":95.0},{"Itemcode":"70100181","Description":"KOH Prep","CDM Revenue Code":"300","CDM HCPCS":"87220","Standard Price":173.0},{"Itemcode":"70100182","Description":"AFB Smear","CDM Revenue Code":"300","CDM HCPCS":"87206","Standard Price":170.0},{"Itemcode":"70100183","Description":"Culture ID: Anaerobic","CDM Revenue Code":"300","CDM HCPCS":"87075","Standard Price":501.0},{"Itemcode":"70100185","Description":"Catheter Tip Culture; Oth Src","CDM Revenue Code":"300","CDM HCPCS":"87070","Standard Price":318.0},{"Itemcode":"70100186","Description":"Culture, Other, Source","CDM Revenue Code":"300","CDM HCPCS":"87070","Standard Price":103.0},{"Itemcode":"70100358","Description":"Inf Agent Det By Na Amp Pr","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1856.0},{"Itemcode":"70100359","Description":"Inf Agent Det By Na Amp Pr2","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1856.0},{"Itemcode":"70100405","Description":"T Vaginalis Rna Quest","CDM Revenue Code":"300","CDM HCPCS":"87661","Standard Price":215.0},{"Itemcode":"70100420","Description":"HIV-1 Integrase Genotype Qst","CDM Revenue Code":"300","CDM HCPCS":"87906","Standard Price":3249.0},{"Itemcode":"70100423","Description":"IA Det By Rna Amp Probe Flu A","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1249.0},{"Itemcode":"70100424","Description":"IA Det By Rna Amp Probe H1","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1251.0},{"Itemcode":"70100437","Description":"Cytomegalovirus by Qual PCR","CDM Revenue Code":"300","CDM HCPCS":"87496","Standard Price":596.0},{"Itemcode":"70100440","Description":"Chlamydiazyme (Chlamydia Ag)","CDM Revenue Code":"300","CDM HCPCS":"87320","Standard Price":295.0},{"Itemcode":"70100508","Description":"C.Pneumoniae DNA Qual Pcr Qst","CDM Revenue Code":"300","CDM HCPCS":"87486","Standard Price":567.0},{"Itemcode":"70100510","Description":"Influenza A Qst","CDM Revenue Code":"300","CDM HCPCS":"87275","Standard Price":89.0},{"Itemcode":"70100511","Description":"Influenza B Qst","CDM Revenue Code":"300","CDM HCPCS":"87276","Standard Price":89.0},{"Itemcode":"70100516","Description":"Bartonella DNA Qual Qst","CDM Revenue Code":"300","CDM HCPCS":"87471","Standard Price":839.0},{"Itemcode":"70100519","Description":"HIV-1 Dns Qual Pcr Qst","CDM Revenue Code":"300","CDM HCPCS":"87535","Standard Price":737.0},{"Itemcode":"70100526","Description":"C.Difficile Toxin PCR","CDM Revenue Code":"300","CDM HCPCS":"87493","Standard Price":245.0},{"Itemcode":"70100529","Description":"Lyme Disease DNA Qst","CDM Revenue Code":"300","CDM HCPCS":"87801","Standard Price":925.0},{"Itemcode":"70100604","Description":"Virus Isol Cent Enhanced By If","CDM Revenue Code":"300","CDM HCPCS":"87254","Standard Price":426.0},{"Itemcode":"70100654","Description":"Jc Polyoma Virus DNA Ql-Quest","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":567.0},{"Itemcode":"70100655","Description":"Parvovirus DNA Pcr -Quest","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1856.0},{"Itemcode":"70100662","Description":"Malaria Smear","CDM Revenue Code":"300","CDM HCPCS":"87207","Standard Price":305.0},{"Itemcode":"70100668","Description":"Influenza DNA Amp Probe","CDM Revenue Code":"300","CDM HCPCS":"87502","Standard Price":895.0},{"Itemcode":"70100670","Description":"Enterovirus Rna Qual Rt-Pcr","CDM Revenue Code":"300","CDM HCPCS":"87498","Standard Price":1139.0},{"Itemcode":"70100671","Description":"Ebv DNA Pcr Qual -Quest","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1173.0},{"Itemcode":"70100684","Description":"CMV Culture - Quest #2627","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":194.0},{"Itemcode":"70100685","Description":"CMV Rapid - Quest #2627","CDM Revenue Code":"300","CDM HCPCS":"87254","Standard Price":230.0},{"Itemcode":"70100813","Description":"Hep B Surface Antigen -Quest","CDM Revenue Code":"300","CDM HCPCS":"87340","Standard Price":170.0},{"Itemcode":"70100876","Description":"MRSA PCR","CDM Revenue Code":"300","CDM HCPCS":"87641","Standard Price":269.0},{"Itemcode":"70100880","Description":"Cryptosporidum/Giardia","CDM Revenue Code":"300","CDM HCPCS":"87300","Standard Price":1135.0},{"Itemcode":"70100895","Description":"Ova Parasite Aspirate","CDM Revenue Code":"300","CDM HCPCS":"87177","Standard Price":145.0},{"Itemcode":"70100937","Description":"Hep B DNA Qual By Pcr Qst","CDM Revenue Code":"300","CDM HCPCS":"87516","Standard Price":1070.0},{"Itemcode":"70100941","Description":"Chlamydia Amp Probe Mpl","CDM Revenue Code":"300","CDM HCPCS":"87491","Standard Price":538.0},{"Itemcode":"70100942","Description":"Gonorrhoea Amp Probe Mpl","CDM Revenue Code":"300","CDM HCPCS":"87591","Standard Price":538.0},{"Itemcode":"70101052","Description":"MIC Susceptibility Ea Microbe","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":68.0},{"Itemcode":"70101054","Description":"Haemophilus Panel","CDM Revenue Code":"300","CDM HCPCS":"87184","Standard Price":189.0},{"Itemcode":"70101056","Description":"Sensitivity Kb Disk/Plate","CDM Revenue Code":"300","CDM HCPCS":"87184","Standard Price":189.0},{"Itemcode":"70101060","Description":"Strep Pneumo Panel-CSF/Bld MIC","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":351.0},{"Itemcode":"70101080","Description":"Strep (Bs) Panel-Kb","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":170.0},{"Itemcode":"70101390","Description":"Herpes Virus 6 DNA Qualitative","CDM Revenue Code":"300","CDM HCPCS":"87532","Standard Price":1022.0},{"Itemcode":"70101402","Description":"Ifa Concentration Quest#10018","CDM Revenue Code":"300","CDM HCPCS":"87015","Standard Price":81.0},{"Itemcode":"70101403","Description":"Spec Stain Parasite Qst#10018","CDM Revenue Code":"300","CDM HCPCS":"87207","Standard Price":181.0},{"Itemcode":"70101425","Description":"HSV Type 1 Dna","CDM Revenue Code":"300","CDM HCPCS":"87530","Standard Price":747.0},{"Itemcode":"70101426","Description":"HSV Type 2 Dna","CDM Revenue Code":"300","CDM HCPCS":"87530","Standard Price":747.0},{"Itemcode":"70101428","Description":"C.Albicans Dna","CDM Revenue Code":"306","CDM HCPCS":"87481","Standard Price":215.0},{"Itemcode":"70101429","Description":"C.Glabrata Dna","CDM Revenue Code":"306","CDM HCPCS":"87481","Standard Price":215.0},{"Itemcode":"70101430","Description":"C.Tropicalis Dna","CDM Revenue Code":"306","CDM HCPCS":"87481","Standard Price":215.0},{"Itemcode":"70101431","Description":"C.Parapsilosis Dna","CDM Revenue Code":"306","CDM HCPCS":"87481","Standard Price":215.0},{"Itemcode":"70101432","Description":"C.Krusei Dna","CDM Revenue Code":"300","CDM HCPCS":"87481","Standard Price":524.0},{"Itemcode":"70101435","Description":"T.Vaginalis","CDM Revenue Code":"300","CDM HCPCS":"87660","Standard Price":196.0},{"Itemcode":"70101436","Description":"G.Vaginalis Dir Nuc Acid Probe","CDM Revenue Code":"300","CDM HCPCS":"87510","Standard Price":196.0},{"Itemcode":"70101437","Description":"Candida","CDM Revenue Code":"300","CDM HCPCS":"87480","Standard Price":196.0},{"Itemcode":"70101623","Description":"Phenotype Prediction","CDM Revenue Code":"300","CDM HCPCS":"87900","Standard Price":811.0},{"Itemcode":"70101624","Description":"Phenotype Analysis 1St 10 Drgs","CDM Revenue Code":"300","CDM HCPCS":"87903","Standard Price":5154.0},{"Itemcode":"70101625","Description":"Phenotype Analysis Drug #11","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101626","Description":"Phenotype Analysis Drug 12","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101627","Description":"Phenotype Analysis Drug #13","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101628","Description":"Phenotype Analysis Drug #14","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101629","Description":"Phenotype Analysis Drug #15","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101630","Description":"Phenotype Analysis Drug #16","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101631","Description":"Phenotype Analysis Drug #17","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101632","Description":"Phenotype Analysis Drug #18","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101633","Description":"Phenotype Analysis Drug #19","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101638","Description":"Phenotype Analysis Drug #20","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":644.0},{"Itemcode":"70101672","Description":"Helicobacter Pylori- Stool","CDM Revenue Code":"300","CDM HCPCS":"87338","Standard Price":1021.0},{"Itemcode":"70101962","Description":"10 Drug MIC Suscept Ea Microbe","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":742.0},{"Itemcode":"70102042","Description":"HIV-1 Rna Quant Pcr","CDM Revenue Code":"300","CDM HCPCS":"87536","Standard Price":584.0},{"Itemcode":"70102043","Description":"Hep C Rna","CDM Revenue Code":"300","CDM HCPCS":"87522","Standard Price":585.0},{"Itemcode":"70103654","Description":"IA By Na Multiple Orgs","CDM Revenue Code":"300","CDM HCPCS":"87800","Standard Price":1413.0},{"Itemcode":"70103812","Description":"IA By Eia; Hepatistis, Delta","CDM Revenue Code":"300","CDM HCPCS":"87380","Standard Price":1125.0},{"Itemcode":"70104082","Description":"Clostridium Difficile Toxin","CDM Revenue Code":"300","CDM HCPCS":"87324","Standard Price":244.0},{"Itemcode":"70104100","Description":"Chlamydia Culture","CDM Revenue Code":"300","CDM HCPCS":"87110","Standard Price":334.0},{"Itemcode":"70104103","Description":"Viral Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":596.0},{"Itemcode":"70104104","Description":"Culture: Viral Herpes","CDM Revenue Code":"300","CDM HCPCS":"87255","Standard Price":311.0},{"Itemcode":"70104107","Description":"Chlamydia Trach Probe","CDM Revenue Code":"300","CDM HCPCS":"87490","Standard Price":137.0},{"Itemcode":"70104111","Description":"GC By DNA Probe(Quest)","CDM Revenue Code":"300","CDM HCPCS":"87590","Standard Price":482.0},{"Itemcode":"70104128","Description":"Viral Culture: Body Fluid","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":774.0},{"Itemcode":"70104154","Description":"Mycoplasma Culture","CDM Revenue Code":"300","CDM HCPCS":"87109","Standard Price":377.0},{"Itemcode":"70104166","Description":"Hepatitis Be Ag","CDM Revenue Code":"300","CDM HCPCS":"87350","Standard Price":249.0},{"Itemcode":"70104199","Description":"PathogenCulture-Presumptv Scrn","CDM Revenue Code":"300","CDM HCPCS":"87081","Standard Price":238.0},{"Itemcode":"70104361","Description":"Chlamydia By DNA Probe","CDM Revenue Code":"300","CDM HCPCS":"87490","Standard Price":726.0},{"Itemcode":"70104401","Description":"Mycobacteria Definitive Id","CDM Revenue Code":"300","CDM HCPCS":"87118","Standard Price":227.0},{"Itemcode":"70104403","Description":"AFB Sensitivity Ea Drug","CDM Revenue Code":"300","CDM HCPCS":"87190","Standard Price":536.0},{"Itemcode":"70104404","Description":"DNA Probe M Tb","CDM Revenue Code":"300","CDM HCPCS":"87555","Standard Price":1866.0},{"Itemcode":"70104405","Description":"DNA Probe M Avium","CDM Revenue Code":"300","CDM HCPCS":"87560","Standard Price":1854.0},{"Itemcode":"70104452","Description":"Fungus Id","CDM Revenue Code":"300","CDM HCPCS":"87106","Standard Price":288.0},{"Itemcode":"70104454","Description":"CultureBacterial-Anaerob ID ea","CDM Revenue Code":"300","CDM HCPCS":"87076","Standard Price":766.0},{"Itemcode":"70104986","Description":"Viral Culture: Tissue","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1598.0},{"Itemcode":"70104987","Description":"Viral Culture: Csf","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":424.0},{"Itemcode":"70105993","Description":"GI PATHOGEN 12-25 TARGETS","CDM Revenue Code":"306","CDM HCPCS":"87507","Standard Price":852.0},{"Itemcode":"70106436","Description":"CMV Ia By Dfa","CDM Revenue Code":"300","CDM HCPCS":"87271","Standard Price":886.0},{"Itemcode":"70107613","Description":"GC By DNA Probe","CDM Revenue Code":"300","CDM HCPCS":"87591","Standard Price":55.0},{"Itemcode":"70107614","Description":"Chlamydia By DNA Probe","CDM Revenue Code":"300","CDM HCPCS":"87491","Standard Price":55.0},{"Itemcode":"70108503","Description":"Culture Urine Id","CDM Revenue Code":"300","CDM HCPCS":"87088","Standard Price":44.0},{"Itemcode":"70108562","Description":"IA Tuberculosis Direct Probe","CDM Revenue Code":"300","CDM HCPCS":"87556","Standard Price":940.0},{"Itemcode":"70109033","Description":"Hepatitis C Viral Rna Genotype","CDM Revenue Code":"300","CDM HCPCS":"87902","Standard Price":864.0},{"Itemcode":"70109110","Description":"Bk Virus Dna, Qual Pcr -Quest","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":795.0},{"Itemcode":"70109111","Description":"Bk Virus Qnt Rt Pcr -Qst","CDM Revenue Code":"300","CDM HCPCS":"87799","Standard Price":1971.0},{"Itemcode":"70109203","Description":"Inf Agent Det By Rna Amp Pr","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1856.0},{"Itemcode":"70109220","Description":"Limulus Amebocyte Lysate (Lal)","CDM Revenue Code":"300","CDM HCPCS":"87999","Standard Price":676.0},{"Itemcode":"70109655","Description":"Giardia Ia By Eia","CDM Revenue Code":"300","CDM HCPCS":"87329","Standard Price":203.0},{"Itemcode":"70109713","Description":"Hepatitis C Amp Probe","CDM Revenue Code":"300","CDM HCPCS":"87521","Standard Price":912.0},{"Itemcode":"70109714","Description":"Chlamydia Quant","CDM Revenue Code":"300","CDM HCPCS":"87492","Standard Price":676.0},{"Itemcode":"70109716","Description":"Chlamydia Trach Probe Amp","CDM Revenue Code":"300","CDM HCPCS":"87491","Standard Price":240.0},{"Itemcode":"70109746","Description":"AFB Cult W/Isolation & Pre Id","CDM Revenue Code":"300","CDM HCPCS":"87116","Standard Price":582.0},{"Itemcode":"70109748","Description":"Cryptosporidium Ia By Eia","CDM Revenue Code":"300","CDM HCPCS":"87328","Standard Price":180.0},{"Itemcode":"70109920","Description":"DNA Probe / M Gordonae","CDM Revenue Code":"300","CDM HCPCS":"87797","Standard Price":1370.0},{"Itemcode":"70109945","Description":"Legionella Antigen","CDM Revenue Code":"300","CDM HCPCS":"87899","Standard Price":278.0},{"Itemcode":"70109947","Description":"Hepatitis B Viral: DNA Quant","CDM Revenue Code":"300","CDM HCPCS":"87517","Standard Price":585.0},{"Itemcode":"70110100","Description":"Susceptibility Beta Lactamase","CDM Revenue Code":"300","CDM HCPCS":"87185","Standard Price":107.0},{"Itemcode":"70110105","Description":"CultureAerobic:Qnt (Not Urine)","CDM Revenue Code":"300","CDM HCPCS":"87071","Standard Price":427.0},{"Itemcode":"70110110","Description":"Mold Id","CDM Revenue Code":"300","CDM HCPCS":"87107","Standard Price":340.0},{"Itemcode":"70110120","Description":"Antibiotic Chg Per Disk (Add)","CDM Revenue Code":"300","CDM HCPCS":"87181","Standard Price":250.0},{"Itemcode":"70110159","Description":"HSV 1 By Pcr -Quest","CDM Revenue Code":"300","CDM HCPCS":"87529","Standard Price":709.0},{"Itemcode":"70110161","Description":"HSV 2 By Pcr -Quest","CDM Revenue Code":"300","CDM HCPCS":"87529","Standard Price":709.0},{"Itemcode":"70110165","Description":"Herpes 1/2 Dna: Pcr Quest -D","CDM Revenue Code":"300","CDM HCPCS":"87529","Standard Price":0.0},{"Itemcode":"70110170","Description":"Cytomegalovirus Dna: Quant Pcr","CDM Revenue Code":"300","CDM HCPCS":"87497","Standard Price":694.0},{"Itemcode":"70110175","Description":"Inf Agent Detection By Na","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1856.0},{"Itemcode":"70110215","Description":"IA Antigen Detection By Eia","CDM Revenue Code":"306","CDM HCPCS":"87449","Standard Price":760.0},{"Itemcode":"70110241","Description":"ABC Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110242","Description":"ABC Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110243","Description":"Adv-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110244","Description":"Adv-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110245","Description":"Adv Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110246","Description":"Ddl-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110247","Description":"Ddl-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110248","Description":"Ddl Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110249","Description":"3TC=A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110250","Description":"3TC=B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110251","Description":"3TC Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110252","Description":"D4T-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110253","Description":"D4T-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110254","Description":"Ddc-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110255","Description":"Ddc-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110256","Description":"Ddc Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110257","Description":"ZDV-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110258","Description":"ZDV-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110259","Description":"ZDV Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110260","Description":"Dlv-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110261","Description":"Dlv-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110262","Description":"Dlv Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110263","Description":"Efv-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110264","Description":"Efv-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110265","Description":"Efv Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110266","Description":"NVP-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110267","Description":"NVP-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110268","Description":"NVP Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110269","Description":"Amp-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110270","Description":"Amp-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110271","Description":"Amp Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110272","Description":"IDV-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110273","Description":"IDV-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110274","Description":"IDV Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110275","Description":"NFV-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110276","Description":"NFV-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110277","Description":"NFV Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110278","Description":"RTV-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110279","Description":"RTV-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110280","Description":"RTV Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110281","Description":"SQV-A Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110282","Description":"SQV-B Tissue Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":1763.0},{"Itemcode":"70110283","Description":"SQV Tissue Culture: Add'L","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":318.0},{"Itemcode":"70110310","Description":"Hepatitis C Quantification","CDM Revenue Code":"300","CDM HCPCS":"87522","Standard Price":2038.0},{"Itemcode":"70110315","Description":"HCV Rna Pcr/Iu","CDM Revenue Code":"300","CDM HCPCS":"87522","Standard Price":4048.0},{"Itemcode":"70110318","Description":"HCV Tissue","CDM Revenue Code":"300","CDM HCPCS":"87521","Standard Price":1856.0},{"Itemcode":"70110320","Description":"Influenza Immunoassay/Optic","CDM Revenue Code":"300","CDM HCPCS":"87804","Standard Price":185.0},{"Itemcode":"70110335","Description":"HIV Genotype","CDM Revenue Code":"300","CDM HCPCS":"87901","Standard Price":2362.0},{"Itemcode":"70110515","Description":"Culture: Water","CDM Revenue Code":"300","CDM HCPCS":"87086","Standard Price":174.0},{"Itemcode":"70113446","Description":"CMV Ia By Dfa","CDM Revenue Code":"300","CDM HCPCS":"87271","Standard Price":886.0},{"Itemcode":"70114999","Description":"Borrelia Species by PCR","CDM Revenue Code":"300","CDM HCPCS":"87476","Standard Price":755.0},{"Itemcode":"70115010","Description":"Ia, Histoplasma Capsulatum","CDM Revenue Code":"300","CDM HCPCS":"87385","Standard Price":1135.0},{"Itemcode":"70115015","Description":"IA If Bordetella Per/Paraper 1","CDM Revenue Code":"300","CDM HCPCS":"87265","Standard Price":564.0},{"Itemcode":"70115016","Description":"IA If Bordetella Per/Paraper 2","CDM Revenue Code":"300","CDM HCPCS":"87265","Standard Price":564.0},{"Itemcode":"70115506","Description":"Genotype DNA Hepatitis B QST","CDM Revenue Code":"300","CDM HCPCS":"87912","Standard Price":1363.0},{"Itemcode":"70115612","Description":"E coli K1 - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115613","Description":"H influenzae - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115614","Description":"L monocytogenes - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115615","Description":"N meningitidis - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115616","Description":"Strep agalactiae - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87653","Standard Price":178.0},{"Itemcode":"70115617","Description":"Strep pneumoniae - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115618","Description":"Enterovirus - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87498","Standard Price":178.0},{"Itemcode":"70115619","Description":"Human parechovirus - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115620","Description":"Culture Aerobic-Blood Referred","CDM Revenue Code":"300","CDM HCPCS":"87040","Standard Price":782.0},{"Itemcode":"70115621","Description":"Culture, MRSA Surveilance","CDM Revenue Code":"300","CDM HCPCS":"87070","Standard Price":122.0},{"Itemcode":"70115623","Description":"VZV - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115624","Description":"C neoformans/gattii - Biofire","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":178.0},{"Itemcode":"70115635","Description":"Enterococcus AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115636","Description":"LMonocytogenes AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115637","Description":"Staphylococcus AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115638","Description":"Streptococcus AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115639","Description":"ABaumannii AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115640","Description":"Enterobacteria AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115641","Description":"HInfluenzae AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115642","Description":"NMeningitidis AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115643","Description":"PAeruginosa AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115644","Description":"CAlbicans AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115645","Description":"CTropicalis AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115646","Description":"Cparap,krus,galb AmpProbe DNA","CDM Revenue Code":"306","CDM HCPCS":"87150","Standard Price":66.0},{"Itemcode":"70115647","Description":"G vaginalis DNA - Quest","CDM Revenue Code":"300","CDM HCPCS":"87512","Standard Price":182.0},{"Itemcode":"70115648","Description":"Lactobacillus sp DNA - Quest","CDM Revenue Code":"300","CDM HCPCS":"87799","Standard Price":182.0},{"Itemcode":"70115649","Description":"A vaginae DNA - Quest","CDM Revenue Code":"300","CDM HCPCS":"87799","Standard Price":182.0},{"Itemcode":"70115650","Description":"Megasphaera sp DNA - Quest","CDM Revenue Code":"300","CDM HCPCS":"87799","Standard Price":182.0},{"Itemcode":"70115673","Description":"Macroscopic Exam Arthropod","CDM Revenue Code":"300","CDM HCPCS":"87168","Standard Price":192.0},{"Itemcode":"70115761","Description":"Cult, typing;ID by DNA/RNA seq","CDM Revenue Code":"300","CDM HCPCS":"87153","Standard Price":1328.0},{"Itemcode":"70115765","Description":"Amplif NA Probe NOS Agent","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":749.0},{"Itemcode":"70115766","Description":"Amplif NA Probe NOS Agent","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":303.0},{"Itemcode":"70115767","Description":"Amplif NA Probe NOS Agent","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":303.0},{"Itemcode":"70115768","Description":"Amplif NA Probe NOS Agent","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":303.0},{"Itemcode":"70115769","Description":"Amplif NA Probe NOS Agent","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":303.0},{"Itemcode":"70115770","Description":"IKBKAP Gene","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":630.0},{"Itemcode":"70115772","Description":"T Vaginalis Rna","CDM Revenue Code":"300","CDM HCPCS":"87661","Standard Price":638.0},{"Itemcode":"70115793","Description":"1-3-beta-D-glucan","CDM Revenue Code":"306","CDM HCPCS":"87449","Standard Price":654.0},{"Itemcode":"70115801","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115802","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115803","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115804","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115805","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115806","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115807","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115808","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115809","Description":"AFB Sensitivity Mic Ea Agent","CDM Revenue Code":"300","CDM HCPCS":"87188","Standard Price":122.0},{"Itemcode":"70115840","Description":"Culture, Herpes Simplex Virus","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":255.0},{"Itemcode":"70115841","Description":"Culture, Cytomegalovirus Rapid","CDM Revenue Code":"300","CDM HCPCS":"87254","Standard Price":638.0},{"Itemcode":"70115842","Description":"Cult, Respiratory Virus Rapid","CDM Revenue Code":"300","CDM HCPCS":"87254","Standard Price":638.0},{"Itemcode":"70115884","Description":"Herpesvirus 6 Quant PCR","CDM Revenue Code":"300","CDM HCPCS":"87533","Standard Price":1134.0},{"Itemcode":"70115927","Description":"Hep B Surface Antigen","CDM Revenue Code":"300","CDM HCPCS":"87340","Standard Price":68.0},{"Itemcode":"70115928","Description":"Hep B Surface Antigen, Confirm","CDM Revenue Code":"300","CDM HCPCS":"87341","Standard Price":340.0},{"Itemcode":"70115949","Description":"Varicella Zoster DFA","CDM Revenue Code":"300","CDM HCPCS":"87290","Standard Price":265.0},{"Itemcode":"70115950","Description":"Herpes Simplex 1 Ag","CDM Revenue Code":"300","CDM HCPCS":"87274","Standard Price":265.0},{"Itemcode":"70115951","Description":"Herpes Simplex 2 Ag","CDM Revenue Code":"300","CDM HCPCS":"87273","Standard Price":265.0},{"Itemcode":"70115952","Description":"Varicella Zoster Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":319.0},{"Itemcode":"70115953","Description":"Varicella Zoster Isolation","CDM Revenue Code":"300","CDM HCPCS":"87254","Standard Price":319.0},{"Itemcode":"70115954","Description":"Herpes Simplex Culture","CDM Revenue Code":"300","CDM HCPCS":"87252","Standard Price":128.0},{"Itemcode":"70115955","Description":"Herpes Simplex Isolation","CDM Revenue Code":"300","CDM HCPCS":"87253","Standard Price":128.0},{"Itemcode":"70116020","Description":"Ref Aer Bacterial ID & Susc","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":345.0},{"Itemcode":"70116078","Description":"C. trachomatis by TMA","CDM Revenue Code":"300","CDM HCPCS":"87491","Standard Price":191.0},{"Itemcode":"70116079","Description":"N. gonorrheae by TMA","CDM Revenue Code":"300","CDM HCPCS":"87591","Standard Price":191.0},{"Itemcode":"70116097","Description":"B.pertussis/parapertussis PCR","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":510.0},{"Itemcode":"70116106","Description":"Norovirus, Groups 1 & 2 by PCR","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":1134.0},{"Itemcode":"70116173","Description":"West Nile Virus RNA, CSF","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":827.0},{"Itemcode":"70116203","Description":"Chlamydia Culture","CDM Revenue Code":"300","CDM HCPCS":"87110","Standard Price":234.0},{"Itemcode":"70116204","Description":"Chlamydia Culture IF","CDM Revenue Code":"300","CDM HCPCS":"87140","Standard Price":234.0},{"Itemcode":"70116219","Description":"Hepatitis C Virus Quant","CDM Revenue Code":"300","CDM HCPCS":"87522","Standard Price":652.0},{"Itemcode":"70116220","Description":"Hepatitis C Virus Genotype","CDM Revenue Code":"300","CDM HCPCS":"87902","Standard Price":652.0},{"Itemcode":"70116230","Description":"Histo Galactomannan Ag,Qt,Ur","CDM Revenue Code":"300","CDM HCPCS":"87385","Standard Price":453.0},{"Itemcode":"70116235","Description":"Histoplasma Antigen, Serum","CDM Revenue Code":"300","CDM HCPCS":"87385","Standard Price":453.0},{"Itemcode":"70116238","Description":"Enterovirus, Amp Probe Tech","CDM Revenue Code":"300","CDM HCPCS":"87498","Standard Price":1856.0},{"Itemcode":"70116239","Description":"Inf Ag Det By Eia","CDM Revenue Code":"300","CDM HCPCS":"87305","Standard Price":808.0},{"Itemcode":"70116240","Description":"Resp Virus PCR 12-25 Targets","CDM Revenue Code":"306","CDM HCPCS":"87633","Standard Price":989.0},{"Itemcode":"70116246","Description":"West Nile Virus by PCR","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":964.0},{"Itemcode":"70116254","Description":"Blastomyces dermatitidis Ag","CDM Revenue Code":"306","CDM HCPCS":"87449","Standard Price":554.0},{"Itemcode":"70116264","Description":"FLU/RSV by Nucleic Acid","CDM Revenue Code":"300","CDM HCPCS":"87631","Standard Price":416.0},{"Itemcode":"70116265","Description":"Strep A by Nucleic Acid","CDM Revenue Code":"300","CDM HCPCS":"87651","Standard Price":237.0},{"Itemcode":"70116315","Description":"Herpes Simplex Virus by PCR","CDM Revenue Code":"300","CDM HCPCS":"87529","Standard Price":510.0},{"Itemcode":"70116340","Description":"Parvovirus B19 by Quant PCR","CDM Revenue Code":"300","CDM HCPCS":"87799","Standard Price":872.0},{"Itemcode":"70116356","Description":"Microbe Susceptible MIC","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":332.0},{"Itemcode":"70116363","Description":"Vulvovag Candida spp by PCR","CDM Revenue Code":"300","CDM HCPCS":"87481","Standard Price":1461.0},{"Itemcode":"70116376","Description":"Phenotype Infect Agent Drug","CDM Revenue Code":"300","CDM HCPCS":"87900","Standard Price":1234.0},{"Itemcode":"70116377","Description":"Genotype DNA HIV Reverse T","CDM Revenue Code":"300","CDM HCPCS":"87901","Standard Price":1234.0},{"Itemcode":"70116378","Description":"Genotype DNA HIV Other Region","CDM Revenue Code":"300","CDM HCPCS":"87901","Standard Price":1234.0},{"Itemcode":"70116384","Description":"Pheno DNA HIV w/Cult;1-10 Drgs","CDM Revenue Code":"300","CDM HCPCS":"87903","Standard Price":2468.0},{"Itemcode":"70116385","Description":"Pheno DNA HIV w/Clt Drug 11","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116386","Description":"Pheno DNA HIV w/Clt Drug 12","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116387","Description":"Pheno DNA HIV w/Clt Drug 13","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116388","Description":"Pheno DNA HIV w/Clt Drug 14","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116389","Description":"Pheno DNA HIV w/Clt Drug 15","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116390","Description":"Pheno DNA HIV w/Clt Drug 16","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116391","Description":"Pheno DNA HIV w/Clt Drug 17","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116392","Description":"Pheno DNA HIV w/Clt Drug 18","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116393","Description":"Pheno DNA HIV w/Clt Drug 19","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116394","Description":"Pheno DNA HIV w/Clt Drug 20","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116395","Description":"Pheno DNA HIV w/Clt Drug 21","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":235.0},{"Itemcode":"70116412","Description":"Toxoplasma gondii by PCR","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":571.0},{"Itemcode":"70116413","Description":"Varicella-Zoster Virus by PCR","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":555.0},{"Itemcode":"70116422","Description":"DNA Sequencing-Bacterial ID","CDM Revenue Code":"300","CDM HCPCS":"87153","Standard Price":594.0},{"Itemcode":"70116423","Description":"Susc-Broth dilution panel","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":457.0},{"Itemcode":"70116424","Description":"Bact ID-Cystic Pseudomonas","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":266.0},{"Itemcode":"70116425","Description":"Bacterial ID-Pseudomonas","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":266.0},{"Itemcode":"70116426","Description":"Bacterial ID","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":266.0},{"Itemcode":"70116427","Description":"Bact ID-Gram positive(Phoenix)","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":266.0},{"Itemcode":"70116428","Description":"Bact ID-Gram negative(Phoenix)","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":266.0},{"Itemcode":"70116429","Description":"Bacterial ID-Bacillus","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":266.0},{"Itemcode":"70116430","Description":"Gm Neg ID&MIC Panel(Phoenix)","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":266.0},{"Itemcode":"70116431","Description":"Susc-AFB/Nocard by broth dil","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":463.0},{"Itemcode":"70116432","Description":"Susc-Automated broth dilution","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":332.0},{"Itemcode":"70116433","Description":"Susc-Beta-lactamase","CDM Revenue Code":"300","CDM HCPCS":"87185","Standard Price":116.0},{"Itemcode":"70116434","Description":"Susc-Anaerobe by broth dil","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":457.0},{"Itemcode":"70116435","Description":"Processing fee","CDM Revenue Code":"300","CDM HCPCS":"87015","Standard Price":217.0},{"Itemcode":"70116436","Description":"Susc-Single drug by broth dil","CDM Revenue Code":"300","CDM HCPCS":"87186","Standard Price":457.0},{"Itemcode":"70116437","Description":"Susc-Disk diffusion","CDM Revenue Code":"300","CDM HCPCS":"87184","Standard Price":247.0},{"Itemcode":"70116438","Description":"Susc-Single drug by Etest","CDM Revenue Code":"300","CDM HCPCS":"87181","Standard Price":449.0},{"Itemcode":"70116439","Description":"Susc-Automated disk diffusion","CDM Revenue Code":"300","CDM HCPCS":"87184","Standard Price":247.0},{"Itemcode":"70116440","Description":"DNA Sequencing-AFB ID","CDM Revenue Code":"300","CDM HCPCS":"87153","Standard Price":491.0},{"Itemcode":"70116441","Description":"DNA Sequencing-Fungal ID","CDM Revenue Code":"300","CDM HCPCS":"87153","Standard Price":705.0},{"Itemcode":"70116442","Description":"Bacterial ID by MALDI-TOF MS","CDM Revenue Code":"300","CDM HCPCS":"87077","Standard Price":409.0},{"Itemcode":"70116443","Description":"Anaer org ID by MALDI-TOF MS","CDM Revenue Code":"300","CDM HCPCS":"87076","Standard Price":409.0},{"Itemcode":"70116444","Description":"Susc-Penicillin Bind Prot 2a","CDM Revenue Code":"300","CDM HCPCS":"87147","Standard Price":322.0},{"Itemcode":"70116445","Description":"Salmonella typing","CDM Revenue Code":"300","CDM HCPCS":"87147","Standard Price":363.0},{"Itemcode":"70116446","Description":"Shigella serotyping","CDM Revenue Code":"300","CDM HCPCS":"87147","Standard Price":509.0},{"Itemcode":"70116447","Description":"E.coli 0157 Lat Agglutination","CDM Revenue Code":"300","CDM HCPCS":"87147","Standard Price":149.0},{"Itemcode":"70116448","Description":"PBP2A Normal Flora use","CDM Revenue Code":"300","CDM HCPCS":"87147","Standard Price":322.0},{"Itemcode":"70116449","Description":"Susc-mecA/mecC Gene Det by PCR","CDM Revenue Code":"300","CDM HCPCS":"87641","Standard Price":580.0},{"Itemcode":"70116450","Description":"Susc-Mod Carbapenem Inact Mtd","CDM Revenue Code":"300","CDM HCPCS":"87185","Standard Price":247.0},{"Itemcode":"70116478","Description":"Cryptococcal Ag by EIA, Serum","CDM Revenue Code":"300","CDM HCPCS":"87327","Standard Price":137.0},{"Itemcode":"70116480","Description":"Legionella pneumophila Ag, Ur","CDM Revenue Code":"300","CDM HCPCS":"87449","Standard Price":108.0},{"Itemcode":"70116481","Description":"Rotavirus Antigen by EIA","CDM Revenue Code":"300","CDM HCPCS":"87425","Standard Price":82.0},{"Itemcode":"70116482","Description":"Cryptococcal Ag by EIA, CSF","CDM Revenue Code":"300","CDM HCPCS":"87327","Standard Price":155.0},{"Itemcode":"70116483","Description":"O&P Trichrome Stain","CDM Revenue Code":"300","CDM HCPCS":"87209","Standard Price":99.0},{"Itemcode":"70116486","Description":"Ehrlichia/Anaplasma Spp by PCR","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":768.0},{"Itemcode":"70116500","Description":"IA Legionella Pneumophila","CDM Revenue Code":"300","CDM HCPCS":"87278","Standard Price":340.0},{"Itemcode":"70116537","Description":"BK Virus, Quantitative by PCR","CDM Revenue Code":"300","CDM HCPCS":"87799","Standard Price":415.0},{"Itemcode":"70116575","Description":"Parasites Smear, Blood","CDM Revenue Code":"300","CDM HCPCS":"87207","Standard Price":514.0},{"Itemcode":"70116585","Description":"Pheno DNA HIV w/Clt;1-10 Drugs","CDM Revenue Code":"300","CDM HCPCS":"87903","Standard Price":2827.0},{"Itemcode":"70116586","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg1","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116587","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg2","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116588","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg3","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116589","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg4","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116590","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg5","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116591","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg6","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116592","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg7","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116593","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg8","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116594","Description":"Pheno DNA HIV w/Clt;Ea Ad Drg9","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116595","Description":"Pheno DNA HIV w/Clt;Ea Ad Dg10","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116596","Description":"Pheno DNA HIV w/Clt;Ea Ad Dg11","CDM Revenue Code":"300","CDM HCPCS":"87904","Standard Price":174.0},{"Itemcode":"70116625","Description":"HCV NS5A Genotype/Resistance","CDM Revenue Code":"300","CDM HCPCS":"87902","Standard Price":1786.0},{"Itemcode":"70116628","Description":"Babesia Species by PCR","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":551.0},{"Itemcode":"70116672","Description":"Aspergillus Galactomannan Bron","CDM Revenue Code":"306","CDM HCPCS":"87305","Standard Price":394.0},{"Itemcode":"70116688","Description":"Drg Resist Mrks of Various NTM","CDM Revenue Code":"300","CDM HCPCS":"87798","Standard Price":407.0},{"Itemcode":"70116721","Description":"Malaria Detect/Speciation PCR","CDM Revenue Code":"306","CDM HCPCS":"87798","Standard Price":1140.0},{"Itemcode":"70118000","Description":"Stool Culture Other Pathogens","CDM Revenue Code":"300","CDM HCPCS":"87046","Standard Price":414.0},{"Itemcode":"70118001","Description":"Concentration Any Type","CDM Revenue Code":"300","CDM HCPCS":"87015","Standard Price":81.0},{"Itemcode":"70118474","Description":"Ebv DNA Ultraquant","CDM Revenue Code":"300","CDM HCPCS":"87799","Standard Price":1659.0},{"Itemcode":"70118479","Description":"Zika Virus RNA Qual RT-PCR QST","CDM Revenue Code":"300","CDM HCPCS":"87662","Standard Price":1777.0},{"Itemcode":"70100048","Description":"Rett Syndrome Mutation Anlys","CDM Revenue Code":"300","CDM HCPCS":"81302","Standard Price":3800.0},{"Itemcode":"70100049","Description":"Fish Prader Willi Qst","CDM Revenue Code":"310","CDM HCPCS":"81331","Standard Price":2772.0},{"Itemcode":"70100053","Description":"AAT Mutation Analysis Qst","CDM Revenue Code":"300","CDM HCPCS":"81331","Standard Price":1016.0},{"Itemcode":"70100231","Description":"Huntington S Disease Qst 10247","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":2200.0},{"Itemcode":"70100782","Description":"Alpha-Globin Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81269","Standard Price":1449.0},{"Itemcode":"70100799","Description":"K Ras Clarient","CDM Revenue Code":"300","CDM HCPCS":"81275","Standard Price":908.0},{"Itemcode":"70100858","Description":"Human Platelet Antigen 1 Geno","CDM Revenue Code":"300","CDM HCPCS":"81105","Standard Price":857.0},{"Itemcode":"70100859","Description":"HLA-B51 DNA Typing","CDM Revenue Code":"300","CDM HCPCS":"81381","Standard Price":528.0},{"Itemcode":"70100871","Description":"Tay-Sachs Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81255","Standard Price":878.0},{"Itemcode":"70100893","Description":"HLA-A Class I DNA Typing Qst","CDM Revenue Code":"300","CDM HCPCS":"81373","Standard Price":330.0},{"Itemcode":"70100918","Description":"Fragile X So Blot Reflex Qst","CDM Revenue Code":"300","CDM HCPCS":"81243","Standard Price":2088.0},{"Itemcode":"70101009","Description":"SMA Diagnostic Athena #11","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":2200.0},{"Itemcode":"70101014","Description":"Combimatrix Oligo 180K Array","CDM Revenue Code":"300","CDM HCPCS":"81299","Standard Price":3795.0},{"Itemcode":"70101044","Description":"Cah (21 Oh) Rare Mutations Qst","CDM Revenue Code":"300","CDM HCPCS":"81405","Standard Price":1832.0},{"Itemcode":"70101046","Description":"HLA Class II Hi Res 1St Allele","CDM Revenue Code":"300","CDM HCPCS":"81383","Standard Price":300.0},{"Itemcode":"70101047","Description":"HLA Class II Hi Res 2Nd Allele","CDM Revenue Code":"300","CDM HCPCS":"81383","Standard Price":300.0},{"Itemcode":"70101048","Description":"HLA Class II Lo Res Ea Antigen","CDM Revenue Code":"300","CDM HCPCS":"81377","Standard Price":300.0},{"Itemcode":"70101087","Description":"Brac 1/2 Analysis Myriad","CDM Revenue Code":"310","CDM HCPCS":"81162","Standard Price":4055.0},{"Itemcode":"70101088","Description":"Brac 1 Analysis Myriad","CDM Revenue Code":"310","CDM HCPCS":"81166","Standard Price":603.0},{"Itemcode":"70101089","Description":"Brac 2 Analysis Myriad","CDM Revenue Code":"300","CDM HCPCS":"81216","Standard Price":288.0},{"Itemcode":"70101097","Description":"Cyp2C9 (Warf Geno)","CDM Revenue Code":"300","CDM HCPCS":"81227","Standard Price":2246.0},{"Itemcode":"70101098","Description":"VKORC1","CDM Revenue Code":"300","CDM HCPCS":"81355","Standard Price":2246.0},{"Itemcode":"70101261","Description":"HLA-B 5701 Typing Quest 22722","CDM Revenue Code":"300","CDM HCPCS":"81241","Standard Price":1449.0},{"Itemcode":"70101297","Description":"SMNI Deletion Athena 215","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":2200.0},{"Itemcode":"70101298","Description":"SMNI Resequencing Athena 215","CDM Revenue Code":"300","CDM HCPCS":"81405","Standard Price":1832.0},{"Itemcode":"70101299","Description":"Smard & Xlsma Athena 215","CDM Revenue Code":"300","CDM HCPCS":"81479","Standard Price":1708.0},{"Itemcode":"70101308","Description":"Jak2 Qst 16539","CDM Revenue Code":"300","CDM HCPCS":"81270","Standard Price":1298.0},{"Itemcode":"70101309","Description":"Jak2 Reflex Qst 16622","CDM Revenue Code":"300","CDM HCPCS":"81403","Standard Price":1298.0},{"Itemcode":"70101340","Description":"Accutype Clopidogrel Cyp2C19","CDM Revenue Code":"300","CDM HCPCS":"81225","Standard Price":846.0},{"Itemcode":"70101394","Description":"Achondroplasia Mutation Analys","CDM Revenue Code":"300","CDM HCPCS":"81404","Standard Price":818.0},{"Itemcode":"70101396","Description":"Melas Mtdna Eval","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":4125.0},{"Itemcode":"70101397","Description":"Merrf Mtdna Eval","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":4125.0},{"Itemcode":"70101398","Description":"Narp Mtdna Eval","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":4125.0},{"Itemcode":"70101399","Description":"Polg DNA Sequencing","CDM Revenue Code":"300","CDM HCPCS":"81406","Standard Price":4125.0},{"Itemcode":"70101438","Description":"Cystic Fibrosis Entire Gene Sq","CDM Revenue Code":"300","CDM HCPCS":"81223","Standard Price":7106.0},{"Itemcode":"70101456","Description":"Combisnp Prenatal/Pediatric","CDM Revenue Code":"300","CDM HCPCS":"81229","Standard Price":3795.0},{"Itemcode":"70101458","Description":"Cytogenomic SNP Microarray","CDM Revenue Code":"300","CDM HCPCS":"81229","Standard Price":5600.0},{"Itemcode":"70101461","Description":"Cytogen Microarray Bac","CDM Revenue Code":"300","CDM HCPCS":"81228","Standard Price":1898.0},{"Itemcode":"70101464","Description":"Myotonic Dystrophy DNA Test","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":3144.0},{"Itemcode":"70101469","Description":"HLA-B27 DNA Typing","CDM Revenue Code":"300","CDM HCPCS":"81374","Standard Price":480.0},{"Itemcode":"70101482","Description":"HLA MOLECULAR TYPING","CDM Revenue Code":"300","CDM HCPCS":"81373","Standard Price":1626.0},{"Itemcode":"70101671","Description":"Admark Apoe Genotype","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":3465.0},{"Itemcode":"70102031","Description":"Factor V Leiden Mutation Qst","CDM Revenue Code":"300","CDM HCPCS":"81241","Standard Price":422.0},{"Itemcode":"70102511","Description":"Braf By Pcr Clarient","CDM Revenue Code":"300","CDM HCPCS":"81210","Standard Price":298.0},{"Itemcode":"70104410","Description":"Jak2 Mutation Qst 16539","CDM Revenue Code":"300","CDM HCPCS":"81270","Standard Price":4363.0},{"Itemcode":"70105580","Description":"Microdeletion Synd Analysis","CDM Revenue Code":"300","CDM HCPCS":"81403","Standard Price":1465.0},{"Itemcode":"70106470","Description":"PCA3 Antigen","CDM Revenue Code":"300","CDM HCPCS":"81313","Standard Price":1800.0},{"Itemcode":"70109003","Description":"Cystic Fibrosis Scrn Qst 10458","CDM Revenue Code":"300","CDM HCPCS":"81220","Standard Price":504.0},{"Itemcode":"70109219","Description":"TPMT Genetic Genotype Prom330","CDM Revenue Code":"300","CDM HCPCS":"81335","Standard Price":2336.0},{"Itemcode":"70109267","Description":"Lacto Type Prometheus #6100","CDM Revenue Code":"300","CDM HCPCS":"81400","Standard Price":1562.0},{"Itemcode":"70109278","Description":"ATG16L1 Snp (Rs2241880)","CDM Revenue Code":"300","CDM HCPCS":"81479","Standard Price":249.0},{"Itemcode":"70109279","Description":"Ecm1 Snp (Rs3737240)","CDM Revenue Code":"300","CDM HCPCS":"81479","Standard Price":249.0},{"Itemcode":"70109280","Description":"Nkx2-3 Snp (Rs10883365)","CDM Revenue Code":"300","CDM HCPCS":"81479","Standard Price":249.0},{"Itemcode":"70109281","Description":"Stat3 Snp (Rs744166)","CDM Revenue Code":"300","CDM HCPCS":"81479","Standard Price":249.0},{"Itemcode":"70109285","Description":"RHCE VARIANTS BY SNP ARRAY","CDM Revenue Code":"310","CDM HCPCS":"81479","Standard Price":1294.0},{"Itemcode":"70111030","Description":"Hereditary Hemochromat Dna","CDM Revenue Code":"300","CDM HCPCS":"81256","Standard Price":1311.0},{"Itemcode":"70112505","Description":"Bcr-Abl By Pcr (81206)","CDM Revenue Code":"300","CDM HCPCS":"81206","Standard Price":1614.0},{"Itemcode":"70112506","Description":"Bcr/Abl Minor Pcr Qnt Clarient","CDM Revenue Code":"300","CDM HCPCS":"81207","Standard Price":310.0},{"Itemcode":"70112507","Description":"Jak2 Clarient","CDM Revenue Code":"300","CDM HCPCS":"81270","Standard Price":298.0},{"Itemcode":"70112508","Description":"Jak2(Ffpe) Clarient","CDM Revenue Code":"300","CDM HCPCS":"81270","Standard Price":298.0},{"Itemcode":"70112509","Description":"PML/RARa CLARIENT","CDM Revenue Code":"300","CDM HCPCS":"81315","Standard Price":264.0},{"Itemcode":"70112510","Description":"KRAS By PCR Clarient","CDM Revenue Code":"300","CDM HCPCS":"81275","Standard Price":908.0},{"Itemcode":"70112511","Description":"Braf By Pcr Clarient","CDM Revenue Code":"300","CDM HCPCS":"81210","Standard Price":298.0},{"Itemcode":"70112512","Description":"Braf V600 Melanoma Clarient","CDM Revenue Code":"300","CDM HCPCS":"81210","Standard Price":298.0},{"Itemcode":"70112513","Description":"Egfr Mutation By Pcr Clarient","CDM Revenue Code":"300","CDM HCPCS":"81235","Standard Price":6203.0},{"Itemcode":"70112514","Description":"MSI By PCR Clarient","CDM Revenue Code":"300","CDM HCPCS":"81301","Standard Price":1440.0},{"Itemcode":"70112515","Description":"HER2 By Pcr Clarient","CDM Revenue Code":"300","CDM HCPCS":"81479","Standard Price":484.0},{"Itemcode":"70112516","Description":"Egfr Viii By Pcr Clarient","CDM Revenue Code":"300","CDM HCPCS":"81401","Standard Price":344.0},{"Itemcode":"70112555","Description":"HLA Tissue Typing Quest 15484","CDM Revenue Code":"300","CDM HCPCS":"81372","Standard Price":760.0},{"Itemcode":"70114000","Description":"Prothrombin Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81240","Standard Price":565.0},{"Itemcode":"70114100","Description":"MTH FR Mutation Detection","CDM Revenue Code":"300","CDM HCPCS":"81291","Standard Price":792.0},{"Itemcode":"70115672","Description":"MPL TRGgene rearrangement anal","CDM Revenue Code":"310","CDM HCPCS":"81342","Standard Price":1710.0},{"Itemcode":"70115688","Description":"EGFR Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81235","Standard Price":2658.0},{"Itemcode":"70115689","Description":"KRAS Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81275","Standard Price":2658.0},{"Itemcode":"70115704","Description":"BRAF Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81210","Standard Price":1200.0},{"Itemcode":"70115705","Description":"NRAS Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81311","Standard Price":2040.0},{"Itemcode":"70115715","Description":"B-cell IGH gene rearrange PCR","CDM Revenue Code":"300","CDM HCPCS":"81261","Standard Price":1716.0},{"Itemcode":"70115716","Description":"CECPA Mutation Analysis","CDM Revenue Code":"300","CDM HCPCS":"81403","Standard Price":2356.0},{"Itemcode":"70115721","Description":"FLT3 Gene Anal- ITD","CDM Revenue Code":"300","CDM HCPCS":"81245","Standard Price":1575.0},{"Itemcode":"70115722","Description":"FLT3 Gene Analysis - TKD","CDM Revenue Code":"300","CDM HCPCS":"81246","Standard Price":1575.0},{"Itemcode":"70115723","Description":"NPM1 GENE","CDM Revenue Code":"300","CDM HCPCS":"81310","Standard Price":300.0},{"Itemcode":"70115736","Description":"M CEBPA Gene Full Sequence","CDM Revenue Code":"310","CDM HCPCS":"81218","Standard Price":2656.0},{"Itemcode":"70115737","Description":"M Kit Gene Targeted Seq Analys","CDM Revenue Code":"310","CDM HCPCS":"81272","Standard Price":2656.0},{"Itemcode":"70115762","Description":"MLH1 PROMOTER METHYLATION","CDM Revenue Code":"310","CDM HCPCS":"81288","Standard Price":1440.0},{"Itemcode":"70115777","Description":"JAK 2 Exon 12 Mutation","CDM Revenue Code":"300","CDM HCPCS":"81403","Standard Price":1320.0},{"Itemcode":"70115878","Description":"HLA-B*57:01","CDM Revenue Code":"300","CDM HCPCS":"81381","Standard Price":600.0},{"Itemcode":"70116010","Description":"Fragile X Detection","CDM Revenue Code":"300","CDM HCPCS":"81243","Standard Price":570.0},{"Itemcode":"70116011","Description":"Fragile X Characterization","CDM Revenue Code":"300","CDM HCPCS":"81244","Standard Price":1880.0},{"Itemcode":"70116012","Description":"Fetal chromosomal aneuploidy","CDM Revenue Code":"300","CDM HCPCS":"81420","Standard Price":1350.0},{"Itemcode":"70116021","Description":"Fetal chromosomal microdeltj","CDM Revenue Code":"300","CDM HCPCS":"81422","Standard Price":1350.0},{"Itemcode":"70116084","Description":"HLA II Typing 1 Allele HR","CDM Revenue Code":"300","CDM HCPCS":"81383","Standard Price":334.0},{"Itemcode":"70116085","Description":"HLA II Typing 1 Locus LR DQ2","CDM Revenue Code":"300","CDM HCPCS":"81376","Standard Price":334.0},{"Itemcode":"70116086","Description":"HLA II Typing 1 Locus LR DQ8","CDM Revenue Code":"300","CDM HCPCS":"81376","Standard Price":334.0},{"Itemcode":"70116091","Description":"TPMT Genotyping, 4 Variants","CDM Revenue Code":"300","CDM HCPCS":"81335","Standard Price":1440.0},{"Itemcode":"70116304","Description":"BRCA1 and BRCA2 Seq & Del/Dup","CDM Revenue Code":"300","CDM HCPCS":"81162","Standard Price":8120.0},{"Itemcode":"70116309","Description":"MGMT Gene Prmtr Mthyltn Alys","CDM Revenue Code":"310","CDM HCPCS":"81287","Standard Price":1280.0},{"Itemcode":"70116310","Description":"IDH1 common variants","CDM Revenue Code":"310","CDM HCPCS":"81120","Standard Price":1060.0},{"Itemcode":"70116311","Description":"IDH2 common variants","CDM Revenue Code":"310","CDM HCPCS":"81121","Standard Price":1060.0},{"Itemcode":"70116339","Description":"PML-RARA Transloc, t(15;17) Qt","CDM Revenue Code":"300","CDM HCPCS":"81315","Standard Price":1380.0},{"Itemcode":"70116364","Description":"Angelman & Prader-Willi Synd","CDM Revenue Code":"300","CDM HCPCS":"81331","Standard Price":1300.0},{"Itemcode":"70116370","Description":"PDGFRA Gene Analysis","CDM Revenue Code":"310","CDM HCPCS":"81314","Standard Price":2000.0},{"Itemcode":"70116406","Description":"NTRK NGS Fusion","CDM Revenue Code":"300","CDM HCPCS":"81479","Standard Price":3200.0},{"Itemcode":"70116417","Description":"CAR ION CHNNLPATH INC 10 GNS","CDM Revenue Code":"300","CDM HCPCS":"81413","Standard Price":4875.0},{"Itemcode":"70116418","Description":"CAR ION CHNNLPATH INC 2 GNS","CDM Revenue Code":"300","CDM HCPCS":"81414","Standard Price":4875.0},{"Itemcode":"70116454","Description":"Dihydropyrimidine Dehydrogenas","CDM Revenue Code":"300","CDM HCPCS":"81232","Standard Price":1045.0},{"Itemcode":"70116460","Description":"SMA Copy Number","CDM Revenue Code":"300","CDM HCPCS":"81329","Standard Price":870.0},{"Itemcode":"70116461","Description":"BCR-ABL1 Major, Qual","CDM Revenue Code":"300","CDM HCPCS":"81206","Standard Price":361.0},{"Itemcode":"70116462","Description":"BCR-ABL1 Minor, Qual","CDM Revenue Code":"300","CDM HCPCS":"81207","Standard Price":361.0},{"Itemcode":"70116463","Description":"BCR-ABL1 Major, Quant","CDM Revenue Code":"300","CDM HCPCS":"81206","Standard Price":988.0},{"Itemcode":"70116464","Description":"BCR-ABL1 Minor, Quant","CDM Revenue Code":"300","CDM HCPCS":"81207","Standard Price":988.0},{"Itemcode":"70116514","Description":"Alpha-1-antitrypsin; Genotype","CDM Revenue Code":"300","CDM HCPCS":"81332","Standard Price":534.0},{"Itemcode":"70116535","Description":"NUDT15 Gene Common Variants","CDM Revenue Code":"300","CDM HCPCS":"81306","Standard Price":700.0},{"Itemcode":"70116578","Description":"IGHV Mutation Analysis by Seq","CDM Revenue Code":"300","CDM HCPCS":"81263","Standard Price":1710.0},{"Itemcode":"70116579","Description":"Hereditary Hemolyt Anemia Seq","CDM Revenue Code":"300","CDM HCPCS":"81443","Standard Price":6470.0},{"Itemcode":"70116582","Description":"CADASIL (NOTCH3) Full Gene Seq","CDM Revenue Code":"300","CDM HCPCS":"81406","Standard Price":4294.0},{"Itemcode":"70116601","Description":"Marfan Syndrome (FBN1) Sequenc","CDM Revenue Code":"300","CDM HCPCS":"81408","Standard Price":5140.0},{"Itemcode":"70116624","Description":"APOE Genotyping","CDM Revenue Code":"310","CDM HCPCS":"81401","Standard Price":542.0},{"Itemcode":"70116626","Description":"Neotype colorectal Tumor Prof","CDM Revenue Code":"310","CDM HCPCS":"81445","Standard Price":6870.0},{"Itemcode":"70116677","Description":"Alpha Thalassemia, 7 Deletions","CDM Revenue Code":"300","CDM HCPCS":"81257","Standard Price":1291.0},{"Itemcode":"70116685","Description":"CYP2C19","CDM Revenue Code":"300","CDM HCPCS":"81225","Standard Price":520.0},{"Itemcode":"70116689","Description":"JAK2 Gene,V617F Mutation,Qual","CDM Revenue Code":"310","CDM HCPCS":"81270","Standard Price":622.0},{"Itemcode":"70116690","Description":"CALR Exon 9 Mutation Analysis","CDM Revenue Code":"310","CDM HCPCS":"81219","Standard Price":950.0},{"Itemcode":"70116691","Description":"MPL Mutation Detection","CDM Revenue Code":"310","CDM HCPCS":"81402","Standard Price":1415.0},{"Itemcode":"64101903","Description":"Electrolyte Panel","CDM Revenue Code":"300","CDM HCPCS":"80051","Standard Price":113.0},{"Itemcode":"70100002","Description":"Comprehensive Metabolic Panel","CDM Revenue Code":"300","CDM HCPCS":"80053","Standard Price":64.0},{"Itemcode":"70100003","Description":"Basic Metabolic Panel","CDM Revenue Code":"300","CDM HCPCS":"80048","Standard Price":46.0},{"Itemcode":"70100097","Description":"Basic Metabolic Panel (Ion Ca)","CDM Revenue Code":"300","CDM HCPCS":"80047","Standard Price":238.0},{"Itemcode":"70100150","Description":"Hepatic Function Panel","CDM Revenue Code":"300","CDM HCPCS":"80076","Standard Price":55.0},{"Itemcode":"70100225","Description":"Coronary Risk Pro/Lipid Panel","CDM Revenue Code":"300","CDM HCPCS":"80061","Standard Price":66.0},{"Itemcode":"70100323","Description":"Electrolyte Panel","CDM Revenue Code":"300","CDM HCPCS":"80051","Standard Price":113.0},{"Itemcode":"70101636","Description":"OB Prenatal Profile","CDM Revenue Code":"300","CDM HCPCS":"80055","Standard Price":2191.0},{"Itemcode":"70109881","Description":"Hepatitis Panel","CDM Revenue Code":"300","CDM HCPCS":"80074","Standard Price":740.0},{"Itemcode":"70109888","Description":"General Health Panel","CDM Revenue Code":"300","CDM HCPCS":"80050","Standard Price":232.0},{"Itemcode":"70109946","Description":"Renal Function Panel","CDM Revenue Code":"300","CDM HCPCS":"80069","Standard Price":142.0},{"Itemcode":"73100109","Description":"Electrolyte Panel","CDM Revenue Code":"300","CDM HCPCS":"80051","Standard Price":113.0},{"Itemcode":"74221017","Description":"Lipid Panel","CDM Revenue Code":"300","CDM HCPCS":"80061","Standard Price":88.0},{"Itemcode":"75452024","Description":"Go Strong Lipid Profile","CDM Revenue Code":"300","CDM HCPCS":"80061","Standard Price":18.0},{"Itemcode":"70100044","Description":"Tobramycin Assay","CDM Revenue Code":"300","CDM HCPCS":"80200","Standard Price":189.0},{"Itemcode":"70100045","Description":"Theophylline Assay","CDM Revenue Code":"300","CDM HCPCS":"80198","Standard Price":111.0},{"Itemcode":"70100046","Description":"Digoxin Assay","CDM Revenue Code":"300","CDM HCPCS":"80162","Standard Price":109.0},{"Itemcode":"70100081","Description":"Cell Count Fluid W/ Diff","CDM Revenue Code":"300","CDM HCPCS":"89051","Standard Price":740.0},{"Itemcode":"70100091","Description":"Cell Count Fluid","CDM Revenue Code":"300","CDM HCPCS":"89050","Standard Price":145.0},{"Itemcode":"70100103","Description":"Gentamycin Assay","CDM Revenue Code":"300","CDM HCPCS":"80170","Standard Price":157.0},{"Itemcode":"70100114","Description":"Ethosuximide","CDM Revenue Code":"300","CDM HCPCS":"80168","Standard Price":204.0},{"Itemcode":"70100196","Description":"Procainamide: Total","CDM Revenue Code":"300","CDM HCPCS":"80190","Standard Price":1233.0},{"Itemcode":"70100281","Description":"Dilantin Assay","CDM Revenue Code":"300","CDM HCPCS":"80185","Standard Price":127.0},{"Itemcode":"70100282","Description":"Phenobarbital Assay","CDM Revenue Code":"300","CDM HCPCS":"80184","Standard Price":100.0},{"Itemcode":"70100285","Description":"MOL Cyto In Situ Hybrid 1","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100286","Description":"MOL Cyto In Situ Hybrid 2","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100287","Description":"MOL Cyto In Situ Hybrid 3","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100288","Description":"MOL Cyto In Situ Hybrid 4","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100289","Description":"MOL Cyto In Situ Hybrid 5","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100290","Description":"MOL Cyto In Situ Hybrid 6","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100291","Description":"MOL Cyto In Situ Hybrid 7","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100292","Description":"MOL Cyto In Situ Hybrid 8","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":143.0},{"Itemcode":"70100293","Description":"MOL Cyto In Situ Hybrid 9","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100294","Description":"MOL Cyto In Situ Hybrid 10","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100295","Description":"MOL Cyto In Situ Hybrid 11","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100296","Description":"MOL Cyto In Situ Hybrid 12","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100297","Description":"MOL Cyto In Situ Hybrid 13","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100298","Description":"MOL Cyto In Situ Hybrid 14","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":143.0},{"Itemcode":"70100299","Description":"MOL Cyto In Situ Hybrid 15","CDM Revenue Code":"310","CDM HCPCS":"88272","Standard Price":142.0},{"Itemcode":"70100330","Description":"Eosinophil: Smear","CDM Revenue Code":"300","CDM HCPCS":"89190","Standard Price":91.0},{"Itemcode":"70100332","Description":"Haloperidol Quest 564","CDM Revenue Code":"300","CDM HCPCS":"80173","Standard Price":452.0},{"Itemcode":"70100377","Description":"Quinidine Assay","CDM Revenue Code":"300","CDM HCPCS":"80194","Standard Price":1077.0},{"Itemcode":"70100412","Description":"Carbamazepine/Tegretol","CDM Revenue Code":"300","CDM HCPCS":"80156","Standard Price":104.0},{"Itemcode":"70100429","Description":"Vancomycin Assay","CDM Revenue Code":"300","CDM HCPCS":"80202","Standard Price":136.0},{"Itemcode":"70100433","Description":"Isotretinoin Quest 26519","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":1073.0},{"Itemcode":"70100515","Description":"5-Flucytosine Serum Qst","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":572.0},{"Itemcode":"70100532","Description":"Wet Prep (Bact:Fungi)","CDM Revenue Code":"300","CDM HCPCS":"Q0111","Standard Price":146.0},{"Itemcode":"70100540","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100541","Description":"MOL Cytogenetics: DNA Probe 4","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100542","Description":"MOL Cytogenetics: DNA Probe 5","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100543","Description":"MOL Cytogenetics: DNA Probe 6","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100544","Description":"MOL Cytogenetics: DNA Probe 7","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100545","Description":"MOL Cytogenetics: DNA Probe 8","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100546","Description":"MOL Cytogenetics: DNA Probe 9","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100547","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100548","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100549","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100550","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100551","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100552","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100553","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100554","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100555","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100556","Description":"MOL Cytogenetics: DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100557","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100558","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100559","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100560","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100561","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100562","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100563","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100564","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100565","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100566","Description":"MOL Cytogenetics: DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100567","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100568","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100569","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100570","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100571","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100572","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100573","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100574","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100575","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100576","Description":"MOL Cytogenetics: DNA Probe 3","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100577","Description":"MOL Cytogenetics: DNA Probe 4","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100578","Description":"MOL Cytogenetics: DNA Probe 4","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100579","Description":"MOL Cytogenetics: DNA Probe 4","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100580","Description":"MOL Cytogenetics: DNA Probe 4","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":151.0},{"Itemcode":"70100581","Description":"MOL Cytogenetics: DNA Probe 4","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":365.0},{"Itemcode":"70100598","Description":"MOL Cytogenetics: DNA Probe 6","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":365.0},{"Itemcode":"70100691","Description":"Tissue Culture Amniotic Fl","CDM Revenue Code":"310","CDM HCPCS":"88235","Standard Price":201.0},{"Itemcode":"70100692","Description":"Chromosome Analysis","CDM Revenue Code":"310","CDM HCPCS":"88269","Standard Price":227.0},{"Itemcode":"70100693","Description":"Chromosome Analysis Adl Karyo","CDM Revenue Code":"310","CDM HCPCS":"88280","Standard Price":185.0},{"Itemcode":"70100802","Description":"Lidocaine Level","CDM Revenue Code":"300","CDM HCPCS":"80176","Standard Price":216.0},{"Itemcode":"70100811","Description":"Crystal Identification","CDM Revenue Code":"300","CDM HCPCS":"89060","Standard Price":78.0},{"Itemcode":"70100817","Description":"Growth Hormone Supprsn Panel","CDM Revenue Code":"300","CDM HCPCS":"80430","Standard Price":210.0},{"Itemcode":"70100820","Description":"GH Stimulation Panel","CDM Revenue Code":"300","CDM HCPCS":"80428","Standard Price":210.0},{"Itemcode":"70100828","Description":"Fat (Stool/Urine/Sputum)","CDM Revenue Code":"300","CDM HCPCS":"89125","Standard Price":108.0},{"Itemcode":"70100857","Description":"Warfarin Ur","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":596.0},{"Itemcode":"70100863","Description":"Felbamate","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":291.0},{"Itemcode":"70100896","Description":"Dantrolene Sp","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":582.0},{"Itemcode":"70100899","Description":"Semen Analysis","CDM Revenue Code":"300","CDM HCPCS":"89322","Standard Price":330.0},{"Itemcode":"70100916","Description":"Drug Quantitation -Quest","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":1072.0},{"Itemcode":"70100944","Description":"Tissue Cult Bn/Bld-Cyto Bm Mpl","CDM Revenue Code":"310","CDM HCPCS":"88237","Standard Price":2883.0},{"Itemcode":"70100945","Description":"Chromosome Analys-Cyto Bm Mpl","CDM Revenue Code":"310","CDM HCPCS":"88264","Standard Price":2883.0},{"Itemcode":"70100946","Description":"Chrom Anyls Addl 1-Cyto Bm Mpl","CDM Revenue Code":"310","CDM HCPCS":"88280","Standard Price":1394.0},{"Itemcode":"70100947","Description":"Chrom Anyls Addl 2-Cyto Bm Mpl","CDM Revenue Code":"310","CDM HCPCS":"88280","Standard Price":1712.0},{"Itemcode":"70100950","Description":"Tissue Culture - Cyto Poc Mpl","CDM Revenue Code":"310","CDM HCPCS":"88233","Standard Price":4836.0},{"Itemcode":"70100951","Description":"Chrom Anaylsis - Cyto Poc Mpl","CDM Revenue Code":"310","CDM HCPCS":"88262","Standard Price":4836.0},{"Itemcode":"70100954","Description":"Tissue Culture -Cyto St Mpl","CDM Revenue Code":"310","CDM HCPCS":"88233","Standard Price":4836.0},{"Itemcode":"70100955","Description":"Chrom Anyls - Cyto St Mpl","CDM Revenue Code":"310","CDM HCPCS":"88262","Standard Price":4836.0},{"Itemcode":"70100959","Description":"Tissue Culture-Cyto Upb Mpl","CDM Revenue Code":"310","CDM HCPCS":"88237","Standard Price":2883.0},{"Itemcode":"70100960","Description":"Chromosome Analys-Cyto Upb Mpl","CDM Revenue Code":"310","CDM HCPCS":"88264","Standard Price":2883.0},{"Itemcode":"70100961","Description":"Chrom Anlys Addl1-Cyto Upb Mpl","CDM Revenue Code":"310","CDM HCPCS":"88280","Standard Price":1712.0},{"Itemcode":"70100962","Description":"Chrom Anlys Addl2-Cyto Upb Mpl","CDM Revenue Code":"310","CDM HCPCS":"88280","Standard Price":1712.0},{"Itemcode":"70101362","Description":"DNA Probe Each Mayo Fish Subt","CDM Revenue Code":"311","CDM HCPCS":"88271","Standard Price":1461.0},{"Itemcode":"70101363","Description":"Chrom Situ Hybrid 10-30 Mayo","CDM Revenue Code":"310","CDM HCPCS":"88273","Standard Price":102.0},{"Itemcode":"70101364","Description":"ChromSituHybrid10-30cells Mayo","CDM Revenue Code":"311","CDM HCPCS":"88273","Standard Price":102.0},{"Itemcode":"70101388","Description":"Panorama Prenatal Test Qst","CDM Revenue Code":"300","CDM HCPCS":"81599","Standard Price":5252.0},{"Itemcode":"70101420","Description":"Dextro/Levo Methorphan Ur Qst","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":636.0},{"Itemcode":"70101463","Description":"Ova1 Quest 16991","CDM Revenue Code":"300","CDM HCPCS":"81503","Standard Price":5285.0},{"Itemcode":"70101608","Description":"Chrmosome Analysis: Hi Res","CDM Revenue Code":"310","CDM HCPCS":"88289","Standard Price":1416.0},{"Itemcode":"70101634","Description":"Sirolimus","CDM Revenue Code":"300","CDM HCPCS":"80195","Standard Price":570.0},{"Itemcode":"70101655","Description":"MOL Cyto Interphase In Situ H","CDM Revenue Code":"310","CDM HCPCS":"88275","Standard Price":682.0},{"Itemcode":"70102568","Description":"MOL Cyto Interphas In Situ Hy","CDM Revenue Code":"311","CDM HCPCS":"88275","Standard Price":1441.0},{"Itemcode":"70104113","Description":"Valproic Acid-Depakene","CDM Revenue Code":"300","CDM HCPCS":"80164","Standard Price":84.0},{"Itemcode":"70104133","Description":"Flecainide Acetate","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":730.0},{"Itemcode":"70104183","Description":"Chromos Analysis Tissue","CDM Revenue Code":"310","CDM HCPCS":"88233","Standard Price":706.0},{"Itemcode":"70104206","Description":"Lithium","CDM Revenue Code":"300","CDM HCPCS":"80178","Standard Price":78.0},{"Itemcode":"70104210","Description":"Amidarone and Metabolite","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":156.0},{"Itemcode":"70104235","Description":"Mysoline Primidone Assay","CDM Revenue Code":"300","CDM HCPCS":"80188","Standard Price":140.0},{"Itemcode":"70104362","Description":"Cyclosporine Level","CDM Revenue Code":"300","CDM HCPCS":"80158","Standard Price":289.0},{"Itemcode":"70105081","Description":"Pap Smear Bethesda;Man Scrn","CDM Revenue Code":"311","CDM HCPCS":"P3000","Standard Price":232.0},{"Itemcode":"70106483","Description":"Dilantin: Free","CDM Revenue Code":"300","CDM HCPCS":"80186","Standard Price":184.0},{"Itemcode":"70108872","Description":"Stool Component Analysis","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":473.0},{"Itemcode":"70109707","Description":"Chromosome: Blood","CDM Revenue Code":"310","CDM HCPCS":"88262","Standard Price":1856.0},{"Itemcode":"70109709","Description":"Chromosome: Bone Marrow","CDM Revenue Code":"310","CDM HCPCS":"88262","Standard Price":2500.0},{"Itemcode":"70109710","Description":"Tissue Cult: Chromo Anal","CDM Revenue Code":"310","CDM HCPCS":"88230","Standard Price":1432.0},{"Itemcode":"70109722","Description":"Digitoxin Assay","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":187.0},{"Itemcode":"70109723","Description":"Insulin Glucose Tolerance","CDM Revenue Code":"300","CDM HCPCS":"80422","Standard Price":261.0},{"Itemcode":"70109725","Description":"Tacrolimus (Fk 506)","CDM Revenue Code":"300","CDM HCPCS":"80197","Standard Price":277.0},{"Itemcode":"70109726","Description":"Procainamide And Napa","CDM Revenue Code":"300","CDM HCPCS":"80192","Standard Price":357.0},{"Itemcode":"70109729","Description":"Sperm Washing","CDM Revenue Code":"300","CDM HCPCS":"89260","Standard Price":426.0},{"Itemcode":"70109876","Description":"Amikacin","CDM Revenue Code":"300","CDM HCPCS":"80150","Standard Price":113.0},{"Itemcode":"70109929","Description":"ACTH Stimulation Panel","CDM Revenue Code":"300","CDM HCPCS":"80400","Standard Price":284.0},{"Itemcode":"70109958","Description":"LIQUID BASED PAP","CDM Revenue Code":"310","CDM HCPCS":"G0123","Standard Price":72.0},{"Itemcode":"70110034","Description":"Fibrosis,Liver,FibroTest-ActiP","CDM Revenue Code":"300","CDM HCPCS":"81599","Standard Price":2135.0},{"Itemcode":"70110040","Description":"Tissue Culture: Bone Marrow","CDM Revenue Code":"310","CDM HCPCS":"88237","Standard Price":1416.0},{"Itemcode":"70110065","Description":"Trazadone","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":1072.0},{"Itemcode":"70110074","Description":"Hypo Osmotic Swelling","CDM Revenue Code":"300","CDM HCPCS":"89398","Standard Price":222.0},{"Itemcode":"70110095","Description":"Sperm Isolation: Complex Prep","CDM Revenue Code":"300","CDM HCPCS":"89261","Standard Price":446.0},{"Itemcode":"70110125","Description":"Methotrexate","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":500.0},{"Itemcode":"70110140","Description":"Topiramate","CDM Revenue Code":"300","CDM HCPCS":"80201","Standard Price":943.0},{"Itemcode":"70110290","Description":"MOL Cytogenetics; DNA Probe 1","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":90.0},{"Itemcode":"70110291","Description":"MOL Cytogenetics; DNA Probe 2","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":90.0},{"Itemcode":"70110292","Description":"MOL Cyto; Interphase (25-99)","CDM Revenue Code":"310","CDM HCPCS":"88274","Standard Price":814.0},{"Itemcode":"70115050","Description":"Presence And/Or Motility Sperm","CDM Revenue Code":"300","CDM HCPCS":"89321","Standard Price":141.0},{"Itemcode":"70115051","Description":"Chromosome Analysis: 20-25 Cel","CDM Revenue Code":"310","CDM HCPCS":"88264","Standard Price":618.0},{"Itemcode":"70115052","Description":"Chromosome Anal: Add Karyotype","CDM Revenue Code":"310","CDM HCPCS":"88280","Standard Price":208.0},{"Itemcode":"70115706","Description":"Voriconazole, LC/MS/MS -Quest","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":833.0},{"Itemcode":"70115720","Description":"Lacosamide,LC/MS/MS-Quest","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":487.0},{"Itemcode":"70115738","Description":"RBC DNA HEA 35 AG 11 BLD GRP","CDM Revenue Code":"300","CDM HCPCS":"0001U","Standard Price":1100.0},{"Itemcode":"70115893","Description":"Maternal Serum Screen Quad","CDM Revenue Code":"300","CDM HCPCS":"81511","Standard Price":468.0},{"Itemcode":"70115894","Description":"MSS Sequential, Specimen 1","CDM Revenue Code":"300","CDM HCPCS":"81508","Standard Price":420.0},{"Itemcode":"70115895","Description":"MSS Sequential, Specimen 2","CDM Revenue Code":"300","CDM HCPCS":"81511","Standard Price":480.0},{"Itemcode":"70115924","Description":"Chrom Anal Periph Bld","CDM Revenue Code":"310","CDM HCPCS":"88262","Standard Price":750.0},{"Itemcode":"70115925","Description":"Chrom Anal Periph Bld Tis Cult","CDM Revenue Code":"310","CDM HCPCS":"88230","Standard Price":750.0},{"Itemcode":"70116087","Description":"Adalimumab Activity","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":960.0},{"Itemcode":"70116089","Description":"Thiopurine Metabolites","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":519.0},{"Itemcode":"70116093","Description":"Infliximab Activity","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":960.0},{"Itemcode":"70116234","Description":"Dexamethasone","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":520.0},{"Itemcode":"70116252","Description":"MCG; DNA Probe Ea","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":550.0},{"Itemcode":"70116253","Description":"MCG; Situ Hybrid 10-30 Cells","CDM Revenue Code":"310","CDM HCPCS":"88273","Standard Price":550.0},{"Itemcode":"70116300","Description":"Antimicrobial Lev-Azithromycin","CDM Revenue Code":"300","CDM HCPCS":"80299","Standard Price":456.0},{"Itemcode":"70116303","Description":"14-3-3 Protein Tau/Theta, CSF","CDM Revenue Code":"300","CDM HCPCS":"0035U","Standard Price":404.0},{"Itemcode":"70116357","Description":"Sperm antibodies, IgA","CDM Revenue Code":"300","CDM HCPCS":"89325","Standard Price":290.0},{"Itemcode":"70116358","Description":"Sperm antibodies, IgG","CDM Revenue Code":"300","CDM HCPCS":"89325","Standard Price":290.0},{"Itemcode":"70116366","Description":"Carbamazepine; free","CDM Revenue Code":"300","CDM HCPCS":"80157","Standard Price":104.0},{"Itemcode":"70116517","Description":"MCG; DNA probe, each","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":342.0},{"Itemcode":"70116518","Description":"MCG; DNA probe, each","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":342.0},{"Itemcode":"70116519","Description":"MCG; DNA probe, each","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":342.0},{"Itemcode":"70116520","Description":"MCG; DNA probe, each","CDM Revenue Code":"310","CDM HCPCS":"88271","Standard Price":342.0},{"Itemcode":"70116521","Description":"MCG; IP SITU 100-300 Cells","CDM Revenue Code":"310","CDM HCPCS":"88275","Standard Price":342.0},{"Itemcode":"70116522","Description":"MCG; IP SITU 100-300 Cells","CDM Revenue Code":"310","CDM HCPCS":"88275","Standard Price":342.0},{"Itemcode":"70116523","Description":"MCG; IP SITU 100-300 Cells","CDM Revenue Code":"310","CDM HCPCS":"88275","Standard Price":342.0},{"Itemcode":"70116524","Description":"MCG; IP SITU 100-300 Cells","CDM Revenue Code":"310","CDM HCPCS":"88275","Standard Price":342.0},{"Itemcode":"70116558","Description":"Topiramate","CDM Revenue Code":"300","CDM HCPCS":"80201","Standard Price":172.0},{"Itemcode":"70116598","Description":"Valproic acid; free","CDM Revenue Code":"300","CDM HCPCS":"80165","Standard Price":268.0},{"Itemcode":"70116636","Description":"Cyclosporine","CDM Revenue Code":"301","CDM HCPCS":"80158","Standard Price":152.0},{"Itemcode":"70116645","Description":"Tacrolimus","CDM Revenue Code":"301","CDM HCPCS":"80197","Standard Price":153.0},{"Itemcode":"70100388","Description":"Immunohistchem Ea Multiplex Ab","CDM Revenue Code":"312","CDM HCPCS":"88344","Standard Price":679.0},{"Itemcode":"70100398","Description":"IHC Each-Armed Forces Ins Pat","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":282.0},{"Itemcode":"70100534","Description":"Direct If Staining Igg Mayo","CDM Revenue Code":"310","CDM HCPCS":"88346","Standard Price":528.0},{"Itemcode":"70100535","Description":"Direct If Staining Igm Mayo","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":153.0},{"Itemcode":"70100536","Description":"Direct If Staining Iga Mayo","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":153.0},{"Itemcode":"70100537","Description":"Direct If Staining C3 Mayo","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":153.0},{"Itemcode":"70100538","Description":"Direct If Fibrinogen Dep Mayo","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":153.0},{"Itemcode":"70100539","Description":"Path Consult Mayo","CDM Revenue Code":"310","CDM HCPCS":"88323","Standard Price":156.0},{"Itemcode":"70100687","Description":"Consult & Rpt Ref Slides","CDM Revenue Code":"310","CDM HCPCS":"88323","Standard Price":664.0},{"Itemcode":"70100784","Description":"IHC Tumor Er Clarient","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":500.0},{"Itemcode":"70100785","Description":"IHC Tumor Pr Clarient","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":500.0},{"Itemcode":"70100786","Description":"IHC Her-2 Clarient","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1341.0},{"Itemcode":"70100787","Description":"IHC Ki67 Clarient","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1339.0},{"Itemcode":"70100788","Description":"Fish Manual 88368 Clarient","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":1677.0},{"Itemcode":"70100789","Description":"Fish Cad 88367 Clarient","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100790","Description":"IHC 88342 Clarient","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":1609.0},{"Itemcode":"70100791","Description":"IHC Tumor Manl 88360 Calrient","CDM Revenue Code":"310","CDM HCPCS":"88360","Standard Price":1677.0},{"Itemcode":"70100792","Description":"Fish 88365 Clarient","CDM Revenue Code":"310","CDM HCPCS":"88365","Standard Price":1677.0},{"Itemcode":"70100965","Description":"F Alk Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100966","Description":"F Alk Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100968","Description":"F Bcl1 Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100969","Description":"F Bcl1 Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100971","Description":"F Bcl 2 Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100972","Description":"F Bcl 2 Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100974","Description":"F Egr1 Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100975","Description":"F Egr1 Probe#2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100977","Description":"F Her2 Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100978","Description":"F Her2 Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100980","Description":"F Pml Rara Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100981","Description":"F Pml Rara Probe #2","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100983","Description":"F Malt Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100984","Description":"F Malt Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100986","Description":"F Mm Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100987","Description":"F Mm Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100989","Description":"F Bcr Abl Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100990","Description":"F Brc Abl Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100991","Description":"F Bcr Abl Probe #3 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100993","Description":"F Myc Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100994","Description":"F Myc Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70100995","Description":"F Myc Probe #3 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70101040","Description":"F Gli Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":1677.0},{"Itemcode":"70101041","Description":"F Gli Probe #2","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":1677.0},{"Itemcode":"70101042","Description":"F Gli Probe #3 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":1677.0},{"Itemcode":"70101043","Description":"F Gli Probe #4","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":1677.0},{"Itemcode":"70101072","Description":"F Cll Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1155.0},{"Itemcode":"70101073","Description":"F Cll Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1155.0},{"Itemcode":"70101074","Description":"F Cll Probe #3 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1155.0},{"Itemcode":"70101075","Description":"F Cll Probe #4 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1155.0},{"Itemcode":"70101076","Description":"F Cll Probe #5 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1155.0},{"Itemcode":"70101077","Description":"F Cll Probe #6 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1155.0},{"Itemcode":"70101110","Description":"DNA Ploidy /S-Phase Mpl","CDM Revenue Code":"310","CDM HCPCS":"88182","Standard Price":1385.0},{"Itemcode":"70101114","Description":"F Mds Probe #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70101115","Description":"F Mds Probe #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70101116","Description":"F Mds Probe #3 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70101117","Description":"F Mds Probe #4 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70101118","Description":"F Mds Probe #5 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70101119","Description":"F Mds Probe #6 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":1677.0},{"Itemcode":"70101121","Description":"Flow T Mpl","CDM Revenue Code":"310","CDM HCPCS":"88185","Standard Price":12308.0},{"Itemcode":"70101123","Description":"Flow Cytometry Marker #1 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88184","Standard Price":563.0},{"Itemcode":"70101124","Description":"Flow Cytometry Marker #2 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88185","Standard Price":563.0},{"Itemcode":"70101125","Description":"Flow Cytometry Marker#3 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88185","Standard Price":299.0},{"Itemcode":"70101126","Description":"Flow Cytometry Marker#4 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88185","Standard Price":299.0},{"Itemcode":"70101127","Description":"Flow Cytometry Marker#5 Mpl","CDM Revenue Code":"310","CDM HCPCS":"88185","Standard Price":299.0},{"Itemcode":"70101240","Description":"Immunofluoroescent Stdy Initl","CDM Revenue Code":"310","CDM HCPCS":"88346","Standard Price":528.0},{"Itemcode":"70101389","Description":"Fish Bladder Cancer","CDM Revenue Code":"310","CDM HCPCS":"88120","Standard Price":1452.0},{"Itemcode":"70101459","Description":"Combisnp Microdisection Manual","CDM Revenue Code":"310","CDM HCPCS":"88381","Standard Price":1898.0},{"Itemcode":"70101462","Description":"Combibac Microdisection Manual","CDM Revenue Code":"310","CDM HCPCS":"88381","Standard Price":1898.0},{"Itemcode":"70101501","Description":"Imunoflor AB Adl Stn, per Spec","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70101601","Description":"Flow Cyto: Cell Marker 15","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70101970","Description":"Therapath Surg Spec Level 4","CDM Revenue Code":"310","CDM HCPCS":"88305","Standard Price":462.0},{"Itemcode":"70101971","Description":"Therapath Spec Stains Grp Ii","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":462.0},{"Itemcode":"70101972","Description":"Therapath Histo-Stain Mscl Bx","CDM Revenue Code":"310","CDM HCPCS":"88314","Standard Price":978.0},{"Itemcode":"70101973","Description":"Therapath Spec Stains Grp III","CDM Revenue Code":"310","CDM HCPCS":"88319","Standard Price":978.0},{"Itemcode":"70101974","Description":"Therapath Histo-Stains Nrv Bx","CDM Revenue Code":"310","CDM HCPCS":"88314","Standard Price":809.0},{"Itemcode":"70101975","Description":"Therapath Microscopy","CDM Revenue Code":"310","CDM HCPCS":"88348","Standard Price":809.0},{"Itemcode":"70101976","Description":"Therapath Nerve Teasing Prep","CDM Revenue Code":"310","CDM HCPCS":"88362","Standard Price":809.0},{"Itemcode":"70101978","Description":"Therapath Surg Spec Lvl 4 Msbx","CDM Revenue Code":"310","CDM HCPCS":"88305","Standard Price":462.0},{"Itemcode":"70101979","Description":"Therapath Spec Stains Ii Msbx","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":462.0},{"Itemcode":"70101981","Description":"ImmunoHisto Ab Slide-Ea Addl","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":173.0},{"Itemcode":"70102566","Description":"Morphometric Analysis; Cad","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":501.0},{"Itemcode":"70102567","Description":"Morphometric Analysis; Manual","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":994.0},{"Itemcode":"70104295","Description":"Morphometric Anal Tumor By Ic","CDM Revenue Code":"310","CDM HCPCS":"88360","Standard Price":1677.0},{"Itemcode":"70105006","Description":"Acid Phosphatase Stain","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":305.0},{"Itemcode":"70105007","Description":"Gram Pos & Neg Bacteria","CDM Revenue Code":"310","CDM HCPCS":"88312","Standard Price":184.0},{"Itemcode":"70105008","Description":"Jones' Kidney Stain","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":138.0},{"Itemcode":"70105009","Description":"Calcium Stain","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":274.0},{"Itemcode":"70105018","Description":"Cd 20 B Cell","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":234.0},{"Itemcode":"70105019","Description":"Cd 34 Endothelial","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":206.0},{"Itemcode":"70105020","Description":"Cd 43 T Cell","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":235.0},{"Itemcode":"70105027","Description":"Cd 43/45 R T&B Cell","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":639.0},{"Itemcode":"70105028","Description":"Common Leukocyte Antigen","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":246.0},{"Itemcode":"70105029","Description":"Desmin","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":245.0},{"Itemcode":"70105030","Description":"Epithelial Membrane Antigen","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":238.0},{"Itemcode":"70105031","Description":"HMB45","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":264.0},{"Itemcode":"70105032","Description":"Pankeratin Ae1/Ae3","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":254.0},{"Itemcode":"70105034","Description":"Prostate Specific Acid Phospha","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":220.0},{"Itemcode":"70105035","Description":"S100","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":233.0},{"Itemcode":"70105036","Description":"Vimentin","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":243.0},{"Itemcode":"70105037","Description":"Kappa Light Chain","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":504.0},{"Itemcode":"70105038","Description":"Lambda Light Chain","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":504.0},{"Itemcode":"70105039","Description":"Human Chorionic Gonadotropin","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":259.0},{"Itemcode":"70105040","Description":"Cytokeratin 7","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":254.0},{"Itemcode":"70105041","Description":"Cytokeratin 20","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":253.0},{"Itemcode":"70105044","Description":"Synaptophysin","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":260.0},{"Itemcode":"70105046","Description":"Cd3","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":238.0},{"Itemcode":"70105048","Description":"KI 67 MIB 1","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1677.0},{"Itemcode":"70105049","Description":"Cd 30","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":235.0},{"Itemcode":"70105052","Description":"Alcian Blue Stain Hyd Digestio","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":305.0},{"Itemcode":"70105053","Description":"Acid Fast","CDM Revenue Code":"310","CDM HCPCS":"88312","Standard Price":529.0},{"Itemcode":"70105054","Description":"Amyloid Stain","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":136.0},{"Itemcode":"70105055","Description":"Cea","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":274.0},{"Itemcode":"70105056","Description":"Chromogranin","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":258.0},{"Itemcode":"70105057","Description":"Consult","CDM Revenue Code":"310","CDM HCPCS":"88321","Standard Price":911.0},{"Itemcode":"70105060","Description":"Elastic Stain","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":132.0},{"Itemcode":"70105061","Description":"Histiology Stain Group 1","CDM Revenue Code":"310","CDM HCPCS":"88312","Standard Price":141.0},{"Itemcode":"70105062","Description":"Giemsa","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":147.0},{"Itemcode":"70105063","Description":"Gomori'S Methenamine Silver","CDM Revenue Code":"310","CDM HCPCS":"88312","Standard Price":204.0},{"Itemcode":"70105065","Description":"Melanin","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":175.0},{"Itemcode":"70105066","Description":"Mucicarmine","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":150.0},{"Itemcode":"70105067","Description":"Periodic Acid Schiff","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":102.0},{"Itemcode":"70105068","Description":"Perio Acid Schiff W/Dias Dige","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":120.0},{"Itemcode":"70105069","Description":"PSA Stain","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":223.0},{"Itemcode":"70105071","Description":"Trichrome","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":154.0},{"Itemcode":"70105073","Description":"Duke University(Muscle Bx'S)","CDM Revenue Code":"310","CDM HCPCS":"88305","Standard Price":242.0},{"Itemcode":"70105074","Description":"Renal Bx Sendout","CDM Revenue Code":"310","CDM HCPCS":"88305","Standard Price":276.0},{"Itemcode":"70105076","Description":"UFDRL Consult","CDM Revenue Code":"310","CDM HCPCS":"88323","Standard Price":1677.0},{"Itemcode":"70105080","Description":"Tissue Level 2","CDM Revenue Code":"310","CDM HCPCS":"88302","Standard Price":224.0},{"Itemcode":"70105082","Description":"Cytopath Fluids: Wash Or Brush","CDM Revenue Code":"310","CDM HCPCS":"88104","Standard Price":352.0},{"Itemcode":"70105087","Description":"Bc 1-2","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":192.0},{"Itemcode":"70105088","Description":"Misc Consult - Sendout","CDM Revenue Code":"310","CDM HCPCS":"88321","Standard Price":911.0},{"Itemcode":"70105090","Description":"Surg Spec Level 4","CDM Revenue Code":"310","CDM HCPCS":"88305","Standard Price":211.0},{"Itemcode":"70105097","Description":"Tissue Level 3","CDM Revenue Code":"310","CDM HCPCS":"88304","Standard Price":199.0},{"Itemcode":"70105098","Description":"Surg Spec Level 5","CDM Revenue Code":"310","CDM HCPCS":"88307","Standard Price":296.0},{"Itemcode":"70105099","Description":"FNA Interp & Report","CDM Revenue Code":"310","CDM HCPCS":"88173","Standard Price":204.0},{"Itemcode":"70105201","Description":"Tissue Level 6","CDM Revenue Code":"310","CDM HCPCS":"88309","Standard Price":325.0},{"Itemcode":"70105524","Description":"Decalcification","CDM Revenue Code":"310","CDM HCPCS":"88311","Standard Price":62.0},{"Itemcode":"70105531","Description":"Surg Path- TB-Frozen Section","CDM Revenue Code":"310","CDM HCPCS":"88331","Standard Price":123.0},{"Itemcode":"70105532","Description":"Frozen Section-Additional TB","CDM Revenue Code":"310","CDM HCPCS":"88332","Standard Price":380.0},{"Itemcode":"70106301","Description":"Est Recept","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1677.0},{"Itemcode":"70106302","Description":"Progest Recept","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1677.0},{"Itemcode":"70106303","Description":"DNA Histo","CDM Revenue Code":"310","CDM HCPCS":"88182","Standard Price":1385.0},{"Itemcode":"70106311","Description":"Est Recept (Blk)","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1677.0},{"Itemcode":"70106312","Description":"Progest Recept (Blk)","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1677.0},{"Itemcode":"70106313","Description":"DNA Histo Analysis (Blk)","CDM Revenue Code":"311","CDM HCPCS":"88182","Standard Price":1385.0},{"Itemcode":"70108030","Description":"Flow Cyto: Cell Marker 1","CDM Revenue Code":"310","CDM HCPCS":"88184","Standard Price":200.0},{"Itemcode":"70108501","Description":"Flow Cyto Interp 2-8 Markers","CDM Revenue Code":"310","CDM HCPCS":"88187","Standard Price":166.0},{"Itemcode":"70109701","Description":"Histology Stain Group Ii","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":150.0},{"Itemcode":"70109703","Description":"Tissue Level I Gross Only","CDM Revenue Code":"310","CDM HCPCS":"88300","Standard Price":78.0},{"Itemcode":"70109711","Description":"Cytopathology Fluid","CDM Revenue Code":"310","CDM HCPCS":"88108","Standard Price":911.0},{"Itemcode":"70109890","Description":"HER-2 Oncoprotein","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":1677.0},{"Itemcode":"70109931","Description":"Flow Cytometry: Molecular Pat","CDM Revenue Code":"310","CDM HCPCS":"88321","Standard Price":911.0},{"Itemcode":"70110019","Description":"Flow Cyto: Cell Marker 1","CDM Revenue Code":"311","CDM HCPCS":"88184","Standard Price":1194.0},{"Itemcode":"70110020","Description":"Flow Cyto: Cell Marker 2","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110021","Description":"Flow Cyto: Cell Marker 3","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110022","Description":"Flow Cyto: Cell Marker 4","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110023","Description":"Flow Cyto: Cell Marker 5","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110024","Description":"Flow Cyto: Cell Marker 6","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110025","Description":"Flow Cyto: Cell Marker 7","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110026","Description":"Flow Cyto: Cell Marker 8","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110027","Description":"Flow Cyto: Cell Marker 9","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110028","Description":"Flow Cyto: Cell Marker 10","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110029","Description":"Flow Cyto: Cell Marker 11","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110030","Description":"Flow Cyto: Cell Marker 12","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110031","Description":"Flow Cyto: Cell Marker 13","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110032","Description":"Flow Cyto: Cell Marker 14","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70110080","Description":"Morphology Tumor Analysis","CDM Revenue Code":"310","CDM HCPCS":"88358","Standard Price":765.0},{"Itemcode":"70110293","Description":"Tissue In Situ Hybridization","CDM Revenue Code":"310","CDM HCPCS":"88365","Standard Price":548.0},{"Itemcode":"70110300","Description":"Electron Microscopy:Diagnostic","CDM Revenue Code":"310","CDM HCPCS":"88348","Standard Price":6833.0},{"Itemcode":"70112093","Description":"Morphometric Analysis: Cad2","CDM Revenue Code":"310","CDM HCPCS":"88367","Standard Price":501.0},{"Itemcode":"70112518","Description":"Alk By Fish Clarient","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":1211.0},{"Itemcode":"70112519","Description":"Alk By Fish Clarient","CDM Revenue Code":"310","CDM HCPCS":"88368","Standard Price":1211.0},{"Itemcode":"70112520","Description":"BCR/ABL by FISH Computerassist","CDM Revenue Code":"310","CDM HCPCS":"88374","Standard Price":2226.0},{"Itemcode":"70112521","Description":"BCR/ABL by FISH Manual","CDM Revenue Code":"310","CDM HCPCS":"88377","Standard Price":2226.0},{"Itemcode":"70115033","Description":"Flow Cytro: Cell Marker 16","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70115034","Description":"Flow Cytro: Cell Marker 17","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70115035","Description":"Flow Cytro: Cell Marker 18","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70115036","Description":"Flow Cytro: Cell Marker 19","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":1011.0},{"Itemcode":"70115037","Description":"Flow Cytro: Cell Marker 20","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":1011.0},{"Itemcode":"70115038","Description":"Flow Cytro: Cell Marker 21","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":1011.0},{"Itemcode":"70115039","Description":"Flow Cytro: Cell Marker 22","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":1011.0},{"Itemcode":"70115654","Description":"Therapath Spec Stains Grp II 1","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":150.0},{"Itemcode":"70115655","Description":"Therapath Histo-Stain Mscl Bx","CDM Revenue Code":"310","CDM HCPCS":"88314","Standard Price":578.0},{"Itemcode":"70115656","Description":"Therapath Spec Stains GrpIII 3","CDM Revenue Code":"310","CDM HCPCS":"88319","Standard Price":978.0},{"Itemcode":"70115657","Description":"Therapath Spec Stains GrpIII 1","CDM Revenue Code":"310","CDM HCPCS":"88319","Standard Price":978.0},{"Itemcode":"70115658","Description":"Therapath Spec Stains GrpIII 2","CDM Revenue Code":"310","CDM HCPCS":"88319","Standard Price":978.0},{"Itemcode":"70115660","Description":"Arkana Light Microscopy 1-1","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":150.0},{"Itemcode":"70115661","Description":"Arkana Light Microscopy 1-2","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":150.0},{"Itemcode":"70115662","Description":"Arkana Light Microscopy 1-3","CDM Revenue Code":"310","CDM HCPCS":"88313","Standard Price":150.0},{"Itemcode":"70115663","Description":"Arkana Electron Microscopy","CDM Revenue Code":"310","CDM HCPCS":"88348","Standard Price":809.0},{"Itemcode":"70115664","Description":"Arkana Immunofluor, Add 1","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115665","Description":"Arkana Immunofluor, Add 2","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115666","Description":"Arkana Immunofluor, Add 3","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115667","Description":"Arkana Immunofluor, Add 4","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115668","Description":"Arkana Immunofluor, Add 5","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115669","Description":"Arkana Immunofluor, Add 6","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115670","Description":"Arkana Immunofluor, Add 7","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115671","Description":"Arkana Immunofluor, Add 8","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":84.0},{"Itemcode":"70115674","Description":"ER IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":500.0},{"Itemcode":"70115675","Description":"HER2 IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":500.0},{"Itemcode":"70115676","Description":"Ki67 IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":520.0},{"Itemcode":"70115677","Description":"PgR IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":520.0},{"Itemcode":"70115678","Description":"MLH1 IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":510.0},{"Itemcode":"70115679","Description":"MSH2 IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":510.0},{"Itemcode":"70115680","Description":"MSH6 IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":510.0},{"Itemcode":"70115681","Description":"PMS2 IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88361","Standard Price":510.0},{"Itemcode":"70115682","Description":"ALK Lung by FISH Computer-asst","CDM Revenue Code":"310","CDM HCPCS":"88374","Standard Price":2652.0},{"Itemcode":"70115683","Description":"ROS1 by FISH Computer-asst","CDM Revenue Code":"310","CDM HCPCS":"88374","Standard Price":2652.0},{"Itemcode":"70115684","Description":"HER2 by FISH Computer-asst","CDM Revenue Code":"310","CDM HCPCS":"88374","Standard Price":2652.0},{"Itemcode":"70115685","Description":"MDM2 by FISH Computer-asst","CDM Revenue Code":"310","CDM HCPCS":"88374","Standard Price":2652.0},{"Itemcode":"70115686","Description":"RET Mutation Analysis","CDM Revenue Code":"310","CDM HCPCS":"88374","Standard Price":2652.0},{"Itemcode":"70115687","Description":"PD-L1 22C3 IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88360","Standard Price":606.0},{"Itemcode":"70115690","Description":"GATA3 IHC","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":270.0},{"Itemcode":"70115691","Description":"p16 IHC","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":270.0},{"Itemcode":"70115692","Description":"NKX3.1 IHC","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":270.0},{"Itemcode":"70115693","Description":"PSA IHC","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":270.0},{"Itemcode":"70115694","Description":"PSAP/HPAP IHC","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":270.0},{"Itemcode":"70115695","Description":"PSMA IHC","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":270.0},{"Itemcode":"70115696","Description":"CD99 IHC","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":270.0},{"Itemcode":"70115697","Description":"MyoD1 IHC","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":270.0},{"Itemcode":"70115698","Description":"S100 IHC","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":270.0},{"Itemcode":"70115699","Description":"CK AE1/AE3 IHC","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":270.0},{"Itemcode":"70115700","Description":"CD117 cKIT IHC","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":270.0},{"Itemcode":"70115701","Description":"PDGFR Alpha IHC","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":270.0},{"Itemcode":"70115702","Description":"PDGFR Beta IHC","CDM Revenue Code":"310","CDM HCPCS":"88341","Standard Price":270.0},{"Itemcode":"70115703","Description":"HPylori IHC","CDM Revenue Code":"310","CDM HCPCS":"88342","Standard Price":270.0},{"Itemcode":"70116022","Description":"Flow Cytometry TC 1st Marker","CDM Revenue Code":"311","CDM HCPCS":"88184","Standard Price":200.0},{"Itemcode":"70116023","Description":"Flow Cytometry Ea Add Marker 1","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116024","Description":"Flow Cytometry Ea Add Marker 2","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116025","Description":"Flow Cytometry Ea Add Marker 3","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116026","Description":"Flow Cytometry Ea Add Marker 4","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116027","Description":"Flow Cytometry Ea Add Marker 5","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116028","Description":"Flow Cytometry Ea Add Marker 6","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116029","Description":"Flow Cytometry Ea Add Marker 7","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116030","Description":"Flow Cytometry Ea Add Marker 8","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116031","Description":"Flow Cytometry Ea Add Marker 9","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116032","Description":"Flow Cytometry Ea Add Marker10","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116033","Description":"Flow Cytometry Ea Add Marker11","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116034","Description":"Flow Cytometry Ea Add Marker12","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116035","Description":"Flow Cytometry Ea Add Marker13","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116036","Description":"Flow Cytometry Ea Add Marker14","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116037","Description":"Flow Cytometry Ea Add Marker15","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116038","Description":"Flow Cytometry Ea Add Marker16","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116039","Description":"Flow Cytometry Ea Add Marker17","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116040","Description":"Flow Cytometry Ea Add Marker18","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116041","Description":"Flow Cytometry Ea Add Marker19","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116042","Description":"Flow Cytometry Ea Add Marker20","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116043","Description":"Flow Cytometry Ea Add Marker21","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116044","Description":"Flow Cytometry Ea Add Marker22","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116045","Description":"Flow Cytometry Ea Add Marker23","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116046","Description":"Flow Cytometry Ea Add Marker24","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116047","Description":"Flow Cytometry Ea Add Marker25","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116048","Description":"Flow Cytometry Ea Add Marker26","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116049","Description":"Flow Cytometry Ea Add Marker27","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116050","Description":"Flow Cytometry Ea Add Marker28","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116051","Description":"Flow Cytometry Ea Add Marker29","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":150.0},{"Itemcode":"70116308","Description":"PgR IHC Tumor","CDM Revenue Code":"310","CDM HCPCS":"88360","Standard Price":330.0},{"Itemcode":"70116451","Description":"MDM2","CDM Revenue Code":"310","CDM HCPCS":"88377","Standard Price":1980.0},{"Itemcode":"70116489","Description":"RBC Band 3 Protein Reduction","CDM Revenue Code":"311","CDM HCPCS":"88184","Standard Price":420.0},{"Itemcode":"70116660","Description":"Immunofluor Antb 1st Stain","CDM Revenue Code":"310","CDM HCPCS":"88346","Standard Price":564.0},{"Itemcode":"70116661","Description":"Immunofluor Antb Addl Stain","CDM Revenue Code":"310","CDM HCPCS":"88350","Standard Price":564.0},{"Itemcode":"70116687","Description":"Plasma Cell Neoplasms FISH","CDM Revenue Code":"312","CDM HCPCS":"88377","Standard Price":2480.0},{"Itemcode":"70116693","Description":"T-Cell Clonality by V-Beta","CDM Revenue Code":"311","CDM HCPCS":"88184","Standard Price":53.0},{"Itemcode":"70116694","Description":"T-Cell Clonality by V-Beta 2","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116695","Description":"T-Cell Clonality by V-Beta 3","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116696","Description":"T-Cell Clonality by V-Beta 4","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116697","Description":"T-Cell Clonality by V-Beta 5","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116698","Description":"T-Cell Clonality by V-Beta 6","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116699","Description":"T-Cell Clonality by V-Beta 7","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116700","Description":"T-Cell Clonality by V-Beta 8","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116701","Description":"T-Cell Clonality by V-Beta 9","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116702","Description":"T-Cell Clonality by V-Beta 10","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116703","Description":"T-Cell Clonality by V-Beta 11","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116704","Description":"T-Cell Clonality by V-Beta 12","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116705","Description":"T-Cell Clonality by V-Beta 13","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116706","Description":"T-Cell Clonality by V-Beta 14","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116707","Description":"T-Cell Clonality by V-Beta 15","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116708","Description":"T-Cell Clonality by V-Beta 16","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116709","Description":"T-Cell Clonality by V-Beta 17","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116710","Description":"T-Cell Clonality by V-Beta 18","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116711","Description":"T-Cell Clonality by V-Beta 19","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116712","Description":"T-Cell Clonality by V-Beta 20","CDM Revenue Code":"310","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116713","Description":"T-Cell Clonality by V-Beta 21","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116715","Description":"T-Cell Clonality by V-Beta 22","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116716","Description":"T-Cell Clonality by V-Beta 23","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116717","Description":"T-Cell Clonality by V-Beta 24","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116718","Description":"T-Cell Clonality by V-Beta 25","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70116719","Description":"T-Cell Clonality by V-Beta 26","CDM Revenue Code":"311","CDM HCPCS":"88185","Standard Price":53.0},{"Itemcode":"70109601","Description":"Venipuncture","CDM Revenue Code":"300","CDM HCPCS":"36415","Standard Price":20.0},{"Itemcode":"70110000","Description":"Specimen Collection","CDM Revenue Code":"300","CDM HCPCS":"36415","Standard Price":22.0},{"Itemcode":"70116367","Description":"Routine Venipuncture, Quest","CDM Revenue Code":"300","CDM HCPCS":"36415","Standard Price":24.0},{"Itemcode":"70116368","Description":"Routine Venipuncture, LabCorp","CDM Revenue Code":"300","CDM HCPCS":"36415","Standard Price":24.0},{"Itemcode":"70116369","Description":"Routine Venipuncture, Other","CDM Revenue Code":"300","CDM HCPCS":"36415","Standard Price":22.0},{"Itemcode":"74202027","Description":"Venipuncture","CDM Revenue Code":"300","CDM HCPCS":"36415","Standard Price":22.0},{"Itemcode":"75452027","Description":"Go Strong Venipuncture","CDM Revenue Code":"300","CDM HCPCS":"36415","Standard Price":6.0},{"Itemcode":"64100864","Description":"RBC'S Ea Unit (Cell Saver)","CDM Revenue Code":"390","CDM HCPCS":"P9021","Standard Price":1911.0},{"Itemcode":"68300180","Description":"Irradiation Blood Product Each","CDM Revenue Code":"300","CDM HCPCS":"86945","Standard Price":138.0},{"Itemcode":"70100061","Description":"Compatibility Testing-Is","CDM Revenue Code":"300","CDM HCPCS":"86920","Standard Price":127.0},{"Itemcode":"70100360","Description":"Sucrose Hemolysis Test","CDM Revenue Code":"300","CDM HCPCS":"86941","Standard Price":227.0},{"Itemcode":"70100611","Description":"Coombs: Direct","CDM Revenue Code":"300","CDM HCPCS":"86880","Standard Price":90.0},{"Itemcode":"70100612","Description":"Coombs: Indirect Qual, Each","CDM Revenue Code":"300","CDM HCPCS":"86885","Standard Price":191.0},{"Itemcode":"70100613","Description":"COOMBS: IND TITER EA ANTIBODY","CDM Revenue Code":"300","CDM HCPCS":"86886","Standard Price":191.0},{"Itemcode":"70100619","Description":"RH Immune Glob Wkup","CDM Revenue Code":"300","CDM HCPCS":"86885","Standard Price":223.0},{"Itemcode":"70100641","Description":"Isohemagglutinin Titer A1 Qst","CDM Revenue Code":"300","CDM HCPCS":"86886","Standard Price":549.0},{"Itemcode":"70100642","Description":"Isohemagglutinin Titer A2 Qst","CDM Revenue Code":"300","CDM HCPCS":"86886","Standard Price":387.0},{"Itemcode":"70100643","Description":"Isohemagglutinin Titer B Qst","CDM Revenue Code":"300","CDM HCPCS":"86886","Standard Price":387.0},{"Itemcode":"70101676","Description":"SERUM PRETX, RC ABSORPT EA","CDM Revenue Code":"300","CDM HCPCS":"86978","Standard Price":792.0},{"Itemcode":"70101677","Description":"SERUM PRETX, DILUTION","CDM Revenue Code":"300","CDM HCPCS":"86976","Standard Price":180.0},{"Itemcode":"70101678","Description":"SERUMPRETX,INHIB INCUBAT EA AB","CDM Revenue Code":"300","CDM HCPCS":"86977","Standard Price":432.0},{"Itemcode":"70105992","Description":"ARC RETICS: RBC PRETMT BY SDG","CDM Revenue Code":"300","CDM HCPCS":"86972","Standard Price":660.0},{"Itemcode":"70106000","Description":"Antibody Id","CDM Revenue Code":"300","CDM HCPCS":"86870","Standard Price":334.0},{"Itemcode":"70106010","Description":"Antigen Screen 1 /Ext Pheno","CDM Revenue Code":"300","CDM HCPCS":"86902","Standard Price":381.0},{"Itemcode":"70106011","Description":"ARC Basic Pt Workup","CDM Revenue Code":"300","CDM HCPCS":"86870","Standard Price":206.0},{"Itemcode":"70106012","Description":"Antigen Screen 2 /Ext Pheno","CDM Revenue Code":"300","CDM HCPCS":"86902","Standard Price":381.0},{"Itemcode":"70106013","Description":"Antigen Screen 3 /Ext Pheno","CDM Revenue Code":"300","CDM HCPCS":"86902","Standard Price":381.0},{"Itemcode":"70106037","Description":"Antigen Screen","CDM Revenue Code":"300","CDM HCPCS":"86902","Standard Price":381.0},{"Itemcode":"70106038","Description":"Antigen Screen 4 /Ext Pheno","CDM Revenue Code":"300","CDM HCPCS":"86902","Standard Price":381.0},{"Itemcode":"70106039","Description":"Antigen Screen 5/Ext Pheno","CDM Revenue Code":"300","CDM HCPCS":"86902","Standard Price":381.0},{"Itemcode":"70106100","Description":"ABO Group","CDM Revenue Code":"300","CDM HCPCS":"86900","Standard Price":40.0},{"Itemcode":"70106101","Description":"Serologic Blood Type Rh","CDM Revenue Code":"300","CDM HCPCS":"86901","Standard Price":41.0},{"Itemcode":"70106150","Description":"Irradiation Of Blood Prod Ea","CDM Revenue Code":"300","CDM HCPCS":"P9038","Standard Price":224.0},{"Itemcode":"70106154","Description":"Adsorption","CDM Revenue Code":"300","CDM HCPCS":"86940","Standard Price":275.0},{"Itemcode":"70106156","Description":"Elution","CDM Revenue Code":"300","CDM HCPCS":"86860","Standard Price":639.0},{"Itemcode":"70106158","Description":"Pooling Of Blood Products","CDM Revenue Code":"300","CDM HCPCS":"86965","Standard Price":134.0},{"Itemcode":"70106471","Description":"AG SCREEN, SERUM PER UNIT","CDM Revenue Code":"300","CDM HCPCS":"86904","Standard Price":360.0},{"Itemcode":"70109700","Description":"Antibody Screen","CDM Revenue Code":"300","CDM HCPCS":"86850","Standard Price":138.0},{"Itemcode":"70110004","Description":"ARC Antigen Type High Inciden","CDM Revenue Code":"300","CDM HCPCS":"86905","Standard Price":310.0},{"Itemcode":"70110005","Description":"ARC Chemical Treatment","CDM Revenue Code":"300","CDM HCPCS":"86970","Standard Price":198.0},{"Itemcode":"70110006","Description":"ARC Phenotype","CDM Revenue Code":"300","CDM HCPCS":"86905","Standard Price":145.0},{"Itemcode":"70110007","Description":"ARC Rh Phenotype","CDM Revenue Code":"300","CDM HCPCS":"86906","Standard Price":175.0},{"Itemcode":"70201000","Description":"FFP Thawing Ea Unit","CDM Revenue Code":"300","CDM HCPCS":"86927","Standard Price":97.0},{"Itemcode":"70205000","Description":"Platelets Pher Leukoreduce","CDM Revenue Code":"390","CDM HCPCS":"P9035","Standard Price":2637.0},{"Itemcode":"70205010","Description":"Red Bld Cells Leuko-Depleted","CDM Revenue Code":"390","CDM HCPCS":"P9016","Standard Price":1321.0},{"Itemcode":"70206009","Description":"Pooled Cryoprecipitate Ea U","CDM Revenue Code":"390","CDM HCPCS":"P9012","Standard Price":286.0},{"Itemcode":"70206010","Description":"Pooled Cryoprecipitate Ea U","CDM Revenue Code":"390","CDM HCPCS":"P9012","Standard Price":286.0},{"Itemcode":"70206011","Description":"Pooled Cryoprecipitate Ea Unit","CDM Revenue Code":"390","CDM HCPCS":"P9012","Standard Price":286.0},{"Itemcode":"70206012","Description":"Pooled Cryoprecipitate Ea Unit","CDM Revenue Code":"390","CDM HCPCS":"P9012","Standard Price":286.0},{"Itemcode":"70206013","Description":"Pooled Cryoprecipitate Ea Unit","CDM Revenue Code":"390","CDM HCPCS":"P9012","Standard Price":286.0},{"Itemcode":"70206019","Description":"Cryoprecipitate Per Unit","CDM Revenue Code":"390","CDM HCPCS":"P9012","Standard Price":286.0},{"Itemcode":"70206020","Description":"FFP<8Hrs /Unit","CDM Revenue Code":"390","CDM HCPCS":"P9017","Standard Price":344.0},{"Itemcode":"70206022","Description":"Platelet Concentrates Ea Unit","CDM Revenue Code":"390","CDM HCPCS":"P9019","Standard Price":108.0},{"Itemcode":"70206051","Description":"Blood Split Unit","CDM Revenue Code":"390","CDM HCPCS":"P9011","Standard Price":461.0},{"Itemcode":"70206052","Description":"Splitting Of Blood Each Unit","CDM Revenue Code":"300","CDM HCPCS":"86985","Standard Price":56.0},{"Itemcode":"70206053","Description":"Irradiation Of Blood Prod Ea","CDM Revenue Code":"390","CDM HCPCS":"P9038","Standard Price":224.0},{"Itemcode":"70206055","Description":"RBC'S Lr Irr Each Unit","CDM Revenue Code":"390","CDM HCPCS":"P9040","Standard Price":730.0},{"Itemcode":"70206056","Description":"ARC Ab/Id Each Selected Cell","CDM Revenue Code":"300","CDM HCPCS":"86885","Standard Price":60.0},{"Itemcode":"70206057","Description":"ARC Pretreatment W/Enzymes","CDM Revenue Code":"300","CDM HCPCS":"86971","Standard Price":72.0},{"Itemcode":"70206166","Description":"Autologous Blood Proc Charge","CDM Revenue Code":"300","CDM HCPCS":"86890","Standard Price":381.0},{"Itemcode":"70206174","Description":"ARC Crossmatch 86922","CDM Revenue Code":"300","CDM HCPCS":"86922","Standard Price":756.0},{"Itemcode":"70206176","Description":"Directed Donation Proced Chg","CDM Revenue Code":"300","CDM HCPCS":"86999","Standard Price":491.0},{"Itemcode":"70206178","Description":"Deglycerized/Washed Blood Prod","CDM Revenue Code":"390","CDM HCPCS":"P9039","Standard Price":2120.0},{"Itemcode":"70206179","Description":"Washed Red Bld Cells Ea Un","CDM Revenue Code":"390","CDM HCPCS":"P9022","Standard Price":409.0},{"Itemcode":"70206180","Description":"ARC Platelet Crossmatch Test","CDM Revenue Code":"300","CDM HCPCS":"86922","Standard Price":376.0},{"Itemcode":"70206185","Description":"HLA Matched Products","CDM Revenue Code":"390","CDM HCPCS":"P9052","Standard Price":2637.0},{"Itemcode":"70206186","Description":"Platelets Lp Irr Pher","CDM Revenue Code":"390","CDM HCPCS":"P9037","Standard Price":1413.0},{"Itemcode":"70206187","Description":"FFP W/In 8-24 Hrs Collection","CDM Revenue Code":"390","CDM HCPCS":"P9059","Standard Price":265.0},{"Itemcode":"70206189","Description":"FFP JUMBO600ML<=1Unitw/in 8Hrs","CDM Revenue Code":"390","CDM HCPCS":"P9017","Standard Price":1032.0},{"Itemcode":"70209739","Description":"Hypotonic Wash RBC Separation","CDM Revenue Code":"300","CDM HCPCS":"86999","Standard Price":488.0},{"Itemcode":"70100017","Description":"Urinalysis","CDM Revenue Code":"300","CDM HCPCS":"81001","Standard Price":32.0},{"Itemcode":"70100753","Description":"Reducing Substances","CDM Revenue Code":"300","CDM HCPCS":"81005","Standard Price":71.0},{"Itemcode":"70100769","Description":"Pregnancy Test-Urine","CDM Revenue Code":"300","CDM HCPCS":"81025","Standard Price":52.0},{"Itemcode":"70101045","Description":"Urine Dipstick - Poc","CDM Revenue Code":"300","CDM HCPCS":"81002","Standard Price":140.0},{"Itemcode":"70101702","Description":"Urine Dipstick No Microscopic","CDM Revenue Code":"300","CDM HCPCS":"81003","Standard Price":48.0},{"Itemcode":"70101735","Description":"Ketone-Urine","CDM Revenue Code":"300","CDM HCPCS":"81005","Standard Price":71.0},{"Itemcode":"70109740","Description":"Urine Microscopic","CDM Revenue Code":"300","CDM HCPCS":"81015","Standard Price":19.0},{"Itemcode":"70109741","Description":"Volume Measurement Timed Coll","CDM Revenue Code":"300","CDM HCPCS":"81050","Standard Price":45.0},{"Itemcode":"70109623","Description":"Travel Allowance P9604","CDM Revenue Code":"300","CDM HCPCS":"P9604","Standard Price":84.0},{"Itemcode":"70206036","Description":"Apheresis Ea Un Granulocytes","CDM Revenue Code":"390","CDM HCPCS":"P9050","Standard Price":4273.0},{"Itemcode":"74221029","Description":"SMOKING CESS GROUP","CDM Revenue Code":"942","CDM HCPCS":"S9453","Standard Price":122.0},{"Itemcode":"77200309","Description":"Insulin Pump Start - 30 Min","CDM Revenue Code":"942","CDM HCPCS":"G0108","Standard Price":225.0},{"Itemcode":"77200310","Description":"O/P Indiv Diab Ed - 30 Min","CDM Revenue Code":"942","CDM HCPCS":"G0108","Standard Price":225.0},{"Itemcode":"77200312","Description":"O/P Group Diab Ed - 30 Min","CDM Revenue Code":"942","CDM HCPCS":"G0109","Standard Price":150.0},{"Itemcode":"64500512","Description":"Endo Mod Sed Ini 15Min >5yrs","CDM Revenue Code":"370","CDM HCPCS":"G0500","Standard Price":157.0},{"Itemcode":"64500523","Description":"Endo Mod Sed Addl 15Min","CDM Revenue Code":"370","CDM HCPCS":"99153","Standard Price":128.0},{"Itemcode":"65100502","Description":"Moderate Sed Ini 15Min <5yrs","CDM Revenue Code":"370","CDM HCPCS":"99151","Standard Price":302.0},{"Itemcode":"65100512","Description":"Moderate Sed Ini 15Min >=5yrs","CDM Revenue Code":"370","CDM HCPCS":"99152","Standard Price":157.0},{"Itemcode":"65100523","Description":"Mod Sed Ea Addl 15Min Any Age","CDM Revenue Code":"370","CDM HCPCS":"99153","Standard Price":128.0},{"Itemcode":"65101094","Description":"Cardiopulmonary Resuscitation","CDM Revenue Code":"450","CDM HCPCS":"92950","Standard Price":2991.0},{"Itemcode":"65103503","Description":"Pericardiocentesis","CDM Revenue Code":"450","CDM HCPCS":"33010","Standard Price":8678.0},{"Itemcode":"72106750","Description":"Pericardiocentesis","CDM Revenue Code":"480","CDM HCPCS":"33010","Standard Price":8678.0},{"Itemcode":"72205052","Description":"Ablation: AF","CDM Revenue Code":"480","CDM HCPCS":"93656","Standard Price":14463.0},{"Itemcode":"72205090","Description":"Ablation: V Tach","CDM Revenue Code":"480","CDM HCPCS":"93654","Standard Price":80150.0},{"Itemcode":"72205597","Description":"Bundle Of His Recording","CDM Revenue Code":"480","CDM HCPCS":"93600","Standard Price":1576.0},{"Itemcode":"72205598","Description":"Right Ventricular Recording","CDM Revenue Code":"480","CDM HCPCS":"93603","Standard Price":1576.0},{"Itemcode":"72206005","Description":"Intra-Atrial Recording","CDM Revenue Code":"480","CDM HCPCS":"93602","Standard Price":22437.0},{"Itemcode":"72206006","Description":"Intra-Atrial Pacing","CDM Revenue Code":"480","CDM HCPCS":"93610","Standard Price":4277.0},{"Itemcode":"73100107","Description":"Arterial Line Insertion","CDM Revenue Code":"361","CDM HCPCS":"36620","Standard Price":377.0},{"Itemcode":"6325","Description":"Dialysis Shunt Evaluation","CDM Revenue Code":"921","CDM HCPCS":"93990","Standard Price":692.0},{"Itemcode":"4781","Description":"THYROGEN INJ SQ/IM NM","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61050253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61050254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61050255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61050256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":438.0},{"Itemcode":"61050815","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61051008","Description":"4N Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61051009","Description":"4N Pneumococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61051027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61052622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61052645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61052996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61055001","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61055510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61100253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61100254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61100255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61100256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61100815","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61101008","Description":"2N Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61101009","Description":"2N Pneumococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61101027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61102622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61102645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61102996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61105001","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61105510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61150253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61150254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61150256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61150815","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61151008","Description":"6N Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61151009","Description":"6N Pneumococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61151027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61152622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61152645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61152996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61155001","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61155510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61200251","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61200254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61200255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61200256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61200815","Description":"IV INFUSION INITIAL UP TO 1HR","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61201008","Description":"5S Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61201009","Description":"5S Pneumococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61201027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61202622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61202645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61202996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61205001","Description":"IV Infusion Ea Add Hr Nonchem","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61205510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61300253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61300254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61300255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61300256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61300815","Description":"IV Infusion Therapy 1St Hour","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61301008","Description":"Flu Vaccination Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61301009","Description":"SJH 5N Pneumococcal Vacc Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61301027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61302622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61302645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61302996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61305001","Description":"IV Infusion Ea Add Hr Nonchem","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61305510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61350253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61350254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61350255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61350256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61350815","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61351008","Description":"Flu Vaccination Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61351009","Description":"Pneumococcal Vaccine Administr","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61351027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61352622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61352645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61352996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61355001","Description":"IV Infusion Ea Add Hr Nonchem","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61355510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61400253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61400254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61400255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61400256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61400815","Description":"IV INFUSION INITIAL UP TO 1HR","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61401008","Description":"Flu Vaccination Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61401009","Description":"SJH 7N Pneumococcal Vacc Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61401027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61402622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61402645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61402996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61405001","Description":"IV Infusion Ea Add Hr Nonchem","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61405510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61450253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61450255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61450256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61450510","Description":"Admin Flu Virus Vaccine","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":34.0},{"Itemcode":"61450815","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61451009","Description":"SJH 7S Pneumococcal Vacc Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61451027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61452622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61452645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61452996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61455001","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61455510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61500253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61500254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61500255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61500256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61500815","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61501008","Description":"Flu Vaccination Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61501009","Description":"Pneumococcal Immuniz admin x1","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61501027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61502622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61502645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61502996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61505001","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61505510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61550253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61550255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61551001","Description":"Hydration Infsn IV Ea Adl 1 Hr","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61551002","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61551003","Description":"IV Infusion Ea Addl 1.0 Hr","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61551008","Description":"Flu Immunizatn Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61552645","Description":"Ea Adl Seqnl IV Push/New Drg","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61552952","Description":"Rhogam Im Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61552996","Description":"IM / Sq Injection","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61552997","Description":"IV Inj/Push Initial","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61700253","Description":"Hydration Infsn Ini 31-60Min","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"61700254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"61700255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61700256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"61700815","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"61701008","Description":"PCU Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"61701009","Description":"PCU Pneumococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"61701027","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"61702622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"61702645","Description":"Ea Sequential IV Push/New Drug","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"61705001","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"61705510","Description":"Non Chemo IV Push Injection","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61800251","Description":"Injection IV Push Initial","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"61800252","Description":"Injection: SQ/IM","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"61800255","Description":"IV Inj Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"61851009","Description":"Pneumococcal Vaccine Administr","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"64101839","Description":"Pneumococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"64201008","Description":"ODS Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"64505423","Description":"IV Push","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"64550010","Description":"HBIG IM Injection","CDM Revenue Code":"761","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"64555423","Description":"IV Push","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"65100251","Description":"Injection: Iv Push Initl Drug","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"65100252","Description":"Injection: Sq/Im","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"65100253","Description":"Hydration First Hour","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"65100254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"65100255","Description":"IV Inj Addl Seq Push Same Drug","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"65100256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"65100509","Description":"PPV Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"65100510","Description":"Admin Flu Virus Vaccine","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":34.0},{"Itemcode":"65101009","Description":"Pneumococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"65102618","Description":"IV Infusion Each Addit. Hr","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"65102622","Description":"IV Infusion Seq Addl Drug","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"65102645","Description":"Ea Sequential IV Push /New Dr","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"65103499","Description":"Vaccine Admin Additional","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"65103500","Description":"Injection: Immunization","CDM Revenue Code":"771","CDM HCPCS":"90471","Standard Price":49.0},{"Itemcode":"65105001","Description":"IV INFUSION EA ADD HR NONCHEMO","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"65106412","Description":"IV Infusion Initial up to 1hr","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"68250253","Description":"Vaccine Admin Initial","CDM Revenue Code":"771","CDM HCPCS":"90471","Standard Price":49.0},{"Itemcode":"68250254","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"68250258","Description":"Hepatitis B Vaccine Admin 1.0","CDM Revenue Code":"771","CDM HCPCS":"G0010","Standard Price":49.0},{"Itemcode":"68250510","Description":"Admin Flu Virus Vaccine","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":34.0},{"Itemcode":"68251000","Description":"Hydration 1St Hour Hhi","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"68251001","Description":"Hydration Ea Addl Hour Hhi","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"68251002","Description":"Non-Chemo Infusion 1St Hr Hhi","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"68251003","Description":"Non-Chemo Infusion Addl Hr Hhi","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"68251004","Description":"Non-Chemo Infusion Seq Hhi","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"68251005","Description":"Non-Chemo Infusion Concrnt Hhi","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"68251006","Description":"SubQ Non-Chemo Infusion 1stHR","CDM Revenue Code":"260","CDM HCPCS":"96369","Standard Price":636.0},{"Itemcode":"68251007","Description":"Non-Chemo Inj Im Sq Hhi","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"68251008","Description":"Non-Chemo IV Inj Intl Drug Hh","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"68251009","Description":"Non-Chemo IV Inj Subsqt Hhi","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"68251037","Description":"IV Inj Seq Push Same Drug Addl","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"68252291","Description":"Appl On-BodyInjtr/Timed SC Inj","CDM Revenue Code":"260","CDM HCPCS":"96377","Standard Price":463.0},{"Itemcode":"68256009","Description":"ADMIN PNEUMOCOCCAL VACCINE","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"68260253","Description":"Immunizatn Adm Initl Vaccine","CDM Revenue Code":"771","CDM HCPCS":"90471","Standard Price":49.0},{"Itemcode":"68260254","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"68260257","Description":"Hep B Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0010","Standard Price":63.0},{"Itemcode":"68260258","Description":"Hepatitis B Vaccine Admin 1.0","CDM Revenue Code":"771","CDM HCPCS":"G0010","Standard Price":49.0},{"Itemcode":"68260510","Description":"Admin Flu Vaccine","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":34.0},{"Itemcode":"68261000","Description":"Hydration IV Infsn 1St Hour","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"68261001","Description":"Hydration Ea Addl Hour Okt","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"68261002","Description":"Non-Chemo Infusion 1St Hr Okt","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"68261003","Description":"Non-Chemo Infusion Addl Hr Okt","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"68261004","Description":"Non-Chemo Infusion Seq Okt","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"68261005","Description":"Non-Chemo Inf Concurrent Okt","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"68261006","Description":"SubQ Non-Chemo Infusion 1stHR","CDM Revenue Code":"260","CDM HCPCS":"96369","Standard Price":636.0},{"Itemcode":"68261007","Description":"Non-Chemo Inj Im Sq Okt","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"68261008","Description":"Non-Chemo IV Inj Intl Drug Ok","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"68261009","Description":"Non-Chemo IV Inj Subsqt Ok","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"68261037","Description":"IV Inj Seq Push Same Drug Addl","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"68262291","Description":"Appl On-BodyInjtr/Timed SC Inj","CDM Revenue Code":"260","CDM HCPCS":"96377","Standard Price":463.0},{"Itemcode":"68266109","Description":"PPV Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"71701008","Description":"Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"72050011","Description":"IV Infusion Therapy 1St Hour","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"72050012","Description":"IV Infusn Therapy Ea Addl 1Hr","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"72050251","Description":"Injection: Iv Push Initl Drug","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"72052645","Description":"Ea Sequential IV Push /New Dr","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"72151008","Description":"ODS Flu Vaccination Admin","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"74200252","Description":"Injection: SQ/IM","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"74201008","Description":"Flu Vaccination Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"74201009","Description":"Pnuemococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"74201011","Description":"Vaccine Admin Initial","CDM Revenue Code":"771","CDM HCPCS":"90471","Standard Price":49.0},{"Itemcode":"74221008","Description":"Flu Vaccination Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"74221009","Description":"Pnuemococcal Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"74401000","Description":"Hydration First Hour","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"74401001","Description":"Hydration Each Additional Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"74401002","Description":"Non-Chemo IV Infusion First H","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"74401003","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"74401004","Description":"Sequential Infusion","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"74401005","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"74401006","Description":"Non-Chemo Inj Sq/Im","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"74401007","Description":"Non-Chemo IV Push Initial","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"74401008","Description":"Ea Sequential IV Push /New Dr","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"74401020","Description":"Flu Vaccine Administration","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"74401021","Description":"PPV Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"74401026","Description":"Vaccine Admin Initial","CDM Revenue Code":"771","CDM HCPCS":"90471","Standard Price":49.0},{"Itemcode":"74401027","Description":"Vaccine Admin Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"74401037","Description":"IV Inj Seq Push Same Drug Addl","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"76970105","Description":"Non-Chemo IV Infusin Ea Add H","CDM Revenue Code":"260","CDM HCPCS":"96366","Standard Price":673.0},{"Itemcode":"76970110","Description":"Non-Chemo IV Infusion First H","CDM Revenue Code":"260","CDM HCPCS":"96365","Standard Price":922.0},{"Itemcode":"76970115","Description":"Non-Chemo Inj Sq/Im","CDM Revenue Code":"260","CDM HCPCS":"96372","Standard Price":342.0},{"Itemcode":"76970240","Description":"Non-Chemo IV Push Initial","CDM Revenue Code":"260","CDM HCPCS":"96374","Standard Price":399.0},{"Itemcode":"76970251","Description":"Hydration First Hour","CDM Revenue Code":"260","CDM HCPCS":"96360","Standard Price":838.0},{"Itemcode":"76970252","Description":"Hydration Each Additional Hour","CDM Revenue Code":"260","CDM HCPCS":"96361","Standard Price":342.0},{"Itemcode":"76970253","Description":"Vaccine Admin Initial","CDM Revenue Code":"771","CDM HCPCS":"90471","Standard Price":49.0},{"Itemcode":"76970254","Description":"Vaccine Admin Ea Addl","CDM Revenue Code":"771","CDM HCPCS":"90472","Standard Price":93.0},{"Itemcode":"76970255","Description":"Sequential Infusion","CDM Revenue Code":"260","CDM HCPCS":"96367","Standard Price":493.0},{"Itemcode":"76970256","Description":"Concurrent Infusion","CDM Revenue Code":"260","CDM HCPCS":"96368","Standard Price":435.0},{"Itemcode":"76970257","Description":"Hep B Vaccine Admin","CDM Revenue Code":"771","CDM HCPCS":"G0010","Standard Price":63.0},{"Itemcode":"76970258","Description":"Hepatitis B Vaccine Admin 1.0","CDM Revenue Code":"771","CDM HCPCS":"G0010","Standard Price":49.0},{"Itemcode":"76970510","Description":"Admin Immuniz Flu Vaccine x1","CDM Revenue Code":"771","CDM HCPCS":"G0008","Standard Price":49.0},{"Itemcode":"76971006","Description":"SubQ Non-Chemo Infusion 1stHR","CDM Revenue Code":"260","CDM HCPCS":"96369","Standard Price":636.0},{"Itemcode":"76971009","Description":"PPV Admin","CDM Revenue Code":"771","CDM HCPCS":"G0009","Standard Price":49.0},{"Itemcode":"76971037","Description":"IV Inj Seq Push Same Drug Addl","CDM Revenue Code":"260","CDM HCPCS":"96376","Standard Price":142.0},{"Itemcode":"76972291","Description":"Appl On-BodyInjtr/Timed SC Inj","CDM Revenue Code":"260","CDM HCPCS":"96377","Standard Price":463.0},{"Itemcode":"76972645","Description":"Ea Sequential IV Push /New Dr","CDM Revenue Code":"260","CDM HCPCS":"96375","Standard Price":354.0},{"Itemcode":"0119","Description":"Breast BX US W/Clip Add Lesion","CDM Revenue Code":"361","CDM HCPCS":"19084","Standard Price":1038.0},{"Itemcode":"0121","Description":"Breast Loc Devic 1stLsn Stereo","CDM Revenue Code":"361","CDM HCPCS":"19081","Standard Price":5116.0},{"Itemcode":"0122","Description":"Breast Bx W/Clip Stereo Addl","CDM Revenue Code":"361","CDM HCPCS":"19082","Standard Price":2278.0},{"Itemcode":"0123","Description":"Brst Loc w/Mammo Guidance 1st","CDM Revenue Code":"361","CDM HCPCS":"19281","Standard Price":1824.0},{"Itemcode":"0125","Description":"Brst Loc DeviceW/US Guidnc 1st","CDM Revenue Code":"361","CDM HCPCS":"19285","Standard Price":2776.0},{"Itemcode":"0126","Description":"Brst Loc Devic W/US Addl Leson","CDM Revenue Code":"361","CDM HCPCS":"19286","Standard Price":2776.0},{"Itemcode":"0128","Description":"LOCALIZATION BI MAMMO GUIDED","CDM Revenue Code":"361","CDM HCPCS":"19281","Standard Price":1824.0},{"Itemcode":"0154","Description":"BX Breast 1st Lesn STRTCTC RT","CDM Revenue Code":"361","CDM HCPCS":"19081","Standard Price":5116.0},{"Itemcode":"0156","Description":"BX Breast 1st Lesn STRTCTC BI","CDM Revenue Code":"361","CDM HCPCS":"19081","Standard Price":5116.0},{"Itemcode":"0187","Description":"BX Breast 1st Lesn STRTCTC LT","CDM Revenue Code":"361","CDM HCPCS":"19081","Standard Price":5116.0},{"Itemcode":"0224","Description":"LOCALIZATION W/MAM ADDL LESION","CDM Revenue Code":"361","CDM HCPCS":"19282","Standard Price":1824.0},{"Itemcode":"0236","Description":"Breast Bx US Guided LT","CDM Revenue Code":"361","CDM HCPCS":"19083","Standard Price":3857.0},{"Itemcode":"0237","Description":"Breast Bx US Guided RT","CDM Revenue Code":"361","CDM HCPCS":"19083","Standard Price":3857.0},{"Itemcode":"0239","Description":"Breast Bx US Guided BI","CDM Revenue Code":"361","CDM HCPCS":"19083","Standard Price":7713.0},{"Itemcode":"1191","Description":"MRI IMAG BX BREAST 1ST LESION","CDM Revenue Code":"361","CDM HCPCS":"19085","Standard Price":4297.0},{"Itemcode":"1192","Description":"MR IMAG BX BREAST ADD LESION","CDM Revenue Code":"361","CDM HCPCS":"19086","Standard Price":3643.0},{"Itemcode":"4233","Description":"ABLATION 1 OR MORE LIVERTUMORS","CDM Revenue Code":"361","CDM HCPCS":"47382","Standard Price":12512.0},{"Itemcode":"4237","Description":"MW ABLATION - LIVER TUMOR","CDM Revenue Code":"361","CDM HCPCS":"47399","Standard Price":1601.0},{"Itemcode":"4238","Description":"MW ABLATION-LUNG/PLEURA TUMOR","CDM Revenue Code":"361","CDM HCPCS":"32999","Standard Price":2031.0},{"Itemcode":"4239","Description":"MW ABLATION- KIDNEY TUMOR","CDM Revenue Code":"361","CDM HCPCS":"53899","Standard Price":682.0},{"Itemcode":"61050515","Description":"4N Exchange Transfusion","CDM Revenue Code":"391","CDM HCPCS":"36455","Standard Price":1087.0},{"Itemcode":"61150515","Description":"Exchange Transfusion","CDM Revenue Code":"391","CDM HCPCS":"36455","Standard Price":1087.0},{"Itemcode":"61300516","Description":"Exchange Transfusion","CDM Revenue Code":"391","CDM HCPCS":"36455","Standard Price":1087.0},{"Itemcode":"61552998","Description":"External Version","CDM Revenue Code":"761","CDM HCPCS":"59412","Standard Price":5655.0},{"Itemcode":"61600189","Description":"Blood Exchng Transfusn-Newborn","CDM Revenue Code":"761","CDM HCPCS":"36450","Standard Price":4219.0},{"Itemcode":"61600220","Description":"Umbilical Artery Cath Newborn","CDM Revenue Code":"761","CDM HCPCS":"36660","Standard Price":1791.0},{"Itemcode":"61600221","Description":"Umbilical Vein Catherization","CDM Revenue Code":"761","CDM HCPCS":"36510","Standard Price":1791.0},{"Itemcode":"65103505","Description":"Intubation","CDM Revenue Code":"450","CDM HCPCS":"31500","Standard Price":517.0},{"Itemcode":"68300257","Description":"Fiducial Markr Placmnt-Prostat","CDM Revenue Code":"361","CDM HCPCS":"55876","Standard Price":3120.0},{"Itemcode":"71700014","Description":"Para Abdomen w/o Imaging","CDM Revenue Code":"361","CDM HCPCS":"49082","Standard Price":1300.0},{"Itemcode":"71703505","Description":"Intubation, Emergency Endotrac","CDM Revenue Code":"761","CDM HCPCS":"31500","Standard Price":517.0},{"Itemcode":"7173","Description":"EPIDRM AGRFT TAL 100CM2/1%%BA","CDM Revenue Code":"361","CDM HCPCS":"15110","Standard Price":2860.0},{"Itemcode":"7174","Description":"EPIDRMAGRFT TAL100CM2/1%%BA AD","CDM Revenue Code":"361","CDM HCPCS":"15111","Standard Price":1100.0},{"Itemcode":"7175","Description":"EPIDRMAGRFT FNHG 100CM2/1%%BA","CDM Revenue Code":"361","CDM HCPCS":"15115","Standard Price":2860.0},{"Itemcode":"7176","Description":"EPIDRMAGRFT FNHG100CM2/1%%BAAD","CDM Revenue Code":"361","CDM HCPCS":"15116","Standard Price":1100.0},{"Itemcode":"7180","Description":"SS APP T/A/L 1ST 25 SQCM (100)","CDM Revenue Code":"361","CDM HCPCS":"15271","Standard Price":4288.0},{"Itemcode":"7181","Description":"SS APP T/A/L EA ADD 25CM (100)","CDM Revenue Code":"361","CDM HCPCS":"15272","Standard Price":905.0},{"Itemcode":"7182","Description":"SS APP TAL 1ST 100SQCM >100CHL","CDM Revenue Code":"361","CDM HCPCS":"15273","Standard Price":6494.0},{"Itemcode":"7183","Description":"SS APP T/A/L ADD 100 CM >100","CDM Revenue Code":"361","CDM HCPCS":"15274","Standard Price":3735.0},{"Itemcode":"7184","Description":"SS APP H/N/H/F 1ST 25 CM (100)","CDM Revenue Code":"361","CDM HCPCS":"15275","Standard Price":4288.0},{"Itemcode":"7185","Description":"SS APP H/N/H/F EA ADD 25 CM","CDM Revenue Code":"361","CDM HCPCS":"15276","Standard Price":846.0},{"Itemcode":"7186","Description":"SS APP H/N/H/F 1ST 100 SQCM","CDM Revenue Code":"361","CDM HCPCS":"15277","Standard Price":3161.0},{"Itemcode":"7187","Description":"SS APP H/N/H/F ADD 100 CM >100","CDM Revenue Code":"361","CDM HCPCS":"15278","Standard Price":450.0},{"Itemcode":"7244","Description":"Surg/Wound Prep trk/arm/leg","CDM Revenue Code":"361","CDM HCPCS":"15002","Standard Price":2000.0},{"Itemcode":"7245","Description":"Addl Prep trk/arm/leg 100 cm","CDM Revenue Code":"361","CDM HCPCS":"15003","Standard Price":2000.0},{"Itemcode":"7246","Description":"Surg/Wound Prep f/n/hf/g","CDM Revenue Code":"361","CDM HCPCS":"15004","Standard Price":1500.0},{"Itemcode":"7247","Description":"Addl Prep f/n/hf/g 100 cm","CDM Revenue Code":"361","CDM HCPCS":"15005","Standard Price":1500.0},{"Itemcode":"73100313","Description":"Intubation","CDM Revenue Code":"361","CDM HCPCS":"31500","Standard Price":517.0},{"Itemcode":"0007","Description":"PUNCTURE CYST ASPIRATION -ADDL","CDM Revenue Code":"361","CDM HCPCS":"19001","Standard Price":590.0},{"Itemcode":"0149","Description":"US Urine Bladder Vol Post Void","CDM Revenue Code":"361","CDM HCPCS":"51798","Standard Price":474.0},{"Itemcode":"0157","Description":"BX Lymph Node LT -Perc Ndl","CDM Revenue Code":"361","CDM HCPCS":"38505","Standard Price":4883.0},{"Itemcode":"0158","Description":"BX Lymph Node RT -Perc Ndl","CDM Revenue Code":"361","CDM HCPCS":"38505","Standard Price":4883.0},{"Itemcode":"0159","Description":"BX Lymph Node BI -Perc Ndl","CDM Revenue Code":"361","CDM HCPCS":"38505","Standard Price":7318.0},{"Itemcode":"0253","Description":"Complex Cystometrogram","CDM Revenue Code":"361","CDM HCPCS":"51726","Standard Price":2121.0},{"Itemcode":"0254","Description":"Complex Cystometrogram W/VP","CDM Revenue Code":"920","CDM HCPCS":"51728","Standard Price":2441.0},{"Itemcode":"0255","Description":"Complex Uroflowmetry","CDM Revenue Code":"920","CDM HCPCS":"51741","Standard Price":524.0},{"Itemcode":"0257","Description":"Intra-Abdominal Pressure","CDM Revenue Code":"920","CDM HCPCS":"51797","Standard Price":541.0},{"Itemcode":"0259","Description":"Breast Cyst Punct Asp Sgl Cyst","CDM Revenue Code":"361","CDM HCPCS":"19000","Standard Price":1942.0},{"Itemcode":"0261","Description":"Breast FNA Inital Site","CDM Revenue Code":"361","CDM HCPCS":"10011","Standard Price":789.0},{"Itemcode":"0263","Description":"Breast FNA Addl Site","CDM Revenue Code":"361","CDM HCPCS":"10010","Standard Price":789.0},{"Itemcode":"0268","Description":"Dye Injection","CDM Revenue Code":"361","CDM HCPCS":"19030","Standard Price":243.0},{"Itemcode":"2211","Description":"Injection Hip","CDM Revenue Code":"361","CDM HCPCS":"20610","Standard Price":906.0},{"Itemcode":"5043","Description":"Percutaneous Sacroplasty Uni","CDM Revenue Code":"361","CDM HCPCS":"0200T","Standard Price":13321.0},{"Itemcode":"5044","Description":"Percutaneous Sacroplasty Bil","CDM Revenue Code":"361","CDM HCPCS":"0201T","Standard Price":13321.0},{"Itemcode":"5046","Description":"CT GUIDED FNA SURG COMPONENT","CDM Revenue Code":"361","CDM HCPCS":"10009","Standard Price":724.0},{"Itemcode":"60950518","Description":"Blood Admin 1 Unit - 1North","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61050508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61100508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61150157","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61200108","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61250508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61300508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61350508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61400508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61450100","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61500508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61500555","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61505890","Description":"Circumcision Of Male Baby","CDM Revenue Code":"723","CDM HCPCS":"54150","Standard Price":3290.0},{"Itemcode":"61552950","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61555810","Description":"Non-Stress Test","CDM Revenue Code":"920","CDM HCPCS":"59025","Standard Price":1760.0},{"Itemcode":"61555820","Description":"Stress Test","CDM Revenue Code":"721","CDM HCPCS":"59020","Standard Price":751.0},{"Itemcode":"61555890","Description":"Circumcision Of Male Baby","CDM Revenue Code":"723","CDM HCPCS":"54150","Standard Price":3290.0},{"Itemcode":"61600006","Description":"Circumcision Of Male Baby","CDM Revenue Code":"723","CDM HCPCS":"54150","Standard Price":3290.0},{"Itemcode":"61600190","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61700108","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61800508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61850508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"61900508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"62100508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"62200508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"6234","Description":"Ablation 1 or More RenalTumors","CDM Revenue Code":"361","CDM HCPCS":"50592","Standard Price":17227.0},{"Itemcode":"63100100","Description":"Hemodialysis (OP Emergent)","CDM Revenue Code":"829","CDM HCPCS":"G0257","Standard Price":3126.0},{"Itemcode":"63100110","Description":"Plasmapheresis","CDM Revenue Code":"940","CDM HCPCS":"36514","Standard Price":13158.0},{"Itemcode":"63100111","Description":"Cytopheresis","CDM Revenue Code":"940","CDM HCPCS":"36511","Standard Price":15839.0},{"Itemcode":"63100112","Description":"RBC Apheresis","CDM Revenue Code":"940","CDM HCPCS":"36512","Standard Price":7627.0},{"Itemcode":"63100113","Description":"Leukopheresis","CDM Revenue Code":"940","CDM HCPCS":"36511","Standard Price":15839.0},{"Itemcode":"63100508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"63200025","Description":"EMG Needle 2 Extrem","CDM Revenue Code":"922","CDM HCPCS":"95861","Standard Price":2024.0},{"Itemcode":"63200110","Description":"Emg Needle 4 Extrem","CDM Revenue Code":"922","CDM HCPCS":"95864","Standard Price":2628.0},{"Itemcode":"63200111","Description":"EMG Needle 1 Extrem","CDM Revenue Code":"922","CDM HCPCS":"95860","Standard Price":657.0},{"Itemcode":"63200114","Description":"EMG Needle 3 Extrem","CDM Revenue Code":"922","CDM HCPCS":"95863","Standard Price":2326.0},{"Itemcode":"63250006","Description":"EMG Needle 1 Extrem","CDM Revenue Code":"922","CDM HCPCS":"95860","Standard Price":657.0},{"Itemcode":"63250007","Description":"EMG Needle 3 Extrem","CDM Revenue Code":"922","CDM HCPCS":"95863","Standard Price":2326.0},{"Itemcode":"63250008","Description":"EMG Needle 2 Extrem","CDM Revenue Code":"922","CDM HCPCS":"95861","Standard Price":2024.0},{"Itemcode":"63600001","Description":"ADVNCD CARE PLAN 1ST 30MIN","CDM Revenue Code":"510","CDM HCPCS":"99497","Standard Price":278.0},{"Itemcode":"63600010","Description":"ADVNCD CARE PLAN ADDL 30MIN","CDM Revenue Code":"510","CDM HCPCS":"99498","Standard Price":278.0},{"Itemcode":"64100009","Description":"ESWL","CDM Revenue Code":"790","CDM HCPCS":"50590","Standard Price":48876.0},{"Itemcode":"64100785","Description":"EMG Two Extremities","CDM Revenue Code":"922","CDM HCPCS":"95861","Standard Price":2024.0},{"Itemcode":"64100786","Description":"Needle EMG Anal/Ureth Sphinctr","CDM Revenue Code":"361","CDM HCPCS":"51785","Standard Price":835.0},{"Itemcode":"64100789","Description":"EMG Cranial Nerve Unilat","CDM Revenue Code":"922","CDM HCPCS":"95867","Standard Price":221.0},{"Itemcode":"64100791","Description":"EMG Cranial Nerve BI","CDM Revenue Code":"922","CDM HCPCS":"95868","Standard Price":221.0},{"Itemcode":"64100792","Description":"EMG Four Extremities","CDM Revenue Code":"922","CDM HCPCS":"95864","Standard Price":2628.0},{"Itemcode":"64100865","Description":"Cell Saver Transfusion","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"64150108","Description":"Blood Admin","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"64200108","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"64300101","Description":"Cardioversion, External, Elect","CDM Revenue Code":"480","CDM HCPCS":"92960","Standard Price":13602.0},{"Itemcode":"64300108","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"64500186","Description":"Emg","CDM Revenue Code":"761","CDM HCPCS":"51784","Standard Price":553.0},{"Itemcode":"64502013","Description":"Bravo Procedure","CDM Revenue Code":"761","CDM HCPCS":"91035","Standard Price":5745.0},{"Itemcode":"64502016","Description":"24 Hour Ph Probe Study","CDM Revenue Code":"761","CDM HCPCS":"91034","Standard Price":5745.0},{"Itemcode":"64504170","Description":"Blood Transfusion X 1","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"64606325","Description":"Cardioversion","CDM Revenue Code":"361","CDM HCPCS":"92960","Standard Price":13602.0},{"Itemcode":"65100094","Description":"INJ ANESTH,OTHR PERIPH NRV/BRN","CDM Revenue Code":"450","CDM HCPCS":"64450","Standard Price":1561.0},{"Itemcode":"65100104","Description":"Replacement Suprapubic Cath","CDM Revenue Code":"450","CDM HCPCS":"51705","Standard Price":552.0},{"Itemcode":"65100260","Description":"PICC Line/VAD Declot","CDM Revenue Code":"450","CDM HCPCS":"36593","Standard Price":763.0},{"Itemcode":"65100508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"65102101","Description":"Nebulizer Ther Initial Tx","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"65103501","Description":"Chest Tube Insertion","CDM Revenue Code":"450","CDM HCPCS":"32551","Standard Price":1952.0},{"Itemcode":"65103502","Description":"Intraosseous Infusion","CDM Revenue Code":"450","CDM HCPCS":"36680","Standard Price":1013.0},{"Itemcode":"65105380","Description":"CL Placement >=5 Yrs","CDM Revenue Code":"450","CDM HCPCS":"36556","Standard Price":6232.0},{"Itemcode":"65106305","Description":"Rem Impct Ear Wax, Lavage, Uni","CDM Revenue Code":"450","CDM HCPCS":"69209","Standard Price":220.0},{"Itemcode":"68251026","Description":"Declot VAD/Picc Line","CDM Revenue Code":"361","CDM HCPCS":"36593","Standard Price":763.0},{"Itemcode":"68251045","Description":"Therapeutic Phlebotomy","CDM Revenue Code":"940","CDM HCPCS":"99195","Standard Price":450.0},{"Itemcode":"68260260","Description":"PICC Line Blood Draw","CDM Revenue Code":"361","CDM HCPCS":"36592","Standard Price":565.0},{"Itemcode":"68261026","Description":"Declot VAD/Picc Line","CDM Revenue Code":"361","CDM HCPCS":"36593","Standard Price":763.0},{"Itemcode":"68261045","Description":"Therapuetic Phlebotomy","CDM Revenue Code":"940","CDM HCPCS":"99195","Standard Price":450.0},{"Itemcode":"68262351","Description":"Vad Blood Draw","CDM Revenue Code":"761","CDM HCPCS":"36591","Standard Price":565.0},{"Itemcode":"68266110","Description":"INITIATION INFUSION >8HRS","CDM Revenue Code":"761","CDM HCPCS":"C8957","Standard Price":862.0},{"Itemcode":"70100621","Description":"Phlebotomy Therapeutic","CDM Revenue Code":"949","CDM HCPCS":"99195","Standard Price":450.0},{"Itemcode":"70205005","Description":"Therapeutic Apheresis","CDM Revenue Code":"940","CDM HCPCS":"36514","Standard Price":13158.0},{"Itemcode":"70206030","Description":"Apheresis W/Col Abs","CDM Revenue Code":"940","CDM HCPCS":"36516","Standard Price":12188.0},{"Itemcode":"70206045","Description":"Therapeutic Cytophresis","CDM Revenue Code":"940","CDM HCPCS":"36511","Standard Price":15839.0},{"Itemcode":"7104","Description":"AVULSION OF NAIL PLATE (EA ADD","CDM Revenue Code":"361","CDM HCPCS":"11732","Standard Price":1033.0},{"Itemcode":"7105","Description":"AVULSION OF NAIL PLATE (FIRST)","CDM Revenue Code":"361","CDM HCPCS":"11730","Standard Price":1289.0},{"Itemcode":"7106","Description":"BENIGN LESION PARING","CDM Revenue Code":"361","CDM HCPCS":"11055","Standard Price":476.0},{"Itemcode":"7107","Description":"BENIGN LESION PARING (2-4)","CDM Revenue Code":"361","CDM HCPCS":"11056","Standard Price":476.0},{"Itemcode":"7108","Description":"BENIGN LESION PARING (>4)","CDM Revenue Code":"361","CDM HCPCS":"11057","Standard Price":1033.0},{"Itemcode":"7109","Description":"BIOPSY (ADDITIONAL)","CDM Revenue Code":"361","CDM HCPCS":"11103","Standard Price":129.0},{"Itemcode":"7110","Description":"BIOPSY COLLECTION","CDM Revenue Code":"361","CDM HCPCS":"11102","Standard Price":836.0},{"Itemcode":"71100017","Description":"PICC Line Insertion VAD","CDM Revenue Code":"361","CDM HCPCS":"36561","Standard Price":5123.0},{"Itemcode":"71100850","Description":"Injection Hip w/ US Guid","CDM Revenue Code":"361","CDM HCPCS":"20611","Standard Price":1635.0},{"Itemcode":"7111","Description":"CALLUC ABRASION <=4 LESNS","CDM Revenue Code":"361","CDM HCPCS":"15787","Standard Price":1289.0},{"Itemcode":"7112","Description":"CALLUC ABRASION (SINGLE)","CDM Revenue Code":"361","CDM HCPCS":"15786","Standard Price":1289.0},{"Itemcode":"7113","Description":"CAUTERY OF WOUND (CHEMICAL)","CDM Revenue Code":"361","CDM HCPCS":"17250","Standard Price":476.0},{"Itemcode":"7114","Description":"CLEAN OUTER EAR CANAL","CDM Revenue Code":"361","CDM HCPCS":"69200","Standard Price":368.0},{"Itemcode":"7115","Description":"DEBRIDEMENT OF NAILS (1-5)","CDM Revenue Code":"361","CDM HCPCS":"11720","Standard Price":368.0},{"Itemcode":"7116","Description":"DEBRIDEMENT OF NAILS (6 or >6)","CDM Revenue Code":"361","CDM HCPCS":"11721","Standard Price":722.0},{"Itemcode":"7117","Description":"I & D COMPLEX","CDM Revenue Code":"361","CDM HCPCS":"10061","Standard Price":923.0},{"Itemcode":"7118","Description":"I & D SIMPLE","CDM Revenue Code":"361","CDM HCPCS":"10060","Standard Price":401.0},{"Itemcode":"7119","Description":"REMOVE IMPACTED CERUMEN","CDM Revenue Code":"361","CDM HCPCS":"69210","Standard Price":849.0},{"Itemcode":"7120","Description":"REMVL OF FOREIGN BODY FRM FOOT","CDM Revenue Code":"361","CDM HCPCS":"28190","Standard Price":3951.0},{"Itemcode":"7121","Description":"SHORT LEG SPLINT APPLICATION","CDM Revenue Code":"361","CDM HCPCS":"29515","Standard Price":1317.0},{"Itemcode":"7123","Description":"TRIM NONDYSTROPHIC NAIL (ANY #","CDM Revenue Code":"361","CDM HCPCS":"11719","Standard Price":919.0},{"Itemcode":"7126","Description":"WOUND DEBRIDE SUBQ <20 CM SQ","CDM Revenue Code":"361","CDM HCPCS":"11042","Standard Price":1260.0},{"Itemcode":"7127","Description":"WOUND DEBRIDE BONE <20 CM SQ","CDM Revenue Code":"361","CDM HCPCS":"11044","Standard Price":3807.0},{"Itemcode":"7128","Description":"WOUND DEBRIDE MUSCLE <20 CM SQ","CDM Revenue Code":"361","CDM HCPCS":"11043","Standard Price":1732.0},{"Itemcode":"71400508","Description":"Blood Transfusion Admin","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"7141","Description":"Punch Biopsy Single Lesion","CDM Revenue Code":"361","CDM HCPCS":"11104","Standard Price":836.0},{"Itemcode":"7142","Description":"WOUND REPAIR SIMPLE UPTO2.5CM","CDM Revenue Code":"361","CDM HCPCS":"12002","Standard Price":1057.0},{"Itemcode":"7143","Description":"WOUND REPAIR SIMPLE 7.6-12.5","CDM Revenue Code":"361","CDM HCPCS":"12004","Standard Price":1230.0},{"Itemcode":"7144","Description":"AMPUTATION TOE TIP","CDM Revenue Code":"361","CDM HCPCS":"28825","Standard Price":6176.0},{"Itemcode":"7145","Description":"BURN DRSG/DEBRIDEMENT SMALL","CDM Revenue Code":"361","CDM HCPCS":"16020","Standard Price":476.0},{"Itemcode":"7146","Description":"BURN DRSG/DEBRIDEMENT MED","CDM Revenue Code":"361","CDM HCPCS":"16025","Standard Price":911.0},{"Itemcode":"7147","Description":"BURN DRSG/DEBRIDEMENT LG","CDM Revenue Code":"361","CDM HCPCS":"16030","Standard Price":911.0},{"Itemcode":"7148","Description":"I&D PILONIDAL CYST SIMPLE","CDM Revenue Code":"361","CDM HCPCS":"10080","Standard Price":2163.0},{"Itemcode":"7149","Description":"I&D PILONIDAL CYST COMPLEX","CDM Revenue Code":"361","CDM HCPCS":"10081","Standard Price":10799.0},{"Itemcode":"7150","Description":"I&D HEMATOMA / SEROMA","CDM Revenue Code":"361","CDM HCPCS":"10140","Standard Price":1751.0},{"Itemcode":"7151","Description":"ASPIRATION CYST/ABCSS/HMTMA","CDM Revenue Code":"361","CDM HCPCS":"10160","Standard Price":1659.0},{"Itemcode":"7152","Description":"BX BONE NEEDLE/TROCAR","CDM Revenue Code":"361","CDM HCPCS":"20220","Standard Price":6556.0},{"Itemcode":"7153","Description":"BX BONE OPEN","CDM Revenue Code":"361","CDM HCPCS":"20240","Standard Price":15335.0},{"Itemcode":"7154","Description":"EXCISION NAIL PART/COMPLETE","CDM Revenue Code":"361","CDM HCPCS":"11750","Standard Price":3048.0},{"Itemcode":"7155","Description":"DEBRIDEMENT SKIN <10% SRFC","CDM Revenue Code":"361","CDM HCPCS":"11000","Standard Price":1732.0},{"Itemcode":"7156","Description":"DEBRIDEMENT SKIN ADDL 10% SFC","CDM Revenue Code":"361","CDM HCPCS":"11001","Standard Price":1623.0},{"Itemcode":"7157","Description":"DEBRIDEMENT SKIN FX","CDM Revenue Code":"361","CDM HCPCS":"11010","Standard Price":3807.0},{"Itemcode":"7158","Description":"DEBRIDE SKIN & MUSCLE (FX)","CDM Revenue Code":"361","CDM HCPCS":"11011","Standard Price":3877.0},{"Itemcode":"7159","Description":"DEBRIDE SKIN/MSCL/BONE (FX)","CDM Revenue Code":"361","CDM HCPCS":"11012","Standard Price":4550.0},{"Itemcode":"7162","Description":"REMOVE FB SUBCUTANEOUS","CDM Revenue Code":"361","CDM HCPCS":"10120","Standard Price":2577.0},{"Itemcode":"7163","Description":"EXCISION BENIGN LESION .6-1 CM","CDM Revenue Code":"361","CDM HCPCS":"11401","Standard Price":5133.0},{"Itemcode":"7164","Description":"EXCISION SKIN/SQ HYDRADENITIS","CDM Revenue Code":"361","CDM HCPCS":"11451","Standard Price":6042.0},{"Itemcode":"7165","Description":"WOUND DEBRIDE SUBQ EA ADDL 20","CDM Revenue Code":"361","CDM HCPCS":"11045","Standard Price":1510.0},{"Itemcode":"7166","Description":"WOUND DEBRIDE MUSCLE ADD 20 CM","CDM Revenue Code":"361","CDM HCPCS":"11046","Standard Price":1510.0},{"Itemcode":"7167","Description":"WOUND DEBRIDE BONE ADDL 20 CM","CDM Revenue Code":"361","CDM HCPCS":"11047","Standard Price":2047.0},{"Itemcode":"7168","Description":"WND RPR COMPLEX 2.3-7.5 CM","CDM Revenue Code":"360","CDM HCPCS":"13132","Standard Price":2476.0},{"Itemcode":"7169","Description":"EXCIS BEN LESN T/A/L 1.1-2.0CM","CDM Revenue Code":"361","CDM HCPCS":"11402","Standard Price":7078.0},{"Itemcode":"71704402","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"71706325","Description":"Cardioversion","CDM Revenue Code":"361","CDM HCPCS":"92960","Standard Price":13602.0},{"Itemcode":"7192","Description":"APPLY RIGID LEG CAST","CDM Revenue Code":"761","CDM HCPCS":"29445","Standard Price":841.0},{"Itemcode":"7193","Description":"REMOVAL/REVISION OF FOOT CAST","CDM Revenue Code":"761","CDM HCPCS":"29700","Standard Price":841.0},{"Itemcode":"7194","Description":"NEG PRESS WOUND TX < 50 CM DT","CDM Revenue Code":"761","CDM HCPCS":"97605","Standard Price":399.0},{"Itemcode":"7195","Description":"NEG PRESS WOUND TX > 50 CM DT","CDM Revenue Code":"761","CDM HCPCS":"97606","Standard Price":1877.0},{"Itemcode":"7196","Description":"NON-SELECTIVE DEBRIDEMENT","CDM Revenue Code":"761","CDM HCPCS":"97602","Standard Price":1049.0},{"Itemcode":"7197","Description":"SELECTIVE DEBRIDEMENT <20 CM","CDM Revenue Code":"761","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"7198","Description":"SELECT DEBRIDEMNT EA ADD 20 CM","CDM Revenue Code":"761","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"7199","Description":"UNNA BOOT APPLICATION","CDM Revenue Code":"761","CDM HCPCS":"29580","Standard Price":920.0},{"Itemcode":"7200","Description":"COMPRESSION WRAP APP/BELOW KNE","CDM Revenue Code":"761","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"7201","Description":"UNNA BOOT APP BILATERAL","CDM Revenue Code":"761","CDM HCPCS":"29580","Standard Price":920.0},{"Itemcode":"7202","Description":"COMPRESSION WRAP BILATERAL","CDM Revenue Code":"761","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"7203","Description":"HBO THERAPY PER 30 MIN","CDM Revenue Code":"413","CDM HCPCS":"G0277","Standard Price":993.0},{"Itemcode":"72102502","Description":"Plcmnt Occulsive Device","CDM Revenue Code":"761","CDM HCPCS":"G0269","Standard Price":459.0},{"Itemcode":"72106325","Description":"Cardioversion","CDM Revenue Code":"480","CDM HCPCS":"92960","Standard Price":13602.0},{"Itemcode":"7211","Description":"Appl Low Cost SS T A L 1st25","CDM Revenue Code":"361","CDM HCPCS":"C5271","Standard Price":4674.0},{"Itemcode":"7212","Description":"Appl Low Cost SS T A L Addl25","CDM Revenue Code":"361","CDM HCPCS":"C5272","Standard Price":986.0},{"Itemcode":"7213","Description":"Appl Low Cost SS T A L 1st100","CDM Revenue Code":"361","CDM HCPCS":"C5273","Standard Price":7078.0},{"Itemcode":"7214","Description":"Appl Low Cost SS T A L Addl100","CDM Revenue Code":"361","CDM HCPCS":"C5274","Standard Price":4071.0},{"Itemcode":"7215","Description":"Appl Low Cost SS H G EX 1st25","CDM Revenue Code":"361","CDM HCPCS":"C5275","Standard Price":4674.0},{"Itemcode":"72150508","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"72156325","Description":"Cardioversion","CDM Revenue Code":"480","CDM HCPCS":"92960","Standard Price":13602.0},{"Itemcode":"7216","Description":"Appl Low Cost SS H G EX Addl25","CDM Revenue Code":"361","CDM HCPCS":"C5276","Standard Price":922.0},{"Itemcode":"7217","Description":"Appl Low cost SS H G EX 1st100","CDM Revenue Code":"361","CDM HCPCS":"C5277","Standard Price":3445.0},{"Itemcode":"7218","Description":"Apl Low Cost SS H G EX Addl100","CDM Revenue Code":"361","CDM HCPCS":"C5278","Standard Price":490.0},{"Itemcode":"72205155","Description":"Cardioversion: External","CDM Revenue Code":"480","CDM HCPCS":"92960","Standard Price":13602.0},{"Itemcode":"7231","Description":"APP MULTLY COMPRSN LWR LG - LT","CDM Revenue Code":"761","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"7232","Description":"APP MULTLY COMPRSN LWR LG - RT","CDM Revenue Code":"761","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"7236","Description":"TX SUPRFIC WND DEHISC,SIMPL","CDM Revenue Code":"361","CDM HCPCS":"12020","Standard Price":1788.0},{"Itemcode":"7237","Description":"TX SUPFCL WND DEHIS; W/PACKNG","CDM Revenue Code":"361","CDM HCPCS":"12021","Standard Price":1830.0},{"Itemcode":"7238","Description":"NEG PRES WND TX DISPO <=50SQCM","CDM Revenue Code":"761","CDM HCPCS":"97607","Standard Price":1156.0},{"Itemcode":"7239","Description":"NEG PRESS WND TX DISPO >50SQCM","CDM Revenue Code":"761","CDM HCPCS":"97608","Standard Price":1318.0},{"Itemcode":"73100001","Description":"IPPB Initial Tx","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73100002","Description":"Nebulizer Therapy Initial Tx","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73100007","Description":"Cpt Initial","CDM Revenue Code":"410","CDM HCPCS":"94667","Standard Price":275.0},{"Itemcode":"73100305","Description":"MDI Initial Tx","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73100306","Description":"MDI Treatment Subsequent","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73100309","Description":"Chest Physio Subseq","CDM Revenue Code":"410","CDM HCPCS":"94668","Standard Price":277.0},{"Itemcode":"73100311","Description":"Nebulizer Therapy Subseq","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73100314","Description":"IPPB Subsequent","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73100400","Description":"External Chest Vibration Initi","CDM Revenue Code":"410","CDM HCPCS":"94667","Standard Price":275.0},{"Itemcode":"73100713","Description":"Ez Pap Initial Tx","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73100714","Description":"Ez Pap Subsequent Tx","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"73103070","Description":"MIPS / MEPS","CDM Revenue Code":"410","CDM HCPCS":"G0237","Standard Price":775.0},{"Itemcode":"73203070","Description":"MIPS / MEPS","CDM Revenue Code":"410","CDM HCPCS":"G0237","Standard Price":775.0},{"Itemcode":"73203079","Description":"Nebulizer Subsequent","CDM Revenue Code":"410","CDM HCPCS":"94640","Standard Price":275.0},{"Itemcode":"74400185","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"74401018","Description":"INITIATION INFUSION >8HRS","CDM Revenue Code":"761","CDM HCPCS":"C8957","Standard Price":862.0},{"Itemcode":"74401023","Description":"PICC Line Blood Draw","CDM Revenue Code":"761","CDM HCPCS":"36592","Standard Price":565.0},{"Itemcode":"74401024","Description":"Port-A-Cath Blood Draw","CDM Revenue Code":"761","CDM HCPCS":"36591","Standard Price":565.0},{"Itemcode":"74401025","Description":"Therapuetic Phlebotomy","CDM Revenue Code":"761","CDM HCPCS":"99195","Standard Price":450.0},{"Itemcode":"74401030","Description":"Declot Picc Line/Vad","CDM Revenue Code":"361","CDM HCPCS":"36593","Standard Price":763.0},{"Itemcode":"75100050","Description":"Dry Needling 1-2 Muscles","CDM Revenue Code":"420","CDM HCPCS":"20560","Standard Price":157.0},{"Itemcode":"75100051","Description":"Dry Needling 3++ Muscles","CDM Revenue Code":"420","CDM HCPCS":"20561","Standard Price":205.0},{"Itemcode":"75100108","Description":"Unna Boot Application","CDM Revenue Code":"420","CDM HCPCS":"29580","Standard Price":920.0},{"Itemcode":"75102102","Description":"Electrical Stim","CDM Revenue Code":"420","CDM HCPCS":"G0283","Standard Price":221.0},{"Itemcode":"75102117","Description":"Compression Wrap App Uni","CDM Revenue Code":"420","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"75102118","Description":"Compression Wrap App Bilateral","CDM Revenue Code":"420","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"75102665","Description":"Wound Care Select <= 20 Sq Cm","CDM Revenue Code":"420","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"75103004","Description":"Wound Care Select Ea Add 20 Cm","CDM Revenue Code":"420","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"75103030","Description":"Wound Care - Non Select","CDM Revenue Code":"420","CDM HCPCS":"97602","Standard Price":1049.0},{"Itemcode":"75110050","Description":"Dry Needling 1-2 Muscles","CDM Revenue Code":"420","CDM HCPCS":"20560","Standard Price":157.0},{"Itemcode":"75110051","Description":"Dry Needling 3++ Muscles","CDM Revenue Code":"420","CDM HCPCS":"20561","Standard Price":205.0},{"Itemcode":"75110108","Description":"Unna Boot Application","CDM Revenue Code":"420","CDM HCPCS":"29580","Standard Price":920.0},{"Itemcode":"75112102","Description":"Electrical Stim","CDM Revenue Code":"420","CDM HCPCS":"G0283","Standard Price":221.0},{"Itemcode":"75112665","Description":"Wound Care Select <=20 Sq Cm","CDM Revenue Code":"420","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"75113004","Description":"Wound Care Select Ea Add 20 Cm","CDM Revenue Code":"420","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"75113030","Description":"Wound Care - Non Select","CDM Revenue Code":"420","CDM HCPCS":"97602","Standard Price":1049.0},{"Itemcode":"75140108","Description":"Unna Boot Application","CDM Revenue Code":"420","CDM HCPCS":"29580","Standard Price":920.0},{"Itemcode":"75142102","Description":"ELECTRIC STIM THERAPY 1++ AREA","CDM Revenue Code":"420","CDM HCPCS":"G0283","Standard Price":221.0},{"Itemcode":"75142665","Description":"Wound Care Select <=20 Sq Cm","CDM Revenue Code":"420","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"75143004","Description":"Wound Care Select Ea Add 20 Cm","CDM Revenue Code":"420","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"75143030","Description":"Wound Care Non Select","CDM Revenue Code":"420","CDM HCPCS":"97602","Standard Price":1049.0},{"Itemcode":"75150050","Description":"Dry Needling 1-2 Muscles","CDM Revenue Code":"420","CDM HCPCS":"20560","Standard Price":157.0},{"Itemcode":"75150051","Description":"Dry Needling 3++ Muscles","CDM Revenue Code":"420","CDM HCPCS":"20561","Standard Price":205.0},{"Itemcode":"75152102","Description":"Electrical Stim","CDM Revenue Code":"420","CDM HCPCS":"G0283","Standard Price":221.0},{"Itemcode":"75152665","Description":"Wound Care Select <=20 Sq Cm","CDM Revenue Code":"420","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"75153004","Description":"Wound Care Select Ea Add 20 Cm","CDM Revenue Code":"420","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"75160050","Description":"Dry Needling 1-2 Muscles","CDM Revenue Code":"420","CDM HCPCS":"20560","Standard Price":157.0},{"Itemcode":"75160051","Description":"Dry Needling 3++ Muscles","CDM Revenue Code":"420","CDM HCPCS":"20561","Standard Price":205.0},{"Itemcode":"75162102","Description":"Electric Stim Unattended>1area","CDM Revenue Code":"420","CDM HCPCS":"G0283","Standard Price":221.0},{"Itemcode":"75162665","Description":"Wound Care Select <=20 Sq Cm","CDM Revenue Code":"420","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"75163004","Description":"Wound Care Select Ea Add 20 cm","CDM Revenue Code":"420","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"75200050","Description":"Dry Needling 1-2 Muscles","CDM Revenue Code":"430","CDM HCPCS":"20560","Standard Price":157.0},{"Itemcode":"75200051","Description":"Dry Needling 3++Muscles","CDM Revenue Code":"430","CDM HCPCS":"20561","Standard Price":205.0},{"Itemcode":"75202102","Description":"Electrical Stim","CDM Revenue Code":"430","CDM HCPCS":"G0283","Standard Price":221.0},{"Itemcode":"75202117","Description":"Comp Wrap Rt Lower Leg","CDM Revenue Code":"430","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"75202118","Description":"Comp Wrap Lt Lower Leg","CDM Revenue Code":"430","CDM HCPCS":"29581","Standard Price":1255.0},{"Itemcode":"75202123","Description":"Comp Wrap Rt Arm/Hand/Fingers","CDM Revenue Code":"430","CDM HCPCS":"29584","Standard Price":798.0},{"Itemcode":"75202124","Description":"Comp Wrap Lt Arm/Hand/Fingers","CDM Revenue Code":"430","CDM HCPCS":"29584","Standard Price":798.0},{"Itemcode":"75203004","Description":"Wnd Care SelDeb Ea Add 20 Cm","CDM Revenue Code":"430","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"75203030","Description":"Wnd Care Non-Sel Debridement","CDM Revenue Code":"430","CDM HCPCS":"97602","Standard Price":1049.0},{"Itemcode":"75203665","Description":"Wound Care Select <=20 Sq Cm","CDM Revenue Code":"430","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"75370169","Description":"Rpr Trnk Cmplx 2.6-7.5CM","CDM Revenue Code":"361","CDM HCPCS":"13101","Standard Price":3445.0},{"Itemcode":"75375600","Description":"Selective Debridement <20 Cm","CDM Revenue Code":"761","CDM HCPCS":"97597","Standard Price":926.0},{"Itemcode":"75375602","Description":"Select Debridemnt Ea Add 20 Cm","CDM Revenue Code":"761","CDM HCPCS":"97598","Standard Price":862.0},{"Itemcode":"75375604","Description":"Non-Selective Debridement","CDM Revenue Code":"761","CDM HCPCS":"97602","Standard Price":1049.0},{"Itemcode":"75375606","Description":"Negative Pressure <50 Cm Sjc","CDM Revenue Code":"761","CDM HCPCS":"97605","Standard Price":399.0},{"Itemcode":"75375608","Description":"Negative Pressure >50 Cm Sjc","CDM Revenue Code":"761","CDM HCPCS":"97606","Standard Price":1877.0},{"Itemcode":"75375610","Description":"Unna Boot Application","CDM Revenue Code":"761","CDM HCPCS":"29580","Standard Price":920.0},{"Itemcode":"75390004","Description":"Pavd Or Vad Declot/Repair (Iv)","CDM Revenue Code":"761","CDM HCPCS":"36593","Standard Price":763.0},{"Itemcode":"75390006","Description":"PICC Insertion (Iv)","CDM Revenue Code":"361","CDM HCPCS":"36569","Standard Price":3488.0},{"Itemcode":"75390018","Description":"PICC Replacement","CDM Revenue Code":"361","CDM HCPCS":"36584","Standard Price":3488.0},{"Itemcode":"75395380","Description":"CL Placement Non-Tun >=5 Yrs","CDM Revenue Code":"361","CDM HCPCS":"36556","Standard Price":6232.0},{"Itemcode":"76970180","Description":"Declot VAD/Picc Line","CDM Revenue Code":"361","CDM HCPCS":"36593","Standard Price":763.0},{"Itemcode":"76970185","Description":"Blood Administration - 1 Unit","CDM Revenue Code":"391","CDM HCPCS":"36430","Standard Price":1412.0},{"Itemcode":"76970260","Description":"PICC Line Blood Draw","CDM Revenue Code":"361","CDM HCPCS":"36592","Standard Price":565.0},{"Itemcode":"76971045","Description":"Therapuetic Phlebotomy","CDM Revenue Code":"940","CDM HCPCS":"99195","Standard Price":450.0},{"Itemcode":"76972351","Description":"Vad Blood Draw","CDM Revenue Code":"761","CDM HCPCS":"36591","Standard Price":565.0},{"Itemcode":"77200600","Description":"MNT Individual Initial-15Min","CDM Revenue Code":"942","CDM HCPCS":"97802","Standard Price":160.0},{"Itemcode":"77200601","Description":"MNT Individual Subsqt - 15min","CDM Revenue Code":"942","CDM HCPCS":"97803","Standard Price":160.0},{"Itemcode":"77200602","Description":"MNT Group 30 MIN","CDM Revenue Code":"942","CDM HCPCS":"97804","Standard Price":54.0},{"Itemcode":"0078","Description":"CHEMO INTRATHECAL","CDM Revenue Code":"331","CDM HCPCS":"96450","Standard Price":1364.0},{"Itemcode":"61051013","Description":"Chemo IV Push Add'L Drug","CDM Revenue Code":"331","CDM HCPCS":"96411","Standard Price":412.0},{"Itemcode":"61051014","Description":"Chemo IV Infusion 1StHr IniDrg","CDM Revenue Code":"335","CDM HCPCS":"96413","Standard Price":922.0},{"Itemcode":"61051015","Description":"Chemo IV Infusion Ea Addl Hr","CDM Revenue Code":"335","CDM HCPCS":"96415","Standard Price":739.0},{"Itemcode":"61051016","Description":"Chemo Infuse 8++Hrs - Pump","CDM Revenue Code":"335","CDM HCPCS":"96416","Standard Price":847.0},{"Itemcode":"61051017","Description":"Chemo IV Infus Addl Sequen/Hr","CDM Revenue Code":"335","CDM HCPCS":"96417","Standard Price":303.0},{"Itemcode":"61051024","Description":"VAD Irrigation","CDM Revenue Code":"260","CDM HCPCS":"96523","Standard Price":365.0},{"Itemcode":"61052320","Description":"Chemo: Sc/Im Non-Hormonal","CDM Revenue Code":"331","CDM HCPCS":"96401","Standard Price":573.0},{"Itemcode":"61055011","Description":"Chemo: IV Push Initial","CDM Revenue Code":"331","CDM HCPCS":"96409","Standard Price":782.0},{"Itemcode":"64505003","Description":"Remicade Infusion 1St Hour","CDM Revenue Code":"335","CDM HCPCS":"96413","Standard Price":922.0},{"Itemcode":"64505004","Description":"Remicade Infusion Ea Addl Hour","CDM Revenue Code":"335","CDM HCPCS":"96415","Standard Price":739.0},{"Itemcode":"65101024","Description":"VAD Irrigation","CDM Revenue Code":"260","CDM HCPCS":"96523","Standard Price":365.0},{"Itemcode":"68251010","Description":"Chemo Inj Im/Sq Non-Hormon Hhi","CDM Revenue Code":"331","CDM HCPCS":"96401","Standard Price":573.0},{"Itemcode":"68251011","Description":"Chemo Inj Im/Sq Hormonal Hhi","CDM Revenue Code":"331","CDM HCPCS":"96402","Standard Price":462.0},{"Itemcode":"68251012","Description":"Chemo IV Inj Initial Drug Hh","CDM Revenue Code":"331","CDM HCPCS":"96409","Standard Price":782.0},{"Itemcode":"68251013","Description":"Chemo IV Inj Subsqnt Drug Hh","CDM Revenue Code":"331","CDM HCPCS":"96411","Standard Price":412.0},{"Itemcode":"68251014","Description":"Chemo IV Infusion 1StHr IniDrg","CDM Revenue Code":"335","CDM HCPCS":"96413","Standard Price":922.0},{"Itemcode":"68251015","Description":"Chemo IV Infusn Ea Add Hr Hh","CDM Revenue Code":"335","CDM HCPCS":"96415","Standard Price":739.0},{"Itemcode":"68251016","Description":"Chemo Infuse 8+Hrs - Pump","CDM Revenue Code":"335","CDM HCPCS":"96416","Standard Price":847.0},{"Itemcode":"68251017","Description":"Chemo IV Inf Add'l Sequential","CDM Revenue Code":"335","CDM HCPCS":"96417","Standard Price":303.0},{"Itemcode":"68251018","Description":"Chemo Intra-Arterial Push","CDM Revenue Code":"331","CDM HCPCS":"96420","Standard Price":461.0},{"Itemcode":"68251019","Description":"Chemo Via Thoracentesis","CDM Revenue Code":"335","CDM HCPCS":"96440","Standard Price":470.0},{"Itemcode":"68251020","Description":"Chemo Into Peritoneal Cav","CDM Revenue Code":"335","CDM HCPCS":"96446","Standard Price":470.0},{"Itemcode":"68251021","Description":"Chemo Intrathecal W LP","CDM Revenue Code":"331","CDM HCPCS":"96450","Standard Price":1364.0},{"Itemcode":"68251022","Description":"Portable Pump Refill/Maint Hhi","CDM Revenue Code":"335","CDM HCPCS":"96521","Standard Price":693.0},{"Itemcode":"68251023","Description":"Implanted Pump Refill/Main Hhi","CDM Revenue Code":"260","CDM HCPCS":"96522","Standard Price":637.0},{"Itemcode":"68251024","Description":"VAD Irrigation Hhi","CDM Revenue Code":"260","CDM HCPCS":"96523","Standard Price":365.0},{"Itemcode":"68251025","Description":"Chemo Inj Subarach/Intravent","CDM Revenue Code":"331","CDM HCPCS":"96542","Standard Price":427.0},{"Itemcode":"68252264","Description":"Chemo Admin:Intralesnl<=7Lesns","CDM Revenue Code":"331","CDM HCPCS":"96405","Standard Price":120.0},{"Itemcode":"68261010","Description":"Chemo Inj Im/Sq Non-Hormon Okt","CDM Revenue Code":"331","CDM HCPCS":"96401","Standard Price":573.0},{"Itemcode":"68261011","Description":"Chemo Inj Im/Sq Hormonal Okt","CDM Revenue Code":"331","CDM HCPCS":"96402","Standard Price":462.0},{"Itemcode":"68261012","Description":"Chemo IV Inj Initial Drug Ok","CDM Revenue Code":"331","CDM HCPCS":"96409","Standard Price":782.0},{"Itemcode":"68261013","Description":"Chemo IV Inj Subsequent Ok","CDM Revenue Code":"331","CDM HCPCS":"96411","Standard Price":412.0},{"Itemcode":"68261014","Description":"Chemo IV Infusion 1St Hr Ok","CDM Revenue Code":"335","CDM HCPCS":"96413","Standard Price":922.0},{"Itemcode":"68261015","Description":"Chemo IV Infusn Ea Addl Hr Ok","CDM Revenue Code":"335","CDM HCPCS":"96415","Standard Price":739.0},{"Itemcode":"68261016","Description":"Chemo Infuse 8+Hrs - Pump","CDM Revenue Code":"335","CDM HCPCS":"96416","Standard Price":847.0},{"Itemcode":"68261017","Description":"Chemo IV Inf Add'l Sequential","CDM Revenue Code":"335","CDM HCPCS":"96417","Standard Price":303.0},{"Itemcode":"68261018","Description":"Chemo Intra-Arterial Push Okt","CDM Revenue Code":"331","CDM HCPCS":"96420","Standard Price":461.0},{"Itemcode":"68261019","Description":"Chemo Via Thoracentesis Okt","CDM Revenue Code":"335","CDM HCPCS":"96440","Standard Price":470.0},{"Itemcode":"68261020","Description":"Chemo Into Peritoneal Cav Okt","CDM Revenue Code":"335","CDM HCPCS":"96446","Standard Price":470.0},{"Itemcode":"68261021","Description":"Chemo Intrathecal W LP","CDM Revenue Code":"331","CDM HCPCS":"96450","Standard Price":1364.0},{"Itemcode":"68261022","Description":"Portable Pump Refill/Maint Okt","CDM Revenue Code":"260","CDM HCPCS":"96521","Standard Price":693.0},{"Itemcode":"68261023","Description":"Implanted Pump Refill/Main Okt","CDM Revenue Code":"260","CDM HCPCS":"96522","Standard Price":637.0},{"Itemcode":"68261024","Description":"Vad Irrigation Okt","CDM Revenue Code":"761","CDM HCPCS":"96523","Standard Price":365.0},{"Itemcode":"68261025","Description":"Chemo Inj Subarach/Intravent","CDM Revenue Code":"331","CDM HCPCS":"96542","Standard Price":427.0},{"Itemcode":"68262264","Description":"Chemo Admin:Intralesnl<=7Lesns","CDM Revenue Code":"331","CDM HCPCS":"96405","Standard Price":120.0},{"Itemcode":"68262265","Description":"Chemo Admin:Intralesnl>=7Lesns","CDM Revenue Code":"331","CDM HCPCS":"96406","Standard Price":480.0},{"Itemcode":"68300259","Description":"Fiducial Markr Placmnt-NonPros","CDM Revenue Code":"333","CDM HCPCS":"49411","Standard Price":2836.0},{"Itemcode":"71700181","Description":"Port Flush","CDM Revenue Code":"761","CDM HCPCS":"96523","Standard Price":365.0},{"Itemcode":"74401009","Description":"MAB/BRN Subq/Im Non-Hormonal","CDM Revenue Code":"331","CDM HCPCS":"96401","Standard Price":573.0},{"Itemcode":"74401011","Description":"MAB/BRN IV Push Initial","CDM Revenue Code":"331","CDM HCPCS":"96409","Standard Price":782.0},{"Itemcode":"74401012","Description":"MAB/BRN IV Push Add'L Drug","CDM Revenue Code":"331","CDM HCPCS":"96411","Standard Price":412.0},{"Itemcode":"74401013","Description":"MAB/BRN IV Infusion First Hr","CDM Revenue Code":"335","CDM HCPCS":"96413","Standard Price":922.0},{"Itemcode":"74401014","Description":"MAB/BRN Infusion Ea Add 1Hr","CDM Revenue Code":"335","CDM HCPCS":"96415","Standard Price":739.0},{"Itemcode":"74401016","Description":"MAB/BRN IV Infus Add'l Sequen","CDM Revenue Code":"335","CDM HCPCS":"96417","Standard Price":303.0},{"Itemcode":"74401017","Description":"Cadd Pump Refill/Maintenance","CDM Revenue Code":"761","CDM HCPCS":"96521","Standard Price":693.0},{"Itemcode":"74401022","Description":"Vad Irrigation","CDM Revenue Code":"761","CDM HCPCS":"96523","Standard Price":365.0},{"Itemcode":"76970130","Description":"Chemo Intrathecal W LP","CDM Revenue Code":"331","CDM HCPCS":"96450","Standard Price":1364.0},{"Itemcode":"76970145","Description":"Chemo: IV Push Initial","CDM Revenue Code":"331","CDM HCPCS":"96409","Standard Price":782.0},{"Itemcode":"76970155","Description":"Chemo Infuse 8+Hrs - Pump","CDM Revenue Code":"335","CDM HCPCS":"96416","Standard Price":847.0},{"Itemcode":"76970160","Description":"Chemo IV Infusion First Hr","CDM Revenue Code":"335","CDM HCPCS":"96413","Standard Price":922.0},{"Itemcode":"76970170","Description":"Chemo: Infusion Ea Add 1Hr","CDM Revenue Code":"335","CDM HCPCS":"96415","Standard Price":739.0},{"Itemcode":"76971023","Description":"Implanted Pump Refill/Main","CDM Revenue Code":"260","CDM HCPCS":"96522","Standard Price":637.0},{"Itemcode":"76971024","Description":"Vad Irrigation","CDM Revenue Code":"260","CDM HCPCS":"96523","Standard Price":365.0},{"Itemcode":"76972264","Description":"Chemo Admin:Intralesnl<=7Lesns","CDM Revenue Code":"331","CDM HCPCS":"96405","Standard Price":120.0},{"Itemcode":"76972265","Description":"Chemo Admin:Intralesnl>=7Lesns","CDM Revenue Code":"331","CDM HCPCS":"96406","Standard Price":480.0},{"Itemcode":"76972300","Description":"Chemo-Pump/Refill/Dc - Port","CDM Revenue Code":"335","CDM HCPCS":"96521","Standard Price":693.0},{"Itemcode":"76972320","Description":"Chemo: Sc/Im Non-Hormonal","CDM Revenue Code":"331","CDM HCPCS":"96401","Standard Price":573.0},{"Itemcode":"76972321","Description":"Chemo Inj: Sq/Im Hormonal","CDM Revenue Code":"331","CDM HCPCS":"96402","Standard Price":462.0},{"Itemcode":"76972348","Description":"Chemo IV Push Add'L Drug","CDM Revenue Code":"331","CDM HCPCS":"96411","Standard Price":412.0},{"Itemcode":"76972349","Description":"Chemo IV Infus Addl Sequen/Hr","CDM Revenue Code":"335","CDM HCPCS":"96417","Standard Price":303.0},{"Itemcode":"0179","Description":"Zevalin Therapuetic Admin","CDM Revenue Code":"340","CDM HCPCS":"79403","Standard Price":4006.0},{"Itemcode":"2106","Description":"Superv Hnd Load- Rad Source","CDM Revenue Code":"333","CDM HCPCS":"77790","Standard Price":633.0},{"Itemcode":"5509","Description":"Brachytherapy-Interstitial Com","CDM Revenue Code":"333","CDM HCPCS":"77778","Standard Price":3665.0},{"Itemcode":"5514","Description":"Brachyth-Intracav-Complex","CDM Revenue Code":"333","CDM HCPCS":"77763","Standard Price":4163.0},{"Itemcode":"5515","Description":"Basic Dosimetry Calculation","CDM Revenue Code":"333","CDM HCPCS":"77300","Standard Price":813.0},{"Itemcode":"68300005","Description":"Simulation Simple","CDM Revenue Code":"333","CDM HCPCS":"77280","Standard Price":1365.0},{"Itemcode":"68300010","Description":"Simulation Intermediate","CDM Revenue Code":"333","CDM HCPCS":"77285","Standard Price":1921.0},{"Itemcode":"68300015","Description":"Simulation Complex","CDM Revenue Code":"333","CDM HCPCS":"77290","Standard Price":2624.0},{"Itemcode":"68300017","Description":"Special Treatment Proc (Srs)","CDM Revenue Code":"333","CDM HCPCS":"77470","Standard Price":3596.0},{"Itemcode":"68300018","Description":"Port Films Rad Image (SRS)","CDM Revenue Code":"333","CDM HCPCS":"77417","Standard Price":355.0},{"Itemcode":"68300020","Description":"Simulation 3D","CDM Revenue Code":"333","CDM HCPCS":"77295","Standard Price":8431.0},{"Itemcode":"68300025","Description":"Basic Dosimetry Calculation","CDM Revenue Code":"333","CDM HCPCS":"77300","Standard Price":813.0},{"Itemcode":"68300030","Description":"IMRT Planning","CDM Revenue Code":"333","CDM HCPCS":"77301","Standard Price":8784.0},{"Itemcode":"68300041","Description":"Telethx Isodose Plan, Simple","CDM Revenue Code":"333","CDM HCPCS":"77306","Standard Price":2027.0},{"Itemcode":"68300046","Description":"Telethx Isodose Plan, Complex","CDM Revenue Code":"333","CDM HCPCS":"77307","Standard Price":2737.0},{"Itemcode":"68300050","Description":"Special Teletherapy Port Plan","CDM Revenue Code":"333","CDM HCPCS":"77321","Standard Price":1699.0},{"Itemcode":"68300056","Description":"Brachytx Isodose Plan Simple","CDM Revenue Code":"333","CDM HCPCS":"77316","Standard Price":1946.0},{"Itemcode":"68300061","Description":"Brachytx Isodose Plan Interm w","CDM Revenue Code":"333","CDM HCPCS":"77317","Standard Price":2455.0},{"Itemcode":"68300066","Description":"Brachytx Isodose Plan Complx w","CDM Revenue Code":"333","CDM HCPCS":"77318","Standard Price":3071.0},{"Itemcode":"68300070","Description":"Special Dosimetry","CDM Revenue Code":"333","CDM HCPCS":"77331","Standard Price":616.0},{"Itemcode":"68300075","Description":"Treatment Devices Simple","CDM Revenue Code":"333","CDM HCPCS":"77332","Standard Price":747.0},{"Itemcode":"68300080","Description":"Treatment Devices Intermediate","CDM Revenue Code":"333","CDM HCPCS":"77333","Standard Price":1192.0},{"Itemcode":"68300085","Description":"Treatment Devices Complex","CDM Revenue Code":"333","CDM HCPCS":"77334","Standard Price":1729.0},{"Itemcode":"68300090","Description":"Continuing Med Phys Consult","CDM Revenue Code":"333","CDM HCPCS":"77336","Standard Price":973.0},{"Itemcode":"68300095","Description":"Treatment Devices Imrt","CDM Revenue Code":"333","CDM HCPCS":"77338","Standard Price":2201.0},{"Itemcode":"68300100","Description":"Special Med Physics Consult","CDM Revenue Code":"333","CDM HCPCS":"77370","Standard Price":784.0},{"Itemcode":"68300102","Description":"Tx Delivery >1MeV, Simple","CDM Revenue Code":"333","CDM HCPCS":"77402","Standard Price":881.0},{"Itemcode":"68300131","Description":"TX Deliv w/Criteria;to 5MeV","CDM Revenue Code":"333","CDM HCPCS":"77412","Standard Price":1232.0},{"Itemcode":"68300150","Description":"Port Films Rad Image","CDM Revenue Code":"333","CDM HCPCS":"77417","Standard Price":355.0},{"Itemcode":"68300154","Description":"IMRT Tx Deliv, Simple","CDM Revenue Code":"333","CDM HCPCS":"77385","Standard Price":1818.0},{"Itemcode":"68300156","Description":"IMRT Tx Deliv, Complex","CDM Revenue Code":"333","CDM HCPCS":"77386","Standard Price":2956.0},{"Itemcode":"68300165","Description":"SBRT MGMT 1+LSNS <=5 FRACTNS","CDM Revenue Code":"333","CDM HCPCS":"77435","Standard Price":768.0},{"Itemcode":"68300170","Description":"Special Treatment Procedure","CDM Revenue Code":"333","CDM HCPCS":"77470","Standard Price":3596.0},{"Itemcode":"68300185","Description":"Brachytherapy Handling/Ldg","CDM Revenue Code":"333","CDM HCPCS":"77790","Standard Price":633.0},{"Itemcode":"68300200","Description":"Brachy Intracav: Simple","CDM Revenue Code":"333","CDM HCPCS":"77761","Standard Price":3209.0},{"Itemcode":"68300205","Description":"Brachy Intracav: Intermediate","CDM Revenue Code":"333","CDM HCPCS":"77762","Standard Price":3328.0},{"Itemcode":"68300210","Description":"Brachy Intracav: Complex","CDM Revenue Code":"333","CDM HCPCS":"77763","Standard Price":4163.0},{"Itemcode":"68300216","Description":"HDRRDNCL NTRSTL/ICAVBRCHTX 1CH","CDM Revenue Code":"333","CDM HCPCS":"77770","Standard Price":2189.0},{"Itemcode":"68300217","Description":"HDRRDNCL NTRSTL/ICAVBRCHTX2-12","CDM Revenue Code":"333","CDM HCPCS":"77771","Standard Price":3090.0},{"Itemcode":"68300218","Description":"HDRRDNCL NTRSTL/ICAVBRCHTX >12","CDM Revenue Code":"333","CDM HCPCS":"77772","Standard Price":4074.0},{"Itemcode":"68300225","Description":"Brachy Interstitial: Complex","CDM Revenue Code":"333","CDM HCPCS":"77778","Standard Price":3665.0},{"Itemcode":"68300245","Description":"Infuse/Instill Radioelement","CDM Revenue Code":"333","CDM HCPCS":"77750","Standard Price":1398.0},{"Itemcode":"68300254","Description":"INSERT CERVICAL CYLINDERS","CDM Revenue Code":"333","CDM HCPCS":"57156","Standard Price":5009.0},{"Itemcode":"68300261","Description":"SRS CRANIAL SGL SESSION","CDM Revenue Code":"333","CDM HCPCS":"77372","Standard Price":27973.0},{"Itemcode":"68300263","Description":"SBRT DELIVRY PER FRACTN >=1LSN","CDM Revenue Code":"333","CDM HCPCS":"77373","Standard Price":17746.0},{"Itemcode":"68320001","Description":"Treatment Devices Simple","CDM Revenue Code":"333","CDM HCPCS":"77332","Standard Price":747.0},{"Itemcode":"68320002","Description":"Treatment Devices Complex","CDM Revenue Code":"333","CDM HCPCS":"77334","Standard Price":1729.0},{"Itemcode":"68320003","Description":"Special Treatment Proc (Srs)","CDM Revenue Code":"333","CDM HCPCS":"77470","Standard Price":3596.0},{"Itemcode":"71820001","Description":"Simulation Complex","CDM Revenue Code":"333","CDM HCPCS":"77290","Standard Price":2624.0},{"Itemcode":"63200012","Description":"EEG","CDM Revenue Code":"740","CDM HCPCS":"95816","Standard Price":1236.0},{"Itemcode":"63200016","Description":"EEG Sleep Deprived","CDM Revenue Code":"740","CDM HCPCS":"95819","Standard Price":1475.0},{"Itemcode":"63200023","Description":"EEG (24 Hour Monitoring)","CDM Revenue Code":"740","CDM HCPCS":"95953","Standard Price":4725.0},{"Itemcode":"63200084","Description":"Video Eeg Monitoring (Ea 24Hr)","CDM Revenue Code":"740","CDM HCPCS":"95951","Standard Price":6346.0},{"Itemcode":"63200086","Description":"EEG Extended (41-60 Minutes)","CDM Revenue Code":"740","CDM HCPCS":"95812","Standard Price":1910.0},{"Itemcode":"63200120","Description":"EEG 61-119 minutes","CDM Revenue Code":"740","CDM HCPCS":"95813","Standard Price":1778.0},{"Itemcode":"63200128","Description":"EEG Coma","CDM Revenue Code":"740","CDM HCPCS":"95822","Standard Price":1446.0},{"Itemcode":"63200205","Description":"Video Eeg Less Than 12 Hours","CDM Revenue Code":"740","CDM HCPCS":"95951","Standard Price":6346.0},{"Itemcode":"63200251","Description":"EEG Inital Set Up","CDM Revenue Code":"740","CDM HCPCS":"95700","Standard Price":1910.0},{"Itemcode":"63200252","Description":"EEG 2-12 Hrs Unmonitored","CDM Revenue Code":"740","CDM HCPCS":"95705","Standard Price":4725.0},{"Itemcode":"63200253","Description":"EEG 2-12 Hrs Intermittent","CDM Revenue Code":"740","CDM HCPCS":"95706","Standard Price":4725.0},{"Itemcode":"63200254","Description":"EEG 2-12 Hrs Continuous","CDM Revenue Code":"740","CDM HCPCS":"95707","Standard Price":4725.0},{"Itemcode":"63200255","Description":"EEG 12-26 Hrs Unmonitored","CDM Revenue Code":"740","CDM HCPCS":"95708","Standard Price":4725.0},{"Itemcode":"63200256","Description":"EEG 12-26 Hrs Intermittent","CDM Revenue Code":"740","CDM HCPCS":"95709","Standard Price":4725.0},{"Itemcode":"63200257","Description":"EEG 12-26 Hrs Continuous","CDM Revenue Code":"740","CDM HCPCS":"95710","Standard Price":4725.0},{"Itemcode":"63200258","Description":"EEG Video 2-12 Hrs Unmonit","CDM Revenue Code":"740","CDM HCPCS":"95711","Standard Price":4725.0},{"Itemcode":"63200259","Description":"EEG Video 2-12 Hrs Intermitt","CDM Revenue Code":"740","CDM HCPCS":"95712","Standard Price":4725.0},{"Itemcode":"63200260","Description":"EEG Video 2-12 Hrs Continuous","CDM Revenue Code":"740","CDM HCPCS":"95713","Standard Price":4725.0},{"Itemcode":"63200261","Description":"EEG Video 12-26 Hrs Unmonit","CDM Revenue Code":"740","CDM HCPCS":"95714","Standard Price":4725.0},{"Itemcode":"63200262","Description":"EEG Video 12-26 Hrs Intermitt","CDM Revenue Code":"740","CDM HCPCS":"95715","Standard Price":4725.0},{"Itemcode":"63200263","Description":"EEG Video 12-26 Hrs Continuous","CDM Revenue Code":"740","CDM HCPCS":"95716","Standard Price":4725.0},{"Itemcode":"64100793","Description":"EEG Non-Intracranial Intraop","CDM Revenue Code":"740","CDM HCPCS":"95955","Standard Price":124.0},{"Itemcode":"65103261","Description":"Monitoring: Nibp","CDM Revenue Code":"921","CDM HCPCS":"93770","Standard Price":211.0},{"Itemcode":"71705543","Description":"Dft Testing","CDM Revenue Code":"361","CDM HCPCS":"93641","Standard Price":1912.0},{"Itemcode":"72205321","Description":"EP Eval Lt:Vent W/Pacing/Rec","CDM Revenue Code":"480","CDM HCPCS":"93622","Standard Price":2028.0},{"Itemcode":"72205529","Description":"Dft (Lead & Gnrtr Test)","CDM Revenue Code":"481","CDM HCPCS":"93641","Standard Price":1912.0},{"Itemcode":"72300038","Description":"Treadmill Stress Testing","CDM Revenue Code":"482","CDM HCPCS":"93017","Standard Price":962.0},{"Itemcode":"72300041","Description":"Holter Monitor Scanning","CDM Revenue Code":"731","CDM HCPCS":"93226","Standard Price":1878.0},{"Itemcode":"72300050","Description":"Holt Monitor Ext 3-14 Days","CDM Revenue Code":"731","CDM HCPCS":"0296T","Standard Price":131.0},{"Itemcode":"72303001","Description":"EKG, 12 LEAD, TRACING ONLY","CDM Revenue Code":"730","CDM HCPCS":"93005","Standard Price":245.0},{"Itemcode":"72303005","Description":"Rhythm Strip, Tracing Only","CDM Revenue Code":"730","CDM HCPCS":"93041","Standard Price":531.0},{"Itemcode":"72303009","Description":"Holter Monitor Use","CDM Revenue Code":"731","CDM HCPCS":"93225","Standard Price":195.0},{"Itemcode":"72303064","Description":"Cardio Stress Test","CDM Revenue Code":"482","CDM HCPCS":"93017","Standard Price":962.0},{"Itemcode":"72303105","Description":"Signal Averaged Ekg","CDM Revenue Code":"730","CDM HCPCS":"93278","Standard Price":542.0},{"Itemcode":"72303176","Description":"Event Monitor Hook-Up","CDM Revenue Code":"730","CDM HCPCS":"93270","Standard Price":1079.0},{"Itemcode":"75800068","Description":"Chd Cardio Stress Test","CDM Revenue Code":"482","CDM HCPCS":"93017","Standard Price":874.0},{"Itemcode":"5510","Description":"ABI W/Wo Exercise-W/Toe Pressu","CDM Revenue Code":"921","CDM HCPCS":"93923","Standard Price":708.0},{"Itemcode":"6105","Description":"Art Abi W/Wave Forms & Toe Prs","CDM Revenue Code":"921","CDM HCPCS":"93922","Standard Price":916.0},{"Itemcode":"61600100","Description":"Hearing Screen","CDM Revenue Code":"470","CDM HCPCS":"92586","Standard Price":1904.0},{"Itemcode":"63200002","Description":"Auditory Brainstem Rp Abr","CDM Revenue Code":"471","CDM HCPCS":"92585","Standard Price":3438.0},{"Itemcode":"63200004","Description":"Tympanometry","CDM Revenue Code":"471","CDM HCPCS":"92567","Standard Price":184.0},{"Itemcode":"63200005","Description":"Audiology Speech Discrim","CDM Revenue Code":"471","CDM HCPCS":"92556","Standard Price":209.0},{"Itemcode":"63200006","Description":"Audiology Sisi","CDM Revenue Code":"471","CDM HCPCS":"92564","Standard Price":207.0},{"Itemcode":"63200007","Description":"Audiology Tone Decay","CDM Revenue Code":"471","CDM HCPCS":"92563","Standard Price":202.0},{"Itemcode":"63200008","Description":"Audiology A B L B","CDM Revenue Code":"471","CDM HCPCS":"92562","Standard Price":189.0},{"Itemcode":"63200010","Description":"Speech Reception Threshol","CDM Revenue Code":"471","CDM HCPCS":"92555","Standard Price":207.0},{"Itemcode":"63200014","Description":"Visual Evoked Response","CDM Revenue Code":"922","CDM HCPCS":"95930","Standard Price":1532.0},{"Itemcode":"63200017","Description":"Somatosensory Upper","CDM Revenue Code":"922","CDM HCPCS":"95925","Standard Price":1291.0},{"Itemcode":"63200040","Description":"Conditioning Play Audiometry","CDM Revenue Code":"471","CDM HCPCS":"92582","Standard Price":1404.0},{"Itemcode":"63200050","Description":"Audiology Air Bone Con","CDM Revenue Code":"471","CDM HCPCS":"92553","Standard Price":292.0},{"Itemcode":"63200051","Description":"Audiology Air Conduction","CDM Revenue Code":"471","CDM HCPCS":"92552","Standard Price":327.0},{"Itemcode":"63200055","Description":"Acoustic Reflex Testing","CDM Revenue Code":"471","CDM HCPCS":"92568","Standard Price":190.0},{"Itemcode":"63200057","Description":"Spontaneous/Gazes","CDM Revenue Code":"471","CDM HCPCS":"92541","Standard Price":358.0},{"Itemcode":"63200058","Description":"Positional Tests","CDM Revenue Code":"471","CDM HCPCS":"92542","Standard Price":358.0},{"Itemcode":"63200060","Description":"Optokinetic Tests","CDM Revenue Code":"471","CDM HCPCS":"92544","Standard Price":358.0},{"Itemcode":"63200061","Description":"Oscillating Tracking Test","CDM Revenue Code":"471","CDM HCPCS":"92545","Standard Price":358.0},{"Itemcode":"63200062","Description":"Vestibular Eval (Eng/Vng)","CDM Revenue Code":"471","CDM HCPCS":"92540","Standard Price":1106.0},{"Itemcode":"63200063","Description":"Tymp-Reflex Threshold & Decay","CDM Revenue Code":"471","CDM HCPCS":"92570","Standard Price":393.0},{"Itemcode":"63200064","Description":"Typmanometry/Reflex Threshold","CDM Revenue Code":"471","CDM HCPCS":"92550","Standard Price":343.0},{"Itemcode":"63200066","Description":"Tympanom/Reflx Thresh- Red Svc","CDM Revenue Code":"471","CDM HCPCS":"92550","Standard Price":343.0},{"Itemcode":"63200067","Description":"Acoustic Reflex Testing-RedSvc","CDM Revenue Code":"471","CDM HCPCS":"92568","Standard Price":95.0},{"Itemcode":"63200068","Description":"EQUI-SOT","CDM Revenue Code":"471","CDM HCPCS":"92548","Standard Price":1422.0},{"Itemcode":"63200069","Description":"Tymp-Refl Thrshld&Decay RedSvc","CDM Revenue Code":"471","CDM HCPCS":"92570","Standard Price":200.0},{"Itemcode":"63200080","Description":"Otoacoustic Emissions","CDM Revenue Code":"471","CDM HCPCS":"92587","Standard Price":379.0},{"Itemcode":"63200087","Description":"Hearing Screen Air Only","CDM Revenue Code":"471","CDM HCPCS":"92551","Standard Price":104.0},{"Itemcode":"63200088","Description":"Somatosensory Lower","CDM Revenue Code":"922","CDM HCPCS":"95926","Standard Price":1149.0},{"Itemcode":"63200091","Description":"Somatosensory Upper & Lower","CDM Revenue Code":"922","CDM HCPCS":"95938","Standard Price":2944.0},{"Itemcode":"63200100","Description":"Use Of Vertical Electrodes","CDM Revenue Code":"471","CDM HCPCS":"92547","Standard Price":348.0},{"Itemcode":"63200124","Description":"ABR With Medication","CDM Revenue Code":"471","CDM HCPCS":"92585","Standard Price":3438.0},{"Itemcode":"63200125","Description":"Visual Reinforcement Audiometr","CDM Revenue Code":"471","CDM HCPCS":"92579","Standard Price":1027.0},{"Itemcode":"63200126","Description":"Comprensive Audiometry","CDM Revenue Code":"471","CDM HCPCS":"92557","Standard Price":1268.0},{"Itemcode":"63200127","Description":"ABR Limited W/Med","CDM Revenue Code":"471","CDM HCPCS":"92586","Standard Price":2972.0},{"Itemcode":"63200202","Description":"Somatosensory Trunk","CDM Revenue Code":"922","CDM HCPCS":"95927","Standard Price":914.0},{"Itemcode":"63200203","Description":"ABR Limited","CDM Revenue Code":"471","CDM HCPCS":"92586","Standard Price":1904.0},{"Itemcode":"63200207","Description":"Stenger Test Pure Tone","CDM Revenue Code":"471","CDM HCPCS":"92565","Standard Price":269.0},{"Itemcode":"63200250","Description":"EQUI - Total","CDM Revenue Code":"471","CDM HCPCS":"92549","Standard Price":1422.0},{"Itemcode":"63250012","Description":"Home Sleep Testing","CDM Revenue Code":"920","CDM HCPCS":"G0400","Standard Price":740.0},{"Itemcode":"64100781","Description":"SSEP Upper Extremities","CDM Revenue Code":"922","CDM HCPCS":"95925","Standard Price":1291.0},{"Itemcode":"64100782","Description":"SSEP Lower Extremities","CDM Revenue Code":"922","CDM HCPCS":"95926","Standard Price":1149.0},{"Itemcode":"64100783","Description":"Transcranial Motor Stim Upper","CDM Revenue Code":"922","CDM HCPCS":"95928","Standard Price":470.0},{"Itemcode":"64100784","Description":"Transcranial Motor Stim Lower","CDM Revenue Code":"922","CDM HCPCS":"95929","Standard Price":463.0},{"Itemcode":"64100787","Description":"Motor Nerve Test- 1-2 Studies","CDM Revenue Code":"922","CDM HCPCS":"95907","Standard Price":438.0},{"Itemcode":"64100790","Description":"Repetitive Stim Mep/Tof","CDM Revenue Code":"922","CDM HCPCS":"95937","Standard Price":723.0},{"Itemcode":"64504500","Description":"Hydrogen Breath Test","CDM Revenue Code":"759","CDM HCPCS":"91065","Standard Price":2504.0},{"Itemcode":"64504600","Description":"Manometry: Anorectal","CDM Revenue Code":"759","CDM HCPCS":"91122","Standard Price":2216.0},{"Itemcode":"64505206","Description":"Pudendal Nerve Conductn Study","CDM Revenue Code":"922","CDM HCPCS":"95907","Standard Price":438.0},{"Itemcode":"65106306","Description":"Pulse Ox Continuous","CDM Revenue Code":"410","CDM HCPCS":"94762","Standard Price":343.0},{"Itemcode":"68261036","Description":"Percut Allergy Skin test","CDM Revenue Code":"924","CDM HCPCS":"95004","Standard Price":140.0},{"Itemcode":"68300260","Description":"RESPIRATORY MOTION MGMT","CDM Revenue Code":"333","CDM HCPCS":"77293","Standard Price":1115.0},{"Itemcode":"7012","Description":"Arterial Lower: W/O Exercise","CDM Revenue Code":"921","CDM HCPCS":"93923","Standard Price":708.0},{"Itemcode":"7013","Description":"Arterial Lower: W/Exercise","CDM Revenue Code":"921","CDM HCPCS":"93924","Standard Price":1405.0},{"Itemcode":"7031","Description":"Ankle/Brachial Ind W-W/O Exer","CDM Revenue Code":"921","CDM HCPCS":"93924","Standard Price":1405.0},{"Itemcode":"7032","Description":"ABI (W/O Exercise)","CDM Revenue Code":"921","CDM HCPCS":"93922","Standard Price":916.0},{"Itemcode":"7082","Description":"Arterial Upper Extr Digits -Bi","CDM Revenue Code":"921","CDM HCPCS":"93923","Standard Price":708.0},{"Itemcode":"7206","Description":"NONINV ART STUDY (MULT LEVELS)","CDM Revenue Code":"921","CDM HCPCS":"93923","Standard Price":708.0},{"Itemcode":"7207","Description":"NONINV ART STUDY-1,2 Lvls","CDM Revenue Code":"921","CDM HCPCS":"93922","Standard Price":916.0},{"Itemcode":"7208","Description":"NONINV ART STUDY (SGL LVL) UNI","CDM Revenue Code":"921","CDM HCPCS":"93922","Standard Price":916.0},{"Itemcode":"72300021","Description":"Pulse Oximetry Single","CDM Revenue Code":"460","CDM HCPCS":"94760","Standard Price":89.0},{"Itemcode":"73100055","Description":"Et Co2 Daily","CDM Revenue Code":"460","CDM HCPCS":"94770","Standard Price":448.0},{"Itemcode":"73100064","Description":"Pulse Oximetry Sngl","CDM Revenue Code":"460","CDM HCPCS":"94760","Standard Price":89.0},{"Itemcode":"73100066","Description":"Pulse Oximetry Max Exrc","CDM Revenue Code":"460","CDM HCPCS":"94761","Standard Price":267.0},{"Itemcode":"73100067","Description":"PFT Bedside","CDM Revenue Code":"460","CDM HCPCS":"94010","Standard Price":411.0},{"Itemcode":"73100071","Description":"Pulse Ox Daily","CDM Revenue Code":"460","CDM HCPCS":"94762","Standard Price":343.0},{"Itemcode":"73100103","Description":"Pulse Oximetry Overnight","CDM Revenue Code":"460","CDM HCPCS":"94762","Standard Price":343.0},{"Itemcode":"73100301","Description":"Spirometry","CDM Revenue Code":"460","CDM HCPCS":"94010","Standard Price":411.0},{"Itemcode":"73103003","Description":"DLCO","CDM Revenue Code":"460","CDM HCPCS":"94729","Standard Price":532.0},{"Itemcode":"73103004","Description":"Pft B/A Bronchodilator","CDM Revenue Code":"460","CDM HCPCS":"94060","Standard Price":485.0},{"Itemcode":"73103006","Description":"FV Loop","CDM Revenue Code":"460","CDM HCPCS":"94375","Standard Price":458.0},{"Itemcode":"73103013","Description":"PFT B/A Bronchodilator Bedsid","CDM Revenue Code":"460","CDM HCPCS":"94060","Standard Price":485.0},{"Itemcode":"73103015","Description":"Pulmonary Stress Test","CDM Revenue Code":"460","CDM HCPCS":"94621","Standard Price":1294.0},{"Itemcode":"73103017","Description":"Indirect Calorimetry","CDM Revenue Code":"460","CDM HCPCS":"94690","Standard Price":959.0},{"Itemcode":"73103020","Description":"PFT Methacholine Chlng","CDM Revenue Code":"460","CDM HCPCS":"94070","Standard Price":281.0},{"Itemcode":"73103068","Description":"MVV - Maximal Vol Ventilation","CDM Revenue Code":"460","CDM HCPCS":"94200","Standard Price":536.0},{"Itemcode":"73103069","Description":"Plethsymography Lung Vol & Raw","CDM Revenue Code":"460","CDM HCPCS":"94726","Standard Price":1406.0},{"Itemcode":"73200301","Description":"Spirometry","CDM Revenue Code":"460","CDM HCPCS":"94010","Standard Price":411.0},{"Itemcode":"73203068","Description":"MVV - Maximal Vol Ventilation","CDM Revenue Code":"460","CDM HCPCS":"94200","Standard Price":536.0},{"Itemcode":"73203069","Description":"Plethsymography Lung Vol & Raw","CDM Revenue Code":"460","CDM HCPCS":"94726","Standard Price":1406.0},{"Itemcode":"73203071","Description":"PFT Bedside","CDM Revenue Code":"460","CDM HCPCS":"94010","Standard Price":411.0},{"Itemcode":"73203072","Description":"DLCO","CDM Revenue Code":"460","CDM HCPCS":"94729","Standard Price":532.0},{"Itemcode":"73203073","Description":"Pft B/A Bronchodilator","CDM Revenue Code":"460","CDM HCPCS":"94060","Standard Price":485.0},{"Itemcode":"73203076","Description":"PFT B/A Bronchodilator Bedsid","CDM Revenue Code":"460","CDM HCPCS":"94060","Standard Price":485.0},{"Itemcode":"74221030","Description":"HTC-Ambulatory BP Recording","CDM Revenue Code":"920","CDM HCPCS":"93786","Standard Price":99.0},{"Itemcode":"74401036","Description":"Perc Allergy SkinTest SPC NMBR","CDM Revenue Code":"924","CDM HCPCS":"95004","Standard Price":140.0},{"Itemcode":"63250002","Description":"Mult Sleep Latency Testing","CDM Revenue Code":"740","CDM HCPCS":"95805","Standard Price":5836.0},{"Itemcode":"63250004","Description":"PSG W/Cpap/Bi Pap","CDM Revenue Code":"740","CDM HCPCS":"95811","Standard Price":6926.0},{"Itemcode":"63250010","Description":"PSG W/3 Parameters","CDM Revenue Code":"740","CDM HCPCS":"95808","Standard Price":3507.0},{"Itemcode":"63250011","Description":"PSG W/4 Or More Parameters","CDM Revenue Code":"740","CDM HCPCS":"95810","Standard Price":6693.0},{"Itemcode":"75100054","Description":"Cogn Funct 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"97129","Standard Price":205.0},{"Itemcode":"75100055","Description":"Cogn Funct Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"97130","Standard Price":125.0},{"Itemcode":"75100162","Description":"VR Exer Therapeutic 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75100163","Description":"VR Gait Training 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97116","Standard Price":158.0},{"Itemcode":"75100307","Description":"Home Management Tx - Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75100309","Description":"Selfcare Home Tx - Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75100314","Description":"Wheelchair Mgmt/Train 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97542","Standard Price":110.0},{"Itemcode":"75100315","Description":"Community Reentry Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97537","Standard Price":581.0},{"Itemcode":"75100316","Description":"Group Treatment","CDM Revenue Code":"420","CDM HCPCS":"97150","Standard Price":367.0},{"Itemcode":"75100337","Description":"PT Rehab IP Eval Low 20Min","CDM Revenue Code":"424","CDM HCPCS":"97161","Standard Price":488.0},{"Itemcode":"75100338","Description":"PT Rehab IP Eval Mod 30Min","CDM Revenue Code":"424","CDM HCPCS":"97162","Standard Price":488.0},{"Itemcode":"75100339","Description":"PT Rehab IP Eval High 45Min","CDM Revenue Code":"424","CDM HCPCS":"97163","Standard Price":488.0},{"Itemcode":"75100340","Description":"PT Rehab IP Re-Eval EST20Min","CDM Revenue Code":"424","CDM HCPCS":"97164","Standard Price":323.0},{"Itemcode":"75100502","Description":"Pre-Op Eval 30 Min","CDM Revenue Code":"420","CDM HCPCS":"97750","Standard Price":238.0},{"Itemcode":"75100503","Description":"Therapeutic Activities 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97530","Standard Price":147.0},{"Itemcode":"75102006","Description":"Physicial Perform Test 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97750","Standard Price":238.0},{"Itemcode":"75102010","Description":"Sensory Integration - 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97533","Standard Price":133.0},{"Itemcode":"75102011","Description":"PT Eval Low 20Min","CDM Revenue Code":"424","CDM HCPCS":"97161","Standard Price":488.0},{"Itemcode":"75102012","Description":"PT Eval Mod 30Min","CDM Revenue Code":"424","CDM HCPCS":"97162","Standard Price":488.0},{"Itemcode":"75102013","Description":"PT Eval High 45Min","CDM Revenue Code":"424","CDM HCPCS":"97163","Standard Price":488.0},{"Itemcode":"75102014","Description":"PT Re-Eval EST 20Min","CDM Revenue Code":"424","CDM HCPCS":"97164","Standard Price":323.0},{"Itemcode":"75102101","Description":"Traction Mechanical >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97012","Standard Price":284.0},{"Itemcode":"75102104","Description":"Paraffin Bath Applic >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97018","Standard Price":133.0},{"Itemcode":"75102105","Description":"Electric Stim Manual Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75102106","Description":"Iontophoresis Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97033","Standard Price":181.0},{"Itemcode":"75102107","Description":"Contrast Baths Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97034","Standard Price":132.0},{"Itemcode":"75102108","Description":"Ultrasound Applic Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97035","Standard Price":181.0},{"Itemcode":"75102109","Description":"Whirlpool Applic >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75102111","Description":"Massage Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97124","Standard Price":141.0},{"Itemcode":"75102113","Description":"Fluidotherapy Applic,Whirlpool","CDM Revenue Code":"420","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75102201","Description":"Therapeutic Exercise Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75102202","Description":"Neuromuscular Re-Ed 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97112","Standard Price":156.0},{"Itemcode":"75102203","Description":"Gait Training 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97116","Standard Price":158.0},{"Itemcode":"75102206","Description":"Adl Training Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75102210","Description":"VR Neuromuscular Re-Ed 15 Mi","CDM Revenue Code":"420","CDM HCPCS":"97112","Standard Price":156.0},{"Itemcode":"75102301","Description":"Orthotic 1st Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75102304","Description":"Orth-Pros Sub Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97763","Standard Price":132.0},{"Itemcode":"75102305","Description":"ProstheticTrain 1stVisit15 Min","CDM Revenue Code":"420","CDM HCPCS":"97761","Standard Price":156.0},{"Itemcode":"75102307","Description":"Aquatic Therapy 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97113","Standard Price":146.0},{"Itemcode":"75102605","Description":"Cpm Exercise","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75102609","Description":"Isokenetic Exercise 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75102632","Description":"Work Condition First 2 Hrs","CDM Revenue Code":"420","CDM HCPCS":"97545","Standard Price":1687.0},{"Itemcode":"75102633","Description":"Work Condition Additional Hr","CDM Revenue Code":"420","CDM HCPCS":"97546","Standard Price":712.0},{"Itemcode":"75102666","Description":"Tens Attended 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75102668","Description":"Manual Therapy Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97140","Standard Price":157.0},{"Itemcode":"75102670","Description":"VR Manual Therapy - 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97140","Standard Price":157.0},{"Itemcode":"75103001","Description":"Orthotic Custom 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75103002","Description":"Orthotic Insert 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75106025","Description":"VR Group Therapy","CDM Revenue Code":"420","CDM HCPCS":"97150","Standard Price":367.0},{"Itemcode":"75110054","Description":"Cogn Funct 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"97129","Standard Price":205.0},{"Itemcode":"75110055","Description":"Cogn Funct Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"97130","Standard Price":125.0},{"Itemcode":"75110231","Description":"PT Eval Low 20min","CDM Revenue Code":"424","CDM HCPCS":"97161","Standard Price":488.0},{"Itemcode":"75110232","Description":"PT Eval Mod 30min","CDM Revenue Code":"424","CDM HCPCS":"97162","Standard Price":488.0},{"Itemcode":"75110233","Description":"PT Eval High 45min","CDM Revenue Code":"424","CDM HCPCS":"97163","Standard Price":488.0},{"Itemcode":"75110234","Description":"PT Re-Eval Est 20Min","CDM Revenue Code":"424","CDM HCPCS":"97164","Standard Price":323.0},{"Itemcode":"75112006","Description":"Physical Perform Test 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97750","Standard Price":238.0},{"Itemcode":"75112101","Description":"Traction Mechanical >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97012","Standard Price":284.0},{"Itemcode":"75112104","Description":"Paraffin Bath Applic >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97018","Standard Price":133.0},{"Itemcode":"75112105","Description":"Electric Stim Manual Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75112106","Description":"Iontophoresis Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97033","Standard Price":181.0},{"Itemcode":"75112108","Description":"Ultrasound Appl Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97035","Standard Price":181.0},{"Itemcode":"75112109","Description":"Whirlpool Applic >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75112111","Description":"Massage Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97124","Standard Price":141.0},{"Itemcode":"75112113","Description":"Fluidotherapy","CDM Revenue Code":"420","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75112116","Description":"Vasopneumatic Therapy >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97016","Standard Price":143.0},{"Itemcode":"75112201","Description":"Therapeutic Exercise Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75112202","Description":"Neuromuscular Re-Ed 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97112","Standard Price":156.0},{"Itemcode":"75112203","Description":"Gait Training 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97116","Standard Price":158.0},{"Itemcode":"75112302","Description":"Orthotic 1st Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75112304","Description":"Orth-Pros Sub Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97763","Standard Price":132.0},{"Itemcode":"75112305","Description":"ProstheticTrain 1stVisit15 Min","CDM Revenue Code":"420","CDM HCPCS":"97761","Standard Price":156.0},{"Itemcode":"75112618","Description":"Therapeutic Activities 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97530","Standard Price":147.0},{"Itemcode":"75112620","Description":"Group Treatment","CDM Revenue Code":"420","CDM HCPCS":"97150","Standard Price":367.0},{"Itemcode":"75112625","Description":"Isokenetic Exercise 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75112649","Description":"Wheelchair Mgmt/Train 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97542","Standard Price":110.0},{"Itemcode":"75112650","Description":"Work Condition First 2 Hours","CDM Revenue Code":"420","CDM HCPCS":"97545","Standard Price":1687.0},{"Itemcode":"75112651","Description":"Work Condition Additional 1 Hr","CDM Revenue Code":"420","CDM HCPCS":"97546","Standard Price":712.0},{"Itemcode":"75112666","Description":"Tens Attended 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75112668","Description":"Manual Therapy Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97140","Standard Price":157.0},{"Itemcode":"75113000","Description":"Orthotic Custom 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75113002","Description":"Orthotic Insert 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75140039","Description":"Selfcare Home Tx - Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75140231","Description":"PT Eval Low 20min","CDM Revenue Code":"424","CDM HCPCS":"97161","Standard Price":488.0},{"Itemcode":"75140232","Description":"PT Eval Mod 30min","CDM Revenue Code":"424","CDM HCPCS":"97162","Standard Price":488.0},{"Itemcode":"75140233","Description":"PT Eval High 45min","CDM Revenue Code":"424","CDM HCPCS":"97163","Standard Price":488.0},{"Itemcode":"75140234","Description":"PT Re-Eval Est 20Min","CDM Revenue Code":"424","CDM HCPCS":"97164","Standard Price":323.0},{"Itemcode":"75140314","Description":"Wheelchair Mgmt/Train 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97542","Standard Price":110.0},{"Itemcode":"75140315","Description":"Community Reentry Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97537","Standard Price":581.0},{"Itemcode":"75140316","Description":"Group Treatment","CDM Revenue Code":"420","CDM HCPCS":"97150","Standard Price":367.0},{"Itemcode":"75140503","Description":"Therapeutic Activities 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97530","Standard Price":147.0},{"Itemcode":"75142006","Description":"Physical Perform Test 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97750","Standard Price":238.0},{"Itemcode":"75142010","Description":"Sensory Integration - 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97533","Standard Price":133.0},{"Itemcode":"75142101","Description":"Traction Mechanical >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97012","Standard Price":284.0},{"Itemcode":"75142105","Description":"Electric Stim Manual Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75142106","Description":"Iontophoresis Applic Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97033","Standard Price":181.0},{"Itemcode":"75142107","Description":"Contrast Baths Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97034","Standard Price":132.0},{"Itemcode":"75142108","Description":"Ultrasound Appl Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97035","Standard Price":181.0},{"Itemcode":"75142111","Description":"Massage Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97124","Standard Price":141.0},{"Itemcode":"75142113","Description":"Fluidotherapy","CDM Revenue Code":"420","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75142201","Description":"Therapeutic Exercise Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75142202","Description":"Neuromuscular Re-Ed 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97112","Standard Price":156.0},{"Itemcode":"75142203","Description":"Gait Training 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97116","Standard Price":158.0},{"Itemcode":"75142206","Description":"Adl Training Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75142632","Description":"Work Condition First 2 Hours","CDM Revenue Code":"420","CDM HCPCS":"97545","Standard Price":1687.0},{"Itemcode":"75142633","Description":"Work Condition Additional 1 Hr","CDM Revenue Code":"420","CDM HCPCS":"97546","Standard Price":712.0},{"Itemcode":"75142666","Description":"Tens Attended - 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75142668","Description":"Manual Therapy Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97140","Standard Price":157.0},{"Itemcode":"75150054","Description":"Cogn Funct 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"97129","Standard Price":205.0},{"Itemcode":"75150055","Description":"Cogn Funct Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"97130","Standard Price":125.0},{"Itemcode":"75150231","Description":"PT Eval Low 20Min","CDM Revenue Code":"424","CDM HCPCS":"97161","Standard Price":488.0},{"Itemcode":"75150232","Description":"PT Eval Med 30Min","CDM Revenue Code":"424","CDM HCPCS":"97162","Standard Price":488.0},{"Itemcode":"75150233","Description":"PT Eval High 45Min","CDM Revenue Code":"424","CDM HCPCS":"97163","Standard Price":488.0},{"Itemcode":"75150234","Description":"PT Re-Eval EST 20Min","CDM Revenue Code":"424","CDM HCPCS":"97164","Standard Price":323.0},{"Itemcode":"75152006","Description":"Physical Perform Test 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97750","Standard Price":238.0},{"Itemcode":"75152010","Description":"Sensory Integration - 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97533","Standard Price":133.0},{"Itemcode":"75152101","Description":"Traction Mechanical >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97012","Standard Price":284.0},{"Itemcode":"75152105","Description":"Electric Stim Manual Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75152106","Description":"Iontophoresis Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97033","Standard Price":181.0},{"Itemcode":"75152107","Description":"Contrast Baths Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97034","Standard Price":132.0},{"Itemcode":"75152108","Description":"Ultrasound Appl Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97035","Standard Price":181.0},{"Itemcode":"75152111","Description":"Massage Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97124","Standard Price":141.0},{"Itemcode":"75152113","Description":"Fluidotherapy","CDM Revenue Code":"420","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75152201","Description":"Therapeutic Exercise Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75152202","Description":"Neuromuscular Re-Ed 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97112","Standard Price":156.0},{"Itemcode":"75152203","Description":"Gait Training 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97116","Standard Price":158.0},{"Itemcode":"75152206","Description":"Adl Training Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75152302","Description":"Orthotic 1st Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75152304","Description":"Orth-Pros Sub Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97763","Standard Price":132.0},{"Itemcode":"75152305","Description":"ProstheticTrain 1stVisit15 Min","CDM Revenue Code":"420","CDM HCPCS":"97761","Standard Price":156.0},{"Itemcode":"75152609","Description":"Community Reentry Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97537","Standard Price":581.0},{"Itemcode":"75152618","Description":"Therapeutic Activities 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97530","Standard Price":147.0},{"Itemcode":"75152620","Description":"Group Treatment","CDM Revenue Code":"420","CDM HCPCS":"97150","Standard Price":367.0},{"Itemcode":"75152649","Description":"Wheelchair Mgmt/Train 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97542","Standard Price":110.0},{"Itemcode":"75152666","Description":"Tens Attended 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75152668","Description":"Manual Therapy Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97140","Standard Price":157.0},{"Itemcode":"75153000","Description":"Orthotic Insert 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75153002","Description":"Orthotic Custom 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75160054","Description":"Cogn Funct 1st 15 min","CDM Revenue Code":"420","CDM HCPCS":"97129","Standard Price":205.0},{"Itemcode":"75160055","Description":"Cogn Funct Add 15 min","CDM Revenue Code":"420","CDM HCPCS":"97130","Standard Price":125.0},{"Itemcode":"75160231","Description":"PT Eval Low 20min","CDM Revenue Code":"424","CDM HCPCS":"97161","Standard Price":488.0},{"Itemcode":"75160232","Description":"PT Eval Mod 30min","CDM Revenue Code":"424","CDM HCPCS":"97162","Standard Price":488.0},{"Itemcode":"75160233","Description":"PT Eval High 45min","CDM Revenue Code":"424","CDM HCPCS":"97163","Standard Price":488.0},{"Itemcode":"75160234","Description":"PT Re-Eval Est 20Min","CDM Revenue Code":"424","CDM HCPCS":"97164","Standard Price":323.0},{"Itemcode":"75162006","Description":"Physical Perform Test 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97750","Standard Price":238.0},{"Itemcode":"75162010","Description":"Sensory Integration - 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97533","Standard Price":133.0},{"Itemcode":"75162101","Description":"Traction Mechanical >=1 Area","CDM Revenue Code":"420","CDM HCPCS":"97012","Standard Price":284.0},{"Itemcode":"75162105","Description":"Electric Stim Manual Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75162106","Description":"Iontophoresis Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97033","Standard Price":181.0},{"Itemcode":"75162107","Description":"Contrast Baths Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97034","Standard Price":132.0},{"Itemcode":"75162108","Description":"Ultrasound Appl Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97035","Standard Price":181.0},{"Itemcode":"75162111","Description":"Massage Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97124","Standard Price":141.0},{"Itemcode":"75162113","Description":"Fluidotherapy >= 1 area","CDM Revenue Code":"420","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75162201","Description":"Therapeutic Exercise Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75162202","Description":"Neuromuscular Re-Ed 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97112","Standard Price":156.0},{"Itemcode":"75162203","Description":"Gait Training 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97116","Standard Price":158.0},{"Itemcode":"75162206","Description":"Adl Training Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75162302","Description":"Orthotic 1st Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75162304","Description":"Orth-Pros Sub Visit 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97763","Standard Price":132.0},{"Itemcode":"75162305","Description":"ProstheticTrain 1stVisit15 Min","CDM Revenue Code":"420","CDM HCPCS":"97761","Standard Price":156.0},{"Itemcode":"75162307","Description":"Aquatic Therapy 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97113","Standard Price":146.0},{"Itemcode":"75162609","Description":"Community Reentry Ea 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97537","Standard Price":581.0},{"Itemcode":"75162618","Description":"Therapeutic Activities 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97530","Standard Price":147.0},{"Itemcode":"75162620","Description":"Group Treatment","CDM Revenue Code":"420","CDM HCPCS":"97150","Standard Price":367.0},{"Itemcode":"75162649","Description":"Wheelchair Mgmt/Train 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97542","Standard Price":110.0},{"Itemcode":"75162666","Description":"Tens Attended 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75162668","Description":"Manual Therapy Each 15 Min","CDM Revenue Code":"420","CDM HCPCS":"97140","Standard Price":157.0},{"Itemcode":"75163000","Description":"Orthotic Custom 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75163002","Description":"Orthotic Insert 1stVisit 15min","CDM Revenue Code":"420","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75200054","Description":"Cogn Funct 1st 15 min","CDM Revenue Code":"430","CDM HCPCS":"97129","Standard Price":205.0},{"Itemcode":"75200055","Description":"Cogn Funct Add 15 min","CDM Revenue Code":"430","CDM HCPCS":"97130","Standard Price":125.0},{"Itemcode":"75200325","Description":"Community Reentry Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97537","Standard Price":581.0},{"Itemcode":"75200335","Description":"Home Mangmnt SelfTx - Ea 15Min","CDM Revenue Code":"430","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75200385","Description":"OT REHAB Eval Low 30Min","CDM Revenue Code":"434","CDM HCPCS":"97165","Standard Price":391.0},{"Itemcode":"75200386","Description":"OT REHAB Eval Mod 45Min","CDM Revenue Code":"434","CDM HCPCS":"97166","Standard Price":391.0},{"Itemcode":"75200387","Description":"OT REHAB Eval High 60Min","CDM Revenue Code":"434","CDM HCPCS":"97167","Standard Price":391.0},{"Itemcode":"75200388","Description":"OT REHAB Re-Eval Est Plan Care","CDM Revenue Code":"434","CDM HCPCS":"97168","Standard Price":271.0},{"Itemcode":"75202006","Description":"Physical Perform Test 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97750","Standard Price":238.0},{"Itemcode":"75202010","Description":"Sensory Integration - 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97533","Standard Price":133.0},{"Itemcode":"75202011","Description":"OT Eval Low 30Min","CDM Revenue Code":"434","CDM HCPCS":"97165","Standard Price":391.0},{"Itemcode":"75202012","Description":"OT Eval Mod 45Min","CDM Revenue Code":"434","CDM HCPCS":"97166","Standard Price":391.0},{"Itemcode":"75202013","Description":"OT Eval High 60Min","CDM Revenue Code":"434","CDM HCPCS":"97167","Standard Price":391.0},{"Itemcode":"75202014","Description":"OT Re-Eval Est Plan Care","CDM Revenue Code":"434","CDM HCPCS":"97168","Standard Price":271.0},{"Itemcode":"75202104","Description":"Paraffin Bath Applic >=1 Area","CDM Revenue Code":"430","CDM HCPCS":"97018","Standard Price":133.0},{"Itemcode":"75202105","Description":"Electric Stim Manual Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75202106","Description":"Iontophoresis Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97033","Standard Price":181.0},{"Itemcode":"75202107","Description":"Contrast Baths Applic Ea 15Min","CDM Revenue Code":"430","CDM HCPCS":"97034","Standard Price":132.0},{"Itemcode":"75202108","Description":"Ultrasound Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97035","Standard Price":181.0},{"Itemcode":"75202109","Description":"Whirlpool","CDM Revenue Code":"430","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75202111","Description":"Ther Massage Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97124","Standard Price":141.0},{"Itemcode":"75202113","Description":"Fluidotherapy","CDM Revenue Code":"430","CDM HCPCS":"97022","Standard Price":148.0},{"Itemcode":"75202116","Description":"Vasopneumatic Therapy","CDM Revenue Code":"430","CDM HCPCS":"97016","Standard Price":143.0},{"Itemcode":"75202201","Description":"Therapeutic Exercise Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97110","Standard Price":159.0},{"Itemcode":"75202202","Description":"Neuromuscular Re-Ed 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97112","Standard Price":156.0},{"Itemcode":"75202204","Description":"Manual Therapy Each 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97140","Standard Price":157.0},{"Itemcode":"75202206","Description":"Adl Training Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75202302","Description":"Orthotic 1st Visit 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75202304","Description":"Orth-Pros Sub Visit 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97763","Standard Price":132.0},{"Itemcode":"75202550","Description":"Dir Therapeutic Activs 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97530","Standard Price":147.0},{"Itemcode":"75202621","Description":"Wheelchair Mgmt/Train 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97542","Standard Price":110.0},{"Itemcode":"75202636","Description":"Selfcare Home Tx - Ea 15 Min","CDM Revenue Code":"430","CDM HCPCS":"97535","Standard Price":134.0},{"Itemcode":"75202658","Description":"Group Treatmt Proc Therapeutic","CDM Revenue Code":"430","CDM HCPCS":"97150","Standard Price":367.0},{"Itemcode":"75203001","Description":"Orthotic Custom 1stVisit 15min","CDM Revenue Code":"430","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75203002","Description":"Orthotic Insert 1stVisit 15min","CDM Revenue Code":"430","CDM HCPCS":"97760","Standard Price":141.0},{"Itemcode":"75203100","Description":"Work Condition Additional 1 Hr","CDM Revenue Code":"430","CDM HCPCS":"97546","Standard Price":712.0},{"Itemcode":"75203101","Description":"Work Condition First 2 Hours","CDM Revenue Code":"430","CDM HCPCS":"97545","Standard Price":1687.0},{"Itemcode":"75203102","Description":"ProstheticTrain 1stVisit15 Min","CDM Revenue Code":"430","CDM HCPCS":"97761","Standard Price":156.0},{"Itemcode":"75203666","Description":"Tens Attended","CDM Revenue Code":"430","CDM HCPCS":"97032","Standard Price":166.0},{"Itemcode":"75300054","Description":"Cogn Funct 1st 15 min","CDM Revenue Code":"430","CDM HCPCS":"97129","Standard Price":205.0},{"Itemcode":"75300055","Description":"Cogn Funct Add 15 min","CDM Revenue Code":"430","CDM HCPCS":"97130","Standard Price":125.0},{"Itemcode":"63200208","Description":"Tinnitus Assessment","CDM Revenue Code":"471","CDM HCPCS":"92625","Standard Price":365.0},{"Itemcode":"63200209","Description":"VEMP - Vest evoked myogenic pt","CDM Revenue Code":"470","CDM HCPCS":"92700","Standard Price":411.0},{"Itemcode":"75301502","Description":"EVAL SPEECH FLUENCY","CDM Revenue Code":"440","CDM HCPCS":"92521","Standard Price":633.0},{"Itemcode":"75301503","Description":"EVAL SPEECH SOUND PRODUCTION","CDM Revenue Code":"440","CDM HCPCS":"92522","Standard Price":633.0},{"Itemcode":"75301504","Description":"EVAL SPEECH SOUND/COMP/EXPRSS","CDM Revenue Code":"440","CDM HCPCS":"92523","Standard Price":633.0},{"Itemcode":"75301505","Description":"BHV/QUAL ANALYSIS VOICE/RESNC","CDM Revenue Code":"440","CDM HCPCS":"92524","Standard Price":633.0},{"Itemcode":"75303000","Description":"Eval Swall Oral Funct","CDM Revenue Code":"440","CDM HCPCS":"92610","Standard Price":468.0},{"Itemcode":"75303003","Description":"Tx Swall Oral Funct Feed","CDM Revenue Code":"440","CDM HCPCS":"92526","Standard Price":473.0},{"Itemcode":"75303020","Description":"Mod Barium Swall Evaluation","CDM Revenue Code":"440","CDM HCPCS":"92611","Standard Price":607.0},{"Itemcode":"75303050","Description":"Aug Communication Eval 1 HR","CDM Revenue Code":"440","CDM HCPCS":"92607","Standard Price":610.0},{"Itemcode":"75303055","Description":"Aug Communication Training","CDM Revenue Code":"440","CDM HCPCS":"92609","Standard Price":2351.0},{"Itemcode":"75303113","Description":"ST Therapy Group","CDM Revenue Code":"440","CDM HCPCS":"92508","Standard Price":422.0},{"Itemcode":"75303114","Description":"ST Individual Thpy","CDM Revenue Code":"440","CDM HCPCS":"92507","Standard Price":479.0},{"Itemcode":"73100023","Description":"Vent Mgmt Initial IP 1st Day","CDM Revenue Code":"410","CDM HCPCS":"94002","Standard Price":2229.0},{"Itemcode":"73100025","Description":"Cpap/Bipap Initial & Mgmt","CDM Revenue Code":"410","CDM HCPCS":"94660","Standard Price":622.0},{"Itemcode":"73100027","Description":"Infant Vent: Cpap Daily","CDM Revenue Code":"410","CDM HCPCS":"94002","Standard Price":2229.0},{"Itemcode":"73100300","Description":"Ventiln Mgmt Ea Subseq IP Day","CDM Revenue Code":"410","CDM HCPCS":"94003","Standard Price":2227.0},{"Itemcode":"0120","Description":"Breast Bx W/Clip Stereo Gd -D","CDM Revenue Code":"361"},{"Itemcode":"0155","Description":"Breast BxW/Clip Stereo Gd BI-D","CDM Revenue Code":"361"},{"Itemcode":"0185","Description":"Breast BxW/Clip Stereo Gd LT-D","CDM Revenue Code":"361"},{"Itemcode":"0191","Description":"Breast BxW/Clip Stereo Gd RT-D","CDM Revenue Code":"361"},{"Itemcode":"0194","Description":"CT GD FIDUCIAL MARKER W/O BX-D","CDM Revenue Code":"350"},{"Itemcode":"0195","Description":"Fiducial Marker Placemnt Ct Gd","CDM Revenue Code":"360","Standard Price":3251.0},{"Itemcode":"0198","Description":"Drain Seroma Us Guided","CDM Revenue Code":"360","Standard Price":474.0},{"Itemcode":"0244","Description":"Biopsy Lymph Node(S)","CDM Revenue Code":"360","Standard Price":2107.0},{"Itemcode":"0245","Description":"Perc LYM ND BXw/ClipW/IMG-LT-D","CDM Revenue Code":"361"},{"Itemcode":"0246","Description":"Perc LY ND BXw/ClipW/IMG-RT -D","CDM Revenue Code":"361"},{"Itemcode":"0247","Description":"Perc L ND BXw/ClipW/IMG-BI -D","CDM Revenue Code":"361"},{"Itemcode":"0251","Description":"Uro Study-D","CDM Revenue Code":"920"},{"Itemcode":"0252","Description":"Uro StudyW/Voiding Pressure -D","CDM Revenue Code":"920","Standard Price":0.0},{"Itemcode":"0258","Description":"Breast Punc/AspSglCyst USgui-D","CDM Revenue Code":"361"},{"Itemcode":"1000","Description":"MRI Brain WO, MRA Head/Neck-D","CDM Revenue Code":"611","Standard Price":0.0},{"Itemcode":"1018","Description":"MRI Abd/Pelvis W&W/O Contr-D","CDM Revenue Code":"610"},{"Itemcode":"2111","Description":"FNA US GUIDED SURG COMPONENT","CDM Revenue Code":"360","Standard Price":2465.0},{"Itemcode":"2130","Description":"CT Neck/Chest W/Contrast- D","CDM Revenue Code":"350"},{"Itemcode":"2131","Description":"CT Neck/Chest W/Wo Contrast -D","CDM Revenue Code":"350"},{"Itemcode":"2133","Description":"CT Neck/Chest/Abd/Pel W/Con -D","CDM Revenue Code":"350"},{"Itemcode":"2134","Description":"CT Neck/Chest/Abd/Pel W/Wo -D","CDM Revenue Code":"350"},{"Itemcode":"2135","Description":"CT Chst/Adb/Pel W/Wo Conrast-D","CDM Revenue Code":"350"},{"Itemcode":"2136","Description":"CT Drainage: Extremity-D","CDM Revenue Code":"350"},{"Itemcode":"2137","Description":"CT Drainage: Extremity -Surg","CDM Revenue Code":"360","Standard Price":10017.0},{"Itemcode":"2138","Description":"CT Chest w/ &CTabd&pelvis w/wo","CDM Revenue Code":"352"},{"Itemcode":"2140","Description":"CT Drainage Lung-D","CDM Revenue Code":"350"},{"Itemcode":"2142","Description":"CT Drainage: Neck-D","CDM Revenue Code":"350"},{"Itemcode":"2143","Description":"CT Drainage Neck- Surg Comp","CDM Revenue Code":"360","Standard Price":4276.0},{"Itemcode":"2144","Description":"CT Drainage: Pelvic-D","CDM Revenue Code":"350"},{"Itemcode":"2145","Description":"CT Drainage Liver-D","CDM Revenue Code":"350"},{"Itemcode":"2151","Description":"CT Drainage Pancreas-D","CDM Revenue Code":"350"},{"Itemcode":"2160","Description":"CT Drainage: Retroperitoneal-D","CDM Revenue Code":"350"},{"Itemcode":"2170","Description":"CT Biopsy: Chest-D","CDM Revenue Code":"350"},{"Itemcode":"2171","Description":"CT Guided Block Celiac Plex -D","CDM Revenue Code":"350"},{"Itemcode":"2172","Description":"Inject Nerve Block Ct Guided","CDM Revenue Code":"360","Standard Price":6453.0},{"Itemcode":"2175","Description":"CT Biopsy: Lung-D","CDM Revenue Code":"350"},{"Itemcode":"2180","Description":"CT Biopsy: Liver-D","CDM Revenue Code":"350"},{"Itemcode":"2185","Description":"CT Biopsy: Breast-D","CDM Revenue Code":"350"},{"Itemcode":"2190","Description":"CT Biopsy: Pancreas-D","CDM Revenue Code":"350"},{"Itemcode":"2195","Description":"CT Biopsy: Retroperitoneal-D","CDM Revenue Code":"350"},{"Itemcode":"2196","Description":"CT Biopsy: Renal-D","CDM Revenue Code":"350"},{"Itemcode":"2217","Description":"CT Drainage Kidney -D","CDM Revenue Code":"360"},{"Itemcode":"2218","Description":"CT Drain: Abdomen-D","CDM Revenue Code":"350"},{"Itemcode":"2219","Description":"Injec SI Joint Fluoro Guide","CDM Revenue Code":"360","Standard Price":459.0},{"Itemcode":"2220","Description":"CT Biopsy: Femur-D","CDM Revenue Code":"359"},{"Itemcode":"2221","Description":"CT Biopsy: Vertebral Body-D","CDM Revenue Code":"352"},{"Itemcode":"2222","Description":"CT Biopsy: Bone Superficial-D","CDM Revenue Code":"352"},{"Itemcode":"2223","Description":"CT Biopsy:Soft Tissue - Body-D","CDM Revenue Code":"352"},{"Itemcode":"2224","Description":"CT Biop:Soft Tissue-Extremty-D","CDM Revenue Code":"359"},{"Itemcode":"2226","Description":"CT Biopsy:Vertebal Body - Surg","CDM Revenue Code":"360","Standard Price":12662.0},{"Itemcode":"2227","Description":"CT Biopsy:Bone Superficial-Sur","CDM Revenue Code":"360","Standard Price":10771.0},{"Itemcode":"2228","Description":"CT Biopsy: Soft Tissue","CDM Revenue Code":"360","Standard Price":10446.0},{"Itemcode":"2229","Description":"CT Biopsy:Soft Tissue:Ext -Sur","CDM Revenue Code":"360","Standard Price":9447.0},{"Itemcode":"2230","Description":"CT Biopsy: Femur - Surg Comp","CDM Revenue Code":"360","Standard Price":5971.0},{"Itemcode":"2240","Description":"CT Guide: Tumor Loc - Lung-D","CDM Revenue Code":"352"},{"Itemcode":"2241","Description":"CT Biopsy - Neck-D","CDM Revenue Code":"352"},{"Itemcode":"2242","Description":"CT Biopsy: Neck Surg Comp","CDM Revenue Code":"360","Standard Price":10115.0},{"Itemcode":"2248","Description":"CT Brain Perfusion -D","CDM Revenue Code":"351"},{"Itemcode":"2252","Description":"Sacroplasty Ct Guided","CDM Revenue Code":"360","Standard Price":5148.0},{"Itemcode":"2253","Description":"CT Guided Sacroplasty -D","CDM Revenue Code":"350"},{"Itemcode":"2254","Description":"Remove Catheter Ct Guided-Surg","CDM Revenue Code":"360","Standard Price":3215.0},{"Itemcode":"2501","Description":"Endoven Saph Ablt Us Tech Time","CDM Revenue Code":"360","Standard Price":1565.0},{"Itemcode":"2654","Description":"MRI Guided Breast Biopsy -D","CDM Revenue Code":"610"},{"Itemcode":"2656","Description":"MRI Guided Breast Biopsy","CDM Revenue Code":"360","Standard Price":4768.0},{"Itemcode":"2657","Description":"MRI Injection Proc","CDM Revenue Code":"360","Standard Price":1874.0},{"Itemcode":"2658","Description":"Fna By Mri","CDM Revenue Code":"360","Standard Price":646.0},{"Itemcode":"2900","Description":"Gi Tube Insertion W/Fluoro Gd","CDM Revenue Code":"360","Standard Price":859.0},{"Itemcode":"3355","Description":"Fistulagram Surg Comp","CDM Revenue Code":"360","Standard Price":714.0},{"Itemcode":"3452","Description":"US Abcess Drainage Surg Comp","CDM Revenue Code":"360","Standard Price":14214.0},{"Itemcode":"3500","Description":"Aspiration Surg Procedure","CDM Revenue Code":"360","Standard Price":2124.0},{"Itemcode":"4235","Description":"RF Ablation Lung Tumor","CDM Revenue Code":"360","Standard Price":5925.0},{"Itemcode":"4236","Description":"CT Guided Rf Ablation Lung-D","CDM Revenue Code":"350"},{"Itemcode":"5035","Description":"CT Drainage Abdomen Surg Comp","CDM Revenue Code":"360","Standard Price":10920.0},{"Itemcode":"5042","Description":"CT Biopsy: Breast Surg Comp","CDM Revenue Code":"360","Standard Price":2895.0},{"Itemcode":"5045","Description":"CT Biopsy: Surg Comp","CDM Revenue Code":"360","Standard Price":11472.0},{"Itemcode":"5053","Description":"Injection Botox Ct Guided","CDM Revenue Code":"360","Standard Price":1125.0},{"Itemcode":"5054","Description":"CT Biopsy: Renal Surg Comp","CDM Revenue Code":"360","Standard Price":10936.0},{"Itemcode":"5055","Description":"CT Biopsy: Lung Surg Comp","CDM Revenue Code":"360","Standard Price":10082.0},{"Itemcode":"5056","Description":"CT Biopsy: Liver Surg Comp","CDM Revenue Code":"360","Standard Price":10930.0},{"Itemcode":"5058","Description":"CT Biopsy: Pancreas Surg Comp","CDM Revenue Code":"360","Standard Price":9850.0},{"Itemcode":"5059","Description":"CT Biopsy:Retroperitoneal Srg","CDM Revenue Code":"360","Standard Price":10510.0},{"Itemcode":"5090","Description":"CT Guided Si Injection-D","CDM Revenue Code":"361"},{"Itemcode":"5095","Description":"Si Inject Ct Gd: Surgical Comp","CDM Revenue Code":"360","Standard Price":3973.0},{"Itemcode":"5171","Description":"CTA ABD/PELVIS CT CHST W/O - D","CDM Revenue Code":"350"},{"Itemcode":"5173","Description":"CTA CHST ABD/PELV, CT ABD - D","CDM Revenue Code":"350"},{"Itemcode":"5400","Description":"LIVER: DRAIN/ASPIRATE SURG COM","CDM Revenue Code":"360","Standard Price":12417.0},{"Itemcode":"5405","Description":"LUNG: DRAIN/ASPIRATE SURG COMP","CDM Revenue Code":"360","Standard Price":12413.0},{"Itemcode":"5406","Description":"KIDNEY: DRAIN/ASPRIATE SURGERY","CDM Revenue Code":"360","Standard Price":10798.0},{"Itemcode":"5630","Description":"CT Pancrease Drain/Aspir Surg","CDM Revenue Code":"360","Standard Price":9043.0},{"Itemcode":"5640","Description":"CT Drainage Pelvic Surg","CDM Revenue Code":"360","Standard Price":7271.0},{"Itemcode":"5700","Description":"CT Drainage Retroperit -Surg","CDM Revenue Code":"360","Standard Price":11679.0},{"Itemcode":"5771","Description":"CT Guided NG Placement-Surg","CDM Revenue Code":"360","Standard Price":764.0},{"Itemcode":"6051","Description":"US Amniocentesis Surgical Proc","CDM Revenue Code":"360","Standard Price":530.0},{"Itemcode":"61050021","Description":"Bedside Procedure","CDM Revenue Code":"360","Standard Price":432.0},{"Itemcode":"61050650","Description":"4N Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61100021","Description":"2N Bedside Procedure","CDM Revenue Code":"360","Standard Price":432.0},{"Itemcode":"61150025","Description":"6N Procedure","CDM Revenue Code":"360","Standard Price":678.0},{"Itemcode":"61150650","Description":"6N Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61200015","Description":"Observation: Admission","CDM Revenue Code":"510","Standard Price":0.0},{"Itemcode":"61200025","Description":"Bedside Procedure 6120","CDM Revenue Code":"360","Standard Price":188.0},{"Itemcode":"61200650","Description":"5S Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61250499","Description":"2S Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61300021","Description":"Bedside Procedure","CDM Revenue Code":"360","Standard Price":412.0},{"Itemcode":"61300650","Description":"5N Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61350021","Description":"Bedside Procedure","CDM Revenue Code":"360","Standard Price":393.0},{"Itemcode":"61350650","Description":"6S Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61400650","Description":"7N Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61405000","Description":"Minor Procedure Charge","CDM Revenue Code":"360","Standard Price":89.0},{"Itemcode":"61450650","Description":"7S Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61455000","Description":"7S Bedside Procedure","CDM Revenue Code":"360","Standard Price":432.0},{"Itemcode":"61500021","Description":"Bedside Procedure","CDM Revenue Code":"360","Standard Price":410.0},{"Itemcode":"61500650","Description":"Peds Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61506152","Description":"Adult Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61550203","Description":"Childbirth Class Sessions","CDM Revenue Code":"942","Standard Price":80.0},{"Itemcode":"61550499","Description":"3Rd Flr Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61552928","Description":"Cerclage Placement","CDM Revenue Code":"360","Standard Price":3011.0},{"Itemcode":"61552930","Description":"Removal Cerclage Suture","CDM Revenue Code":"360","Standard Price":6447.0},{"Itemcode":"61552931","Description":"Laminaria Insertion","CDM Revenue Code":"360","Standard Price":1221.0},{"Itemcode":"61555645","Description":"LDR Recovery: First Hour","CDM Revenue Code":"710","Standard Price":910.0},{"Itemcode":"61555656","Description":"LDR Recovery: Each Addl Hour","CDM Revenue Code":"710","Standard Price":1076.0},{"Itemcode":"61555860","Description":"Anesthesia:Epidural Continuous","CDM Revenue Code":"370","Standard Price":2510.0},{"Itemcode":"61555870","Description":"Anesthesia: General 30 Min","CDM Revenue Code":"370","Standard Price":613.0},{"Itemcode":"61555880","Description":"Anesthesia:Spinal/Saddle Block","CDM Revenue Code":"370","Standard Price":889.0},{"Itemcode":"61555935","Description":"LDR Surg Time Per 30 Min","CDM Revenue Code":"360","Standard Price":437.0},{"Itemcode":"61557925","Description":"Epidural Blood Patch","CDM Revenue Code":"360","Standard Price":997.0},{"Itemcode":"61567926","Description":"Minor Proc","CDM Revenue Code":"360","Standard Price":72.0},{"Itemcode":"61700021","Description":"Bedside Procedure","CDM Revenue Code":"360","Standard Price":407.0},{"Itemcode":"6177","Description":"Breast Bx US Guided-LT - D","CDM Revenue Code":"361"},{"Itemcode":"6178","Description":"Breast BX US Guidew/Clip-RT -D","CDM Revenue Code":"361"},{"Itemcode":"6179","Description":"BreastBX US Guidew/Clip-BI -D","CDM Revenue Code":"361"},{"Itemcode":"61800052","Description":"Iabp Daily Charge","CDM Revenue Code":"360","Standard Price":222.0},{"Itemcode":"61800300","Description":"CCU OPEN HRT RECOVERY 1ST HR","CDM Revenue Code":"710","Standard Price":2127.0},{"Itemcode":"61800301","Description":"CCU OPEN HRT RECOVERY ADDL HR","CDM Revenue Code":"710","Standard Price":1136.0},{"Itemcode":"61800650","Description":"Ccu Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61850650","Description":"ICU Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"61900027","Description":"ICP Pres Monit Daily","CDM Revenue Code":"360","Standard Price":49.0},{"Itemcode":"61900650","Description":"NICU Recovery Hourly Charge","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"63101002","Description":"Hemodialysis (Op)-D","CDM Revenue Code":"761","Standard Price":0.0},{"Itemcode":"63200076","Description":"VES AUDIOMETRIC EVAL","CDM Revenue Code":"920","Standard Price":159.0},{"Itemcode":"64100096","Description":"Surgery Time Per 30 Min","CDM Revenue Code":"360","Standard Price":2830.0},{"Itemcode":"64101820","Description":"Ecmo Daily Management","CDM Revenue Code":"360","Standard Price":2009.0},{"Itemcode":"64102579","Description":"Ds Ent Procedure","CDM Revenue Code":"360","Standard Price":1083.0},{"Itemcode":"64102582","Description":"Minor Procedure Room Charge","CDM Revenue Code":"360","Standard Price":3238.0},{"Itemcode":"64102583","Description":"Blood Patch Day Surgery","CDM Revenue Code":"360","Standard Price":678.0},{"Itemcode":"64102699","Description":"Surg Time Major Proc 1st 30min","CDM Revenue Code":"360","Standard Price":4592.0},{"Itemcode":"64102700","Description":"Surg Time Minor Proc 1st 30min","CDM Revenue Code":"360","Standard Price":2830.0},{"Itemcode":"64102701","Description":"Surg Time Additional 30 min","CDM Revenue Code":"360","Standard Price":2830.0},{"Itemcode":"64102702","Description":"SURG TIME MAJOR 2 PROC 1ST 30M","CDM Revenue Code":"360","Standard Price":6378.0},{"Itemcode":"64102703","Description":"SURG TIME ADD'L 30MIN-MAJOR 2","CDM Revenue Code":"360","Standard Price":3189.0},{"Itemcode":"64102704","Description":"SURG TIME ADD'L 30MIN-MAJOR PR","CDM Revenue Code":"360","Standard Price":2830.0},{"Itemcode":"64102705","Description":"SURG TIME ADD'L 30MIN - MINOR","CDM Revenue Code":"360","Standard Price":2296.0},{"Itemcode":"64102706","Description":"CDD IN OR MAJ Proc 1st 30min","CDM Revenue Code":"750","Standard Price":4592.0},{"Itemcode":"64102707","Description":"CDD IN OR ADD'L 30MIN-MAJOR PR","CDM Revenue Code":"750","Standard Price":2830.0},{"Itemcode":"64102708","Description":"Bronc in OR Maj Proc 1st 30min","CDM Revenue Code":"360","Standard Price":4595.0},{"Itemcode":"64102709","Description":"Bronc in OR Add'l 30min-Major","CDM Revenue Code":"360","Standard Price":2830.0},{"Itemcode":"64103003","Description":"Perfusion: Open Heart Fee","CDM Revenue Code":"360","Standard Price":19430.0},{"Itemcode":"64104043","Description":"Perfusion: Iabp Intra-Aortic","CDM Revenue Code":"360","Standard Price":3503.0},{"Itemcode":"64116467","Description":"Perfusion: Beating Heart Lv Ii","CDM Revenue Code":"360","Standard Price":9302.0},{"Itemcode":"64117158","Description":"Edwards Perf Open Heart Servic","CDM Revenue Code":"360","Standard Price":28885.0},{"Itemcode":"64138834","Description":"OR Dental/PlasticClient 1st HR","CDM Revenue Code":"360","Standard Price":1275.0},{"Itemcode":"64138835","Description":"OR Dental/PlasticCli addl15min","CDM Revenue Code":"360","Standard Price":319.0},{"Itemcode":"64138899","Description":"TAVR HEART FEE","CDM Revenue Code":"360","Standard Price":4415.0},{"Itemcode":"64140512","Description":"Moderate Sed Ini 15Min >5yrs","CDM Revenue Code":"370","Standard Price":165.0},{"Itemcode":"64140523","Description":"Moderat Sed Addl 15Min any age","CDM Revenue Code":"370","Standard Price":135.0},{"Itemcode":"64141382","Description":"Anesthesia: General 30 Min","CDM Revenue Code":"370","Standard Price":770.0},{"Itemcode":"64141401","Description":"Anesthesia Mac 30 Min","CDM Revenue Code":"370","Standard Price":626.0},{"Itemcode":"64142699","Description":"Surg Time Major Proc 1st 30min","CDM Revenue Code":"360","Standard Price":4415.0},{"Itemcode":"64142700","Description":"Surg Time Minor Proc 1st 30min","CDM Revenue Code":"360","Standard Price":2721.0},{"Itemcode":"64142702","Description":"SURG TIME MAJOR 2 PROC 1ST 30M","CDM Revenue Code":"360","Standard Price":6133.0},{"Itemcode":"64142703","Description":"SURG TIME ADD'L 30MIN-MAJOR 2","CDM Revenue Code":"360","Standard Price":3066.0},{"Itemcode":"64142704","Description":"SURG TIME ADD'L 30MIN-MAJOR PR","CDM Revenue Code":"360","Standard Price":2721.0},{"Itemcode":"64142705","Description":"SURG TIME ADD'L 30MIN - MINOR","CDM Revenue Code":"360","Standard Price":2208.0},{"Itemcode":"64145002","Description":"Moderate Sed Ini 15Min <5yrs","CDM Revenue Code":"370","Standard Price":319.0},{"Itemcode":"64146300","Description":"Surg Ctr Recovery 1st Hour","CDM Revenue Code":"710","Standard Price":757.0},{"Itemcode":"64146316","Description":"Surg Ctr Recovery Ea Addl Hr","CDM Revenue Code":"710","Standard Price":475.0},{"Itemcode":"64300100","Description":"Cardioversion, External, Ele-D","CDM Revenue Code":"361","Standard Price":0.0},{"Itemcode":"64306300","Description":"Pacu Recovery: First Hour","CDM Revenue Code":"710","Standard Price":2127.0},{"Itemcode":"64306316","Description":"Pacu Recovery: Each Addl Hour","CDM Revenue Code":"710","Standard Price":1180.0},{"Itemcode":"64400012","Description":"Anesthesia Spinal/Epidural","CDM Revenue Code":"370","Standard Price":713.0},{"Itemcode":"64400500","Description":"Anesthesia Regional Block","CDM Revenue Code":"370","Standard Price":822.0},{"Itemcode":"64400501","Description":"Anesthesia: Bier Block","CDM Revenue Code":"370","Standard Price":915.0},{"Itemcode":"64400502","Description":"Moderate Sed Ini 15Min <5yrs","CDM Revenue Code":"370","Standard Price":332.0},{"Itemcode":"64400512","Description":"Moderate Sed Ini 15Min >5yrs","CDM Revenue Code":"370","Standard Price":172.0},{"Itemcode":"64400523","Description":"Moderat Sed Addl 15Min any age","CDM Revenue Code":"370","Standard Price":140.0},{"Itemcode":"64401382","Description":"Anesthesia: General 30 Min","CDM Revenue Code":"370","Standard Price":801.0},{"Itemcode":"64401401","Description":"Anesthesia Mac 30 Min","CDM Revenue Code":"370","Standard Price":651.0},{"Itemcode":"64502055","Description":"Solesta Injection Procedure","CDM Revenue Code":"360","Standard Price":639.0},{"Itemcode":"64504771","Description":"EMG/RUS/PN/AM -D","CDM Revenue Code":"750","Standard Price":0.0},{"Itemcode":"64504772","Description":"RUSs/ARMS -D","CDM Revenue Code":"750","Standard Price":0.0},{"Itemcode":"64505001","Description":"Procedure Time Per 30 Min","CDM Revenue Code":"750","Standard Price":1970.0},{"Itemcode":"64508206","Description":"Pudendal Nerve Study-D","CDM Revenue Code":"750","Standard Price":0.0},{"Itemcode":"64515001","Description":"Endo Procedure Time Per 30 Min","CDM Revenue Code":"750","Standard Price":1894.0},{"Itemcode":"64600500","Description":"Regional Block","CDM Revenue Code":"370","Standard Price":720.0},{"Itemcode":"64600501","Description":"Retrobulbar Block","CDM Revenue Code":"370","Standard Price":601.0},{"Itemcode":"64601382","Description":"Anesthesia General 30 Min","CDM Revenue Code":"370","Standard Price":750.0},{"Itemcode":"64601401","Description":"Anesthesia Mac 30 Min","CDM Revenue Code":"370","Standard Price":667.0},{"Itemcode":"64602582","Description":"Minor Procedure Room Charge","CDM Revenue Code":"360","Standard Price":3238.0},{"Itemcode":"64605002","Description":"Moderate Sed Ini 15Min <5yrs","CDM Revenue Code":"370","Standard Price":332.0},{"Itemcode":"64605012","Description":"Moderate Sed Ini 15Min >5yrs","CDM Revenue Code":"370","Standard Price":172.0},{"Itemcode":"64605023","Description":"Moderat Sed Addl 15Min any age","CDM Revenue Code":"370","Standard Price":140.0},{"Itemcode":"64606300","Description":"Surg Ctr Recovery 1st Hour","CDM Revenue Code":"710","Standard Price":787.0},{"Itemcode":"64606316","Description":"Surg Ctr Recovery Ea Addl Hr","CDM Revenue Code":"710","Standard Price":494.0},{"Itemcode":"64608834","Description":"ASC Dental/PlasticClient 1stHR","CDM Revenue Code":"360","Standard Price":1275.0},{"Itemcode":"64608835","Description":"ASC Dental/PlasticCli adl15min","CDM Revenue Code":"360","Standard Price":319.0},{"Itemcode":"64608836","Description":"ASC ENT Client 1st HR","CDM Revenue Code":"360","Standard Price":957.0},{"Itemcode":"64608837","Description":"ASC ENT CLIENT EA addl15min","CDM Revenue Code":"360","Standard Price":240.0},{"Itemcode":"64609905","Description":"Surg Time Per 30 Minutes","CDM Revenue Code":"360","Standard Price":2090.0},{"Itemcode":"64609906","Description":"Yag Laser Procedure","CDM Revenue Code":"360","Standard Price":1289.0},{"Itemcode":"65103000","Description":"Delivery Vaginal","CDM Revenue Code":"360","Standard Price":6100.0},{"Itemcode":"65103001","Description":"ED Vaginal Delivery - D","CDM Revenue Code":"450"},{"Itemcode":"65103504","Description":"Paracentesis","CDM Revenue Code":"459","Standard Price":7601.0},{"Itemcode":"65106296","Description":"Category 1 Procedure","CDM Revenue Code":"450","Standard Price":298.0},{"Itemcode":"65106297","Description":"Category 2 Procedure","CDM Revenue Code":"450","Standard Price":583.0},{"Itemcode":"65106301","Description":"Insert Bladder Cath Simple","CDM Revenue Code":"450","Standard Price":996.0},{"Itemcode":"65106302","Description":"Insert Temp Bladder Cath","CDM Revenue Code":"450","Standard Price":996.0},{"Itemcode":"65106303","Description":"Insert Bladder Cath Complex","CDM Revenue Code":"450","Standard Price":1779.0},{"Itemcode":"65106304","Description":"Temp External Pacing","CDM Revenue Code":"450","Standard Price":1398.0},{"Itemcode":"65106416","Description":"Category 3 Procedure","CDM Revenue Code":"450","Standard Price":667.0},{"Itemcode":"65106600","Description":"Intraosseous Infusion Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106610","Description":"Paracentesis Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106620","Description":"Chest Tube Insertion Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106630","Description":"Intubation Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106640","Description":"Pericardiocentesis Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106650","Description":"Lumbar Punct: Pediatric Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106660","Description":"Lumbar Puncture: Adult Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106670","Description":"Central Line Placement Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106680","Description":"Precipitous Birth Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106690","Description":"Gastro Tube Replacement Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106700","Description":"Thoracentesis Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106710","Description":"Emergency Airway Insertion Dri","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"65106720","Description":"Nasal Hem Packing Driver","CDM Revenue Code":"450","Standard Price":0.0},{"Itemcode":"6651","Description":"Paracentesis Us Gd -Surg Comp","CDM Revenue Code":"360","Standard Price":1560.0},{"Itemcode":"68260270","Description":"Bone Marrow Biopsy","CDM Revenue Code":"360","Standard Price":402.0},{"Itemcode":"68300195","Description":"Laryngoscopy","CDM Revenue Code":"360","Standard Price":696.0},{"Itemcode":"6861","Description":"US-Surg Comp-Gall Bladr Drain","CDM Revenue Code":"360","Standard Price":3062.0},{"Itemcode":"6886","Description":"Thoracentesis Asp/Bx Us Guided","CDM Revenue Code":"360","Standard Price":938.0},{"Itemcode":"6901","Description":"Thyroid Biopsy Us Guided -Surg","CDM Revenue Code":"360","Standard Price":1560.0},{"Itemcode":"6906","Description":"Thyroid Aspiration Us Gd -Surg","CDM Revenue Code":"360","Standard Price":298.0},{"Itemcode":"6998","Description":"US Biopsy Surg Comp","CDM Revenue Code":"360","Standard Price":1800.0},{"Itemcode":"7006","Description":"US Biopsy: Liver Surg Comp","CDM Revenue Code":"360","Standard Price":188.0},{"Itemcode":"7008","Description":"US Biopsy: Renal Surg Comp","CDM Revenue Code":"360","Standard Price":4067.0},{"Itemcode":"70101300","Description":"FNA W/O Imaging","CDM Revenue Code":"360","Standard Price":168.0},{"Itemcode":"7100","Description":"US Pseudoaneurysm INJ Surg Com","CDM Revenue Code":"360","Standard Price":10406.0},{"Itemcode":"71100015","Description":"Injection Tx Psuedoaneurysm","CDM Revenue Code":"361","Standard Price":2080.0},{"Itemcode":"71102213","Description":"Small Joint Injection","CDM Revenue Code":"361","Standard Price":824.0},{"Itemcode":"71102214","Description":"Sacroiliac Joint Injection","CDM Revenue Code":"361","Standard Price":1418.0},{"Itemcode":"71106102","Description":"Periocardiocentesis w/Img","CDM Revenue Code":"360","Standard Price":3021.0},{"Itemcode":"71502171","Description":"CT Guided Block Celiac Plex -D","CDM Revenue Code":"350"},{"Itemcode":"71700004","Description":"Lumbar/Sacral LESI w/ guidance","CDM Revenue Code":"361","Standard Price":1362.0},{"Itemcode":"71705245","Description":"Surg Time: Specials Per Min","CDM Revenue Code":"360","Standard Price":156.0},{"Itemcode":"71705515","Description":"Insert Pm Single System","CDM Revenue Code":"360","Standard Price":23686.0},{"Itemcode":"71705541","Description":"Loop Recorder Insertion","CDM Revenue Code":"360","Standard Price":3090.0},{"Itemcode":"71708015","Description":"Chest Tube Insertion","CDM Revenue Code":"360","Standard Price":6750.0},{"Itemcode":"72103003","Description":"Perfusion: Open Heart Fee","CDM Revenue Code":"360","Standard Price":17990.0},{"Itemcode":"72104043","Description":"Perfusion: Iabp Intra-Aortic","CDM Revenue Code":"360","Standard Price":3243.0},{"Itemcode":"72106467","Description":"Perfusion: Beating Heart Lv Ii","CDM Revenue Code":"360","Standard Price":8613.0},{"Itemcode":"72108899","Description":"TAVR HEART FEE","CDM Revenue Code":"360","Standard Price":4088.0},{"Itemcode":"72158800","Description":"CRU Recovery: First Hour","CDM Revenue Code":"710","Standard Price":0.0},{"Itemcode":"72158821","Description":"CRU Recovery: Each Addl Hour","CDM Revenue Code":"710","Standard Price":0.0},{"Itemcode":"72158825","Description":"CRU Nc Recovery - Each Hour","CDM Revenue Code":"719","Standard Price":0.0},{"Itemcode":"72203003","Description":"Perfusion: Open Heart Fee","CDM Revenue Code":"360","Standard Price":17990.0},{"Itemcode":"72204043","Description":"Perfusion: Iabp Intra-Aortic","CDM Revenue Code":"360","Standard Price":3243.0},{"Itemcode":"72206473","Description":"Perfusion: Beating Heart Lv Ii","CDM Revenue Code":"360","Standard Price":8613.0},{"Itemcode":"72208899","Description":"TAVR HEART FEE","CDM Revenue Code":"360","Standard Price":4088.0},{"Itemcode":"72300051","Description":"Tee Incomplete","CDM Revenue Code":"360","Standard Price":612.0},{"Itemcode":"73100013","Description":"Eval Resp Thrpy 1/4 Hr","CDM Revenue Code":"410","Standard Price":0.0},{"Itemcode":"73100204","Description":"Bronch Thoracentesis","CDM Revenue Code":"360","Standard Price":1922.0},{"Itemcode":"73100310","Description":"Extubation","CDM Revenue Code":"410","Standard Price":0.0},{"Itemcode":"73101206","Description":"Endobronchial Ultrasound Ad-On","CDM Revenue Code":"360","Standard Price":10639.0},{"Itemcode":"73200206","Description":"Injection Of Dye Lung Tissue","CDM Revenue Code":"360","Standard Price":10022.0},{"Itemcode":"73200740","Description":"Bronch Proc Time Per 30 Min","CDM Revenue Code":"360","Standard Price":1662.0},{"Itemcode":"73200742","Description":"Laryngoscopy","CDM Revenue Code":"360","Standard Price":644.0},{"Itemcode":"73200743","Description":"Chest Tube Placement","CDM Revenue Code":"360","Standard Price":1675.0},{"Itemcode":"73200750","Description":"Time Ebus/Superd Proc Ea 30 Mn","CDM Revenue Code":"360","Standard Price":2460.0},{"Itemcode":"73201206","Description":"Endobronchial Ultrasound Ad-On","CDM Revenue Code":"360","Standard Price":5174.0},{"Itemcode":"73206300","Description":"Bronch Recovery: First Hour","CDM Revenue Code":"710","Standard Price":2127.0},{"Itemcode":"73206316","Description":"Bronch Recovery Each Addl Hour","CDM Revenue Code":"710","Standard Price":1180.0},{"Itemcode":"74200120","Description":"DM-Hypertension Prog Lvl One","CDM Revenue Code":"942","Standard Price":385.22},{"Itemcode":"74200125","Description":"DM-Hypertension Prog Lvl Two","CDM Revenue Code":"942","Standard Price":716.94},{"Itemcode":"74200130","Description":"DM-Hypertension Prog Lvl Three","CDM Revenue Code":"942","Standard Price":1027.25},{"Itemcode":"74200140","Description":"DM-Hyperlipidemia Prog Lvl 1","CDM Revenue Code":"942","Standard Price":235.42},{"Itemcode":"74200145","Description":"DM-Hyperlipidemia Prog Lvl 2","CDM Revenue Code":"942","Standard Price":470.82},{"Itemcode":"74200150","Description":"DM-Hyperlipidemia Prog Lvl 3","CDM Revenue Code":"942","Standard Price":706.24},{"Itemcode":"74220120","Description":"Hypertension Prog Lvl One","CDM Revenue Code":"942","Standard Price":370.0},{"Itemcode":"74220125","Description":"Hypertension Prog Lvl Two","CDM Revenue Code":"942","Standard Price":689.0},{"Itemcode":"74220130","Description":"Hypertension Prog Lvl Three","CDM Revenue Code":"942","Standard Price":987.0},{"Itemcode":"74220140","Description":"Hyperlipidemia Prog Lvl 1","CDM Revenue Code":"942","Standard Price":226.0},{"Itemcode":"74220145","Description":"Hyperlipidemia Prog Lvl 2","CDM Revenue Code":"942","Standard Price":453.0},{"Itemcode":"74220150","Description":"Hyperlipidemia Prog Lvl 3","CDM Revenue Code":"942","Standard Price":679.0},{"Itemcode":"75100115","Description":"Fluidotherapy And Ultrasound-D","CDM Revenue Code":"420","Standard Price":0.0},{"Itemcode":"75108888","Description":"PT FUNCTIONAL STATUS MAPPING#","CDM Revenue Code":"420","Standard Price":0.0},{"Itemcode":"75110015","Description":"PPD - Permanent Impairment %","CDM Revenue Code":"420","Standard Price":342.0},{"Itemcode":"75110115","Description":"Fluidotherapy And Ultrasound-D","CDM Revenue Code":"420","Standard Price":0.0},{"Itemcode":"75112020","Description":"Physical Capacity Profile","CDM Revenue Code":"420","Standard Price":245.0},{"Itemcode":"75112021","Description":"FCE First Hour","CDM Revenue Code":"420","Standard Price":817.0},{"Itemcode":"75112022","Description":"FCE Each Addl Hour","CDM Revenue Code":"420","Standard Price":817.0},{"Itemcode":"75112023","Description":"FCE Connect","CDM Revenue Code":"420","Standard Price":922.0},{"Itemcode":"75140115","Description":"Fluidotherapy And Ultrasound-D","CDM Revenue Code":"420","Standard Price":0.0},{"Itemcode":"75200115","Description":"Fluidotherapy And Ultrasound-D","CDM Revenue Code":"430","Standard Price":0.0},{"Itemcode":"75208888","Description":"OT FUNCTIONAL STATUS MAPPING#","CDM Revenue Code":"430","Standard Price":0.0},{"Itemcode":"75230115","Description":"Fluidotherapy And Ultrasound-D","CDM Revenue Code":"430","Standard Price":0.0},{"Itemcode":"75308888","Description":"SP FUNCTIONAL STATUS MAPPING#","CDM Revenue Code":"440","Standard Price":0.0},{"Itemcode":"75451000","Description":"Disease Mgt Wt Mgt Level 2","CDM Revenue Code":"942","Standard Price":2333.0},{"Itemcode":"75451001","Description":"Disease Mgt Wt Mgt Level 3","CDM Revenue Code":"942","Standard Price":4666.0},{"Itemcode":"75452000","Description":"Disease Mgt Camp Fun","CDM Revenue Code":"942","Standard Price":304.0},{"Itemcode":"75452001","Description":"Disease Mgt Wt Maintenance","CDM Revenue Code":"942","Standard Price":1374.0},{"Itemcode":"75452002","Description":"Disease Mgt DMC HYBRID","CDM Revenue Code":"942","Standard Price":1853.0},{"Itemcode":"75452020","Description":"Go Strong Level 1 Quarter","CDM Revenue Code":"940","Standard Price":811.0},{"Itemcode":"75452021","Description":"Go Strong Level 2 Quarter","CDM Revenue Code":"940","Standard Price":336.0},{"Itemcode":"75452022","Description":"Go Strong Rmr","CDM Revenue Code":"940","Standard Price":117.0},{"Itemcode":"75452023","Description":"Go Strong Education Fee","CDM Revenue Code":"940","Standard Price":36.0},{"Itemcode":"75452028","Description":"Coaching/Biometric 30 Min","CDM Revenue Code":"940","Standard Price":29.0},{"Itemcode":"75452029","Description":"Personal Training 30 Min","CDM Revenue Code":"940","Standard Price":21.0},{"Itemcode":"75452030","Description":"Lifestyle Lab","CDM Revenue Code":"940","Standard Price":17.0},{"Itemcode":"75452040","Description":"Disease Wt Mgt Level 2 Qtr1","CDM Revenue Code":"942","Standard Price":1264.0},{"Itemcode":"75452041","Description":"Disease Wt Mgt Level 2 Qtr2","CDM Revenue Code":"942","Standard Price":427.86},{"Itemcode":"75452042","Description":"Disease Wt Mgt Level 2 Qtr3","CDM Revenue Code":"942","Standard Price":321.0},{"Itemcode":"75452043","Description":"Disease Wt Mgt Level 2 Qtr4","CDM Revenue Code":"942","Standard Price":321.0},{"Itemcode":"75452050","Description":"Disease Wt Mgt Level 3 Qtr1","CDM Revenue Code":"942","Standard Price":2205.0},{"Itemcode":"75452051","Description":"Disease Wt Mgt Level 3 Qtr2","CDM Revenue Code":"942","Standard Price":1177.0},{"Itemcode":"75452052","Description":"Disease Wt Mgt Level 3 Qtr3","CDM Revenue Code":"942","Standard Price":856.0},{"Itemcode":"75452053","Description":"Disease Wt Mgt Level 3 Qtr4","CDM Revenue Code":"942","Standard Price":428.0},{"Itemcode":"75452060","Description":"Disease Wt Mgt Weigh To Go Q1","CDM Revenue Code":"942","Standard Price":562.0},{"Itemcode":"75452061","Description":"Disease Wt Mgt Weigh To Go Q2","CDM Revenue Code":"942","Standard Price":284.0},{"Itemcode":"75452062","Description":"Disease Wt Mgt Weigh To Go Q3","CDM Revenue Code":"942","Standard Price":284.0},{"Itemcode":"75452063","Description":"Disease Wt Mgt Weigh To Go Q4","CDM Revenue Code":"942","Standard Price":284.0},{"Itemcode":"75458888","Description":"Biometric Screen","CDM Revenue Code":"940","Standard Price":0.0},{"Itemcode":"76970270","Description":"Bone Marrow Biopsy","CDM Revenue Code":"360","Standard Price":402.0},{"Itemcode":"77200050","Description":"Inpatient Diabetic Ed - 30 Min","CDM Revenue Code":"942","Standard Price":0.0},{"Itemcode":"77200135","Description":"Asthma Management Program","CDM Revenue Code":"942","Standard Price":340.0},{"Itemcode":"77200136","Description":"Dietician Initial Consult","CDM Revenue Code":"942","Standard Price":71.0},{"Itemcode":"77200137","Description":"Dietician Follow-Up","CDM Revenue Code":"942","Standard Price":44.0},{"Itemcode":"77200804","Description":"SBG First Year","CDM Revenue Code":"942","Standard Price":2828.0},{"Itemcode":"77200805","Description":"SBG Annual Re-Enrollment","CDM Revenue Code":"942","Standard Price":1985.0},{"Itemcode":"77200806","Description":"SBG MAINTENANCE DIABETES","CDM Revenue Code":"942","Standard Price":1778.0},{"Itemcode":"77200807","Description":"SBG PREVENTT2","CDM Revenue Code":"942","Standard Price":622.0},{"Itemcode":"8001","Description":"CT Cervicl Thoracic Lumbar W/O","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8002","Description":"CT cervical,lumbar wo con D","CDM Revenue Code":"350","Standard Price":2630.0},{"Itemcode":"8003","Description":"CT Head MaxiloFacl W/O Contra","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8004","Description":"CT Thorax W Abd W/Wo Contrast","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8006","Description":"CT ThoraxW Abd W/Wo PelW Contr","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8007","Description":"CTSft Tissuneck ThoraxW/OCon D","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8008","Description":"CT Thorax Abd W/O Contrast","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8009","Description":"CT Thorax Abd W/Contrast","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8010","Description":"CT Sft Tiss Neck Thx W/Contras","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8011","Description":"CT Abd Pelvis Wo/ Contrast-D","CDM Revenue Code":"350"},{"Itemcode":"8013","Description":"CT Abd Pelvis W/Contrast - D","CDM Revenue Code":"350"},{"Itemcode":"8014","Description":"CT Thorax Abd Pelvis W/O Contr","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8015","Description":"CT Thorax Abd Pelvis W/Contr-D","CDM Revenue Code":"350"},{"Itemcode":"8016","Description":"CTA Carotid CTA Cow- D","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8017","Description":"Head W/O Cta Carotid Cta Cow","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8018","Description":"CT Thoracic Lumbr W/O Contrast","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8019","Description":"CT Cervical Thoracic W/OContr","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8020","Description":"CTA Pulsatile Tinnitus Hd/Nk-D","CDM Revenue Code":"350"},{"Itemcode":"8021","Description":"CT Brain Perfusion For Reach-D","CDM Revenue Code":"350"},{"Itemcode":"8022","Description":"CTA Abd W/Wo &CTA Chest W/Wo-D","CDM Revenue Code":"350"},{"Itemcode":"8023","Description":"CTA Chest Pe & Ct Abd/Pel W","CDM Revenue Code":"350","Standard Price":0.0},{"Itemcode":"8024","Description":"CT Thorax W/Abd Pel W/Wo -D","CDM Revenue Code":"350"},{"Itemcode":"8025","Description":"MRI Brain Mra Head Neck Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8026","Description":"MRI Brain Mra Head W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8027","Description":"MRI Brain Mra Head Neck W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8028","Description":"MRI Lumbar Hip Lt Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8029","Description":"MRI Lumbar Hip Rt Wo-D","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8030","Description":"MRI Lumbar Hip Bilat Wo - D","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8031","Description":"MRI Brain And Cervical Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8032","Description":"MRI Brain/Orbits W/Wo -D","CDM Revenue Code":"611"},{"Itemcode":"8034","Description":"MRI Brain/Orbits W/O Cont -D","CDM Revenue Code":"610"},{"Itemcode":"8035","Description":"CT Tavr -D","CDM Revenue Code":"350"},{"Itemcode":"8036","Description":"MRI Brain Mra Head Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8037","Description":"MRI Thoracic W/Wo Lumbar Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8038","Description":"MRI Thoracic Lumbar W/Wo - D","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8041","Description":"MRI Brain Cerv Thorac Lumb Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8042","Description":"MRI Brain Cerv Thor Lumb W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8043","Description":"MRI Cervical Thoracic Wo - D","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8045","Description":"MRI Cervical Lumbar Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8046","Description":"MRI Cervical Lumbar W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8047","Description":"MRI Cervical Wo Lumbar W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8048","Description":"MRI Thoracic Lumbar Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8050","Description":"MRI Cervicalthorac Lumbar Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8051","Description":"MRI Lumbar Hip Lt W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8052","Description":"MRI Lumbar Hip Bilat W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8053","Description":"MRI Lumbar W/Wo Hip Lt Wo-D","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8054","Description":"MRI Lumbar W/Wo Hip Rt Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8055","Description":"MRI Brain/Cerv Sp W/WoCont - D","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8056","Description":"MRI Brain W/Wo Cervical Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8057","Description":"MRI Brain Cervical Thoracic Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8058","Description":"MRI Cervical Thor Lumb W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8060","Description":"MRI Lumbar Hip Rt W/Wo","CDM Revenue Code":"610","Standard Price":0.0},{"Itemcode":"8061","Description":"MRA Runoff-D","CDM Revenue Code":"610"},{"Itemcode":"8063","Description":"CT THX/ABD/PEL WWO - D","CDM Revenue Code":"350"},{"Itemcode":"8064","Description":"CT Brain and Cervical Spine wo","CDM Revenue Code":"350"},{"Itemcode":"8065","Description":"CT Brain/Maxillofacial/Cervica","CDM Revenue Code":"350"},{"Itemcode":"8215","Description":"Chest Tube Insertion Fluoro Gd","CDM Revenue Code":"360","Standard Price":6750.0},{"Itemcode":"8234","Description":"CT RF Ablation Uni Liver-D","CDM Revenue Code":"350"},{"Itemcode":"8235","Description":"RF Ablat Unilat Renaltumors- D","CDM Revenue Code":"352","Standard Price":0.0},{"Itemcode":"8270","Description":"Stent-Cervical Carotid","CDM Revenue Code":"360","Standard Price":8235.0},{"Itemcode":"8670","Description":"Lumbar Spinal Puncture W/Floro","CDM Revenue Code":"360","Standard Price":6630.0},{"Itemcode":"8880","Description":"CTA CHEST/ABD/PELVIS - D","CDM Revenue Code":"352"},{"Itemcode":"8882","Description":"CTA Thx/Ct Abd W/Contrast-D","CDM Revenue Code":"352"},{"Itemcode":"8883","Description":"CTA Thx/Ct Abd W/Wo Contrast-D","CDM Revenue Code":"352"},{"Itemcode":"8884","Description":"CTA Thx/Ct Abd&Pel W/Con -D","CDM Revenue Code":"351"},{"Itemcode":"8885","Description":"CTA Thx/Ct Ab W/Wo Pel W/Cn-D","CDM Revenue Code":"351"},{"Itemcode":"8886","Description":"CTA Thx/Ct Ab&Pel W/Wo Cn -D","CDM Revenue Code":"351"},{"Itemcode":"8889","Description":"CTA Thx/Ct Abd&Pel W/Con -D","CDM Revenue Code":"350"},{"Itemcode":"8890","Description":"CTA Thx/Ct Abd&Pel W/Wo -D","CDM Revenue Code":"350"},{"Itemcode":"61551050","Description":"Labor & Delivery Svcs","CDM Revenue Code":"720","Standard Price":4972.0},{"Itemcode":"61551051","Description":"Labor & Delivery Svcs Ii","CDM Revenue Code":"720","Standard Price":4972.0},{"Itemcode":"61555050","Description":"Amniocentesis","CDM Revenue Code":"721","Standard Price":1402.0},{"Itemcode":"61600005","Description":"Circumcision Of Male Baby-D","CDM Revenue Code":"723","Standard Price":0.0},{"Itemcode":"60950003","Description":"CH 1 - Adm Room & Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"60958888","Description":"CH 1 - Adm Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61050005","Description":"CH 4N Room & Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61050009","Description":"CH 4N Stem Cell R&B Rad:Tram","CDM Revenue Code":"147","Standard Price":1138.0},{"Itemcode":"61050022","Description":"4 North Room & Board Monitored","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61058888","Description":"CH 4N Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61100003","Description":"CH 2N Room & Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61100009","Description":"CH 2N Room & Board (Monitored)","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61108888","Description":"CH 2N Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61150001","Description":"6 North Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61150002","Description":"6 North Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61150015","Description":"6 North Room & Board Monitored","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61156666","Description":"CH 1N Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61157777","Description":"SJH 6Th Fl Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61158888","Description":"CH 6N Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61200001","Description":"5 South Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61200002","Description":"5 South Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61200009","Description":"5 South Room & Board- Monitore","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61208888","Description":"SJH 5S Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61250001","Description":"2 South Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61258888","Description":"SJH 2S Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61300001","Description":"SJH 5 North Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61300002","Description":"SJH 5 North Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61300006","Description":"5 North Room & Board- Monitor","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61300009","Description":"SJH 5N Room & Board - Tram","CDM Revenue Code":"147","Standard Price":1138.0},{"Itemcode":"61308888","Description":"SJH 5N Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61350006","Description":"CH 6S Room & Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61350009","Description":"6 South Room & Board Monitored","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61358888","Description":"CH 6S Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61400001","Description":"7 North Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61400002","Description":"7 North Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61400009","Description":"SJH 7N Room & Board (Monitore","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61400011","Description":"SJH 7N Room & Board (Monitor-","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61408888","Description":"SJH 7N Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61450001","Description":"SJH 7 South MED/SURG R&B","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61458888","Description":"SJH 7S Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61500016","Description":"CH Pediatric Room And Board","CDM Revenue Code":"113","Standard Price":1265.0},{"Itemcode":"61500068","Description":"CH Peds Adult Overflow R&B","CDM Revenue Code":"111","Standard Price":1265.0},{"Itemcode":"61500101","Description":"Postpartum Rm Charge - Ped","CDM Revenue Code":"112","Standard Price":1265.0},{"Itemcode":"61508888","Description":"CH 5N Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61550005","Description":"3Rd Floor Room & Board","CDM Revenue Code":"112","Standard Price":1265.0},{"Itemcode":"61558888","Description":"CH 3Rd Fl Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61560016","Description":"CH PEDIATRIC RM & BD","CDM Revenue Code":"113","Standard Price":1265.0},{"Itemcode":"61560100","Description":"CH Postpartum Rm Charge","CDM Revenue Code":"112","Standard Price":1265.0},{"Itemcode":"61700099","Description":"Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61700100","Description":"Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61707777","Description":"SJH 3Rd Fl Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61708888","Description":"CH Pcu Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"61800100","Description":"Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61850100","Description":"Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61900002","Description":"Private Room","CDM Revenue Code":"111","Standard Price":1265.0},{"Itemcode":"61900013","Description":"NICU Op Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"62100001","Description":"Rehab Room And Board","CDM Revenue Code":"118","Standard Price":1484.0},{"Itemcode":"62200001","Description":"Sub-Acute Room And Board","CDM Revenue Code":"121","Standard Price":1181.0},{"Itemcode":"64148888","Description":"NO CHARGE POOLER","CDM Revenue Code":"110","Standard Price":0.0},{"Itemcode":"64150100","Description":"Room And Board","CDM Revenue Code":"111","Standard Price":1265.0},{"Itemcode":"64158888","Description":"CH Post Surg Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"64209002","Description":"Day Surgery Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"64309994","Description":"Room And Board - Pacu","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"64518888","Description":"NO CHARGE POOLER","CDM Revenue Code":"110","Standard Price":0.0},{"Itemcode":"65100098","Description":"Ed Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"72109900","Description":"Card Cath: Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"72150001","Description":"CRU Room And Board - Monitored","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"72150002","Description":"CRU Room And Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"72158888","Description":"CRU Outpatient Room","CDM Revenue Code":"121","Standard Price":0.0},{"Itemcode":"73109900","Description":"Resp Therapy: Room and Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"73209900","Description":"Pulmonary Dx: Room and Board","CDM Revenue Code":"121","Standard Price":1265.0},{"Itemcode":"61500200","Description":"Newborn Room Charge - Ped","CDM Revenue Code":"171","Standard Price":696.0},{"Itemcode":"61558000","Description":"3Rd Floor Newborn Nursery","CDM Revenue Code":"171","Standard Price":696.0},{"Itemcode":"61560200","Description":"CH Newborn Room Charge","CDM Revenue Code":"171","Standard Price":696.0},{"Itemcode":"61600002","Description":"Scn Level 2","CDM Revenue Code":"172","Standard Price":2003.0},{"Itemcode":"61600009","Description":"CH Newborn Nursery","CDM Revenue Code":"171","Standard Price":696.0},{"Itemcode":"61650001","Description":"Newborn Nursery Charge","CDM Revenue Code":"171","Standard Price":696.0},{"Itemcode":"61450003","Description":"SJH 7 SOUTH R&B MONITRD-PCU","CDM Revenue Code":"206","Standard Price":1652.0},{"Itemcode":"61700001","Description":"PCU Room And Board","CDM Revenue Code":"206","Standard Price":1652.0},{"Itemcode":"61800001","Description":"Ccu Room And Board","CDM Revenue Code":"210","Standard Price":4123.0},{"Itemcode":"61800101","Description":"CCU Intermediate Care R&B","CDM Revenue Code":"214","Standard Price":1559.0},{"Itemcode":"61850001","Description":"Intensive Care Room & Board","CDM Revenue Code":"200","Standard Price":4123.0},{"Itemcode":"61900001","Description":"NICU Room And Board","CDM Revenue Code":"202","Standard Price":4123.0},{"Itemcode":"60950004","Description":"CH 1 - Adm Observation Hour","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61050003","Description":"CH 4N Observ Hour","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61050020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61050111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61050150","Description":"CH 4N Observation - Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61100004","Description":"CH 2N Observ Hour","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61100020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61100111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61100150","Description":"CH 2N Observation-Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61100505","Description":"CH 2N OBS R & B (Monitored)","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61150005","Description":"CH 6N Observ Hour","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61150020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61150111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61150150","Description":"CH 6N Observation-Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61150200","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61150505","Description":"6 North-Ortho Hr OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61200020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61200111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61200505","Description":"5 South Hourly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61250015","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61250020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61250111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61250505","Description":"2 South Hourly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61300015","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61300020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61300111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61300505","Description":"5 North Hourly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61350003","Description":"CH 6S Observ Hour","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61350020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61350111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61350150","Description":"CH 6S Observation-Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61400015","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61400021","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61400111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61400505","Description":"7 North Hourly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61400506","Description":"SJH 7N OBS R & B (Monitored)","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61450015","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61450021","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61450111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61450505","Description":"7 South Hourly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61450506","Description":"OBS R & B (Monitored)","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61500004","Description":"CH Peds Observ Hour","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61500020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61500111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61500150","Description":"CH Pediatric Observation-Admis","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61500510","Description":"CH Adult OBS Hourly Chg","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61550021","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61550111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61550150","Description":"3Rd Floor Observation-Adm","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61550505","Description":"LDRP Hourly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61560020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61560111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61560150","Description":"OBS Admission - Postpartum","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61560505","Description":"CH Postpartum Hrly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61700020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61700106","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61700111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61700505","Description":"PCU Monit Hourly OBS Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"61800015","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61800020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61800111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61800506","Description":"Ccu OBS R & B","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":171.0},{"Itemcode":"61850015","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61850020","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61850105","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61850506","Description":"Intensive Care OBS R & B","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":171.0},{"Itemcode":"61900014","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61900021","Description":"Observation Direct Admit","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"61900111","Description":"Observation Per Hr Over 48 Hrs","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"61900506","Description":"NICU OBS R & B","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":171.0},{"Itemcode":"64150001","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"64150002","Description":"Observation: Hourly Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"64200505","Description":"Observation: Hourly Charge","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":49.0},{"Itemcode":"65100103","Description":"Observation: Admission","CDM Revenue Code":"762","Standard Price":0.0},{"Itemcode":"65101505","Description":"Observation: Emergency Room","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":59.0},{"Itemcode":"72150020","Description":"OBSERVATION DIRECT ADMIT","CDM Revenue Code":"762","CDM HCPCS":"G0379","Standard Price":393.0},{"Itemcode":"72150505","Description":"CRU OBS Hourly Chg - Monitored","CDM Revenue Code":"762","CDM HCPCS":"G0378","Standard Price":59.0},{"Itemcode":"64100193","Description":"Alloderm 6X12 Xthick","CDM Revenue Code":"636","CDM HCPCS":"Q4116","Standard Price":8818.86},{"Itemcode":"64100237","Description":"GraftJacket Xpress Inj 2cc","CDM Revenue Code":"636","CDM HCPCS":"Q4113","Standard Price":8487.2},{"Itemcode":"64100424","Description":"Integra Skin Sub Bmw2021 2X2In","CDM Revenue Code":"636","CDM HCPCS":"C9363","Standard Price":6776.37},{"Itemcode":"64100851","Description":"Integra Bilayer Meshed Mwm4101","CDM Revenue Code":"636","CDM HCPCS":"C9363","Standard Price":18231.3433333333,"Note":"**"},{"Itemcode":"64134399","Description":"Integra WD Bilayer Matrx 4x10","CDM Revenue Code":"636","CDM HCPCS":"Q4104","Standard Price":16462.49},{"Itemcode":"64134405","Description":"Tissue Micronized Alloderm 2Cc","CDM Revenue Code":"636","CDM HCPCS":"Q4112","Standard Price":1704.65},{"Itemcode":"64134493","Description":"Apligraf 7.5x7.5cm 40361","CDM Revenue Code":"636","CDM HCPCS":"Q4101","Standard Price":5633.07},{"Itemcode":"64134650","Description":"Alloderm Tissue 8X12 102096","CDM Revenue Code":"636","CDM HCPCS":"Q4116","Standard Price":7940.27},{"Itemcode":"64134809","Description":"Matrix Wound Flow 10cc Fwd301","CDM Revenue Code":"636","CDM HCPCS":"Q4114","Standard Price":12921.35,"Note":"**"},{"Itemcode":"64135569","Description":"Allograft BiofixFlow 2.0cc BFA","CDM Revenue Code":"636","CDM HCPCS":"Q4162","Standard Price":21377.65},{"Itemcode":"64135589","Description":"Integra Matrix 5x5cm","CDM Revenue Code":"636","CDM HCPCS":"Q4108","Standard Price":9086.145,"Note":"**"},{"Itemcode":"64135604","Description":"Epifix Injectable 160mg","CDM Revenue Code":"636","CDM HCPCS":"Q4145","Standard Price":9912.06836734694,"Note":"**"},{"Itemcode":"64135696","Description":"Epifix 5.0 X 5.5Cm ES-5500","CDM Revenue Code":"636","CDM HCPCS":"Q4186","Standard Price":9323.56},{"Itemcode":"64135741","Description":"PuraPlyAM-COM 2X4","CDM Revenue Code":"636","CDM HCPCS":"Q4196","Standard Price":4011.85,"Note":"**"},{"Itemcode":"64600173","Description":"Integra MatrxWnd Flow Inj 10cc","CDM Revenue Code":"636","CDM HCPCS":"Q4114","Standard Price":14114.09},{"Itemcode":"64600182","Description":"Epifix 5.0 X 5.5Cm ES-550","CDM Revenue Code":"636","CDM HCPCS":"Q4186","Standard Price":9323.56},{"Itemcode":"64600214","Description":"Integra Mesh Mwm4051 10X12.5CM","CDM Revenue Code":"636","CDM HCPCS":"C9363","Standard Price":16867.28},{"Itemcode":"64600916","Description":"GraftJacket 2X4 8600-2X04","CDM Revenue Code":"636","CDM HCPCS":"Q4107","Standard Price":5602.17},{"Itemcode":"64605727","Description":"Alloderm Thick16x20cm 1519320","CDM Revenue Code":"636","CDM HCPCS":"Q4116","Standard Price":31168.83},{"Itemcode":"68250425","Description":"Meningococcal (A,C,Y&W-135)Pol","CDM Revenue Code":"636","CDM HCPCS":"90733","Standard Price":661.26},{"Itemcode":"68250511","Description":"Fluzone-High Dose 0.5Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90662","Standard Price":47.38},{"Itemcode":"68251282","Description":"Ascorbic Acid 500Mg/1Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"68252020","Description":"TUBERCULIN VL 5TU/0.1ML","CDM Revenue Code":"254","Standard Price":59.74},{"Itemcode":"68252039","Description":"CALCIUM GLUCONATE 10ML INJ","CDM Revenue Code":"636","CDM HCPCS":"J0610","Standard Price":59.74},{"Itemcode":"68252045","Description":"Prevnar 13 Syringe","CDM Revenue Code":"636","CDM HCPCS":"90670","Standard Price":59.74},{"Itemcode":"68252048","Description":"NACL 0.45% 1000ML","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"68252049","Description":"HYDROCORTISONE NA SUC 100MGINJ","CDM Revenue Code":"636","CDM HCPCS":"J1720","Standard Price":39.14},{"Itemcode":"68252055","Description":"ARSENIC TRIOX(6ML VL) 1 MG EA","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":165.83,"Note":"**"},{"Itemcode":"68252059","Description":"Triptorelin Depo 3.75MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J3315","Standard Price":2488.34491803279,"Note":"**"},{"Itemcode":"68252060","Description":"GOSERELIN ACETATE EA 3.6 MG","CDM Revenue Code":"636","CDM HCPCS":"J9202","Standard Price":2567.79,"Note":"**"},{"Itemcode":"68252065","Description":"Hydromorphone HCL 1MG/ML Inj","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":59.74},{"Itemcode":"68252066","Description":"Hydrocodon/Aceto10mg/325mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68252079","Description":"CYTARABINE 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J9100","Standard Price":56.65},{"Itemcode":"68252083","Description":"Hylenex Inj Ea 1.0 USP Unit","CDM Revenue Code":"636","CDM HCPCS":"J3473","Standard Price":2.06},{"Itemcode":"68252084","Description":"Pneumococcal 23 Vac Conj 0.5ml","CDM Revenue Code":"636","CDM HCPCS":"90732","Standard Price":378.01},{"Itemcode":"68252087","Description":"LEUPROLIDE ACETATE INJ 3.75MG","CDM Revenue Code":"636","CDM HCPCS":"J1950","Standard Price":4872.93,"Note":"**"},{"Itemcode":"68252089","Description":"MORPHINE EA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":56.65},{"Itemcode":"68252090","Description":"ECULIZUMAB EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1300","Standard Price":499.721666666667,"Note":"**"},{"Itemcode":"68252091","Description":"RANITIDINE/ZANTAC EA 25 MG","CDM Revenue Code":"636","CDM HCPCS":"J2780","Standard Price":28.84},{"Itemcode":"68252099","Description":"OLARATUMAB 500MG/50ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":10335.02},{"Itemcode":"68252100","Description":"LIBATAYO 350 MG/7 ML VIAL","CDM Revenue Code":"636","Standard Price":9654.19},{"Itemcode":"68252105","Description":"Heparin Sodium per 10 unit inj","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":5.18039930555556,"Note":"**"},{"Itemcode":"68252106","Description":"Normal Saline 1000 CC HHI","CDM Revenue Code":"636","CDM HCPCS":"J7030","Standard Price":20.4182352941176,"Note":"**"},{"Itemcode":"68252107","Description":"Normal Saline 500Ml","CDM Revenue Code":"258","CDM HCPCS":"J7040","Standard Price":19.3148059701492,"Note":"**"},{"Itemcode":"68252108","Description":"Normal Saline 250 Cc","CDM Revenue Code":"636","CDM HCPCS":"J7050","Standard Price":19.57,"Note":"**"},{"Itemcode":"68252109","Description":"Lipidox Ea 10 Mg","CDM Revenue Code":"636","CDM HCPCS":"Q2049","Standard Price":1455.39},{"Itemcode":"68252111","Description":"Interferon Alfa 2B 1M Unts Hhi","CDM Revenue Code":"636","CDM HCPCS":"J9214","Standard Price":125.66},{"Itemcode":"68252112","Description":"Gammagard Ea 500 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":179.120322580646,"Note":"**"},{"Itemcode":"68252113","Description":"BAVENCIO 200 MG/10 ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9023","Standard Price":1643.88},{"Itemcode":"68252116","Description":"Ipilimumab Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9228","Standard Price":487.19,"Note":"**"},{"Itemcode":"68252117","Description":"Solumedrol Up To 125 Mg","CDM Revenue Code":"636","CDM HCPCS":"J2930","Standard Price":59.2691428571428,"Note":"**"},{"Itemcode":"68252118","Description":"Furosemide/Lasix Up To 20 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1940","Standard Price":59.74,"Note":"**"},{"Itemcode":"68252119","Description":"Iron Sucrose Ea 1 Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1756","Standard Price":5.15},{"Itemcode":"68252120","Description":"Carfilzomib / Kyprolis 1Mg Inj","CDM Revenue Code":"636","Standard Price":138.029048316252,"Note":"**"},{"Itemcode":"68252121","Description":"Decitabine/Dacogen Inj Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J0894","Standard Price":60.101891891892,"Note":"**"},{"Itemcode":"68252122","Description":"Sipuleucel-T/Provenge Per Vial","CDM Revenue Code":"636","CDM HCPCS":"Q2043","Standard Price":77714.53},{"Itemcode":"68252123","Description":"Vincristine Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9370","Standard Price":59.675625,"Note":"**"},{"Itemcode":"68252126","Description":"Dexrazoxane/Zinecard 250 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1190","Standard Price":554.14},{"Itemcode":"68252127","Description":"Vinblastine Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9360","Standard Price":13.39,"Note":"**"},{"Itemcode":"68252128","Description":"Gamunex Ea 500 Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":184.37},{"Itemcode":"68252129","Description":"Ondansetron/Zofran Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J2405","Standard Price":7.21,"Note":"**"},{"Itemcode":"68252130","Description":"Cladribine/Leustatin Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9065","Standard Price":77.25},{"Itemcode":"68252131","Description":"Erlotinib 100 Mg Tab","CDM Revenue Code":"637","Standard Price":711.0},{"Itemcode":"68252132","Description":"ZOLEDRONIC ACID IV-ea 1 mg","CDM Revenue Code":"636","CDM HCPCS":"J3489","Standard Price":917.017765957447,"Note":"**"},{"Itemcode":"68252133","Description":"D5W 1000Ml","CDM Revenue Code":"636","CDM HCPCS":"J7070","Standard Price":56.65,"Note":"**"},{"Itemcode":"68252134","Description":"D5W 500Ml","CDM Revenue Code":"636","CDM HCPCS":"J7060","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"68252135","Description":"D5W 250 Ml","CDM Revenue Code":"258","Standard Price":19.57},{"Itemcode":"68252138","Description":"Panitumumab Ea 10 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9303","Standard Price":465.56},{"Itemcode":"68252139","Description":"Lorazepam Tab 0.5mg","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"68252140","Description":"Ondansetron Tablet Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"Q0162","Standard Price":3.09},{"Itemcode":"68252141","Description":"Kadcyla Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9354","Standard Price":101.97},{"Itemcode":"68252142","Description":"Doxorubicin/Doxil Ea 10 Mg","CDM Revenue Code":"636","CDM HCPCS":"Q2050","Standard Price":2320.73714285715,"Note":"**"},{"Itemcode":"68252143","Description":"Brentuximab/Adcetris Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9042","Standard Price":474.83,"Note":"**"},{"Itemcode":"68252144","Description":"Clofarabine/Clolar Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9027","Standard Price":600.49},{"Itemcode":"68252145","Description":"Filgramstim(G-Csf) EaMcg INJ","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":5.15,"Note":"**"},{"Itemcode":"68252146","Description":"Pertuzumab/Perjeta Ea 1 Mg Hhi","CDM Revenue Code":"636","CDM HCPCS":"J9306","Standard Price":48.0666666666667,"Note":"**"},{"Itemcode":"68252147","Description":"GRANIX/TBO-FILGRASTIM Inj 1Mcg","CDM Revenue Code":"636","CDM HCPCS":"J1447","Standard Price":19.57},{"Itemcode":"68252148","Description":"TOPOTECAN 0.1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9351","Standard Price":13.39,"Note":"**"},{"Itemcode":"68252149","Description":"LORAZEPAM EA 2 MG","CDM Revenue Code":"636","CDM HCPCS":"J2060","Standard Price":59.74,"Note":"**"},{"Itemcode":"68252150","Description":"DEXTROSE 5%/0.45% NACL 500ml","CDM Revenue Code":"258","Standard Price":13.39},{"Itemcode":"68252151","Description":"EPINEPHRINE 0.1 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J0171","Standard Price":6.18},{"Itemcode":"68252152","Description":"PACLITAXEL PROTEIN BND 1MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9264","Standard Price":50.0226955074875,"Note":"**"},{"Itemcode":"68252153","Description":"FLUOROURACIL 500 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J9190","Standard Price":59.0980465116279,"Note":"**"},{"Itemcode":"68252154","Description":"PEMETREXED/ALIMTA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9305","Standard Price":217.272169954476,"Note":"**"},{"Itemcode":"68252155","Description":"PALONOSETRON/ALOXI 25MCG HHI","CDM Revenue Code":"636","CDM HCPCS":"J2469","Standard Price":62.5450197628459,"Note":"**"},{"Itemcode":"68252156","Description":"ATROPINE SULFATE 0.01 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J0461","Standard Price":5.15,"Note":"**"},{"Itemcode":"68252157","Description":"BEVACIZUMAB 10 MG INJ HHI","CDM Revenue Code":"636","CDM HCPCS":"J9035","Standard Price":325.53523659306,"Note":"**"},{"Itemcode":"68252158","Description":"BLEOMYCIN SULFATE 15U Inj HHI","CDM Revenue Code":"636","CDM HCPCS":"J9040","Standard Price":141.11},{"Itemcode":"68252160","Description":"IRINOTECAN Inj 20 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J9206","Standard Price":13.39,"Note":"**"},{"Itemcode":"68252161","Description":"CARBOPLATIN EA 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J9045","Standard Price":12.36,"Note":"**"},{"Itemcode":"68252162","Description":"ALTEPLASE 1MG INJ HHI","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":303.0775,"Note":"**"},{"Itemcode":"68252163","Description":"CISPLATIN EA 10 MG Inj HHI","CDM Revenue Code":"636","CDM HCPCS":"J9060","Standard Price":12.36,"Note":"**"},{"Itemcode":"68252165","Description":"B-12 INJ UP TO 1000 MCG HHI","CDM Revenue Code":"636","CDM HCPCS":"J3420","Standard Price":55.9018947368421,"Note":"**"},{"Itemcode":"68252166","Description":"CYCLOPHOSPHAMIDE 100 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J9070","Standard Price":179.222283813747,"Note":"**"},{"Itemcode":"68252167","Description":"DACARBAZINE/DTIC 100 MG HHI","CDM Revenue Code":"636","Standard Price":29.87,"Note":"**"},{"Itemcode":"68252169","Description":"DEXAMETHASONE EA 1 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":6.18,"Note":"**"},{"Itemcode":"68252170","Description":"DIPHENHYDRAMINE HCL UP TO 50MG","CDM Revenue Code":"636","CDM HCPCS":"J1200","Standard Price":59.0416949152542,"Note":"**"},{"Itemcode":"68252171","Description":"DOCETAXEL 1 MG INJ HHI","CDM Revenue Code":"636","Standard Price":20.1633568342052,"Note":"**"},{"Itemcode":"68252172","Description":"DOXORUBICIN HCL 10 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J9000","Standard Price":23.5517129629629,"Note":"**"},{"Itemcode":"68252173","Description":"FOSAPREPITANT EA 1MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J1453","Standard Price":9.27,"Note":"**"},{"Itemcode":"68252174","Description":"EPIRUBICIN HCL 2 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J9178","Standard Price":14.42},{"Itemcode":"68252175","Description":"CETUXIMAB 10 MG INJ HHI","CDM Revenue Code":"636","CDM HCPCS":"J9055","Standard Price":245.14},{"Itemcode":"68252176","Description":"FAMOTIDINE ea 20mg","CDM Revenue Code":"250","Standard Price":58.9321568627451,"Note":"**"},{"Itemcode":"68252177","Description":"ERIBULIN MESYLATE 0.1 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J9179","Standard Price":461.44,"Note":"**"},{"Itemcode":"68252178","Description":"ROMIPLOSTIM/NPLATE 10MCG","CDM Revenue Code":"636","CDM HCPCS":"J2796","Standard Price":240.608,"Note":"**"},{"Itemcode":"68252179","Description":"DENOSUMAB Inj EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J0897","Standard Price":75.5572173913043,"Note":"**"},{"Itemcode":"68252180","Description":"OCTREOTIDE DEPOT IM ING EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J2353","Standard Price":814.787222222223,"Note":"**"},{"Itemcode":"68252181","Description":"BORTIZOMIB/VELCADE EA .1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9041","Standard Price":192.862641509434,"Note":"**"},{"Itemcode":"68252182","Description":"AZACITIDINE EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9025","Standard Price":24.3501104972376,"Note":"**"},{"Itemcode":"68252183","Description":"DARBEPOETIN ALFA EA 1 MCG HHI","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":29.5033365691305,"Note":"**"},{"Itemcode":"68252184","Description":"MESNA EA 200 MG HHI","CDM Revenue Code":"636","CDM HCPCS":"J9209","Standard Price":26.78},{"Itemcode":"68252185","Description":"IXABEPILONE 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9207","Standard Price":318.27},{"Itemcode":"68252186","Description":"CABAZITAXEL 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9043","Standard Price":557.23,"Note":"**"},{"Itemcode":"68252187","Description":"METHOTREXATE EA 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J9260","Standard Price":56.65},{"Itemcode":"68252188","Description":"EPO INJ Non-ESRD EA 1000 UNITS","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":96.4704313280364,"Note":"**"},{"Itemcode":"68252192","Description":"FLUDARBINE EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J9185","Standard Price":258.53},{"Itemcode":"68252193","Description":"GEMCITABINE Inj EA 200 MG","CDM Revenue Code":"636","CDM HCPCS":"J9201","Standard Price":174.726334586466,"Note":"**"},{"Itemcode":"68252194","Description":"InjectAFer EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1439","Standard Price":6.18,"Note":"**"},{"Itemcode":"68252195","Description":"GRANISETRON HCL EA 100 MCG","CDM Revenue Code":"636","CDM HCPCS":"J1626","Standard Price":6.18,"Note":"**"},{"Itemcode":"68252196","Description":"Neulasta/Pegfilgramsim 6MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":17000.2496774193,"Note":"**"},{"Itemcode":"68252197","Description":"PAMIDRONATE INJ EA 30MG","CDM Revenue Code":"636","CDM HCPCS":"J2430","Standard Price":53.56},{"Itemcode":"68252198","Description":"RITUXAN EA 100 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9312","Standard Price":3833.66},{"Itemcode":"68252199","Description":"VINORELBINE/NAVELBINE 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J9390","Standard Price":59.74},{"Itemcode":"68252200","Description":"Copper, 0.4mg/ml, Inj","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":154.5},{"Itemcode":"68252201","Description":"IFOSFAMIDE/IFEX 1 GM","CDM Revenue Code":"636","CDM HCPCS":"J9208","Standard Price":133.9},{"Itemcode":"68252203","Description":"NOVOLIN EA 5 UNITS INJ","CDM Revenue Code":"636","CDM HCPCS":"J1815","Standard Price":3.09},{"Itemcode":"68252204","Description":"MITOXANTRONE HCL 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9293","Standard Price":82.4},{"Itemcode":"68252205","Description":"MAGNESIUM CITRATE","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68252206","Description":"KCL 20 MEQ / 15ML ORAL","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68252208","Description":"DESMOPRESSIN ACETATE 1 MCG","CDM Revenue Code":"636","CDM HCPCS":"J2597","Standard Price":47.38},{"Itemcode":"68252209","Description":"FULVESTRANT/FASLODEX 25 MG","CDM Revenue Code":"636","CDM HCPCS":"J9395","Standard Price":378.317019230769,"Note":"**"},{"Itemcode":"68252210","Description":"FERUMOXYTOL 1 MG","CDM Revenue Code":"636","CDM HCPCS":"Q0138","Standard Price":6.18,"Note":"**"},{"Itemcode":"68252211","Description":"FERRIC NA GLUCONATE INJ 12.5MG","CDM Revenue Code":"636","CDM HCPCS":"J2916","Standard Price":11.33},{"Itemcode":"68252212","Description":"TRASTUZUMAB/HERCE MDV 10 MGINJ","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":360.5,"Note":"**"},{"Itemcode":"68252213","Description":"kcl 2 mEq","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":19.4777611940298,"Note":"**"},{"Itemcode":"68252214","Description":"Acetaminophen 10Mg","CDM Revenue Code":"636","CDM HCPCS":"J0131","Standard Price":2.06},{"Itemcode":"68252216","Description":"FLUZONE VACCINE V4","CDM Revenue Code":"636","CDM HCPCS":"90686","Standard Price":77.25},{"Itemcode":"68252218","Description":"CYRAMZA EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9308","Standard Price":235.87},{"Itemcode":"68252220","Description":"Meningococcal Vac IM 0.5ml Inj","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":469.68},{"Itemcode":"68252223","Description":"TRANSDERM-SCOP 1PATCH","CDM Revenue Code":"637","Standard Price":69.75},{"Itemcode":"68252224","Description":"TEMSIROLIMUS/TORISEL 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9330","Standard Price":285.31},{"Itemcode":"68252225","Description":"BENDAMUSTINE/TREANDA EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9033","Standard Price":96.82},{"Itemcode":"68252226","Description":"Etoposide/Toposar 10 mg","CDM Revenue Code":"636","CDM HCPCS":"J9181","Standard Price":6.18,"Note":"**"},{"Itemcode":"68252227","Description":"PRIVIGEN INJ EA 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":167.89,"Note":"**"},{"Itemcode":"68252228","Description":"PACLITAXEL 1.0 MG","CDM Revenue Code":"636","CDM HCPCS":"J9267","Standard Price":21.2216042545157,"Note":"**"},{"Itemcode":"68252229","Description":"PROCHLORPERAZINE <=10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J0780","Standard Price":66.95},{"Itemcode":"68252230","Description":"OXALIPLATIN INJ 0.5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9263","Standard Price":5.15,"Note":"**"},{"Itemcode":"68252232","Description":"TESTOSTERONE CYPIONATE 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1071","Standard Price":59.74},{"Itemcode":"68252233","Description":"BICNU 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J9050","Standard Price":3998.46},{"Itemcode":"68252234","Description":"MITOMYCIN 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9280","Standard Price":556.2,"Note":"**"},{"Itemcode":"68252235","Description":"MANNITOL 25%, 50ml VIAL","CDM Revenue Code":"636","CDM HCPCS":"J2150","Standard Price":19.4115384615384,"Note":"**"},{"Itemcode":"68252236","Description":"MG Sulfate 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":19.5118079096046,"Note":"**"},{"Itemcode":"68252237","Description":"LEUCOVORIN CALCIUM INJ EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J0640","Standard Price":28.5263069544364,"Note":"**"},{"Itemcode":"68252239","Description":"HEPARIN PER 1000 U INJ","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":59.74},{"Itemcode":"68252240","Description":"ZIV-AFLIBERCEPT/ZALTRAP EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9400","Standard Price":92.7},{"Itemcode":"68252241","Description":"Neulasta Delivery Kit 6mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":16864.5333333333,"Note":"**"},{"Itemcode":"68252242","Description":"Keytruda Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J9271","Standard Price":192.066388888889,"Note":"**"},{"Itemcode":"68252243","Description":"Mycafungin - Micamine each 1MG","CDM Revenue Code":"636","CDM HCPCS":"J2248","Standard Price":3.09},{"Itemcode":"68252244","Description":"ZARXIO,FILGRSTM(G-CSF) BS 1MCG","CDM Revenue Code":"636","CDM HCPCS":"Q5101","Standard Price":6.18,"Note":"**"},{"Itemcode":"68252245","Description":"Trabectedin/Yondelis 0.1MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9352","Standard Price":1192.74},{"Itemcode":"68252246","Description":"Pentostatin/Nipent Inj 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9268","Standard Price":8357.42},{"Itemcode":"68252247","Description":"Pegaspargase Inj SDV 3750IU5ml","CDM Revenue Code":"636","CDM HCPCS":"J9266","Standard Price":57182.51},{"Itemcode":"68252248","Description":"CIPROFLOXACIN 500MG ORAL TAB","CDM Revenue Code":"637","Standard Price":5.25},{"Itemcode":"68252250","Description":"Gazyva / Obinutuzumab 10MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J9301","Standard Price":213.771818181819,"Note":"**"},{"Itemcode":"68252251","Description":"Gammaplex Inj 500mg","CDM Revenue Code":"636","CDM HCPCS":"J1557","Standard Price":160.68},{"Itemcode":"68252252","Description":"Aminocaproic Acid 250mg/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":6.18},{"Itemcode":"68252253","Description":"Albuterol-Nebulizer NonCom 1mg","CDM Revenue Code":"250","CDM HCPCS":"J7611","Standard Price":6.18},{"Itemcode":"68252254","Description":"Iron Sucrose Comp Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J1756","Standard Price":6.18},{"Itemcode":"68252255","Description":"BENDAMUSTINE/BENDEKA 1MG MDV","CDM Revenue Code":"636","CDM HCPCS":"J9034","Standard Price":96.7576669449081,"Note":"**"},{"Itemcode":"68252256","Description":"Ertapenem Na Inj 500 mg","CDM Revenue Code":"636","CDM HCPCS":"J1335","Standard Price":259.56},{"Itemcode":"68252257","Description":"ISTODAX/RomiDEPsin pwdr 1mg","CDM Revenue Code":"636","CDM HCPCS":"J9315","Standard Price":1244.24},{"Itemcode":"68252258","Description":"DEXAMETHASONE ORAL EA 0.25MG","CDM Revenue Code":"636","CDM HCPCS":"J8540","Standard Price":3.09},{"Itemcode":"68252259","Description":"IMLYGIC/TalLah 1M PFU/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9325","Standard Price":197.76},{"Itemcode":"68252260","Description":"IMLYGIC 100xM PFU Inj EA Vial","CDM Revenue Code":"636","CDM HCPCS":"J9325","Standard Price":96.82},{"Itemcode":"68252261","Description":"Engerix-B 10mcg/0.5 ml Ped SDV","CDM Revenue Code":"636","CDM HCPCS":"90744","Standard Price":94.76},{"Itemcode":"68252262","Description":"Amlodipine 5MG Oral Tab","CDM Revenue Code":"637","Standard Price":1.5},{"Itemcode":"68252263","Description":"Darzalex 10mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9145","Standard Price":204.60150310559,"Note":"**"},{"Itemcode":"68252266","Description":"CIPROFLOXACIN 200MG IV INJ","CDM Revenue Code":"636","CDM HCPCS":"J0744","Standard Price":10.3},{"Itemcode":"68252267","Description":"HEP A VACC PED/ADOL 2DSE IMINJ","CDM Revenue Code":"636","CDM HCPCS":"90633","Standard Price":125.66},{"Itemcode":"68252268","Description":"PREDNISONE IR/DR ORAL 1MG TAB","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":5.15},{"Itemcode":"68252269","Description":"ARRANON INJ EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J9261","Standard Price":596.37},{"Itemcode":"68252270","Description":"CYCLOPHOSPHAMIDE CAP EA 25MG","CDM Revenue Code":"636","CDM HCPCS":"J8530","Standard Price":23.69},{"Itemcode":"68252271","Description":"EMEND CAP EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J8501","Standard Price":43.26},{"Itemcode":"68252272","Description":"Rasburicase/Elitek 0.5mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2783","Standard Price":1117.55},{"Itemcode":"68252273","Description":"Leuprolide Acet/Eligard 7.5Mg","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":1858.635,"Note":"**"},{"Itemcode":"68252275","Description":"GANCICLOVIR 500MG PWVL","CDM Revenue Code":"636","CDM HCPCS":"J1570","Standard Price":339.9},{"Itemcode":"68252277","Description":"ELOTUZUMAB/EMPLICITI INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9176","Standard Price":25.75,"Note":"**"},{"Itemcode":"68252278","Description":"MENACWY VACCINE IM SDV","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":472.77},{"Itemcode":"68252279","Description":"CIPROFLOXACIN 250MG ORAL TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68252280","Description":"Bleomycin 15 Un Inj (Imported)","CDM Revenue Code":"636","CDM HCPCS":"J9040","Standard Price":594.31},{"Itemcode":"68252281","Description":"PEGINTERFERON ALFA2A 180MCG/ML","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":4125.15},{"Itemcode":"68252282","Description":"HYDROCORTISONE NONCHEMO10MGTAB","CDM Revenue Code":"636","CDM HCPCS":"J8499","Standard Price":6.18},{"Itemcode":"68252283","Description":"TECENTRIQ/ATEZOLIZUMAB INJ10MG","CDM Revenue Code":"636","CDM HCPCS":"J9022","Standard Price":251.32,"Note":"**"},{"Itemcode":"68252284","Description":"Vancomycin HCL 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":81.37},{"Itemcode":"68252285","Description":"Chlorpromazine HCL Inj to 50MG","CDM Revenue Code":"636","CDM HCPCS":"J3230","Standard Price":115.36},{"Itemcode":"68252286","Description":"SUSTOL INJ 10MG/0.4ML INJ","CDM Revenue Code":"636","Standard Price":2153.73},{"Itemcode":"68252287","Description":"Tranexamic Acid 10ml IV","CDM Revenue Code":"250","Standard Price":218.36},{"Itemcode":"68252288","Description":"Infanrix DTAP Peds 0.5ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90700","Standard Price":93.73},{"Itemcode":"68252289","Description":"Ofatumumab/Arzerra 10mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9302","Standard Price":214.24},{"Itemcode":"68252290","Description":"ALBUTEROL HFA MDI 200INH 18GM","CDM Revenue Code":"636","CDM HCPCS":"J3535","Standard Price":184.37},{"Itemcode":"68252292","Description":"Fentanyl Ptch-Xtd Rel 25mcg/hr","CDM Revenue Code":"637","Standard Price":9.0},{"Itemcode":"68252293","Description":"HYQVIA IMMUNGLOBULIN INJ 100MG","CDM Revenue Code":"636","CDM HCPCS":"J1575","Standard Price":9251.46},{"Itemcode":"68252294","Description":"FLUCONAZOLE/DIFLUCAN INJ 200MG","CDM Revenue Code":"636","CDM HCPCS":"J1450","Standard Price":59.74},{"Itemcode":"68252295","Description":"Hydralazine 25Mg Tab","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68252296","Description":"ELOSULFASEALFA,VIMIZIM INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1322","Standard Price":973.35},{"Itemcode":"68252297","Description":"GALSULFASE/NAGLAZYM INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1458","Standard Price":1554.27},{"Itemcode":"68252298","Description":"ImmuneGlobul-Octagam 500mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1568","Standard Price":220.42},{"Itemcode":"68252299","Description":"Varubi Inj 166.5mg/92.5ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":1251.45},{"Itemcode":"68252301","Description":"Degarelix/Firmagon Inj 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9155","Standard Price":15.45},{"Itemcode":"68252322","Description":"DEPO_MEDROL 40 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1030","Standard Price":28.84},{"Itemcode":"68252345","Description":"Filgrastim-Neupogen Inj 1Mcg","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":5.15,"Note":"**"},{"Itemcode":"68252346","Description":"Montelukast Sod 10mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68252352","Description":"ALLOPURINOL 300MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68252353","Description":"ALLOPURINOL 100MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68252354","Description":"NIVOLUMAB / OPDIVO, INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9299","Standard Price":107.930398899587,"Note":"**"},{"Itemcode":"68252355","Description":"Somatuline Depot ea 1mg, Inj","CDM Revenue Code":"636","CDM HCPCS":"J1930","Standard Price":285.767777777777,"Note":"**"},{"Itemcode":"68252356","Description":"ALEMTUZUMAB/CAMPATH Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J0202","Standard Price":0.0},{"Itemcode":"68252357","Description":"Levoleucovorin Calcm Inj 0.5mg","CDM Revenue Code":"636","CDM HCPCS":"J0641","Standard Price":8.24},{"Itemcode":"68252358","Description":"CARPUJET,MORPH SULF 4MG/ML INJ","CDM Revenue Code":"250","Standard Price":77.25},{"Itemcode":"68252359","Description":"OLARATUMAB INJ 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9285","Standard Price":200.85},{"Itemcode":"68252360","Description":"Sustol Inj ea 0.1mg","CDM Revenue Code":"636","CDM HCPCS":"J1627","Standard Price":2260.85},{"Itemcode":"68252361","Description":"TRASTUZUMAB/HER INJ SDV 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":424.365711645101,"Note":"**"},{"Itemcode":"68252362","Description":"IRINOTECAN LIP/ONIVYDE INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9205","Standard Price":166.882391304348,"Note":"**"},{"Itemcode":"68252363","Description":"FLEBOGAMMA IG 5%%DIF 500MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1572","Standard Price":166.86,"Note":"**"},{"Itemcode":"68252364","Description":"Fentanyl 100mcg/2Ml Inj SDV","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":59.74},{"Itemcode":"68252365","Description":"COPANLISIB/ALIQOPA 1mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9057","Standard Price":17823.12},{"Itemcode":"68252366","Description":"DURVALUMAB/IMFINZI INJ 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9173","Standard Price":239.041541666667,"Note":"**"},{"Itemcode":"68252367","Description":"CARIMUNE NF,IG 500MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1566","Standard Price":122.57,"Note":"**"},{"Itemcode":"68252368","Description":"Vedolizumab/Entyvio Inj, 1mg","CDM Revenue Code":"636","CDM HCPCS":"J3380","Standard Price":82.4},{"Itemcode":"68252369","Description":"GEMTUZUMAB OZOGAMICIN IN 0.1MG","CDM Revenue Code":"636","CDM HCPCS":"J9203","Standard Price":772.5},{"Itemcode":"68252370","Description":"AMLODIPENE BESYLATE 10MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68252371","Description":"METOPROLOL TARTRATE 100MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68252372","Description":"HAVRIX 1440U/ 1ML SYR INJ","CDM Revenue Code":"250","Standard Price":268.83},{"Itemcode":"68252373","Description":"9VHPVGARDASIL VAC2-3D 0.5MLINJ","CDM Revenue Code":"636","CDM HCPCS":"90651","Standard Price":805.46},{"Itemcode":"68252400","Description":"RITUXAN EA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9312","Standard Price":372.242,"Note":"**"},{"Itemcode":"68252425","Description":"Emicizumab-KXWH 0.5 mg","CDM Revenue Code":"636","CDM HCPCS":"J7170","Standard Price":153.1404},{"Itemcode":"68252450","Description":"Cemiplimab-rwlc 1mg ea","CDM Revenue Code":"636","CDM HCPCS":"J9119","Standard Price":86.52,"Note":"**"},{"Itemcode":"68252451","Description":"Fulphila 0.5mg inj HHI","CDM Revenue Code":"636","CDM HCPCS":"Q5108","Standard Price":1118.58},{"Itemcode":"68252453","Description":"Romosozumab 105mg/1.17ml syr","CDM Revenue Code":"636","CDM HCPCS":"J3590","Standard Price":3213.6,"Note":"**"},{"Itemcode":"68252454","Description":"Mogamulizumab-kpkc 1mg EA","CDM Revenue Code":"636","CDM HCPCS":"J9204","Standard Price":634.48},{"Itemcode":"68252455","Description":"POLATUZUMAB 1MG VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":50212.5,"Note":"**"},{"Itemcode":"68252456","Description":"Pentamidine iset 300mg inh pwd","CDM Revenue Code":"250","CDM HCPCS":"J2545","Standard Price":418.18},{"Itemcode":"68252458","Description":"Ravulizumab-CWVZ EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1303","Standard Price":714.82},{"Itemcode":"68252459","Description":"Romosozumab-AQQG 1mg ea","CDM Revenue Code":"636","CDM HCPCS":"J3111","Standard Price":35.02,"Note":"**"},{"Itemcode":"68252460","Description":"Bevacizumab-AWWB 10mg (MVASI)","CDM Revenue Code":"636","CDM HCPCS":"Q5107","Standard Price":268.83},{"Itemcode":"68252461","Description":"TRASTUZ-ANNS (KANJINTI) 10MG","CDM Revenue Code":"636","CDM HCPCS":"Q5117","Standard Price":284.28},{"Itemcode":"68252464","Description":"NaPhos 45mmol/15ml vial","CDM Revenue Code":"250","Standard Price":131.84,"Note":"**"},{"Itemcode":"68252466","Description":"Enfortumab Vedotin-ejfv 1mg","CDM Revenue Code":"636","CDM HCPCS":"J3590","Standard Price":353.29},{"Itemcode":"68252468","Description":"TRUXIMA 10 mg","CDM Revenue Code":"636","CDM HCPCS":"Q5115","Standard Price":264.71},{"Itemcode":"68252469","Description":"Reblozyl 1mg inj","CDM Revenue Code":"636","CDM HCPCS":"J3590","Standard Price":460.41},{"Itemcode":"68252504","Description":"Cerezyme (Imiglucerase) 10Unit","CDM Revenue Code":"636","CDM HCPCS":"J1786","Standard Price":168.92},{"Itemcode":"68252505","Description":"Methylprednisolone 40MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J2920","Standard Price":59.74},{"Itemcode":"68252506","Description":"Leuprolide Depot Ea 7.5Mg","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":5841.54824242424,"Note":"**"},{"Itemcode":"68252508","Description":"Vitamin K / Mephyton ea 5mg","CDM Revenue Code":"250","Standard Price":237.93},{"Itemcode":"68252509","Description":"Folic Acid ea 1mg","CDM Revenue Code":"250","Standard Price":6.18},{"Itemcode":"68252510","Description":"Levofloxacin/Levaquin 250 mg","CDM Revenue Code":"636","CDM HCPCS":"J1956","Standard Price":19.57},{"Itemcode":"68252511","Description":"Magnesium Oxide 400mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68252512","Description":"Pralatrexate / Folotyn ea 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9307","Standard Price":870.35},{"Itemcode":"68252513","Description":"Cefepime/Maxepine Inj ea 500MG","CDM Revenue Code":"636","CDM HCPCS":"J0692","Standard Price":15.45},{"Itemcode":"68252514","Description":"Nivolumab/Optivo 10mg/ml","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":1105.19},{"Itemcode":"68252517","Description":"ADDAMEL N INJ10ML AMP (TRA ME)","CDM Revenue Code":"250","Standard Price":64.89},{"Itemcode":"68252518","Description":"Velaglucerase Alfa/VPRIV100UIn","CDM Revenue Code":"636","CDM HCPCS":"J3385","Standard Price":1460.54},{"Itemcode":"68252638","Description":"Gammagard S/D 500 mg Powder","CDM Revenue Code":"636","CDM HCPCS":"J1566","Standard Price":294.333397101449,"Note":"**"},{"Itemcode":"68252646","Description":"EPOETIN ALFA -EBX 1000U","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":1705.4946,"Note":"**"},{"Itemcode":"68256113","Description":"INFLIXIMAB INJ 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1745","Standard Price":470.71},{"Itemcode":"68257534","Description":"Lidocaine 1%% 2Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":51.5},{"Itemcode":"68257537","Description":"Lidocaine 1%% 30Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":2.06},{"Itemcode":"68257538","Description":"Lidocaine 1%% 30Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":2.06},{"Itemcode":"68258888","Description":"Nonchargable","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"68259017","Description":"ARSENIC TRIOXIDE 10MG/10ML VL","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":5861.73,"Note":"**"},{"Itemcode":"68259467","Description":"RITUXIMAB/HYALURONIDASE","CDM Revenue Code":"636","CDM HCPCS":"J9311","Standard Price":6773.8774,"Note":"**"},{"Itemcode":"68259468","Description":"RITUXIMAB/HYALURONIDASE","CDM Revenue Code":"636","CDM HCPCS":"J9311","Standard Price":677.3795,"Note":"**"},{"Itemcode":"68260425","Description":"Meningococcal (A,C,Y&W-135)Pol","CDM Revenue Code":"636","CDM HCPCS":"90733","Standard Price":661.26},{"Itemcode":"68260511","Description":"Fluzone-High Dose 0.5Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90662","Standard Price":47.38},{"Itemcode":"68261282","Description":"Ascorbic Acid 500Mg/ 1Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"68261492","Description":"Prochlorperazine 10Mg2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0780","Standard Price":30.9,"Note":"**"},{"Itemcode":"68262018","Description":"Hydrocodone 5MG/APAP 325MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262019","Description":"HYDRALAZINE 20 MG/ML","CDM Revenue Code":"636","CDM HCPCS":"J0360","Standard Price":59.74},{"Itemcode":"68262020","Description":"TUBERCULIN VL 5TU/0.1ML","CDM Revenue Code":"254","Standard Price":59.74},{"Itemcode":"68262021","Description":"IPOL","CDM Revenue Code":"636","CDM HCPCS":"90713","Standard Price":153.47},{"Itemcode":"68262022","Description":"ISOVUE EA 1ML","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":6.18},{"Itemcode":"68262023","Description":"LABETALOL 20MG/4ML","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"68262024","Description":"LOPERAMIDE 2 MG CAPSULE","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262026","Description":"METOCLOPRPAMIDE 10MG/2ML INJ","CDM Revenue Code":"636","CDM HCPCS":"J2765","Standard Price":59.74},{"Itemcode":"68262027","Description":"METOCLOPRAMIDE 10MG 1TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262028","Description":"MEASLES-MUMPS-RUBELLA II","CDM Revenue Code":"636","CDM HCPCS":"90707","Standard Price":272.95},{"Itemcode":"68262029","Description":"OXYCODONE 5MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68262030","Description":"OXYCODONE 5MG/APAP 325MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68262031","Description":"PROBENECID 500MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262032","Description":"PROCHLORPERAZINE Oral EA 5MG","CDM Revenue Code":"636","CDM HCPCS":"Q0164","Standard Price":6.18},{"Itemcode":"68262033","Description":"PROMETHAZINE 25MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262034","Description":"BELIMUMAB/BENLYSTA INJ 10MG","CDM Revenue Code":"636","CDM HCPCS":"J0490","Standard Price":178.19},{"Itemcode":"68262035","Description":"SODIUM POLYSTYRENE SULF ORAL","CDM Revenue Code":"637","Standard Price":1.5},{"Itemcode":"68262036","Description":"SOD. THIOSULFATE 25%% 50ML VIA","CDM Revenue Code":"250","Standard Price":14.42},{"Itemcode":"68262037","Description":"ALBUTEROL INHALER PER USE 1INH","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262038","Description":"LORATADINE 10MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262039","Description":"CALCIUM GLUCONATE 10ML INJ","CDM Revenue Code":"636","CDM HCPCS":"J0610","Standard Price":59.74},{"Itemcode":"68262041","Description":"DIPHENOXYLATE/ATROPIN 2.5MGTAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262043","Description":"PREDNISONE 5 MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262044","Description":"PEDAXHIB VACCINE 7.5ug / 0.5mL","CDM Revenue Code":"636","CDM HCPCS":"90647","Standard Price":100.94},{"Itemcode":"68262045","Description":"PREVNAR 13 SYRINGE","CDM Revenue Code":"636","CDM HCPCS":"90670","Standard Price":59.74},{"Itemcode":"68262046","Description":"PROMETHAZINE UP TO 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J2550","Standard Price":59.74},{"Itemcode":"68262047","Description":"SODIUM BICARB 8.4%% VIAL","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"68262048","Description":"NACL 0.45%% 1000ML","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"68262049","Description":"HYDROCORTISONE NA SUC 100MGINJ","CDM Revenue Code":"636","CDM HCPCS":"J1720","Standard Price":39.14},{"Itemcode":"68262051","Description":"WINRHO EACH 100 IU","CDM Revenue Code":"636","CDM HCPCS":"J2792","Standard Price":99.91},{"Itemcode":"68262052","Description":"PHYTONADIONE/VIT K EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J3430","Standard Price":6.18},{"Itemcode":"68262053","Description":"HepB Vac 20mcg/1ml","CDM Revenue Code":"636","CDM HCPCS":"90747","Standard Price":97.85},{"Itemcode":"68262054","Description":"TDAP VACCINE","CDM Revenue Code":"636","CDM HCPCS":"90715","Standard Price":173.04},{"Itemcode":"68262055","Description":"ARSENIC TRIOX(6ML VL) 1 MG EA","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":165.83},{"Itemcode":"68262057","Description":"HYDROMORPHONE 4 MG","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":29.87},{"Itemcode":"68262058","Description":"GLUCAGEN 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1610","Standard Price":717.91},{"Itemcode":"68262059","Description":"TRIPTORELIN DEPO 3.75 MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J3315","Standard Price":2492.6,"Note":"**"},{"Itemcode":"68262060","Description":"GOSERELIN ACETATE EA 3.6 MG","CDM Revenue Code":"636","CDM HCPCS":"J9202","Standard Price":2567.79},{"Itemcode":"68262061","Description":"ALBUTEROL HFA MDI 60INH 8GM","CDM Revenue Code":"636","CDM HCPCS":"J3535","Standard Price":81.37},{"Itemcode":"68262062","Description":"TEMOZOLOMIDE ORAL EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J8700","Standard Price":13.39},{"Itemcode":"68262063","Description":"LACTATED RINGERS 500 ML","CDM Revenue Code":"258","CDM HCPCS":"J7120","Standard Price":59.74},{"Itemcode":"68262064","Description":"LACTATED RINGERS 1000 ML","CDM Revenue Code":"258","CDM HCPCS":"J7120","Standard Price":59.74},{"Itemcode":"68262065","Description":"Hydromorphone HCL 1MG/ML","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":59.74},{"Itemcode":"68262066","Description":"Hydrocodon/Aceto10mg/325mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262068","Description":"GRANISETRON HCL 1 MG TAB","CDM Revenue Code":"636","CDM HCPCS":"Q0166","Standard Price":5.15},{"Itemcode":"68262070","Description":"FLUMAZENIL 0.1MG/ML 5ML INJ MD","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":16.48},{"Itemcode":"68262072","Description":"ASPARAGINASE 10,000 UNITS","CDM Revenue Code":"636","CDM HCPCS":"J9020","Standard Price":421.27},{"Itemcode":"68262073","Description":"D5W 500 ML","CDM Revenue Code":"636","CDM HCPCS":"J7060","Standard Price":59.3848275862069,"Note":"**"},{"Itemcode":"68262074","Description":"D5W 1000 ML","CDM Revenue Code":"636","CDM HCPCS":"J7070","Standard Price":56.65},{"Itemcode":"68262075","Description":"D5W/NACL 0.9%% 500ML","CDM Revenue Code":"636","CDM HCPCS":"J7042","Standard Price":56.65},{"Itemcode":"68262076","Description":"D5W/NACL 0.45%% 1000 ML","CDM Revenue Code":"258","Standard Price":56.65},{"Itemcode":"68262078","Description":"DEFEROXAMINE INJ 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J0895","Standard Price":56.65},{"Itemcode":"68262079","Description":"CYTARABINE 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J9100","Standard Price":56.65},{"Itemcode":"68262081","Description":"MANVEO VACCINE","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":536.63},{"Itemcode":"68262082","Description":"ActHIB VACCIN 4DoseIM","CDM Revenue Code":"636","CDM HCPCS":"90648","Standard Price":152.44},{"Itemcode":"68262083","Description":"HYLENEX INJ EA 1 USP UNIT","CDM Revenue Code":"636","CDM HCPCS":"J3473","Standard Price":2.06},{"Itemcode":"68262084","Description":"Pneumococcal 23 Vac Conj 0.5ml","CDM Revenue Code":"636","CDM HCPCS":"90732","Standard Price":378.01},{"Itemcode":"68262085","Description":"NACL 0.45%%500 ML","CDM Revenue Code":"258","Standard Price":56.65},{"Itemcode":"68262086","Description":"ENOXAPARIN EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":12.36},{"Itemcode":"68262087","Description":"LEUPROLIDE ACETATE INJ 3.75MG","CDM Revenue Code":"636","CDM HCPCS":"J1950","Standard Price":4900.66076923077,"Note":"**"},{"Itemcode":"68262088","Description":"MEPERIDINE UP TO 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J2175","Standard Price":56.65},{"Itemcode":"68262089","Description":"MORPHINE EA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":56.65},{"Itemcode":"68262090","Description":"ECULIZUMAB EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1300","Standard Price":505.73},{"Itemcode":"68262091","Description":"RANITIDINE/ZANTAC EA 25 MG","CDM Revenue Code":"636","CDM HCPCS":"J2780","Standard Price":28.84},{"Itemcode":"68262092","Description":"IDARUBICIN EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9211","Standard Price":186.43},{"Itemcode":"68262094","Description":"CEFTRIAXONE EA 250 MG","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":33.99},{"Itemcode":"68262095","Description":"VISTIDE 375 MG","CDM Revenue Code":"636","CDM HCPCS":"J0740","Standard Price":2877.82},{"Itemcode":"68262097","Description":"CORTROSYN 0.25 MG","CDM Revenue Code":"636","CDM HCPCS":"J0834","Standard Price":80.34},{"Itemcode":"68262098","Description":"DACTINOMYCIN 0.5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9120","Standard Price":2625.47},{"Itemcode":"68262099","Description":"OLARATUMAB 500MG/50ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":10335.02},{"Itemcode":"68262100","Description":"LIBATAYO 350 MG/7 ML VIAL","CDM Revenue Code":"636","Standard Price":9654.19},{"Itemcode":"68262102","Description":"ZIPRASIDONE MESYLATE EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J3486","Standard Price":79.31},{"Itemcode":"68262103","Description":"KETOROLAC TROMETHAMINE 15MG LC","CDM Revenue Code":"636","CDM HCPCS":"J1885","Standard Price":10.3},{"Itemcode":"68262105","Description":"Heparin Sodium per 10 unit inj","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":1.03,"Note":"**"},{"Itemcode":"68262106","Description":"Normal Saline 1000 CC OKT","CDM Revenue Code":"636","CDM HCPCS":"J7030","Standard Price":20.085,"Note":"**"},{"Itemcode":"68262107","Description":"Normal Saline Sterile 500Ml","CDM Revenue Code":"258","CDM HCPCS":"J7040","Standard Price":19.3028530259366,"Note":"**"},{"Itemcode":"68262108","Description":"Normal Saline 250 Cc","CDM Revenue Code":"636","CDM HCPCS":"J7050","Standard Price":6.18,"Note":"**"},{"Itemcode":"68262109","Description":"Lipidox Ea 10 Mg","CDM Revenue Code":"636","CDM HCPCS":"Q2049","Standard Price":1455.39},{"Itemcode":"68262111","Description":"Interferon Alfa 2B 1M Unts","CDM Revenue Code":"636","CDM HCPCS":"J9214","Standard Price":125.66},{"Itemcode":"68262112","Description":"Gammagard Inj Ea 500 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":178.510660377359,"Note":"**"},{"Itemcode":"68262113","Description":"BAVENCIO 200 MG/10 ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9023","Standard Price":1643.88},{"Itemcode":"68262116","Description":"Ipilimumab Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9228","Standard Price":599.46},{"Itemcode":"68262117","Description":"Solumedrol Up To 125 Mg","CDM Revenue Code":"636","CDM HCPCS":"J2930","Standard Price":59.251186440678,"Note":"**"},{"Itemcode":"68262118","Description":"Furosemide/Lasix Up To 20 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1940","Standard Price":59.74},{"Itemcode":"68262119","Description":"Iron Sucrose Each 1 Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1756","Standard Price":5.15},{"Itemcode":"68262120","Description":"Carfilzomib / Kyprolis 1Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9047","Standard Price":140.505079365079,"Note":"**"},{"Itemcode":"68262121","Description":"Decitabine/Dacogen Inj Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J0894","Standard Price":59.6607692307692,"Note":"**"},{"Itemcode":"68262122","Description":"Sipuleucel-T/Provenge Per Vial","CDM Revenue Code":"636","CDM HCPCS":"Q2043","Standard Price":77714.53},{"Itemcode":"68262123","Description":"Vincristine Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9370","Standard Price":58.5628571428572,"Note":"**"},{"Itemcode":"68262126","Description":"Dexrazoxane/Zinecard 250 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1190","Standard Price":554.14},{"Itemcode":"68262127","Description":"Vinblastine Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9360","Standard Price":13.39,"Note":"**"},{"Itemcode":"68262128","Description":"Gamunex Inj Ea 500 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":184.37,"Note":"**"},{"Itemcode":"68262129","Description":"Ondansetron/Zofran Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J2405","Standard Price":7.21,"Note":"**"},{"Itemcode":"68262130","Description":"Cladribine/Leustatin Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9065","Standard Price":75.19,"Note":"**"},{"Itemcode":"68262132","Description":"ZOLEDRONIC ACID IV-ea 1mg","CDM Revenue Code":"636","CDM HCPCS":"J3489","Standard Price":916.667301587302,"Note":"**"},{"Itemcode":"68262135","Description":"D5W 250 Ml","CDM Revenue Code":"258","Standard Price":19.57},{"Itemcode":"68262138","Description":"PANITUMUMAB EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J9303","Standard Price":465.56,"Note":"**"},{"Itemcode":"68262139","Description":"LORAZEPAM TABLET 0.5mg","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"68262140","Description":"ONDANSETRON TABLET EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"Q0162","Standard Price":5.15,"Note":"**"},{"Itemcode":"68262141","Description":"KADCYLA EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9354","Standard Price":101.97},{"Itemcode":"68262142","Description":"DOXORUBICIN/DOXIL EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"Q2050","Standard Price":2364.55301587302,"Note":"**"},{"Itemcode":"68262143","Description":"BRENTUXIMAB/ADCETRIS EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9042","Standard Price":489.25},{"Itemcode":"68262144","Description":"CLOFARABINE/CLOLAR EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9027","Standard Price":600.49},{"Itemcode":"68262145","Description":"Filgramstim (G-Csf) Ea Mcg INJ","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":5.15,"Note":"**"},{"Itemcode":"68262146","Description":"Pertuzumab/Perjeta Ea 1 Mg Okt","CDM Revenue Code":"636","CDM HCPCS":"J9306","Standard Price":48.0541818181819,"Note":"**"},{"Itemcode":"68262147","Description":"GRANIX/TBO-FILGRASTIM Inj 1Mcg","CDM Revenue Code":"636","CDM HCPCS":"J1447","Standard Price":19.57},{"Itemcode":"68262148","Description":"TOPOTECAN EA 0.1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9351","Standard Price":13.39,"Note":"**"},{"Itemcode":"68262149","Description":"Lorazepam Ea 2mg","CDM Revenue Code":"636","CDM HCPCS":"J2060","Standard Price":59.225,"Note":"**"},{"Itemcode":"68262150","Description":"DEXTROSE 5%/0.45% NACL 500ml","CDM Revenue Code":"258","Standard Price":13.39},{"Itemcode":"68262151","Description":"EPINEPHRINE 0.1 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J0171","Standard Price":6.18},{"Itemcode":"68262152","Description":"PACLITAXEL PROTEIN BND 1MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9264","Standard Price":50.1548858447488,"Note":"**"},{"Itemcode":"68262153","Description":"FLUOROURACIL 500 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9190","Standard Price":59.0222139673106,"Note":"**"},{"Itemcode":"68262154","Description":"PEMETREXED/ALIMTA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9305","Standard Price":217.64190140845,"Note":"**"},{"Itemcode":"68262155","Description":"PALONOSETRON/ALOXI 25MCG OKT","CDM Revenue Code":"636","CDM HCPCS":"J2469","Standard Price":62.2216062176166,"Note":"**"},{"Itemcode":"68262156","Description":"ATROPINE SULFATE 0.01 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J0461","Standard Price":5.15,"Note":"**"},{"Itemcode":"68262157","Description":"BEVACIZUMAB 10 MG Inj OKT","CDM Revenue Code":"636","CDM HCPCS":"J9035","Standard Price":328.101818181819,"Note":"**"},{"Itemcode":"68262158","Description":"BLEOMYCIN SULFATE 15U Inj","CDM Revenue Code":"636","CDM HCPCS":"J9040","Standard Price":141.11,"Note":"**"},{"Itemcode":"68262160","Description":"IRINOTECAN Inj 20 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9206","Standard Price":13.39,"Note":"**"},{"Itemcode":"68262161","Description":"CARBOPLATIN EA 50 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9045","Standard Price":12.36,"Note":"**"},{"Itemcode":"68262162","Description":"ALTEPLASE 1MG INJ OKT","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":308.014782608696,"Note":"**"},{"Itemcode":"68262163","Description":"CISPLATIN EA 10 MG Inj OKT","CDM Revenue Code":"636","CDM HCPCS":"J9060","Standard Price":12.36,"Note":"**"},{"Itemcode":"68262165","Description":"B-12 INJ UP TO 1000 MCG OKT","CDM Revenue Code":"636","CDM HCPCS":"J3420","Standard Price":55.8870370370371,"Note":"**"},{"Itemcode":"68262166","Description":"CYCLOPHOSPHAMIDE 100 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9070","Standard Price":178.24547123623,"Note":"**"},{"Itemcode":"68262167","Description":"DACARBAZINE/DTIC 100 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9130","Standard Price":29.87,"Note":"**"},{"Itemcode":"68262169","Description":"DEXAMETHASONE EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":6.18,"Note":"**"},{"Itemcode":"68262170","Description":"DIPHENHYDRAMINE HCL UP TO 50MG","CDM Revenue Code":"636","CDM HCPCS":"J1200","Standard Price":59.3039877300613,"Note":"**"},{"Itemcode":"68262171","Description":"DOCETAXEL INJ 1 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9171","Standard Price":21.8302777777777,"Note":"**"},{"Itemcode":"68262172","Description":"DOXORUBICIN HCL 10 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9000","Standard Price":23.4097278911565,"Note":"**"},{"Itemcode":"68262173","Description":"FOSAPREPITANT EA 1MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J1453","Standard Price":9.27,"Note":"**"},{"Itemcode":"68262174","Description":"EPIRUBICIN HCL 2 MG OKT","CDM Revenue Code":"636","CDM HCPCS":"J9178","Standard Price":14.42},{"Itemcode":"68262175","Description":"CETUXIMAB 10 MG Inj OKT","CDM Revenue Code":"636","CDM HCPCS":"J9055","Standard Price":242.318695652174,"Note":"**"},{"Itemcode":"68262176","Description":"FAMOTIDINE 10 MG/ML 2 ML VIAL","CDM Revenue Code":"250","Standard Price":58.9860130718955,"Note":"**"},{"Itemcode":"68262177","Description":"ERIBULIN MESYLATE INJ 0.1MG","CDM Revenue Code":"636","CDM HCPCS":"J9179","Standard Price":458.131882352942,"Note":"**"},{"Itemcode":"68262178","Description":"ROMIPLOSTIM/NPLATE INJ 10MCG","CDM Revenue Code":"636","CDM HCPCS":"J2796","Standard Price":245.875714285715,"Note":"**"},{"Itemcode":"68262179","Description":"DENOSUMAB Inj EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J0897","Standard Price":75.5640619621343,"Note":"**"},{"Itemcode":"68262180","Description":"OCTREOTIDE DEPOT IM ING EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J2353","Standard Price":817.539090909091,"Note":"**"},{"Itemcode":"68262181","Description":"BORTIZOMIB/VELCADE EA .1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9041","Standard Price":191.795223880597,"Note":"**"},{"Itemcode":"68262182","Description":"AZACITIDINE EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9025","Standard Price":24.2702816901408,"Note":"**"},{"Itemcode":"68262183","Description":"DARBEPOETIN ALFA INJ EA 1MCG","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":29.5964638511095,"Note":"**"},{"Itemcode":"68262184","Description":"Mesna ea 200 MG","CDM Revenue Code":"636","CDM HCPCS":"J9209","Standard Price":26.78},{"Itemcode":"68262185","Description":"IXABEPILONE 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9207","Standard Price":291.49},{"Itemcode":"68262186","Description":"Cabazitaxel 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9043","Standard Price":540.75,"Note":"**"},{"Itemcode":"68262187","Description":"Methotrexate Ea 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J9260","Standard Price":56.65},{"Itemcode":"68262188","Description":"EPO INJ NonESRD EA 1000 Units","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":97.6712873134328,"Note":"**"},{"Itemcode":"68262192","Description":"FLUDARBINE EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J9185","Standard Price":258.53},{"Itemcode":"68262193","Description":"GEMCITABINE Inj EA 200 MG","CDM Revenue Code":"636","CDM HCPCS":"J9201","Standard Price":173.628350824588,"Note":"**"},{"Itemcode":"68262194","Description":"InjectAFer EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1439","Standard Price":6.18,"Note":"**"},{"Itemcode":"68262195","Description":"GRANISETRON HCL EA 100 MCG","CDM Revenue Code":"636","CDM HCPCS":"J1626","Standard Price":6.18,"Note":"**"},{"Itemcode":"68262196","Description":"Neulasta/Pegfilgramsim Inj 6MG","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":17052.3301886793,"Note":"**"},{"Itemcode":"68262197","Description":"Pamidronate Inj 30 MG","CDM Revenue Code":"636","CDM HCPCS":"J2430","Standard Price":53.56},{"Itemcode":"68262198","Description":"RITUXAN INJ EA 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J9312","Standard Price":3722.42,"Note":"**"},{"Itemcode":"68262199","Description":"VINORELBINE/NAVELB 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9390","Standard Price":58.800350877193,"Note":"**"},{"Itemcode":"68262200","Description":"Copper, 0.4mg/ml, Inj","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":154.5},{"Itemcode":"68262201","Description":"IFOSFAMIDE/IFEX 1 GM","CDM Revenue Code":"636","CDM HCPCS":"J9208","Standard Price":133.9},{"Itemcode":"68262204","Description":"MITOXANTRONE HCL 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9293","Standard Price":82.4},{"Itemcode":"68262205","Description":"Magnesium Citrate","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262206","Description":"KCL 20 MEQ /15 ML ORAL","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68262208","Description":"DESMOPRESSIN ACETATE 1 MCG","CDM Revenue Code":"636","CDM HCPCS":"J2597","Standard Price":18.54},{"Itemcode":"68262209","Description":"FULVESTRANT/FASLODEX INJ 25 MG","CDM Revenue Code":"636","CDM HCPCS":"J9395","Standard Price":378.668055555556,"Note":"**"},{"Itemcode":"68262210","Description":"FERUMOXYTOL 1 MG","CDM Revenue Code":"636","CDM HCPCS":"Q0138","Standard Price":6.18,"Note":"**"},{"Itemcode":"68262211","Description":"FERRIC NA GLUCONATE INJ 12.5MG","CDM Revenue Code":"636","CDM HCPCS":"J2916","Standard Price":11.33},{"Itemcode":"68262212","Description":"TRASTUZUMAB/HERCE MDV 10 MGINJ","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":362.56,"Note":"**"},{"Itemcode":"68262213","Description":"KCL 2 mEq","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":19.2266666666667,"Note":"**"},{"Itemcode":"68262214","Description":"Acetaminophen 10Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0131","Standard Price":2.06},{"Itemcode":"68262216","Description":"FLUZONE VACCINE V4","CDM Revenue Code":"636","CDM HCPCS":"90686","Standard Price":77.25},{"Itemcode":"68262218","Description":"CYRAMZA EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9308","Standard Price":232.32899408284,"Note":"**"},{"Itemcode":"68262219","Description":"ELELYSO EA 10 UNITS","CDM Revenue Code":"636","CDM HCPCS":"J3060","Standard Price":165.83},{"Itemcode":"68262220","Description":"Meningococcal Vac IM 0.5ml Inj","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":469.68},{"Itemcode":"68262223","Description":"TRANSDERM-SCOP 1PATCH","CDM Revenue Code":"637","Standard Price":69.75},{"Itemcode":"68262224","Description":"TEMSIROLIMUS/TORISEL 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9330","Standard Price":285.31},{"Itemcode":"68262225","Description":"BENDAMUSTINE/TREANDA EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9033","Standard Price":96.82},{"Itemcode":"68262226","Description":"Etoposide/Toposar 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J9181","Standard Price":6.18,"Note":"**"},{"Itemcode":"68262227","Description":"PRIVIGEN INJ EA 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":167.89,"Note":"**"},{"Itemcode":"68262228","Description":"PACLITAXEL 1.0 MG","CDM Revenue Code":"636","CDM HCPCS":"J9267","Standard Price":21.2164005765029,"Note":"**"},{"Itemcode":"68262229","Description":"PROCHLORPERAZINE <=10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J0780","Standard Price":65.92,"Note":"**"},{"Itemcode":"68262230","Description":"OXALIPLATIN INJ 0.5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9263","Standard Price":5.15,"Note":"**"},{"Itemcode":"68262231","Description":"SARGRAMOSTIM INJ EA 50 MCG","CDM Revenue Code":"636","CDM HCPCS":"J2820","Standard Price":130.81},{"Itemcode":"68262232","Description":"TESTOSTERONE CYPIONATE 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1071","Standard Price":59.74},{"Itemcode":"68262233","Description":"BICNU 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J9050","Standard Price":728.21},{"Itemcode":"68262234","Description":"MITOMYCIN 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9280","Standard Price":556.2,"Note":"**"},{"Itemcode":"68262235","Description":"MANNITOL 25%%, 50ml VIAL","CDM Revenue Code":"636","CDM HCPCS":"J2150","Standard Price":19.57,"Note":"**"},{"Itemcode":"68262236","Description":"MG SULFATE 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":19.2234579439253,"Note":"**"},{"Itemcode":"68262237","Description":"LEUCOVORIN CALCIUM INJ EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J0640","Standard Price":28.480736,"Note":"**"},{"Itemcode":"68262238","Description":"INFED/IRON DEXTRAN EA 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J1750","Standard Price":81.37},{"Itemcode":"68262239","Description":"HEPARIN INJ PER 1000 UNITS","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":59.74},{"Itemcode":"68262240","Description":"ZIV-AFLIBERCEPT/ZALTRAP EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9400","Standard Price":92.7},{"Itemcode":"68262241","Description":"Neulasta Inj Delivery Kit 6mg","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":16873.1498924731,"Note":"**"},{"Itemcode":"68262242","Description":"Keytruda Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J9271","Standard Price":192.722632360218,"Note":"**"},{"Itemcode":"68262243","Description":"Mycafungin - Micamine ea 1MG","CDM Revenue Code":"636","CDM HCPCS":"J2248","Standard Price":3.09},{"Itemcode":"68262244","Description":"ZARXIO,FILGRSTM(G-CSF) BS 1MCG","CDM Revenue Code":"636","CDM HCPCS":"Q5101","Standard Price":6.18,"Note":"**"},{"Itemcode":"68262245","Description":"Trabectedin/Yondelis 0.1MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9352","Standard Price":1182.73428571428,"Note":"**"},{"Itemcode":"68262246","Description":"Pentostatin/Nipent Inj 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9268","Standard Price":8357.42},{"Itemcode":"68262247","Description":"Pegaspargase Inj SDV 3750IU5ml","CDM Revenue Code":"636","CDM HCPCS":"J9266","Standard Price":57182.51},{"Itemcode":"68262248","Description":"CIPROFLOXACIN 500MG ORAL TAB","CDM Revenue Code":"637","Standard Price":5.25},{"Itemcode":"68262250","Description":"Gazyva / Obinutuzumab 10MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J9301","Standard Price":212.294444444444,"Note":"**"},{"Itemcode":"68262251","Description":"Gammaplex Inj 500mg","CDM Revenue Code":"636","CDM HCPCS":"J1557","Standard Price":160.68},{"Itemcode":"68262252","Description":"Aminocaproic Acid 250mg/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":6.18},{"Itemcode":"68262253","Description":"Albuterol-Nebulizer NonCom 1mg","CDM Revenue Code":"250","CDM HCPCS":"J7611","Standard Price":6.18},{"Itemcode":"68262254","Description":"Iron Sucrose Comp Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J1756","Standard Price":6.18},{"Itemcode":"68262255","Description":"BENDAMUSTINE/BENDEKA 1MG MDV","CDM Revenue Code":"636","CDM HCPCS":"J9034","Standard Price":97.3109794776119,"Note":"**"},{"Itemcode":"68262256","Description":"Ertapenem Na Inj 500 mg","CDM Revenue Code":"636","CDM HCPCS":"J1335","Standard Price":259.56},{"Itemcode":"68262257","Description":"ISTODAX/RomiDEPsin pwdr 1mg","CDM Revenue Code":"636","CDM HCPCS":"J9315","Standard Price":1244.24},{"Itemcode":"68262258","Description":"DEXAMETHASONE ORAL EA 0.25MG","CDM Revenue Code":"636","CDM HCPCS":"J8540","Standard Price":3.09},{"Itemcode":"68262259","Description":"IMLYGIC/TalLah 1M PFU/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9325","Standard Price":197.76},{"Itemcode":"68262260","Description":"IMLYGIC 100X PFU Inj EA Vial","CDM Revenue Code":"636","CDM HCPCS":"J9325","Standard Price":96.82},{"Itemcode":"68262261","Description":"Engerix-B 10mcg/0.5 ml Ped SDV","CDM Revenue Code":"636","CDM HCPCS":"90744","Standard Price":94.76},{"Itemcode":"68262262","Description":"Amlodipine 5MG Oral Tab","CDM Revenue Code":"637","Standard Price":1.5},{"Itemcode":"68262263","Description":"Darzalex 10mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9145","Standard Price":203.608433292533,"Note":"**"},{"Itemcode":"68262266","Description":"CIPROFLOXACIN 200MG IV INJ","CDM Revenue Code":"636","CDM HCPCS":"J0744","Standard Price":10.3},{"Itemcode":"68262267","Description":"HEP A VACC PED/ADOL 2DSE IMINJ","CDM Revenue Code":"636","CDM HCPCS":"90633","Standard Price":125.66},{"Itemcode":"68262268","Description":"PREDNISONE IR/DR ORAL 1MG TAB","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":5.15},{"Itemcode":"68262269","Description":"ARRANON INJ EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J9261","Standard Price":596.37},{"Itemcode":"68262270","Description":"CYCLOPHOSPHAMIDE CAP EA 25MG","CDM Revenue Code":"636","CDM HCPCS":"J8530","Standard Price":23.69,"Note":"**"},{"Itemcode":"68262271","Description":"EMEND CAP EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J8501","Standard Price":43.26},{"Itemcode":"68262272","Description":"Rasburicase/Elitek 0.5mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2783","Standard Price":1117.55},{"Itemcode":"68262273","Description":"Leuprolide Acet/Eligard 7.5Mg","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":1858.635,"Note":"**"},{"Itemcode":"68262275","Description":"GANCICLOVIR 500MG PWVL","CDM Revenue Code":"636","CDM HCPCS":"J1570","Standard Price":242.05},{"Itemcode":"68262277","Description":"ELOTUZUMAB/EMPLICITI INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9176","Standard Price":26.78},{"Itemcode":"68262278","Description":"MENACWY VACCINE IM SDV","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":472.77},{"Itemcode":"68262279","Description":"CIPROFLOXACIN 250MG ORAL TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68262280","Description":"Bleomycin 15 Un Inj (Imported)","CDM Revenue Code":"636","CDM HCPCS":"J9040","Standard Price":612.85},{"Itemcode":"68262281","Description":"PEGINTERFERON ALFA2A 180MCG/ML","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":4125.15},{"Itemcode":"68262282","Description":"HYDROCORTISONE NONCHEMO10MGTAB","CDM Revenue Code":"636","CDM HCPCS":"J8499","Standard Price":6.18},{"Itemcode":"68262283","Description":"TECENTRIQ/ATEZOLIZUMAB INJ10MG","CDM Revenue Code":"636","CDM HCPCS":"J9022","Standard Price":249.116944444444,"Note":"**"},{"Itemcode":"68262284","Description":"Vancomycin HCL 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":81.37},{"Itemcode":"68262285","Description":"Chlorpromazine HCL Inj to 50MG","CDM Revenue Code":"636","CDM HCPCS":"J3230","Standard Price":115.36},{"Itemcode":"68262286","Description":"SUSTOL INJ 10MG/0.4ML INJ","CDM Revenue Code":"636","Standard Price":2153.73},{"Itemcode":"68262287","Description":"Tranexamic Acid 10ml IV","CDM Revenue Code":"250","Standard Price":218.36},{"Itemcode":"68262288","Description":"Infanrix DTAP Peds 0.5ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90700","Standard Price":93.73},{"Itemcode":"68262289","Description":"Ofatumumab/Arzerra 10mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9302","Standard Price":214.24},{"Itemcode":"68262290","Description":"ALBUTEROL HFA MDI 200INH 18GM","CDM Revenue Code":"636","CDM HCPCS":"J3535","Standard Price":184.37},{"Itemcode":"68262292","Description":"Fentanyl Ptch-Xtd Rel 25mcg/hr","CDM Revenue Code":"637","Standard Price":9.0},{"Itemcode":"68262293","Description":"HYQVIA IMMUNGLOBULIN INJ 100MG","CDM Revenue Code":"636","CDM HCPCS":"J1575","Standard Price":9251.46},{"Itemcode":"68262294","Description":"FLUCONAZOLE/DIFLUCAN INJ 200MG","CDM Revenue Code":"636","CDM HCPCS":"J1450","Standard Price":59.74},{"Itemcode":"68262295","Description":"Hydralazine 25Mg Tab","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68262296","Description":"ELOSULFASEALFA,VIMIZIM INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1322","Standard Price":973.35},{"Itemcode":"68262297","Description":"GALSULFASE/NAGLAZYM INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1458","Standard Price":1546.27235294118,"Note":"**"},{"Itemcode":"68262298","Description":"ImmuneGlobul-Octagam 500mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1568","Standard Price":220.42},{"Itemcode":"68262299","Description":"Varubi Inj 166.5mg/92.5ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":1251.45},{"Itemcode":"68262301","Description":"Degarelix/Firmagon Inj 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9155","Standard Price":15.45},{"Itemcode":"68262322","Description":"DEPO_MEDROL 40 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1030","Standard Price":28.84},{"Itemcode":"68262345","Description":"Filgrastim-Neupogen Inj 1Mcg","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":5.15,"Note":"**"},{"Itemcode":"68262346","Description":"Montelukast Sod 10mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262352","Description":"ALLOPURINOL 300MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262353","Description":"ALLOPURINOL 100MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262354","Description":"NIVOLUMAB / OPDIVO, INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9299","Standard Price":108.428553459119,"Note":"**"},{"Itemcode":"68262355","Description":"Somatuline Depot ea 1mg, Inj","CDM Revenue Code":"636","CDM HCPCS":"J1930","Standard Price":289.43,"Note":"**"},{"Itemcode":"68262356","Description":"ALEMTUZUMAB/CAMPATH Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J0202","Standard Price":0.0},{"Itemcode":"68262357","Description":"Levoleucovorin Calcm Inj 0.5mg","CDM Revenue Code":"636","CDM HCPCS":"J0641","Standard Price":8.24},{"Itemcode":"68262358","Description":"CARPUJET,MORPH SULF 4MG/ML INJ","CDM Revenue Code":"250","Standard Price":77.25},{"Itemcode":"68262359","Description":"OLARATUMAB INJ 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9285","Standard Price":200.85},{"Itemcode":"68262360","Description":"Sustol Inj ea 0.1mg","CDM Revenue Code":"636","CDM HCPCS":"J1627","Standard Price":2260.85},{"Itemcode":"68262361","Description":"TRASTUZUMAB/HER INJ SDV 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":421.547176079734,"Note":"**"},{"Itemcode":"68262362","Description":"IRINOTECAN LIP/ONIVYDE INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9205","Standard Price":166.0875,"Note":"**"},{"Itemcode":"68262363","Description":"FLEBOGAMMA IG 5%%DIF 500MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1572","Standard Price":166.86,"Note":"**"},{"Itemcode":"68262364","Description":"Fentanyl 100mcg/2Ml Inj SDV","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":59.74},{"Itemcode":"68262365","Description":"COPANLISIB/ALIQOPA 1mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9057","Standard Price":17823.12},{"Itemcode":"68262366","Description":"DURVALUMAB/IMFINZI INJ 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9173","Standard Price":240.877899824253,"Note":"**"},{"Itemcode":"68262367","Description":"CARIMUNE NF,IG 500MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1566","Standard Price":122.57},{"Itemcode":"68262368","Description":"Vedolizumab/Entyvio Inj, 1mg","CDM Revenue Code":"636","CDM HCPCS":"J3380","Standard Price":81.9422222222223,"Note":"**"},{"Itemcode":"68262369","Description":"GEMTUZUMAB OZOGAMICIN IN 0.1MG","CDM Revenue Code":"636","CDM HCPCS":"J9203","Standard Price":772.5},{"Itemcode":"68262370","Description":"AMLODIPENE BESYLATE 10MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68262371","Description":"METOPROLOL TARTRATE 100MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"68262372","Description":"HAVRIX 1440U/ 1ML SYR INJ","CDM Revenue Code":"250","Standard Price":268.83},{"Itemcode":"68262373","Description":"9VHPVGARDASIL VAC2-3D 0.5MLINJ","CDM Revenue Code":"636","CDM HCPCS":"90651","Standard Price":805.46},{"Itemcode":"68262400","Description":"RITUXAN EA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9312","Standard Price":372.242,"Note":"**"},{"Itemcode":"68262425","Description":"Emicizumab-KXWH 0.5 mg","CDM Revenue Code":"636","CDM HCPCS":"J7170","Standard Price":153.1404},{"Itemcode":"68262450","Description":"Cemiplimab-rwlc 1 mg ea","CDM Revenue Code":"636","CDM HCPCS":"J9119","Standard Price":86.52,"Note":"**"},{"Itemcode":"68262451","Description":"Fulphila 0.5mg inj NR","CDM Revenue Code":"636","CDM HCPCS":"Q5108","Standard Price":1118.58},{"Itemcode":"68262453","Description":"Romosozumab 105mg/1.17ml syr","CDM Revenue Code":"636","CDM HCPCS":"J3590","Standard Price":3213.6,"Note":"**"},{"Itemcode":"68262454","Description":"Mogamulizumab-kpkc 1mg EA","CDM Revenue Code":"636","CDM HCPCS":"J9204","Standard Price":634.48},{"Itemcode":"68262455","Description":"POLATUZUMAB 1MG VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":358.44},{"Itemcode":"68262456","Description":"Pentamidine iset 300mg inh pwd","CDM Revenue Code":"250","CDM HCPCS":"J2545","Standard Price":418.18},{"Itemcode":"68262458","Description":"Ravulizumab-CWVZ EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1303","Standard Price":714.82},{"Itemcode":"68262459","Description":"Romosozumab-AQQG 1mg ea","CDM Revenue Code":"636","CDM HCPCS":"J3111","Standard Price":35.02,"Note":"**"},{"Itemcode":"68262460","Description":"Bevacizumab-AWWB 10mg (MVASI)","CDM Revenue Code":"636","CDM HCPCS":"Q5107","Standard Price":268.83},{"Itemcode":"68262461","Description":"TRASTUZ-ANNS (KANJINTI) 10MG","CDM Revenue Code":"636","CDM HCPCS":"Q5117","Standard Price":284.28},{"Itemcode":"68262464","Description":"NaPhos 45mmol/15ml vial","CDM Revenue Code":"250","Standard Price":131.84},{"Itemcode":"68262466","Description":"Enfortumab Vedotin-ejfv 1mg","CDM Revenue Code":"636","CDM HCPCS":"J3590","Standard Price":353.29,"Note":"**"},{"Itemcode":"68262468","Description":"TRUXIMA 10 mg","CDM Revenue Code":"636","CDM HCPCS":"Q5115","Standard Price":264.71},{"Itemcode":"68262500","Description":"Abatacept Inj 10mg SDV","CDM Revenue Code":"636","CDM HCPCS":"J0129","Standard Price":159.65},{"Itemcode":"68262501","Description":"Amifostine 500mg","CDM Revenue Code":"636","CDM HCPCS":"J0207","Standard Price":1494.53},{"Itemcode":"68262502","Description":"Amikacin Sulfate 100mg","CDM Revenue Code":"636","CDM HCPCS":"J0278","Standard Price":56.65},{"Itemcode":"68262504","Description":"Cerezyme (Imiglucerase) 10Unit","CDM Revenue Code":"636","CDM HCPCS":"J1786","Standard Price":168.92},{"Itemcode":"68262505","Description":"Methylprednisolone Inj <=40MG","CDM Revenue Code":"636","CDM HCPCS":"J2920","Standard Price":59.74},{"Itemcode":"68262506","Description":"Leuprolide Depot Ea 7.5Mg","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":5823.37922077922,"Note":"**"},{"Itemcode":"68262508","Description":"Vitamin K (Mephyton) ea 5mg","CDM Revenue Code":"250","Standard Price":237.93},{"Itemcode":"68262509","Description":"Folic Acid ea 1mg","CDM Revenue Code":"250","Standard Price":6.18},{"Itemcode":"68262510","Description":"Levofloxacin/Levaquin 250 mg","CDM Revenue Code":"636","CDM HCPCS":"J1956","Standard Price":19.57},{"Itemcode":"68262511","Description":"Magnesium Oxide 400mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"68262512","Description":"Praltrexate / Folotyn ea 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9307","Standard Price":870.35},{"Itemcode":"68262513","Description":"Cefepime/Maxepine Inj ea 500MG","CDM Revenue Code":"636","CDM HCPCS":"J0692","Standard Price":15.45},{"Itemcode":"68262516","Description":"Tetanus-Diptheria (Tenivac)0.5","CDM Revenue Code":"636","CDM HCPCS":"90714","Standard Price":94.76},{"Itemcode":"68262517","Description":"ADDAMEL N INJ10ML AMP (TRA ME)","CDM Revenue Code":"250","Standard Price":64.89},{"Itemcode":"68262518","Description":"Velaglucerase Alfa/VPRIV100UIn","CDM Revenue Code":"636","CDM HCPCS":"J3385","Standard Price":1460.54},{"Itemcode":"68262638","Description":"Gammagard S/D 500 mg Powder","CDM Revenue Code":"636","CDM HCPCS":"J1566","Standard Price":254.41},{"Itemcode":"68262646","Description":"EPOETIN ALFA -EBX 1000U","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":37.08,"Note":"**"},{"Itemcode":"68265000","Description":"Bevacizumab 10MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9035","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265001","Description":"Keytruda Inj 1mg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9271","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265002","Description":"Nivol/Opdivo 1mg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9299","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265003","Description":"EMEND CAP EA 5 MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J8501","Standard Price":0.0103},{"Itemcode":"68265004","Description":"Rituximab/Hyal - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9311","Standard Price":0.0103},{"Itemcode":"68265005","Description":"TRAST/HER I10MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265006","Description":"OCTREO INJ 1MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J2353","Standard Price":0.0103},{"Itemcode":"68265007","Description":"Dalbavancin 500mg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J0875","Standard Price":0.0103},{"Itemcode":"68265008","Description":"INFLIXIMAB 10 MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J1745","Standard Price":0.0103},{"Itemcode":"68265009","Description":"NATALIZUMAB 1MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J2323","Standard Price":0.0103},{"Itemcode":"68265010","Description":"BRENT/ADCETRIS 1Mg- Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9042","Standard Price":0.0103},{"Itemcode":"68265011","Description":"TECENTRIQ 10MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9022","Standard Price":0.0103},{"Itemcode":"68265012","Description":"Velcade Ea 0.1MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9041","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265013","Description":"Perjeta Ea 1 Mg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9306","Standard Price":0.0103},{"Itemcode":"68265014","Description":"DENOSUMAB EA 1 MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J0897","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265015","Description":"Ocrevus 300mg/10ml Foundation","CDM Revenue Code":"636","CDM HCPCS":"J2350","Standard Price":0.0103},{"Itemcode":"68265016","Description":"Erbitux 10MG Inj - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9055","Standard Price":0.0103},{"Itemcode":"68265017","Description":"Neulasta Inj 6mg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265018","Description":"BENDAMUSTINE/BENDEKA 1MG MDV","CDM Revenue Code":"636","CDM HCPCS":"J9034","Standard Price":0.0103},{"Itemcode":"68265019","Description":"Neulasta Onpro - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265020","Description":"ALTEPLASE 1MG INJ - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":0.0103},{"Itemcode":"68265021","Description":"Abatacept Inj 10mg SDV","CDM Revenue Code":"636","CDM HCPCS":"J0129","Standard Price":0.0103},{"Itemcode":"68265024","Description":"EMPLICITI INJ 1MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9176","Standard Price":0.0103},{"Itemcode":"68265025","Description":"Entyvio Inj 1mg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J3380","Standard Price":0.0103},{"Itemcode":"68265026","Description":"IMFINZI INJ 10MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9173","Standard Price":0.0103},{"Itemcode":"68265027","Description":"Nuyzra 100mg vial","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":0.0103},{"Itemcode":"68265028","Description":"Neupogen Inj 1Mcg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":0.0103},{"Itemcode":"68265029","Description":"InjectAFer 1 MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J1439","Standard Price":0.0103},{"Itemcode":"68265030","Description":"ALIMTA 10 MG - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9305","Standard Price":0.0103},{"Itemcode":"68265031","Description":"Leuprolide Depot - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J1950","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68265032","Description":"Azacitidine 1 Mg - Foundation","CDM Revenue Code":"636","CDM HCPCS":"J9025","Standard Price":0.0103,"Note":"**"},{"Itemcode":"68266111","Description":"DEHYDROERGOTAMINE INJ TO 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1110","Standard Price":272.95},{"Itemcode":"68266112","Description":"Alpha1-ProtnaseInhibitrInj10mg","CDM Revenue Code":"636","CDM HCPCS":"J0256","Standard Price":59.74},{"Itemcode":"68266113","Description":"INFLIXIMAB INJ 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1745","Standard Price":466.030698924731,"Note":"**"},{"Itemcode":"68266114","Description":"PANTOPRAZOL SODIM INJ PER VIAL","CDM Revenue Code":"636","CDM HCPCS":"C9113","Standard Price":59.74},{"Itemcode":"68266115","Description":"NATALIZUMAB INJECTION 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J2323","Standard Price":80.34},{"Itemcode":"68266116","Description":"IBANDRONATE SODIUM INJ 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1740","Standard Price":692.16},{"Itemcode":"68266117","Description":"TOCILIZUMAB INJECTION 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J3262","Standard Price":18.54},{"Itemcode":"68266120","Description":"Fingolimod Hydrochloride 0.5Mg","CDM Revenue Code":"637","Standard Price":6.0},{"Itemcode":"68266121","Description":"Inj, belatacept, 1 mg","CDM Revenue Code":"636","CDM HCPCS":"J0485","Standard Price":63.86},{"Itemcode":"68266123","Description":"Prepen 1ml Inj","CDM Revenue Code":"250","Standard Price":21104.7},{"Itemcode":"68266124","Description":"Histamine Positive Control 1ml","CDM Revenue Code":"250","Standard Price":1777.78},{"Itemcode":"68266125","Description":"Penicillin 10,000 Units, Inj","CDM Revenue Code":"250","Standard Price":530.45},{"Itemcode":"68266126","Description":"Saline Negative control 1ml S","CDM Revenue Code":"250","Standard Price":24.72},{"Itemcode":"68266127","Description":"GOLIMUMAB FOR IV USE 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1602","Standard Price":489.25},{"Itemcode":"68267534","Description":"Lidocaine 1%% 2Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":51.5},{"Itemcode":"68267537","Description":"Lidocaine 1%% 30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":2.06},{"Itemcode":"68267538","Description":"Lidocaine 1%% 30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":2.06},{"Itemcode":"68269017","Description":"ARSENIC TRIOXIDE 10MG/10ML VL","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":5861.73,"Note":"**"},{"Itemcode":"68269467","Description":"RITUXIMAB/HYALURONIDASE","CDM Revenue Code":"636","CDM HCPCS":"J9311","Standard Price":6977.22},{"Itemcode":"68269468","Description":"RITUXIMAB/HYALURONIDASE","CDM Revenue Code":"636","CDM HCPCS":"J9311","Standard Price":677.3795},{"Itemcode":"70206023","Description":"RH Immune Globulin/Unit","CDM Revenue Code":"636","CDM HCPCS":"J2790","Standard Price":263.265367412141,"Note":"**"},{"Itemcode":"70206028","Description":"Micro Rhogam","CDM Revenue Code":"636","CDM HCPCS":"J2790","Standard Price":156.56},{"Itemcode":"71103000","Description":"Syringe: .9% Sodium Chloride","CDM Revenue Code":"250","Standard Price":12.36},{"Itemcode":"7129","Description":"EPIFIX PER SQ CM","CDM Revenue Code":"636","CDM HCPCS":"Q4186","Standard Price":973.35,"Note":"**"},{"Itemcode":"7131","Description":"APLIGRAF PER SQ CM","CDM Revenue Code":"636","CDM HCPCS":"Q4101","Standard Price":221.863182936834,"Note":"**"},{"Itemcode":"7132","Description":"Dermagraft Per Sq Cm","CDM Revenue Code":"636","CDM HCPCS":"Q4106","Standard Price":178.348461538461,"Note":"**"},{"Itemcode":"7133","Description":"Theraskin Per Sq Cm","CDM Revenue Code":"636","CDM HCPCS":"Q4121","Standard Price":351.23,"Note":"**"},{"Itemcode":"7134","Description":"OASIS WOUND DRESSING PER SQ CM","CDM Revenue Code":"636","CDM HCPCS":"Q4102","Standard Price":85.49,"Note":"**"},{"Itemcode":"7135","Description":"EPICORD PER SQ CM","CDM Revenue Code":"636","CDM HCPCS":"Q4187","Standard Price":973.35,"Note":"**"},{"Itemcode":"71402303","Description":"DIPYRIDAMOLE 10MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1245","Standard Price":8.24},{"Itemcode":"71405305","Description":"Kinevac Per 2Mcg","CDM Revenue Code":"636","CDM HCPCS":"J2805","Standard Price":853.846046511628,"Note":"**"},{"Itemcode":"7178","Description":"PuraPly per sq cm","CDM Revenue Code":"636","CDM HCPCS":"Q4195","Standard Price":553.11,"Note":"**"},{"Itemcode":"7179","Description":"PuraPly AM per sq cm","CDM Revenue Code":"636","CDM HCPCS":"Q4196","Standard Price":600.49,"Note":"**"},{"Itemcode":"7191","Description":"Primatrix per Sq Cm","CDM Revenue Code":"636","CDM HCPCS":"Q4110","Standard Price":169.95},{"Itemcode":"7233","Description":"HYALOMATRIX PER SQ CM","CDM Revenue Code":"636","CDM HCPCS":"Q4117","Standard Price":57.68,"Note":"**"},{"Itemcode":"7234","Description":"Waste PuraPly AM per sq cm","CDM Revenue Code":"636","Standard Price":600.49},{"Itemcode":"7235","Description":"Waste PuraPly per sq cm","CDM Revenue Code":"636","CDM HCPCS":"Q4195","Standard Price":553.11},{"Itemcode":"7240","Description":"Grafix Prime Per Sq Cm","CDM Revenue Code":"636","CDM HCPCS":"Q4133","Standard Price":266.77,"Note":"**"},{"Itemcode":"7241","Description":"Affinity Per Sq Cm","CDM Revenue Code":"636","CDM HCPCS":"Q4159","Standard Price":1015.58},{"Itemcode":"7242","Description":"Nushield Per Sq Cm","CDM Revenue Code":"636","CDM HCPCS":"Q4160","Standard Price":777.65,"Note":"**"},{"Itemcode":"74100004","Description":"Hydrocortisone Na Suc 1000Mg","CDM Revenue Code":"636","CDM HCPCS":"J1720","Standard Price":385.22},{"Itemcode":"74100007","Description":"Hydrocortisone Na Suc 500Mginj","CDM Revenue Code":"636","CDM HCPCS":"J1720","Standard Price":59.74},{"Itemcode":"74100009","Description":"Novantrone 25Mg/Vial","CDM Revenue Code":"636","CDM HCPCS":"J9293","Standard Price":414.06},{"Itemcode":"74100010","Description":"Hydrocortisone Na Suc 100Mginj","CDM Revenue Code":"636","CDM HCPCS":"J1720","Standard Price":58.9866832269297,"Note":"**"},{"Itemcode":"74100011","Description":"Dextrose 25% 10Ml","CDM Revenue Code":"258","Standard Price":59.74,"Note":"**"},{"Itemcode":"74100013","Description":"Methylprednisolone 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2930","Standard Price":59.1322605363985,"Note":"**"},{"Itemcode":"74100014","Description":"Ifex (Ifosfamide) 1Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J9208","Standard Price":132.425686274509,"Note":"**"},{"Itemcode":"74100015","Description":"Mesna 1000Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9209","Standard Price":132.441425287356,"Note":"**"},{"Itemcode":"74100016","Description":"Methylprednisolone 1000Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2930","Standard Price":88.6357643312102,"Note":"**"},{"Itemcode":"74100019","Description":"Methylprednisolone 125Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2930","Standard Price":58.7768088967601,"Note":"**"},{"Itemcode":"74100022","Description":"Methylprednisolone 40Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2920","Standard Price":58.8867864868892,"Note":"**"},{"Itemcode":"74100031","Description":"Acetaminophen Liq 160Mg/5Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100033","Description":"Apap-Butabarbital/1 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100034","Description":"Acetaminophen 650Mg/20Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100036","Description":"Oxycodone Hcl 10Mg Cr Tab","CDM Revenue Code":"637","Standard Price":10.5,"Note":"**"},{"Itemcode":"74100037","Description":"Acetaminophen 325Mg Supp","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100040","Description":"Acetaminophen 650 Mg Supp","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100044","Description":"Nimodipine 30 Mg Cap","CDM Revenue Code":"637","Standard Price":23.25,"Note":"**"},{"Itemcode":"74100049","Description":"Acetic Acid Irr 0.25% 250Ml","CDM Revenue Code":"250","Standard Price":61.8},{"Itemcode":"74100053","Description":"Loratadine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100067","Description":"Act Charcoal/Sorbitol 25Gm 120","CDM Revenue Code":"250","Standard Price":59.0808,"Note":"**"},{"Itemcode":"74100071","Description":"Bio Glucose Tab/ Bx/6","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100073","Description":"Alteplase: Recom 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":14531.0990526315,"Note":"**"},{"Itemcode":"74100075","Description":"Tuberculin Ppd 1Unit 1St Str","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74100078","Description":"Mutamycin 5Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9280","Standard Price":551.5856,"Note":"**"},{"Itemcode":"74100079","Description":"Nifedipine Extended Release 30","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100081","Description":"Benzocaine 20% Aerosol 60Gm","CDM Revenue Code":"637","Standard Price":10.5,"Note":"**"},{"Itemcode":"74100084","Description":"Lidocaine 2% 20Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.8043805719092,"Note":"**"},{"Itemcode":"74100086","Description":"Lidocaine 2% W Epi 20Ml Vial","CDM Revenue Code":"250","Standard Price":58.9284848484848,"Note":"**"},{"Itemcode":"74100092","Description":"Bicitra 15Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100094","Description":"Epinephrine 1:1000 Inj 1Ml","CDM Revenue Code":"636","CDM HCPCS":"J0171","Standard Price":58.9402275571447,"Note":"**"},{"Itemcode":"74100100","Description":"Epinephine 1:1000 Inj 30Ml","CDM Revenue Code":"636","CDM HCPCS":"J0171","Standard Price":243.801,"Note":"**"},{"Itemcode":"74100103","Description":"Doxorubicin-Pfs 10Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9000","Standard Price":23.329621749409,"Note":"**"},{"Itemcode":"74100115","Description":"Ibuprofen 200 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100116","Description":"Beclomethasone Aq Nas Spy 25Gm","CDM Revenue Code":"637","Standard Price":838.5},{"Itemcode":"74100117","Description":"Capsaicin 0.025% Cr 45Gm","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74100119","Description":"Preparation-H Oint 30Gm","CDM Revenue Code":"637","Standard Price":30.75,"Note":"**"},{"Itemcode":"74100120","Description":"Acetaminophen 120Mg Supp","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100121","Description":"Polymixin B 500Ku Powder Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74100122","Description":"Lidocaine 1% With Epi 20Ml","CDM Revenue Code":"250","Standard Price":58.2816084359052,"Note":"**"},{"Itemcode":"74100130","Description":"Oxymetazoline Nasal Drops 20Ml","CDM Revenue Code":"637","Standard Price":13.5},{"Itemcode":"74100133","Description":"Leuprolide 7.5Mg/Ml Depot (Im)","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":5855.77071428572,"Note":"**"},{"Itemcode":"74100135","Description":"Cetaphil Lotion 16 Oz","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100143","Description":"Lansoprazole 15Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100146","Description":"Ional T Shampoo 120Ml Bot","CDM Revenue Code":"637","Standard Price":22.5},{"Itemcode":"74100148","Description":"Spironolactone/Hct 25/25 Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100156","Description":"Ziac 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100158","Description":"Lorazepam 2Mg/Ml 10Ml","CDM Revenue Code":"636","CDM HCPCS":"J2060","Standard Price":58.71,"Note":"**"},{"Itemcode":"74100161","Description":"Neostigmine 1-1000 10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2710","Standard Price":432.571427683616,"Note":"**"},{"Itemcode":"74100163","Description":"Spironolactone 50 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100166","Description":"Spironolactone 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100178","Description":"Methyldopa 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100183","Description":"Demadex Amp 20 Mg","CDM Revenue Code":"636","CDM HCPCS":"J3265","Standard Price":59.74},{"Itemcode":"74100185","Description":"Morphine 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100187","Description":"Methyldopa 50Mg/Ml 5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0210","Standard Price":169.95},{"Itemcode":"74100191","Description":"Solution Z Nose Drops","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74100200","Description":"Acetaminophen 325Mg Tab","CDM Revenue Code":"637"},{"Itemcode":"74100201","Description":"Calcium Chloride 1Gm Syringe","CDM Revenue Code":"250","Standard Price":58.8651141213389,"Note":"**"},{"Itemcode":"74100204","Description":"Aspirin Enteric 325Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100208","Description":"Melphalan 2Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8600","Standard Price":59.74},{"Itemcode":"74100211","Description":"Allopurinol 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100219","Description":"Candida Skin Test 1:100","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74100227","Description":"Goserelin Acetate 3.6Mg Syr","CDM Revenue Code":"636","CDM HCPCS":"J9202","Standard Price":1493.5},{"Itemcode":"74100235","Description":"Alum Hydroxide Susp 30 Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100239","Description":"Sterile Water 1000Ml Irrigatio","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74100248","Description":"Hetastarch 500Ml","CDM Revenue Code":"258","Standard Price":59.328,"Note":"**"},{"Itemcode":"74100251","Description":"Isosorbide Dinitrate 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100254","Description":"Zosyn 2.25 Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J2543","Standard Price":58.8491891891892,"Note":"**"},{"Itemcode":"74100256","Description":"Benzocaine Ointment 30 Gm Tube","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74100257","Description":"Acetazolamide 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100258","Description":"Readicat 450Ml","CDM Revenue Code":"255","Standard Price":58.5149181834372,"Note":"**"},{"Itemcode":"74100260","Description":"Piperacillian/Tazobactam 3.375","CDM Revenue Code":"636","CDM HCPCS":"J2543","Standard Price":58.9589753590028,"Note":"**"},{"Itemcode":"74100261","Description":"Zosyn 4.5 Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J2543","Standard Price":58.8632546566441,"Note":"**"},{"Itemcode":"74100262","Description":"Aminocaproic Acid 500Mg Tab","CDM Revenue Code":"637","Standard Price":58.5,"Note":"**"},{"Itemcode":"74100264","Description":"Lidocaine 2% Jelly 30Gm","CDM Revenue Code":"250","Standard Price":59.225,"Note":"**"},{"Itemcode":"74100265","Description":"Amikacin 500Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0278","Standard Price":58.9893875,"Note":"**"},{"Itemcode":"74100266","Description":"Lidocaine 5% Ointment 36Gm","CDM Revenue Code":"250","Standard Price":128.884347826087,"Note":"**"},{"Itemcode":"74100270","Description":"Isoproterenol 1:5000 Inj 5Ml","CDM Revenue Code":"250","Standard Price":7457.84375,"Note":"**"},{"Itemcode":"74100273","Description":"Bupivacaine 0.25% Inj 30Ml Vl","CDM Revenue Code":"250","Standard Price":58.4522772972973,"Note":"**"},{"Itemcode":"74100274","Description":"Aminocaproic Acid Inj 5Gm/20Ml","CDM Revenue Code":"250","Standard Price":58.8109261744966,"Note":"**"},{"Itemcode":"74100278","Description":"Phenylephrine 1% 10Mg/1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2370","Standard Price":58.9558726293518,"Note":"**"},{"Itemcode":"74100285","Description":"Hydrocortisone Na Suc 250Mg In","CDM Revenue Code":"636","CDM HCPCS":"J1720","Standard Price":58.6718518518519,"Note":"**"},{"Itemcode":"74100289","Description":"Aminophylline 250Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0280","Standard Price":59.132131147541,"Note":"**"},{"Itemcode":"74100290","Description":"Tetracaine 0.5% 2Ml Opth Sol","CDM Revenue Code":"250","Standard Price":53.0205375,"Note":"**"},{"Itemcode":"74100291","Description":"Atracurium Besyl 10Mg/Ml 10Ml","CDM Revenue Code":"250","Standard Price":58.5148542600896,"Note":"**"},{"Itemcode":"74100292","Description":"Aminophylline 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0280","Standard Price":59.74,"Note":"**"},{"Itemcode":"74100296","Description":"Rabies Vaccine 1 Dose","CDM Revenue Code":"636","CDM HCPCS":"90675","Standard Price":1339.56281696969,"Note":"**"},{"Itemcode":"74100305","Description":"Imdur 60Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100321","Description":"Amiodarone 150Mg/3Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0282","Standard Price":58.9582564102564,"Note":"**"},{"Itemcode":"74100322","Description":"Amitriptyline 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100323","Description":"Granisetron Hcl 1Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"Q0166","Standard Price":5.15},{"Itemcode":"74100324","Description":"Dorzolamide Hcl 2% 0Pth Sol5Ml","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74100325","Description":"Amitriptyline 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100329","Description":"Mesalamine 250Mg Cap","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74100330","Description":"Stavudine 40Mg Cap","CDM Revenue Code":"637","Standard Price":23.25},{"Itemcode":"74100331","Description":"Amitriptyline 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100332","Description":"Terbinafine Hcl 1% 15Gm Cr","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100335","Description":"Lotrel Capsule 5/10 Cap","CDM Revenue Code":"637","Standard Price":25.5,"Note":"**"},{"Itemcode":"74100338","Description":"Metfromin Hcl 850Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100339","Description":"Alendronate 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100342","Description":"Nifedipine Extended Release 60","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74100344","Description":"Estradiol Oral 0.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100347","Description":"Midazolam 5Mg/Ml 5Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74100350","Description":"Na Polystyren So4 Enema 30Gm","CDM Revenue Code":"637","Standard Price":121.5,"Note":"**"},{"Itemcode":"74100354","Description":"Dinoprostone 10Mg Vaginal Inse","CDM Revenue Code":"637","Standard Price":1071.0,"Note":"**"},{"Itemcode":"74100355","Description":"Amoxicillin 250Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100356","Description":"Botulinum Toxin Type A 100Unit","CDM Revenue Code":"636","CDM HCPCS":"J0585","Standard Price":2486.62064935065,"Note":"**"},{"Itemcode":"74100358","Description":"Amoxicillin 500Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100360","Description":"Risperidone 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.45,"Note":"**"},{"Itemcode":"74100368","Description":"Oxycodone Hcl 20Mg Cr Tab","CDM Revenue Code":"637","Standard Price":19.42,"Note":"**"},{"Itemcode":"74100375","Description":"Cephalexin 250Mg/5Ml 100Ml Sus","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74100379","Description":"Verapamil Sr 120Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100386","Description":"Flunisolide Menthol Inh 7Gm","CDM Revenue Code":"637","Standard Price":22.5},{"Itemcode":"74100392","Description":"Timolol Xe 0.5 Ophth Sol 5Ml","CDM Revenue Code":"637","Standard Price":342.0,"Note":"**"},{"Itemcode":"74100393","Description":"Cisatracurium 2Mg/Ml 20 Ml Inj","CDM Revenue Code":"250","Standard Price":59.0845454545455,"Note":"**"},{"Itemcode":"74100396","Description":"Ipratropium Nasal 0.03% 30Ml","CDM Revenue Code":"637","Standard Price":54.0,"Note":"**"},{"Itemcode":"74100398","Description":"Ipratropium Nasal 0.06% 15Ml","CDM Revenue Code":"637","Standard Price":51.75,"Note":"**"},{"Itemcode":"74100401","Description":"Sandimmune 250Mg/5 Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J7516","Standard Price":225.57,"Note":"**"},{"Itemcode":"74100402","Description":"Immuran 100 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J7501","Standard Price":360.5},{"Itemcode":"74100404","Description":"Glimerpiride 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100405","Description":"Acarbose 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100406","Description":"Flucytosine 250Mg Cap","CDM Revenue Code":"637","Standard Price":197.25},{"Itemcode":"74100409","Description":"Flucytosine 500Mg Cap","CDM Revenue Code":"637","Standard Price":381.0,"Note":"**"},{"Itemcode":"74100412","Description":"Succinylcholine Cl 20Mg/Ml 10M","CDM Revenue Code":"636","CDM HCPCS":"J0330","Standard Price":58.6523621767242,"Note":"**"},{"Itemcode":"74100417","Description":"Augmentin 875Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100420","Description":"Naproxen 500Mg Tab Ec","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100422","Description":"Octreotide Acetate 0.5Mg/Ml","CDM Revenue Code":"636","CDM HCPCS":"J2354","Standard Price":159.291033274956,"Note":"**"},{"Itemcode":"74100423","Description":"Haemophilus 8 Vaccine","CDM Revenue Code":"636","CDM HCPCS":"90648","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"74100427","Description":"Antabuse/250Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100428","Description":"Vitamin E Cr 60Ml","CDM Revenue Code":"637"},{"Itemcode":"74100429","Description":"Nisoldipine 20Mg Tab","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74100430","Description":"Physostigmine 1Mg/Ml 2Ml Amp","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74100435","Description":"Ziac 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100436","Description":"Antivenin Micrurus Fulviu Vial","CDM Revenue Code":"250","Standard Price":21005.82},{"Itemcode":"74100441","Description":"Muro-128 Ophth Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":58.6241666666667,"Note":"**"},{"Itemcode":"74100442","Description":"Meclizine Hcl 12.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100443","Description":"Meclizine 25Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100444","Description":"Valium 5 Mg Tab-Brand Nec","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74100451","Description":"Anusol Oint 30Ml","CDM Revenue Code":"637","Standard Price":22.5},{"Itemcode":"74100452","Description":"Terbinafine 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100454","Description":"Anusol Supp","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100455","Description":"Timolol 5 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100457","Description":"Anusol: Hc 2.5% Cr 30Gm","CDM Revenue Code":"637","Standard Price":48.75,"Note":"**"},{"Itemcode":"74100458","Description":"Zerit 30 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100459","Description":"Lamivudine 150Mg Tablet","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74100460","Description":"Hydrocortisone Supp 25Mg","CDM Revenue Code":"637","Standard Price":19.5,"Note":"**"},{"Itemcode":"74100464","Description":"Insulin Humalog 100U 10Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":240.75},{"Itemcode":"74100465","Description":"Bicalutamide 50Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":6.18,"Note":"**"},{"Itemcode":"74100472","Description":"Hydralazine 20Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0360","Standard Price":58.9481940978972,"Note":"**"},{"Itemcode":"74100473","Description":"Estradiol 0.05 Mg Top Patch","CDM Revenue Code":"637","Standard Price":55.5},{"Itemcode":"74100475","Description":"Hydralazine 25Mg Tab","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"74100478","Description":"Hydralazine 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100484","Description":"Phytonadione 10Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3430","Standard Price":63.126301369863,"Note":"**"},{"Itemcode":"74100487","Description":"Phytonadione 1Mg/0.5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3430","Standard Price":59.0982576271187,"Note":"**"},{"Itemcode":"74100535","Description":"Ammonia Aspiroles: Aromatic Ea","CDM Revenue Code":"250","Standard Price":59.2521052631579,"Note":"**"},{"Itemcode":"74100547","Description":"Ascorbic Acid Tab 250Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100550","Description":"Ascriptin Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100568","Description":"Aspirin/300Mg/1Ea/Supp","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100580","Description":"Aspirin 600Mg Supp","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100583","Description":"Aspirin 325Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100586","Description":"Hydroxyzine 2Mg/Ml Syrup 60Ml","CDM Revenue Code":"637","Standard Price":9.75},{"Itemcode":"74100589","Description":"Hydroxyzine Hcl 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100592","Description":"Hydroxyzine Hcl 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100598","Description":"Lorazepam 2Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2060","Standard Price":58.7554013599348,"Note":"**"},{"Itemcode":"74100604","Description":"Lorazepam 1Mg Tablet","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74100610","Description":"Lorazepam 0.5Mg Tablet","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"74100628","Description":"Atropine O.4Mg/Ml 1Ml","CDM Revenue Code":"636","CDM HCPCS":"J0461","Standard Price":46.4677971830986,"Note":"**"},{"Itemcode":"74100631","Description":"Atropine 1% Opth Soln 1Ml","CDM Revenue Code":"250","Standard Price":59.4230769230769,"Note":"**"},{"Itemcode":"74100637","Description":"Ipratropium Bromide 14Gm Inh","CDM Revenue Code":"637","Standard Price":998.25,"Note":"**"},{"Itemcode":"74100643","Description":"Augmentin 250Mg/5Ml 75Ml","CDM Revenue Code":"637","Standard Price":155.25},{"Itemcode":"74100646","Description":"Augmentin 250/250Mg/1Tab","CDM Revenue Code":"637","Standard Price":14.25},{"Itemcode":"74100649","Description":"Augmentin 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100652","Description":"Benzocaine/Antipyrine 10Ml","CDM Revenue Code":"637"},{"Itemcode":"74100670","Description":"Nortriptyline 10Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100671","Description":"Cefepime 1 Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J0692","Standard Price":30.8684139913752,"Note":"**"},{"Itemcode":"74100688","Description":"Norethindrone Acetate 5Mg Tab","CDM Revenue Code":"637","Standard Price":27.0},{"Itemcode":"74100691","Description":"Aztreonam 1Gm Inj","CDM Revenue Code":"250","Standard Price":114.013035465116,"Note":"**"},{"Itemcode":"74100694","Description":"Azactam 2Gm Inj","CDM Revenue Code":"250","Standard Price":228.66,"Note":"**"},{"Itemcode":"74100700","Description":"Gabapentin 300Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100703","Description":"Gabapentin 100Mg Cap","CDM Revenue Code":"637","Standard Price":25.13,"Note":"**"},{"Itemcode":"74100715","Description":"Sulfasalazine 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100727","Description":"Bacitracin Opth Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":465.224558208955,"Note":"**"},{"Itemcode":"74100730","Description":"Bacitracin Oint 15Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100736","Description":"Famciclovir 500Mg Tab","CDM Revenue Code":"637","Standard Price":8.32,"Note":"**"},{"Itemcode":"74100739","Description":"Bacitracin 50:000 Units","CDM Revenue Code":"250","Standard Price":56.2281641826215,"Note":"**"},{"Itemcode":"74100751","Description":"Mupirocin 2% Oint 22Gm","CDM Revenue Code":"637","Standard Price":26.8,"Note":"**"},{"Itemcode":"74100763","Description":"Aspirin Chewable 81Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74100769","Description":"Penicillin 250Mg/5Ml 100Ml Bot","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74100775","Description":"Diphenhydramine 25Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100787","Description":"Diphenhydramine 50Mg/Ml Syring","CDM Revenue Code":"250","CDM HCPCS":"J1200","Standard Price":57.3964262704732,"Note":"**"},{"Itemcode":"74100793","Description":"Dicyclomine 10Mg.Ml 2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0500","Standard Price":197.834918947368,"Note":"**"},{"Itemcode":"74100796","Description":"Dyclomine 10Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100799","Description":"Dicyclomine 10Mg/5Ml Syr 60Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100803","Description":"Diltiazem 125 Mg Vial","CDM Revenue Code":"250","Standard Price":57.0988170212766,"Note":"**"},{"Itemcode":"74100850","Description":"Levobunolol 0.5Ml Op Sol","CDM Revenue Code":"637","Standard Price":41.25},{"Itemcode":"74100856","Description":"Betamethasone Val 0.1% Cr 15Gm","CDM Revenue Code":"637","Standard Price":34.5,"Note":"**"},{"Itemcode":"74100874","Description":"Bethanechol 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100877","Description":"Milrinone 20Mg/20Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2260","Standard Price":59.74},{"Itemcode":"74100880","Description":"Bethamechol 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100898","Description":"Bicillin L-A/600Ku/1Ml/Sy","CDM Revenue Code":"636","CDM HCPCS":"J0561","Standard Price":114.33,"Note":"**"},{"Itemcode":"74100901","Description":"Bicillin La 1:200:000 Units","CDM Revenue Code":"636","CDM HCPCS":"J0561","Standard Price":359.506785714285,"Note":"**"},{"Itemcode":"74100910","Description":"Bisacodyl 10Mg Supp","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100913","Description":"Bisacodyl 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100919","Description":"Bleomycin 15 Units Vial","CDM Revenue Code":"636","CDM HCPCS":"J9040","Standard Price":136.99,"Note":"**"},{"Itemcode":"74100928","Description":"Blephamide Opth Sol 5Cc","CDM Revenue Code":"637","Standard Price":380.25},{"Itemcode":"74100940","Description":"Terbutaline 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100948","Description":"Enoxaparin 40 Mg/0.4 Ml Syrd","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":58.9761761738465,"Note":"**"},{"Itemcode":"74100949","Description":"Esmolol Hcl 100Mg/10Ml Vl","CDM Revenue Code":"250","Standard Price":59.1191244851259,"Note":"**"},{"Itemcode":"74100952","Description":"Mexthohexital Na 500Mg Inj","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74100955","Description":"Terbutaline 1Mg/1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3105","Standard Price":58.4685647214854,"Note":"**"},{"Itemcode":"74100973","Description":"Bss Plus Ophth Irrig 500Ml","CDM Revenue Code":"250","Standard Price":284.28},{"Itemcode":"74100979","Description":"Bumetanide 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100982","Description":"Bumetanide 0.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100985","Description":"Bumetanide 1Mg/4Ml Inj","CDM Revenue Code":"250","Standard Price":59.1389374792507,"Note":"**"},{"Itemcode":"74100991","Description":"Buspirone 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100995","Description":"Verapamil Sr 180Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74100999","Description":"Magnesium Lact Sr 84Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101001","Description":"Propafenone Hcl 150Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101004","Description":"Retrovir 200Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J3485","Standard Price":124.63,"Note":"**"},{"Itemcode":"74101007","Description":"Oramorph (Morphine) 100Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101010","Description":"Divalproex Na Er 250 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101015","Description":"Ergotami Tarira Caffe 1Ta","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101027","Description":"Pramoxine-Calamine 6 Oz Bot","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101030","Description":"Calamine Lotion 120Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101033","Description":"Ampicillin 500 Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101036","Description":"Verapamil 80Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101039","Description":"Verapamil 120Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101048","Description":"Verapamil Sr 240Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101057","Description":"Calciton-Salmon200IU/Ml2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0630","Standard Price":9608.5447368421,"Note":"**"},{"Itemcode":"74101072","Description":"Calcium Gluconate 10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0610","Standard Price":59.0697063794532,"Note":"**"},{"Itemcode":"74101081","Description":"Tramdol Hcl 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101090","Description":"Captopril 12.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101093","Description":"Captropil 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101096","Description":"Captopril 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101117","Description":"Sucralfate 1 Gram Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101123","Description":"Mepivacaine Hcl 1% 30Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0670","Standard Price":59.74},{"Itemcode":"74101126","Description":"Mepivacaine Hcl 2% 20Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0670","Standard Price":59.74,"Note":"**"},{"Itemcode":"74101133","Description":"Nicardine 20Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101135","Description":"Diltiazem 60Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101137","Description":"Diltiazem Sr 120Mg Cap","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74101156","Description":"Caster Oil Flavored 30Cc","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74101168","Description":"Clonidine Hcl 0.1Mg Tab","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"74101171","Description":"Clonidine Hcl 0.2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101174","Description":"Clonidine Hcl 0.3Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101177","Description":"Clonidine Tts 1 Patch","CDM Revenue Code":"637","Standard Price":79.5,"Note":"**"},{"Itemcode":"74101180","Description":"Clonidine Tts 2 Patch","CDM Revenue Code":"637","Standard Price":132.72,"Note":"**"},{"Itemcode":"74101183","Description":"Clonidine Tts 3 Patch","CDM Revenue Code":"637","Standard Price":186.0,"Note":"**"},{"Itemcode":"74101228","Description":"Cefotetan 1Gram Inj","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74101231","Description":"Cefuroxime 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101234","Description":"Cefuroxime 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101243","Description":"Betameth Na Phos/Acet 6Mg/1Ml","CDM Revenue Code":"636","CDM HCPCS":"J0702","Standard Price":58.733175,"Note":"**"},{"Itemcode":"74101252","Description":"Losartan 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101255","Description":"Cepacol Loz 9 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101273","Description":"Lactulose Syrup 20G/30Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101279","Description":"Abciximab 10mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0130","Standard Price":5254.03},{"Itemcode":"74101282","Description":"Ascorbic Acid 500Mg/1Ml","CDM Revenue Code":"250","Standard Price":59.2303092783506,"Note":"**"},{"Itemcode":"74101294","Description":"Cherry Syrup Charge","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74101297","Description":"Glipizide Xl 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101303","Description":"Chlordiazepoxide 5Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101306","Description":"Chlordiazepexide 10Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101309","Description":"Chlordiazepoxide 25Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101318","Description":"Chloramphenicol 1Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J0720","Standard Price":165.83},{"Itemcode":"74101339","Description":"Chlorpromazine 25Mg Tab","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74101348","Description":"Chlorthalidone 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101366","Description":"Chromagen Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101381","Description":"Ciprofloxacin 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101384","Description":"Ciprofloxacin 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101387","Description":"Ciprofloxacin 750Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101390","Description":"Citrate Magnesia 345 Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101396","Description":"Cefotaxime 1Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J0698","Standard Price":59.74},{"Itemcode":"74101402","Description":"Clindamycin 150Mg Cap","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74101405","Description":"Clindamycin 300Mg/2Ml Inj","CDM Revenue Code":"250","Standard Price":58.71,"Note":"**"},{"Itemcode":"74101420","Description":"Clindamycin 600Mg/4Ml Inj","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74101426","Description":"Sulindac 150Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101429","Description":"Sulindac 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101447","Description":"Cocaine Hcl 10% Top Soln 4Ml","CDM Revenue Code":"250","Standard Price":763.23},{"Itemcode":"74101450","Description":"Codeine Oral Soln 15Mg/5Ml","CDM Revenue Code":"637","Standard Price":15.0},{"Itemcode":"74101459","Description":"Codeine 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101465","Description":"Benztropine Mesyl 2Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0515","Standard Price":254.41,"Note":"**"},{"Itemcode":"74101468","Description":"Benztropine Mesylate 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74101471","Description":"Probenecid+Colchicine 500Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101492","Description":"Prochlorperazine 10Mg2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0780","Standard Price":38.5723895910781,"Note":"**"},{"Itemcode":"74101501","Description":"Prochlorperazine 25Mg Supp","CDM Revenue Code":"637","Standard Price":29.25,"Note":"**"},{"Itemcode":"74101507","Description":"Prochlorperazine 5Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"Q0164","Standard Price":6.18},{"Itemcode":"74101510","Description":"Prochlorperazine 10Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"Q0164","Standard Price":6.18,"Note":"**"},{"Itemcode":"74101516","Description":"Amiodarone 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101537","Description":"Nadolol 40Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101547","Description":"Hydrocortisone Enema 100Mg 60M","CDM Revenue Code":"637","Standard Price":50.25,"Note":"**"},{"Itemcode":"74101558","Description":"Cortisporin Opth Susp 7.5Ml","CDM Revenue Code":"250","Standard Price":234.22818,"Note":"**"},{"Itemcode":"74101564","Description":"Cortisporin Otic Solution 10Ml","CDM Revenue Code":"637","Standard Price":236.22,"Note":"**"},{"Itemcode":"74101567","Description":"Cortisporin Otic Suspension 10","CDM Revenue Code":"637","Standard Price":204.0,"Note":"**"},{"Itemcode":"74101573","Description":"Cortrosyn 0.25Mg/1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0834","Standard Price":79.6687640449438,"Note":"**"},{"Itemcode":"74101582","Description":"Dactinomycin 0.5Mg Inj Vial","CDM Revenue Code":"636","CDM HCPCS":"J9120","Standard Price":5735.04},{"Itemcode":"74101588","Description":"Warfarin 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101591","Description":"Warfarin Sodium 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101612","Description":"Cyanocobalamin 1000Mcg/Ml 1Ml","CDM Revenue Code":"636","CDM HCPCS":"J3420","Standard Price":56.0765602836879,"Note":"**"},{"Itemcode":"74101642","Description":"Cyproheptadine Hci 4Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101654","Description":"Cytomel/5Mcg/1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101660","Description":"Cytarabine 100 Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9100","Standard Price":26.78},{"Itemcode":"74101663","Description":"Cytarabine 1000 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9100","Standard Price":265.74},{"Itemcode":"74101667","Description":"Cyclophosphamide 25Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8530","Standard Price":58.2293333333333,"Note":"**"},{"Itemcode":"74101668","Description":"Cytoxan 50Mg 1Tab","CDM Revenue Code":"636","CDM HCPCS":"J8530","Standard Price":59.43,"Note":"**"},{"Itemcode":"74101669","Description":"Cyclophosphamide 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9070","Standard Price":893.483649635037,"Note":"**"},{"Itemcode":"74101672","Description":"D.H.E.45/1Mg/1Ml/Amp","CDM Revenue Code":"636","CDM HCPCS":"J1110","Standard Price":522.233953488372,"Note":"**"},{"Itemcode":"74101687","Description":"Danocrine/100Mg/1Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101690","Description":"Danocrine/50Mg/1Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101720","Description":"Desmopressin Acet 4Mcg/Ml 1Ml","CDM Revenue Code":"636","CDM HCPCS":"J2597","Standard Price":187.697740560293,"Note":"**"},{"Itemcode":"74101723","Description":"Desmopressin 0.01% Nasal Spray","CDM Revenue Code":"637","Standard Price":429.75,"Note":"**"},{"Itemcode":"74101729","Description":"Carbamide Perox 6.5% Otic 15Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101735","Description":"Dexamethasone Oral Sol 60Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101738","Description":"Dexamethasone 0.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101741","Description":"Decadron Ocumeter 5Ml Opt","CDM Revenue Code":"250","Standard Price":58.9388888888889,"Note":"**"},{"Itemcode":"74101756","Description":"Demeclocycline 150Mg Cap","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74101771","Description":"Estradiol Valerate 20Mg Syr","CDM Revenue Code":"636","CDM HCPCS":"J1380","Standard Price":58.7252383561643,"Note":"**"},{"Itemcode":"74101780","Description":"Meperidine 25Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2175","Standard Price":58.5655884979897,"Note":"**"},{"Itemcode":"74101783","Description":"Meperidine 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2175","Standard Price":59.225,"Note":"**"},{"Itemcode":"74101789","Description":"Meperidine 75Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2175","Standard Price":59.74},{"Itemcode":"74101793","Description":"Meperidine 10Mg/Ml 30Ml PCA","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74101794","Description":"Meperidine 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2175","Standard Price":59.0042014319809,"Note":"**"},{"Itemcode":"74101801","Description":"Meperidine 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74101807","Description":"Depakene/250Mg/1Cap","CDM Revenue Code":"637","Standard Price":14.25,"Note":"**"},{"Itemcode":"74101816","Description":"Divalproex Sodium 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101819","Description":"Divalproex Sodium 500Mg Tab","CDM Revenue Code":"637","Standard Price":17.87,"Note":"**"},{"Itemcode":"74101822","Description":"Depo-Estradiol 5mg/1Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1000","Standard Price":59.74},{"Itemcode":"74101825","Description":"Methylprednisolone Ace 40Mg/Ml","CDM Revenue Code":"636","CDM HCPCS":"J1030","Standard Price":59.0269230769231,"Note":"**"},{"Itemcode":"74101828","Description":"Medroxyprogesterone 400Mg/Ml 2","CDM Revenue Code":"250","Standard Price":836.36},{"Itemcode":"74101846","Description":"Deferoxamine 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0895","Standard Price":56.65,"Note":"**"},{"Itemcode":"74101849","Description":"Trazodone 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74101852","Description":"Venlafazine Hcl 37.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101855","Description":"Dexamethasone 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74101861","Description":"Dexamethasone 0.75Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74101870","Description":"Dexamethasone 4Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8540","Standard Price":6.16685792563601,"Note":"**"},{"Itemcode":"74101873","Description":"Dexamethasone 4Mg/Ml 5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":58.6787446730482,"Note":"**"},{"Itemcode":"74101876","Description":"Dexamethasone 4Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":58.2200672585746,"Note":"**"},{"Itemcode":"74101882","Description":"D10W 250Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74101888","Description":"D10W 1000Ml","CDM Revenue Code":"258","Standard Price":59.1562214983713,"Note":"**"},{"Itemcode":"74101894","Description":"D10W/Nacl 0.9% 1000Ml","CDM Revenue Code":"258","Standard Price":59.1799078341014,"Note":"**"},{"Itemcode":"74101900","Description":"D2.5W/Nacl 0.45% 1000Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74101912","Description":"D5W 50Ml","CDM Revenue Code":"258","Standard Price":58.7441802547771,"Note":"**"},{"Itemcode":"74101915","Description":"D5W 100Ml","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74101921","Description":"D5W 150Ml","CDM Revenue Code":"258","Standard Price":57.68,"Note":"**"},{"Itemcode":"74101924","Description":"D5W 250Ml","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74101927","Description":"D5W 500Ml","CDM Revenue Code":"258","CDM HCPCS":"J7060","Standard Price":58.4810695530726,"Note":"**"},{"Itemcode":"74101930","Description":"D5W 1000Ml","CDM Revenue Code":"636","CDM HCPCS":"J7070","Standard Price":58.9794718019258,"Note":"**"},{"Itemcode":"74101933","Description":"D5W/Kcl 20Meq 1000Ml","CDM Revenue Code":"258","Standard Price":58.7252592592592,"Note":"**"},{"Itemcode":"74101939","Description":"D5W/Rl 500Ml","CDM Revenue Code":"258","CDM HCPCS":"J7121","Standard Price":57.68,"Note":"**"},{"Itemcode":"74101942","Description":"D5W/Rl 1000Ml","CDM Revenue Code":"258","CDM HCPCS":"J7121","Standard Price":58.8111206427015,"Note":"**"},{"Itemcode":"74101948","Description":"D5W/Nacl 0.9% Ns 500Ml","CDM Revenue Code":"636","CDM HCPCS":"J7042","Standard Price":56.65},{"Itemcode":"74101951","Description":"D5W/Nacl 0.9% 1000Ml","CDM Revenue Code":"636","CDM HCPCS":"J7042","Standard Price":58.9896300512236,"Note":"**"},{"Itemcode":"74101963","Description":"D5W/Nacl 0.45% 500Ml","CDM Revenue Code":"258","Standard Price":58.0233333333333,"Note":"**"},{"Itemcode":"74101966","Description":"D5W/Nacl 0.45% 1000Ml","CDM Revenue Code":"258","Standard Price":58.7330197552836,"Note":"**"},{"Itemcode":"74101969","Description":"D5W/Nacl 0.45%% /Kcl 20Meq 100","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":58.9824858037056,"Note":"**"},{"Itemcode":"74101972","Description":"D5W/Nacl 0.45% /Kcl 30Meq 1000","CDM Revenue Code":"258","Standard Price":58.8972727272727,"Note":"**"},{"Itemcode":"74101975","Description":"D5W/Nacl 0.45% /Kcl 40Meq 1000","CDM Revenue Code":"258","Standard Price":59.3966666666667,"Note":"**"},{"Itemcode":"74101978","Description":"D5W/Nacl 0.2% 250Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74101981","Description":"D5W/Nacl 0.2% 1000Ml","CDM Revenue Code":"258","Standard Price":59.3844670050762,"Note":"**"},{"Itemcode":"74101984","Description":"D5W/Nacl 0.2% 500Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74101987","Description":"D5W/Nacl 0.2%% /Kcl 20Meq 1000","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":58.8571428571428,"Note":"**"},{"Itemcode":"74101990","Description":"Dextrose 50% 50Cc Syringe","CDM Revenue Code":"250","Standard Price":58.9147484636871,"Note":"**"},{"Itemcode":"74101999","Description":"Nitroglycerin 2% Oint 1Gm","CDM Revenue Code":"637","Standard Price":5.99,"Note":"**"},{"Itemcode":"74102002","Description":"Glyburide 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102005","Description":"Glyburide 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102017","Description":"Acetazolamide 500Mg Injection","CDM Revenue Code":"636","CDM HCPCS":"J1120","Standard Price":90.3126071428572,"Note":"**"},{"Itemcode":"74102020","Description":"Acetazolamide 500Mg Sequel","CDM Revenue Code":"637","Standard Price":27.75,"Note":"**"},{"Itemcode":"74102026","Description":"Diazepam Soln 5Mg/Ml 1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3360","Standard Price":59.74,"Note":"**"},{"Itemcode":"74102035","Description":"Diazepam 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102053","Description":"Dibenzyline 10Mg 1Cap","CDM Revenue Code":"637","Standard Price":189.0},{"Itemcode":"74102077","Description":"Digoxin Immune (Digibind) 40Mg","CDM Revenue Code":"636","CDM HCPCS":"J1162","Standard Price":10717.356,"Note":"**"},{"Itemcode":"74102089","Description":"Phenytoin 250Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1165","Standard Price":59.1677777777777,"Note":"**"},{"Itemcode":"74102092","Description":"Phenytoin 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1165","Standard Price":58.8356097560976,"Note":"**"},{"Itemcode":"74102095","Description":"Phenytoin 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102098","Description":"Phenytoin 100Mg Cap","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74102101","Description":"Flu Vac 4Val Fluzone 0.5ml","CDM Revenue Code":"636","CDM HCPCS":"90686","Standard Price":59.5453048780488,"Note":"**"},{"Itemcode":"74102104","Description":"Phenytoin 100Mg/4Ml Susp Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102116","Description":"Hydromorphone 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74102128","Description":"Dimenhydrinate 50Mg/Ml Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74102164","Description":"Diphenoxylate/Atropin 2.5Mgtab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74102176","Description":"Diprolene 0.05% 45Gm Cr","CDM Revenue Code":"637","Standard Price":194.25,"Note":"**"},{"Itemcode":"74102182","Description":"Diprolene 0.05% Af 15Gm Cr","CDM Revenue Code":"637","Standard Price":12.0,"Note":"**"},{"Itemcode":"74102206","Description":"Triacinalone .5% 15Gm Cr","CDM Revenue Code":"250","Standard Price":59.5111111111111,"Note":"**"},{"Itemcode":"74102209","Description":"Salsalate 750Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102212","Description":"Salsalate 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102218","Description":"Oxybutynin Cl 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102239","Description":"Dobutamine Inj 250Mg/20Ml","CDM Revenue Code":"636","CDM HCPCS":"J1250","Standard Price":59.74},{"Itemcode":"74102242","Description":"Docusate Na 100Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102248","Description":"Docusate Na 100Mg/10Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102281","Description":"Domeboro Packet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102290","Description":"Donnatal Elix 5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102302","Description":"Dopamine 800Mg In D5W 250Ml","CDM Revenue Code":"636","CDM HCPCS":"J1265","Standard Price":58.730659025788,"Note":"**"},{"Itemcode":"74102311","Description":"Doxapram 20Mg/Ml 20Ml Inj","CDM Revenue Code":"250","Standard Price":178.19},{"Itemcode":"74102317","Description":"Doxycycline 100Mg Inj","CDM Revenue Code":"250","Standard Price":58.7467154831199,"Note":"**"},{"Itemcode":"74102323","Description":"Doxycycline 100Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102335","Description":"Nefazodone 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102344","Description":"Dtic-Dome 200Mg/Vial","CDM Revenue Code":"636","CDM HCPCS":"J9130","Standard Price":55.1785714285715,"Note":"**"},{"Itemcode":"74102359","Description":"Cefadroxyl/500Mg/1 Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102383","Description":"Triamterene Cap 50Mg","CDM Revenue Code":"637","Standard Price":28.5,"Note":"**"},{"Itemcode":"74102434","Description":"Phosphorated Carbohydr 120Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102461","Description":"Methyclothiazi/2.5Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102518","Description":"Ephedrine 50Mg/Ml Inj","CDM Revenue Code":"250","Standard Price":58.8888333481944,"Note":"**"},{"Itemcode":"74102527","Description":"Epifoam 1%/10Gm","CDM Revenue Code":"637","Standard Price":222.75},{"Itemcode":"74102536","Description":"Magneium Sulfate Cryst 454Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102548","Description":"Erythromycin 500Mg Iv","CDM Revenue Code":"636","CDM HCPCS":"J1364","Standard Price":145.23,"Note":"**"},{"Itemcode":"74102551","Description":"Erythromycin Stearate 250Mg Ta","CDM Revenue Code":"637","Standard Price":30.0,"Note":"**"},{"Itemcode":"74102554","Description":"Erythromycin Base 250Mg Tab","CDM Revenue Code":"637","Standard Price":31.5,"Note":"**"},{"Itemcode":"74102557","Description":"Erythromycin 1Gm Iv","CDM Revenue Code":"636","CDM HCPCS":"J1364","Standard Price":159.65},{"Itemcode":"74102572","Description":"Eskalith Cr 450Mg/1Tab Tb","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102581","Description":"Estradiol Oral 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102584","Description":"Estradiol 0.05Mg Top Patch","CDM Revenue Code":"637","Standard Price":39.0,"Note":"**"},{"Itemcode":"74102587","Description":"Estradiol 0.1Mg Top Patch","CDM Revenue Code":"637","Standard Price":45.75,"Note":"**"},{"Itemcode":"74102602","Description":"Estratest Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102641","Description":"Piroxicam 20Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102644","Description":"Fentanyl 0.1MG/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":58.6466084694876,"Note":"**"},{"Itemcode":"74102674","Description":"Ferrous Gluconate 320Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102677","Description":"Ferrous Sulfate 300Mg/5Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102683","Description":"Ferrous Sulfate Tab 325Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102684","Description":"Fioricet Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74102689","Description":"Fiorinal Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102695","Description":"Metronidazole 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102701","Description":"Fleet Enema Disp 133Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102713","Description":"Cyclobenzaprine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102719","Description":"Fludrocortisone Acet 0.1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102728","Description":"Fluor-1-Strip Each","CDM Revenue Code":"250","Standard Price":58.0882134430726,"Note":"**"},{"Itemcode":"74102731","Description":"Fluorescein 10% 5Ml","CDM Revenue Code":"250","Standard Price":59.0709967845659,"Note":"**"},{"Itemcode":"74102737","Description":"Fluorouracil 500Mg/10Ml","CDM Revenue Code":"636","CDM HCPCS":"J9190","Standard Price":55.0814803149606,"Note":"**"},{"Itemcode":"74102743","Description":"Fluorometholone 0.1% Op Sol5Ml","CDM Revenue Code":"637","Standard Price":195.75,"Note":"**"},{"Itemcode":"74102752","Description":"Folic Acid 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102755","Description":"Estratest Hs Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102758","Description":"Folic Acid 5Mg/Ml 10Ml Inj","CDM Revenue Code":"250","Standard Price":59.2174365821094,"Note":"**"},{"Itemcode":"74102761","Description":"Isoflurane 100Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74102779","Description":"Amphotericin B 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0285","Standard Price":140.286,"Note":"**"},{"Itemcode":"74102782","Description":"Nitrofurantoin25Mg/5Ml Liq60Ml","CDM Revenue Code":"637","Standard Price":8.25},{"Itemcode":"74102788","Description":"Furodemide 40Mg/5Ml Liq Ud","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102833","Description":"Gentamicin 0.3% Opth Soln 1Ml","CDM Revenue Code":"250","Standard Price":58.71,"Note":"**"},{"Itemcode":"74102836","Description":"Gentamycin Opt Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"74102839","Description":"HOCM: Gastrografin 120Ml /Soln","CDM Revenue Code":"255","CDM HCPCS":"Q9963","Standard Price":58.5777950857143,"Note":"**"},{"Itemcode":"74102842","Description":"Gaviscon Liquid 360Ml","CDM Revenue Code":"637","Standard Price":18.0},{"Itemcode":"74102845","Description":"Gaviscon Foamtab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102857","Description":"Gelfoam Size 100 Cm Pad","CDM Revenue Code":"250","Standard Price":172.431875525651,"Note":"**"},{"Itemcode":"74102875","Description":"Gentamicin Inj 80Mg/2Ml","CDM Revenue Code":"636","CDM HCPCS":"J1580","Standard Price":58.9934558336697,"Note":"**"},{"Itemcode":"74102878","Description":"Gentamicin Inj 20Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1580","Standard Price":6.18,"Note":"**"},{"Itemcode":"74102884","Description":"Gentamicin Oint 0.1% 15Gm","CDM Revenue Code":"637","Standard Price":88.5,"Note":"**"},{"Itemcode":"74102887","Description":"Gentamycin 80Mg Iv","CDM Revenue Code":"636","CDM HCPCS":"J1580","Standard Price":58.2890758122744,"Note":"**"},{"Itemcode":"74102890","Description":"Gentian Violet 1%/60Ml/So","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74102896","Description":"Gevrabon 60Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102905","Description":"Glucagon 1Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1610","Standard Price":336.609129882812,"Note":"**"},{"Itemcode":"74102908","Description":"Glucagon Kit","CDM Revenue Code":"636","CDM HCPCS":"J1610","Standard Price":1191.71,"Note":"**"},{"Itemcode":"74102911","Description":"Glipizide 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102914","Description":"Glipizide 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102920","Description":"Glycerin Supp Adult","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102923","Description":"Glycerin 60Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102926","Description":"Golytely 4000Ml","CDM Revenue Code":"637","Standard Price":41.91,"Note":"**"},{"Itemcode":"74102929","Description":"Goniosol 2.5% Opth Drops 15Ml","CDM Revenue Code":"250","Standard Price":58.5418367346939,"Note":"**"},{"Itemcode":"74102938","Description":"Gris-Peg 250Mg 1Tab","CDM Revenue Code":"637","Standard Price":15.0},{"Itemcode":"74102956","Description":"Hepatitis B Immune Globulin5Ml","CDM Revenue Code":"636","CDM HCPCS":"90371","Standard Price":3414.45},{"Itemcode":"74102962","Description":"Triazolam 0.125Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102968","Description":"Haloperidol 5Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1630","Standard Price":58.0204230051813,"Note":"**"},{"Itemcode":"74102974","Description":"Haloperidol 0.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74102977","Description":"Haloperidol 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102980","Description":"Haloperidol 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74102983","Description":"Haloperidol 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74103004","Description":"Heparin 100 Units/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":58.7786666666667,"Note":"**"},{"Itemcode":"74103007","Description":"Heparin Lock Flush 10U/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":3.09},{"Itemcode":"74103010","Description":"Heparin 1000U Inj Tubex 1Ea","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":58.7849321824908,"Note":"**"},{"Itemcode":"74103016","Description":"Heparin 5000 Units/Ml 1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":58.98893968026,"Note":"**"},{"Itemcode":"74103019","Description":"Heparin 1000 U/Ml 10Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":59.0423619790941,"Note":"**"},{"Itemcode":"74103022","Description":"Omeprazole 20Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103028","Description":"Heparin 25:000 Units/D5W 500Ml","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":58.9697503121099,"Note":"**"},{"Itemcode":"74103034","Description":"Heparin 1000 U/Nacl 0.9%% 500M","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":59.0107298911748,"Note":"**"},{"Itemcode":"74103040","Description":"Risperidone 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103058","Description":"Hiprex 1Gm 1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103070","Description":"Homatropine 5% 2Ml Opgtts","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74103073","Description":"Tetanus Immune Globulin 250Uni","CDM Revenue Code":"636","CDM HCPCS":"J1670","Standard Price":2113.56},{"Itemcode":"74103079","Description":"Humulin Nph 100U 10Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":40.5},{"Itemcode":"74103082","Description":"Humulin Reg 100U 10Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":40.5},{"Itemcode":"74103088","Description":"Hurricaine 20% Spray 60Ml","CDM Revenue Code":"250","Standard Price":58.916,"Note":"**"},{"Itemcode":"74103118","Description":"Hydralazine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103130","Description":"Hydroxyurea 500Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103133","Description":"Hydrocortisone 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103142","Description":"Hydrocortisone 1% 30Gm Cr","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103145","Description":"Hydrocortisone 2.5% 20Gm Cr","CDM Revenue Code":"637","Standard Price":33.0,"Note":"**"},{"Itemcode":"74103163","Description":"Hydroxyzine/25Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103169","Description":"Hydroxyzine Hcl 50Mg/Ml Inj","CDM Revenue Code":"250","Standard Price":59.6689655172414,"Note":"**"},{"Itemcode":"74103172","Description":"Hydroxyzine Pamoate 50Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103175","Description":"Hydroxyzine Pamoate 25Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"Q0177","Standard Price":6.18,"Note":"**"},{"Itemcode":"74103181","Description":"Isovue-M-300 15 Ml Vial","CDM Revenue Code":"250","Standard Price":359.47,"Note":"**"},{"Itemcode":"74103190","Description":"Hydrocortisone 0.5% Cream 30Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103196","Description":"Terazosin 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103197","Description":"Terazosin 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103198","Description":"Terazosin 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103265","Description":"Loperamide 2Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103271","Description":"Azathioprine 50Mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J7500","Standard Price":6.18,"Note":"**"},{"Itemcode":"74103274","Description":"Droperidol 2.5Mg/Ml 2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1790","Standard Price":59.74},{"Itemcode":"74103277","Description":"Propranolol 1Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1800","Standard Price":57.68,"Note":"**"},{"Itemcode":"74103280","Description":"Propranolol 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103283","Description":"Fluticasone Propio.16Gm Nasinh","CDM Revenue Code":"637","Standard Price":65.82,"Note":"**"},{"Itemcode":"74103286","Description":"Propranalol 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103289","Description":"Propranolol 80Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103295","Description":"Propranolol La 60Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103298","Description":"Propranolol La 80Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103301","Description":"Propranolol La 120Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103325","Description":"Indigotindisulfonate 8Mg/Ml5Ml","CDM Revenue Code":"250","Standard Price":654.794578313253,"Note":"**"},{"Itemcode":"74103328","Description":"Indomethacin 25Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103331","Description":"Indomethacin 50Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103343","Description":"Indomethacin Cap Sr 75Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103346","Description":"Venlafaxine Hcl 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103382","Description":"Cromolyn Sodium Inh 8.1Gm","CDM Revenue Code":"637","Standard Price":176.25},{"Itemcode":"74103388","Description":"Cromolyn Sodium Neb Soln","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74103394","Description":"Dopamine 400Mg/5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1265","Standard Price":59.74},{"Itemcode":"74103424","Description":"Isoniazid 300Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103445","Description":"Tobrex Ophth Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":857.99,"Note":"**"},{"Itemcode":"74103451","Description":"D10W 500Ml","CDM Revenue Code":"258","Standard Price":58.9821280432823,"Note":"**"},{"Itemcode":"74103454","Description":"Diltiazem Sr 90Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103457","Description":"Cefotetan 2Gram Inj","CDM Revenue Code":"250","Standard Price":161.493020030008,"Note":"**"},{"Itemcode":"74103463","Description":"Clarithromycin 250Mg/5Ml Oral","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74103493","Description":"Pilocarpine 4% Ophth Soln 15Ml","CDM Revenue Code":"250","Standard Price":358.44},{"Itemcode":"74103499","Description":"Pilocarpine 6% Ophth Soln.15Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74103511","Description":"Isopto Hyoscine 0.25%/5Ml","CDM Revenue Code":"250","Standard Price":147.29},{"Itemcode":"74103526","Description":"Isosorbide Dinitrate 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103529","Description":"Isosorbide 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103532","Description":"Sorbitrate Dinitrate 40Mg Sa T","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74103538","Description":"Isuprel 0.2Mg 1Ml Amp","CDM Revenue Code":"250","Standard Price":6178.7074509804,"Note":"**"},{"Itemcode":"74103553","Description":"Potassium Chloride Tab 20Meq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103556","Description":"K Chloride 20Meq Pack","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74103568","Description":"K Bicarbonate 25Meq Eff Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74103577","Description":"K Phosphate 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103583","Description":"K Phosphate 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103604","Description":"Kanamycin 1Gm/3Ml Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74103610","Description":"Bismuth Subsalicylate Liq 30Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103628","Description":"Cephalexin 250Mg Cap","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74103631","Description":"Cephalexin 500Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103654","Description":"Cefuroxime 1.5Gm Adv","CDM Revenue Code":"636","CDM HCPCS":"J0697","Standard Price":59.74,"Note":"**"},{"Itemcode":"74103656","Description":"Cefuroxime 750Mg Adv","CDM Revenue Code":"636","CDM HCPCS":"J0697","Standard Price":57.2979636363636,"Note":"**"},{"Itemcode":"74103658","Description":"Fentanyl .05Mg/Ml 20Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":58.7240136054422,"Note":"**"},{"Itemcode":"74103673","Description":"Cefazolin 1Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J0690","Standard Price":58.8859141166634,"Note":"**"},{"Itemcode":"74103679","Description":"Triamcinolone Dental Paste 5Gm","CDM Revenue Code":"637","Standard Price":105.75,"Note":"**"},{"Itemcode":"74103682","Description":"Triamcinalone Acet .025% Cr 15","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74103709","Description":"Triamcinolone Acet 0.1% Cr 15G","CDM Revenue Code":"637","Standard Price":10.5,"Note":"**"},{"Itemcode":"74103718","Description":"Triamcinolone Lotion 0.1% 60","CDM Revenue Code":"637","Standard Price":98.25,"Note":"**"},{"Itemcode":"74103721","Description":"Triaminalone Acet 0.1% Cr 15G","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74103751","Description":"Ketamine 50Mg/Ml 10Ml Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74103754","Description":"Ketamine 100Mg/Ml 1Ml Charge","CDM Revenue Code":"250","Standard Price":56.6290254545455,"Note":"**"},{"Itemcode":"74103763","Description":"Sincalide 5Mcg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2805","Standard Price":354.32},{"Itemcode":"74103766","Description":"Clonazepam 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103769","Description":"Clonazepam 0.5 Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74103787","Description":"Lacri-Lube Oph Ointment 3.5Gm","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74103796","Description":"Lactated Ringers: 500Ml","CDM Revenue Code":"258","CDM HCPCS":"J7120","Standard Price":59.2077181208054,"Note":"**"},{"Itemcode":"74103799","Description":"Lactated Ringers: 1000Ml Bag","CDM Revenue Code":"258","CDM HCPCS":"J7120","Standard Price":58.7316902018063,"Note":"**"},{"Itemcode":"74103808","Description":"Lactrase 250Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74103829","Description":"Lanoxin 0.5Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1160","Standard Price":58.9572817460318,"Note":"**"},{"Itemcode":"74103832","Description":"Lanoxin Tab 0.125Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103835","Description":"Lanoxin Tab 0.25Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103862","Description":"Furosemide 40Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103868","Description":"Furosemide 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103871","Description":"Furosemide 20Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1940","Standard Price":58.9405157024794,"Note":"**"},{"Itemcode":"74103874","Description":"Furosemide 40Mg/4Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1940","Standard Price":58.849429208084,"Note":"**"},{"Itemcode":"74103877","Description":"Furosemide 100Mg/10Ml Inj","CDM Revenue Code":"250","Standard Price":59.074102079395,"Note":"**"},{"Itemcode":"74103889","Description":"Leucovorin Calcium 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0640","Standard Price":59.3174358974359,"Note":"**"},{"Itemcode":"74103901","Description":"Chlorambucil 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74103907","Description":"Norepinephrine 1Mg/1Ml Inj 4Ml","CDM Revenue Code":"250","Standard Price":59.0195202020202,"Note":"**"},{"Itemcode":"74103913","Description":"Levothyroxine Sod 175Mcg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103916","Description":"Hyoscyamine 0.125Mg/Ml 15Ml","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74103919","Description":"Hysocyamine Sulfate 0.125Mg Ta","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74103928","Description":"Chlordiazepoxide/Clidinum Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103937","Description":"Fluocinonide 0.5%% Oint 15Gm","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74103943","Description":"Lidex .05% 60Mg Oint","CDM Revenue Code":"637","Standard Price":217.5},{"Itemcode":"74103946","Description":"Fluocinonide-E Cream 0.05% 15G","CDM Revenue Code":"637","Standard Price":60.0,"Note":"**"},{"Itemcode":"74103967","Description":"Lidocaine 100Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.8679176201373,"Note":"**"},{"Itemcode":"74103970","Description":"Lidocaine 2Grams In D5W 500Ml","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.1,"Note":"**"},{"Itemcode":"74103985","Description":"Baclofen 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74103997","Description":"Fat Emulsion 10% 500Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74104000","Description":"Fat Emulsion 20% 500Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74104006","Description":"Lithium Carbonate 300Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104012","Description":"Minoxidil 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104015","Description":"Minoxidil 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104021","Description":"Gemfibrozil 600Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104024","Description":"Metoprolol Tart.5Mg/5Ml 5Mlin","CDM Revenue Code":"250","Standard Price":59.1016728476821,"Note":"**"},{"Itemcode":"74104027","Description":"Metoprolol Tartrate 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104030","Description":"Metorprolol Tartrate 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104051","Description":"Clotrimazole 1% Cr 15Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104057","Description":"Clotrimazole/Betameth 15Gm Cr","CDM Revenue Code":"637","Standard Price":50.25,"Note":"**"},{"Itemcode":"74104069","Description":"Indapamide 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104072","Description":"Flanders Oint 60Gm","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74104120","Description":"Maalox Plus/1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104126","Description":"Nitrofurantoin Macro 100Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104129","Description":"Nitrofurantoin (Macro)50Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104138","Description":"Magnesium Sulfate 4.06Meq/Ml","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":58.7550585335798,"Note":"**"},{"Itemcode":"74104144","Description":"Mandelamine Equiv. 1000Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104156","Description":"Mannitol 12.5Gm/50Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2150","Standard Price":58.81712,"Note":"**"},{"Itemcode":"74104162","Description":"Bupivacaine 0.25% 10Ml","CDM Revenue Code":"250","Standard Price":58.7386116146062,"Note":"**"},{"Itemcode":"74104165","Description":"Bupivaca 0.25% W/Epi 10Ml P","CDM Revenue Code":"250","Standard Price":58.9224623350254,"Note":"**"},{"Itemcode":"74104168","Description":"Bupivacaine 0.5% 10Ml Vl","CDM Revenue Code":"250","Standard Price":58.9476923076923,"Note":"**"},{"Itemcode":"74104174","Description":"Bupivacain 0.5% W Epi 10Ml Pf","CDM Revenue Code":"250","Standard Price":58.3956349900596,"Note":"**"},{"Itemcode":"74104177","Description":"Bupivacaine 0.75% 10Ml Vl","CDM Revenue Code":"250","Standard Price":58.3930409090909,"Note":"**"},{"Itemcode":"74104183","Description":"Dronabinol 2.5Mg Oral Cap","CDM Revenue Code":"636","CDM HCPCS":"Q0167","Standard Price":59.1061225296443,"Note":"**"},{"Itemcode":"74104186","Description":"Marinol/5Mg/1Cap","CDM Revenue Code":"637","Standard Price":29.25},{"Itemcode":"74104204","Description":"Maxitrol Ophth Sol 5Ml","CDM Revenue Code":"250","Standard Price":58.916,"Note":"**"},{"Itemcode":"74104207","Description":"Neo Decadron Op Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":57.5434939759036,"Note":"**"},{"Itemcode":"74104210","Description":"Triamterene 75Mg/Hctz 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104213","Description":"Triamterene37.5Mg/Hctz 25Mgtab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104216","Description":"MCT Oil/ Med Chain Tricl","CDM Revenue Code":"259","Standard Price":59.74},{"Itemcode":"74104219","Description":"Ferro Sequels Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104234","Description":"Methylprednisolone 4Mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J7509","Standard Price":6.18,"Note":"**"},{"Itemcode":"74104258","Description":"Mefoxin 1Gm Advant Vial","CDM Revenue Code":"636","CDM HCPCS":"J0694","Standard Price":59.74,"Note":"**"},{"Itemcode":"74104264","Description":"Mefoxin 2Mg Addvant Vial","CDM Revenue Code":"636","CDM HCPCS":"J0694","Standard Price":58.0233333333333,"Note":"**"},{"Itemcode":"74104273","Description":"Megestrol Acetate 40Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":6.18,"Note":"**"},{"Itemcode":"74104279","Description":"Thioridazine 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104282","Description":"Thioridazine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104318","Description":"Meprobamate 400Mg Tab","CDM Revenue Code":"637","Standard Price":5.25},{"Itemcode":"74104336","Description":"Pyridostigmine Br Sr 180Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104339","Description":"Pyridostigmine Br 10Mg/2Ml Inj","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74104348","Description":"Metamucil Pkts","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104360","Description":"Methylergonovine 0.2Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2210","Standard Price":59.0958513931889,"Note":"**"},{"Itemcode":"74104363","Description":"Methylergonovine 0.2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104369","Description":"Methocarbamol 750Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104372","Description":"Methotrexate 2.5Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8610","Standard Price":6.18,"Note":"**"},{"Itemcode":"74104387","Description":"Methotrexate 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9260","Standard Price":10.3,"Note":"**"},{"Itemcode":"74104399","Description":"Methylene Blue INJ 1%% 10Ml","CDM Revenue Code":"636","CDM HCPCS":"Q9968","Standard Price":813.063116666667,"Note":"**"},{"Itemcode":"74104420","Description":"Cardene 25 Mg/10Ml Amp","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74104426","Description":"Metronidazole 500Mg Iv","CDM Revenue Code":"250","Standard Price":58.9474130083206,"Note":"**"},{"Itemcode":"74104435","Description":"Lovastatin 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104438","Description":"Mexitiletine Hcl 150Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104441","Description":"Mexitil/200Mg/1Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104471","Description":"Amiloride 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104477","Description":"Milk Of Magnesia 30Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104483","Description":"Mineral Oil 30Cc","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104486","Description":"Prazosin 5Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104489","Description":"Prazosin 2Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104492","Description":"Prazosin 1Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104504","Description":"Minocycline 100Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104513","Description":"Miochol 1%/2Ml Opth Inj","CDM Revenue Code":"250","Standard Price":196.73,"Note":"**"},{"Itemcode":"74104519","Description":"Ca Polycarbophil 625 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104543","Description":"Amiloride+Hctz 5/50 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104552","Description":"Miconazole Nitrate-3 Vag Supp","CDM Revenue Code":"637","Standard Price":45.0,"Note":"**"},{"Itemcode":"74104555","Description":"Miconazole Nitrate-7 Vag Supp","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74104558","Description":"Miconazole Nitrate 2% Cr 45Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104567","Description":"Morphine Inj 10Mg/Ml","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":58.8268041237114,"Note":"**"},{"Itemcode":"74104573","Description":"Morphine 8Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":58.71,"Note":"**"},{"Itemcode":"74104576","Description":"Morphine 2Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":58.8565328329988,"Note":"**"},{"Itemcode":"74104579","Description":"Morphine 4Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":58.6100922616794,"Note":"**"},{"Itemcode":"74104585","Description":"Morphine 1Mg/Ml 30Ml Pca Inj","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":58.7252752262444,"Note":"**"},{"Itemcode":"74104591","Description":"Ibuprofen 400Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104594","Description":"Ibuprofen 600Mg Tablet","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74104597","Description":"Ibuprofen 800Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104603","Description":"Morphine Sr 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104606","Description":"Acetylcysteine 10% 4Ml","CDM Revenue Code":"637","Standard Price":24.0,"Note":"**"},{"Itemcode":"74104609","Description":"Acetylcysteine 20% 4Ml","CDM Revenue Code":"637","Standard Price":36.0,"Note":"**"},{"Itemcode":"74104612","Description":"Acetylcysteine 20% 30Ml","CDM Revenue Code":"637","Standard Price":62.25,"Note":"**"},{"Itemcode":"74104615","Description":"Vitamin Multi Liq 5Ml Ud","CDM Revenue Code":"637","Standard Price":6.0},{"Itemcode":"74104618","Description":"Muri-Lube Mineral Oil/2Ml","CDM Revenue Code":"637","Standard Price":33.0},{"Itemcode":"74104627","Description":"Mutamycin/20Mg/Vial","CDM Revenue Code":"636","CDM HCPCS":"J9280","Standard Price":2201.11,"Note":"**"},{"Itemcode":"74104630","Description":"Myambutol/100Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104633","Description":"Myambutol 400Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104636","Description":"Clotrimazole 10Mg Troche","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74104648","Description":"Nystatin 15Gm Cream","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74104660","Description":"Nystatin 15Gm Oint","CDM Revenue Code":"637","Standard Price":15.56,"Note":"**"},{"Itemcode":"74104663","Description":"Mycostatin Oral/ 1 Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104666","Description":"Nystatin Topical Powder 15Gm","CDM Revenue Code":"637","Standard Price":65.13,"Note":"**"},{"Itemcode":"74104690","Description":"Simethicone Drops 40Mg/0.6Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104693","Description":"Simethicone 80Mg Tab Chew","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104702","Description":"Primidone 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104705","Description":"Primidone 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104714","Description":"Imipenem-Cilastati500Mg Advvia","CDM Revenue Code":"636","CDM HCPCS":"J0743","Standard Price":78.1058088235294,"Note":"**"},{"Itemcode":"74104723","Description":"Nafcillin 2Gm Adv","CDM Revenue Code":"250","Standard Price":58.9687684729064,"Note":"**"},{"Itemcode":"74104726","Description":"Naphazoline 0.1% Op Sol 15Ml","CDM Revenue Code":"637","Standard Price":8.25},{"Itemcode":"74104729","Description":"Naprosyn 375Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104732","Description":"Naprosyn 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104735","Description":"Naprosyn 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104744","Description":"Naloxone 0.4Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2310","Standard Price":60.3134594594595,"Note":"**"},{"Itemcode":"74104750","Description":"Naloxone 1Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2310","Standard Price":153.28048,"Note":"**"},{"Itemcode":"74104759","Description":"Nasalcrom Nas Spy 13Ml","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74104768","Description":"Oxycodone 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104774","Description":"Carteolol Hcl 1% Opth Soln 5Ml","CDM Revenue Code":"637","Standard Price":59.25},{"Itemcode":"74104777","Description":"Thiothixene 5Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104783","Description":"Thiothixene 1Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104795","Description":"Tobramycin 80Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3260","Standard Price":58.8956349809886,"Note":"**"},{"Itemcode":"74104813","Description":"Neo Calglucon Syr 60Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104822","Description":"Phenylephrine 1/4% 15Ml Spray","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74104831","Description":"Phenylephrine 1/2% 15 Ml Spray","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74104837","Description":"Phenylephrine 10% 5Ml Op Bot","CDM Revenue Code":"250","Standard Price":58.6264864864865,"Note":"**"},{"Itemcode":"74104840","Description":"Oxymetazoline Nas Spray 15Ml","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74104852","Description":"Neomycin Sulfate 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104864","Description":"Neomycin-Bac-Poly Op Sol 10Ml","CDM Revenue Code":"250","Standard Price":58.195,"Note":"**"},{"Itemcode":"74104873","Description":"Neomycin-Bac-Polymyx Oint Pkt","CDM Revenue Code":"250","Standard Price":31.9290902208202,"Note":"**"},{"Itemcode":"74104876","Description":"Neomycin/Polymyxin B 40Mg Gu","CDM Revenue Code":"250","Standard Price":58.0797014925373,"Note":"**"},{"Itemcode":"74104879","Description":"Methazolamide 50Mg Tab","CDM Revenue Code":"637","Standard Price":18.75},{"Itemcode":"74104882","Description":"Methazolamide 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104888","Description":"Chloroprocaine 2%% Mpf 20Ml In","CDM Revenue Code":"636","CDM HCPCS":"J2400","Standard Price":107.738,"Note":"**"},{"Itemcode":"74104891","Description":"Chloroprocaine 3%% 20Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2400","Standard Price":110.21,"Note":"**"},{"Itemcode":"74104894","Description":"Ciprofloxacin 0.3% Op Sol 5Ml","CDM Revenue Code":"250","Standard Price":59.225,"Note":"**"},{"Itemcode":"74104897","Description":"K + Na Phosphates 1.25Gm Pkt","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104909","Description":"Niacin 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104918","Description":"Mineral Oil Lt Steri 10Ml","CDM Revenue Code":"250","Standard Price":58.8541245421245,"Note":"**"},{"Itemcode":"74104927","Description":"Niacin 500Mg Sr Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104930","Description":"Niacin 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104933","Description":"Nicotine Polacrilex 2Mg Gum","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104945","Description":"Nitroglycerin Patch 0.3Mg/Hr","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74104951","Description":"Nitroglycerin 0.6Mg Patch","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74104966","Description":"Nitroglycerin Cap Sr 2.5Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74104972","Description":"Nitrogly 50Mg Vial + Set","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74104981","Description":"Nitrolingual Spray 13.8Gm","CDM Revenue Code":"250","Standard Price":161.268571428572,"Note":"**"},{"Itemcode":"74104987","Description":"Nitroprusside 50Mg Inj","CDM Revenue Code":"250","Standard Price":58.1647058823529,"Note":"**"},{"Itemcode":"74104990","Description":"Ipratropium 0.02% Inh Soln 2.5","CDM Revenue Code":"250","Standard Price":58.6128509561305,"Note":"**"},{"Itemcode":"74105002","Description":"Ketoconazole 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105005","Description":"Ketoconazole 2% Cr 15Gm","CDM Revenue Code":"637","Standard Price":55.5,"Note":"**"},{"Itemcode":"74105006","Description":"Ofloxacin 0.3% Opth Sol 5Ml","CDM Revenue Code":"250","Standard Price":57.0212018786127,"Note":"**"},{"Itemcode":"74105007","Description":"Thyroid 60Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105008","Description":"Chloral Hydrate Cap 500Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105009","Description":"Benazepril Hcl 20Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105010","Description":"Nacl 0.9% Aluer 10Ml Vial","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74105013","Description":"Morphine 2Mg/Ml Soln Chg","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74105015","Description":"Flecainide 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105019","Description":"Ketoprofen 200Mg Cap","CDM Revenue Code":"637","Standard Price":8.25},{"Itemcode":"74105020","Description":"Tamoxifen 10Mg Tab","CDM Revenue Code":"250","CDM HCPCS":"J9999","Standard Price":57.7072810810811,"Note":"**"},{"Itemcode":"74105021","Description":"Morphine Pf 500Mg/20Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2274","Standard Price":1263.81,"Note":"**"},{"Itemcode":"74105022","Description":"Bss Soln 15Ml","CDM Revenue Code":"250","Standard Price":58.7023158730159,"Note":"**"},{"Itemcode":"74105023","Description":"Vecuronium Bromide 10Mg Inj","CDM Revenue Code":"250","Standard Price":58.7954727448454,"Note":"**"},{"Itemcode":"74105025","Description":"Lidocaine 0.5% With Epi 50Ml","CDM Revenue Code":"250","Standard Price":59.1061538461539,"Note":"**"},{"Itemcode":"74105026","Description":"Orphenadrine Cit 30Mg/Ml2Mlinj","CDM Revenue Code":"636","CDM HCPCS":"J2360","Standard Price":59.74},{"Itemcode":"74105029","Description":"Orphenadrine Citrate 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105041","Description":"Nacl 0.9% 100Ml Adv","CDM Revenue Code":"258","Standard Price":59.74,"Note":"**"},{"Itemcode":"74105044","Description":"Labetalol 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105047","Description":"Labetalol 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105050","Description":"Labetalol 20mg/4ml Syringe","CDM Revenue Code":"250","Standard Price":58.8610475318472,"Note":"**"},{"Itemcode":"74105059","Description":"Disopyramid P04 Cap 150Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105062","Description":"Disopyramide Po4 Cr 100Mg Cap","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74105065","Description":"Disopyramide Po4 Cr 150Mg Cap","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74105068","Description":"Desipramine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105071","Description":"Desipramine 25Mg 1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105095","Description":"Novolin-N 10Ml INJ","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":40.5,"Note":"**"},{"Itemcode":"74105098","Description":"Novolin-R 100U 10Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":40.5,"Note":"**"},{"Itemcode":"74105101","Description":"Novolin 70/30 100U/Ml 10Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":40.5,"Note":"**"},{"Itemcode":"74105104","Description":"Nalbuphine 10Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2300","Standard Price":58.7827642265795,"Note":"**"},{"Itemcode":"74105122","Description":"Nystatin Oral Susp 60Ml","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74105125","Description":"Nystatin-Triamcinolone Cr 15Gm","CDM Revenue Code":"637","Standard Price":49.5,"Note":"**"},{"Itemcode":"74105128","Description":"Nystatin-Triamcinolone Oint 15","CDM Revenue Code":"637","Standard Price":24.75,"Note":"**"},{"Itemcode":"74105131","Description":"Nacl 0.65% Nas Spray 45Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105152","Description":"Ampicillin 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0290","Standard Price":59.3748362235067,"Note":"**"},{"Itemcode":"74105164","Description":"Ampicillin 250Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0290","Standard Price":59.2136277602524,"Note":"**"},{"Itemcode":"74105167","Description":"Nitroglycerin 0.3Mg Pp100","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105170","Description":"Vincristine 1 Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9370","Standard Price":58.9016279069767,"Note":"**"},{"Itemcode":"74105194","Description":"Orabase With Benzocaine 5Gm","CDM Revenue Code":"637","Standard Price":18.75},{"Itemcode":"74105203","Description":"Hydrochlorothiazide 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105239","Description":"OS Cal Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105248","Description":"Cal Oyster Shell 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74105254","Description":"Omnipaque 300 10Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":170.98},{"Itemcode":"74105266","Description":"Pancrease Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105278","Description":"Papaverine HCL Inj 2Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2440","Standard Price":58.8991836734694,"Note":"**"},{"Itemcode":"74105287","Description":"Chlorzoxazone 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105290","Description":"Paregoric/5Ml/Liqu","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105299","Description":"Bromocriptine Mesyl 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74105317","Description":"Pancuronium Br 2Mg/Ml 5Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105353","Description":"Pentamidine 300Mg Inj","CDM Revenue Code":"250","Standard Price":200.85},{"Itemcode":"74105362","Description":"Thiopental 500Mg Syr","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105368","Description":"Famotidine 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105374","Description":"Famotidine 20Mg/2Ml Inj","CDM Revenue Code":"250","Standard Price":58.7452607934192,"Note":"**"},{"Itemcode":"74105380","Description":"Bismuth Subsalicylate 120Ml","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74105382","Description":"Platinol Aq 50mg/50Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9060","Standard Price":92.5019230769231,"Note":"**"},{"Itemcode":"74105383","Description":"Percocet-5 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105398","Description":"Peridex Oral Rinse 473Ml","CDM Revenue Code":"637","Standard Price":12.0},{"Itemcode":"74105407","Description":"Cimetidine 300Mg Iv","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105413","Description":"Dipyridamole 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105416","Description":"Dipyridamole 75Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105419","Description":"Dipyridamole 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105428","Description":"Penicillin G Potassl2.5Mu Inj","CDM Revenue Code":"636","CDM HCPCS":"J2540","Standard Price":233.541304347826,"Note":"**"},{"Itemcode":"74105431","Description":"Penicillin G Potassium 1Mu Inj","CDM Revenue Code":"250","Standard Price":58.222706600111,"Note":"**"},{"Itemcode":"74105434","Description":"Phenazopyridine 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105437","Description":"Phenazopyridine 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105446","Description":"Promethazine 12.5Mg Supp","CDM Revenue Code":"637","Standard Price":29.25,"Note":"**"},{"Itemcode":"74105449","Description":"Phenergan/50Mg/1Ea/Supp","CDM Revenue Code":"637","Standard Price":80.25},{"Itemcode":"74105452","Description":"Promethazine 25Mg Supp","CDM Revenue Code":"637","Standard Price":29.25,"Note":"**"},{"Itemcode":"74105461","Description":"Promethazine 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74105470","Description":"Promethazine 6.25Mg/5Ml 30Ml","CDM Revenue Code":"636","CDM HCPCS":"Q0169","Standard Price":6.18,"Note":"**"},{"Itemcode":"74105488","Description":"Phenobarbital Tab 15Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105491","Description":"Phenobarbital Tab 30 Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105494","Description":"Phenobarbital/65Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105497","Description":"Phenobarbital 130Mg Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105509","Description":"Phisohex 150Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105533","Description":"Pilocarpine 2% Op Sol 2Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105551","Description":"Diltiazem Sr 60Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105554","Description":"Oxytocin 10Units/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2590","Standard Price":59.0439703624734,"Note":"**"},{"Itemcode":"74105563","Description":"Vasopressin 20 Units/Ml 1Ml In","CDM Revenue Code":"250","Standard Price":639.44487148301,"Note":"**"},{"Itemcode":"74105572","Description":"Hydroxychloroquine 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105581","Description":"Pneumococcal Vaccine Polyvalen","CDM Revenue Code":"636","CDM HCPCS":"90732","Standard Price":365.729230769231,"Note":"**"},{"Itemcode":"74105587","Description":"Poly Vi Sol C Iron 50Ml","CDM Revenue Code":"637","Standard Price":24.0,"Note":"**"},{"Itemcode":"74105596","Description":"Amoxicillin Susp 250Mg/5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105599","Description":"Ondansetron Hcl 4Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2405","Standard Price":58.5001978872784,"Note":"**"},{"Itemcode":"74105614","Description":"Pontocaine 0.5%/15Mg/Soln","CDM Revenue Code":"250","Standard Price":59.071891891892,"Note":"**"},{"Itemcode":"74105626","Description":"Calcium Phos 600Mg+Vit D Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105629","Description":"Potassium Acetate 40Meq Inj.","CDM Revenue Code":"250","Standard Price":59.240606060606,"Note":"**"},{"Itemcode":"74105632","Description":"Potassium Chloride 20Meq Inj","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":59.2207296849088,"Note":"**"},{"Itemcode":"74105635","Description":"Potassium Chloride 40Meq Inj","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":58.8208154020385,"Note":"**"},{"Itemcode":"74105644","Description":"Potassium Chl.20Meq/15Ml Liq","CDM Revenue Code":"637","Standard Price":13.49,"Note":"**"},{"Itemcode":"74105647","Description":"Potassium Po4 45Mm/15Ml Vial","CDM Revenue Code":"250","Standard Price":59.2646153846154,"Note":"**"},{"Itemcode":"74105653","Description":"Prednisolone Acetate 1% 5Ml","CDM Revenue Code":"250","Standard Price":59.09625,"Note":"**"},{"Itemcode":"74105662","Description":"Prednisone 1Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":6.18,"Note":"**"},{"Itemcode":"74105666","Description":"Prednisone 10Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":6.17761300047104,"Note":"**"},{"Itemcode":"74105668","Description":"Prednisone IR/DR 5Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":6.18,"Note":"**"},{"Itemcode":"74105671","Description":"Prednisone IR/DR 20Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":6.16359980457523,"Note":"**"},{"Itemcode":"74105677","Description":"Estrogen Conjug 5Mg/Ml 5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1410","Standard Price":1215.915,"Note":"**"},{"Itemcode":"74105683","Description":"Estrogen Conjugated 0.625Mgtab","CDM Revenue Code":"637","Standard Price":15.75,"Note":"**"},{"Itemcode":"74105686","Description":"Estrogen Conjugated 0.3Mgtab","CDM Revenue Code":"637","Standard Price":15.75,"Note":"**"},{"Itemcode":"74105689","Description":"Estrogen Conjug Vag Cr 42.5Gm","CDM Revenue Code":"250","Standard Price":1638.75893088235,"Note":"**"},{"Itemcode":"74105695","Description":"Primatene Inh. Areo. 15Ml","CDM Revenue Code":"637","Standard Price":56.25},{"Itemcode":"74105698","Description":"Imipenem-Cilastatin 250Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0743","Standard Price":59.74,"Note":"**"},{"Itemcode":"74105713","Description":"Lisinopril 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105716","Description":"Lisinopril 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74105719","Description":"Propantheline 15Mg 1Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105725","Description":"Procalamine With Elect. 1000Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74105737","Description":"Nifedipine 10Mg Cap","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74105743","Description":"Proctofoam 1% 15Gm Foam","CDM Revenue Code":"637","Standard Price":112.5,"Note":"**"},{"Itemcode":"74105746","Description":"Proctofoam Hc 10Gm Foam","CDM Revenue Code":"637","Standard Price":171.0},{"Itemcode":"74105749","Description":"Progesterone 10Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2675","Standard Price":59.74},{"Itemcode":"74105752","Description":"Fluphenazine 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105785","Description":"Promethazine 25Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2550","Standard Price":58.0102273754652,"Note":"**"},{"Itemcode":"74105791","Description":"Promethazine+Codeine 120Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105800","Description":"Procainamide 1Gm/10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2690","Standard Price":334.75},{"Itemcode":"74105809","Description":"Chlorpromazine 50Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3230","Standard Price":59.418125,"Note":"**"},{"Itemcode":"74105812","Description":"Hydromorphone 2Mg/Ml 1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":49.9384755721832,"Note":"**"},{"Itemcode":"74105818","Description":"Propylthiourrail Tab 50Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105824","Description":"Oxacillin 1Gm Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105830","Description":"Protamine Sul 50Mg/5Ml","CDM Revenue Code":"636","CDM HCPCS":"J2720","Standard Price":59.0462542955327,"Note":"**"},{"Itemcode":"74105833","Description":"Protamine 250Mg/25Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2720","Standard Price":58.7935135135135,"Note":"**"},{"Itemcode":"74105836","Description":"Protopam Chl. 1Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J2730","Standard Price":367.71},{"Itemcode":"74105839","Description":"Albuterol 0.5% Inh Soln 20Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74105848","Description":"Albuterol 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105851","Description":"Albuterol 4Mg Tab","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74105854","Description":"Albuterol 4Mg Repetab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105860","Description":"Medroxyprogerstone 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105866","Description":"Fluoxetine 20Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105869","Description":"Pseudoephedrine 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105878","Description":"Pyrazinamide 500Mg Tab","CDM Revenue Code":"637","Standard Price":15.75,"Note":"**"},{"Itemcode":"74105884","Description":"Pyridoxine 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105896","Description":"Quinidine Gluconate 324Mg Tab","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74105902","Description":"Quinidine Sul Tab 200Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105905","Description":"Quinidine 300Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74105920","Description":"Retrovir Syrup 60 Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105938","Description":"Phentolamine 5Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2760","Standard Price":148.32,"Note":"**"},{"Itemcode":"74105944","Description":"Metoclopropamide Syr 10Mg/10Ml","CDM Revenue Code":"636","CDM HCPCS":"J8597","Standard Price":6.18,"Note":"**"},{"Itemcode":"74105947","Description":"Metoclopramide 10Mg 1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105956","Description":"Metocloprpamide 10Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2765","Standard Price":58.6722424800193,"Note":"**"},{"Itemcode":"74105980","Description":"Temazepam 15Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105983","Description":"Zidovudine 100Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105989","Description":"Rifampin 300Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74105998","Description":"Zinecard 500Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J1190","Standard Price":1108.28},{"Itemcode":"74106002","Description":"Loratadine 1Mg/Ml Syrup 60Ml","CDM Revenue Code":"637","Standard Price":5.05,"Note":"**"},{"Itemcode":"74106010","Description":"Methylphenidate 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106013","Description":"Miconazole Nitrate 2% 3O Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106016","Description":"Methocarbanol 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106022","Description":"Methocarbamol 100Mg/Ml Inj 10M","CDM Revenue Code":"636","CDM HCPCS":"J2800","Standard Price":275.557797368421,"Note":"**"},{"Itemcode":"74106034","Description":"Glycopyrrolate 0.2Mg/Ml 1Mlinj","CDM Revenue Code":"250","Standard Price":58.6733743742256,"Note":"**"},{"Itemcode":"74106040","Description":"Guaifenesin 100Mg/5Ml 10Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106051","Description":"Robitussin-Dm 5Ml/Syrp","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106061","Description":"Calcitriol 0.25Mcg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106067","Description":"Ceftriaxone 250Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":58.1847470626632,"Note":"**"},{"Itemcode":"74106091","Description":"Mesalamine 4Gm/60Ml Enema","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74106094","Description":"Azatadine-Pseudoephedrine Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106136","Description":"Acebutolol Hcl 200Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106139","Description":"Tobramycin 1.2Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J3260","Standard Price":700.797401574804,"Note":"**"},{"Itemcode":"74106148","Description":"Selenium 40Mcg/Ml 1Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74106157","Description":"Senna Concentrate 187Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106160","Description":"Senna Conc 187Mg/Docusatena5Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106166","Description":"Co-Trimoxazole Liquid 20Ml Ud","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74106169","Description":"Co-Trimoxazole Ds Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106232","Description":"Carbidopa 10Mg+Levo 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106235","Description":"Carbidopa 25Mg+Levo 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106238","Description":"Carbidopa 25Mg+Levo 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106241","Description":"Doxepin 10Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106244","Description":"Doxepin 25Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106247","Description":"Doxepin 50Mg/1Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106271","Description":"Theophylline 80Mg/15mlOral syr","CDM Revenue Code":"637","Standard Price":30.0,"Note":"**"},{"Itemcode":"74106274","Description":"Ferrous Sulfate Sr Tab 160Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106277","Description":"Sodium Acetate 40Meq/20Ml","CDM Revenue Code":"250","Standard Price":58.2171770334929,"Note":"**"},{"Itemcode":"74106280","Description":"Sodium Bicarb 650Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106286","Description":"Sodium Bicarb 5Meq Infant Syr","CDM Revenue Code":"250","Standard Price":58.5726666666667,"Note":"**"},{"Itemcode":"74106295","Description":"Sodium Bicarb 10Meq Ped Syr","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74106301","Description":"Nacl 1Gm Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106308","Description":"NS 5% 500Ml+Adapter","CDM Revenue Code":"250","Standard Price":64.89},{"Itemcode":"74106310","Description":"Nacl Conc 4Meq Per Ml Chg","CDM Revenue Code":"250","Standard Price":59.3327906976744,"Note":"**"},{"Itemcode":"74106313","Description":"Nacl 0.45% 500Ml","CDM Revenue Code":"258","Standard Price":59.0968361153263,"Note":"**"},{"Itemcode":"74106316","Description":"Nacl 0.45% 1000Ml","CDM Revenue Code":"258","Standard Price":58.9773307726664,"Note":"**"},{"Itemcode":"74106325","Description":"Nacl 0.9% 100Ml Bag Inj","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74106328","Description":"Nacl 0.9% 150Ml","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74106331","Description":"Nacl 0.9% 250Ml","CDM Revenue Code":"636","CDM HCPCS":"J7050","Standard Price":0.0},{"Itemcode":"74106334","Description":"Nacl 0.9%% 500Ml Bag","CDM Revenue Code":"258","CDM HCPCS":"J7040","Standard Price":58.2857068317013,"Note":"**"},{"Itemcode":"74106337","Description":"Nacl 250Ml For For Irrigation","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74106340","Description":"Nacl 1000Ml For Irrigation","CDM Revenue Code":"250","Standard Price":59.134691943128,"Note":"**"},{"Itemcode":"74106343","Description":"Nacl 3000Ml Irrigation Bag","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74106346","Description":"Nacl 3%% 500Ml","CDM Revenue Code":"258","CDM HCPCS":"J7131","Standard Price":58.3506976744186,"Note":"**"},{"Itemcode":"74106349","Description":"Chlorothiazide 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1205","Standard Price":1247.06419354839,"Note":"**"},{"Itemcode":"74106358","Description":"Na Phosphates 60 Meq/15 Ml Inj","CDM Revenue Code":"250","Standard Price":59.2327758420441,"Note":"**"},{"Itemcode":"74106361","Description":"SOD . Polystyren Sul 15Gm/60Ml","CDM Revenue Code":"637","Standard Price":26.98,"Note":"**"},{"Itemcode":"74106391","Description":"Carisoprodol 350Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106397","Description":"Sorbitol 70% 60Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106398","Description":"Sorbitol 70% 30 Ml Bot","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106425","Description":"Spectazole Cream 15Mg","CDM Revenue Code":"637","Standard Price":234.0},{"Itemcode":"74106433","Description":"SSKI/30Ml/Soln","CDM Revenue Code":"637","Standard Price":31.5},{"Itemcode":"74106436","Description":"Butorphanol 1Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0595","Standard Price":59.74},{"Itemcode":"74106439","Description":"Butorphanol 2Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0595","Standard Price":59.74},{"Itemcode":"74106448","Description":"Trifluoperazine 5Mg/1 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106451","Description":"Trifluoperazine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106454","Description":"Trifluoperazine 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106457","Description":"Sterile Water 10Ml Vial","CDM Revenue Code":"250","CDM HCPCS":"A4216","Standard Price":0.0},{"Itemcode":"74106481","Description":"Streptomycin Sulf.1Gm/Via","CDM Revenue Code":"636","CDM HCPCS":"J3000","Standard Price":77.25},{"Itemcode":"74106484","Description":"Stuartnatal 1 + 1 Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106487","Description":"Sufenta/100Mcg/2Ml/Amp","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74106490","Description":"Sufenta/50Mcg/5Ml/Amp","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74106505","Description":"Tetracyline 250Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106529","Description":"Amantadine 100Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106532","Description":"Symmetrel Syrup 100Mg/10Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106559","Description":"Levothyroxin Sod 0.075Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106562","Description":"Levothyroxine Sod 0.05Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106565","Description":"Levothyroxine Sod 0.1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106574","Description":"Levothyroxine 0.15Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106577","Description":"Levothyroxine Sod 0.025Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106580","Description":"Levothyroxine Sod 200Mcg Inj","CDM Revenue Code":"250","Standard Price":892.666666666667,"Note":"**"},{"Itemcode":"74106607","Description":"Tagamet 400Mg/1Tab","CDM Revenue Code":"637"},{"Itemcode":"74106610","Description":"Cimetidine 300Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106631","Description":"Flecainide 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106637","Description":"Methimazole 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106646","Description":"Clemastine Fumarate 2.68Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106655","Description":"Ceftazidime 2 Gram Vial","CDM Revenue Code":"636","CDM HCPCS":"J0713","Standard Price":107.369851485149,"Note":"**"},{"Itemcode":"74106658","Description":"Ceftazidime 1 Gram Vial","CDM Revenue Code":"636","CDM HCPCS":"J0713","Standard Price":59.0894736842106,"Note":"**"},{"Itemcode":"74106664","Description":"Artifical Tears Op Sol 15Ml","CDM Revenue Code":"637","Standard Price":77.25,"Note":"**"},{"Itemcode":"74106670","Description":"Carbamazepine 200Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106673","Description":"Carbamazepine 100Mg Chewable","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106682","Description":"Guafacine 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106691","Description":"Atenolol 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106694","Description":"Atenolol 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106700","Description":"Terconazole 80Mg Vag Sup 3'S","CDM Revenue Code":"637","Standard Price":81.75},{"Itemcode":"74106718","Description":"Benzonatate 100Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106724","Description":"Tetanus-Diptheria Tox 0.5Ml","CDM Revenue Code":"636","CDM HCPCS":"90714","Standard Price":128.063333333333,"Note":"**"},{"Itemcode":"74106730","Description":"Tetracycline Susp 125Mg/5Ml 60","CDM Revenue Code":"637","Standard Price":53.25},{"Itemcode":"74106739","Description":"Theophylline Sa 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74106742","Description":"Theophylline Sa 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106745","Description":"Theophylline Sa 300Mg Tab","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74106766","Description":"Theo-24 200Mg Cap","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74106769","Description":"Theo-24 300Mg Cap","CDM Revenue Code":"637","Standard Price":9.75},{"Itemcode":"74106781","Description":"Vitamin Multi+Mineral Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106787","Description":"Thiamine 100Mg/Ml 2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3411","Standard Price":59.1638046642541,"Note":"**"},{"Itemcode":"74106790","Description":"Thiamine 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106796","Description":"Thiamine 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106820","Description":"Chlorpromazine 25Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3230","Standard Price":103.272647058824,"Note":"**"},{"Itemcode":"74106868","Description":"Trimethobenzamide 200Mg/2Ml In","CDM Revenue Code":"636","CDM HCPCS":"J3250","Standard Price":59.74},{"Itemcode":"74106880","Description":"Timentin 3.1Gm Addvantage","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74106889","Description":"Timolol Opth Soln 0.5% 2.5Ml","CDM Revenue Code":"250","Standard Price":58.9909090909091,"Note":"**"},{"Itemcode":"74106892","Description":"Benaoin Tincture 120Ml Top","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74106898","Description":"Tolnaftate 1% 15Gm Cream","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74106913","Description":"Tobrex 0.3% Ophth Sol 5Ml","CDM Revenue Code":"250","Standard Price":58.8917647058824,"Note":"**"},{"Itemcode":"74106919","Description":"Imipramine Hcl 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106922","Description":"Imipramine 10Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74106961","Description":"Topicort 15Gm Top Cream","CDM Revenue Code":"637","Standard Price":77.25},{"Itemcode":"74106976","Description":"Trace Metals Inj 5Ml","CDM Revenue Code":"250","Standard Price":58.9581518151815,"Note":"**"},{"Itemcode":"74106994","Description":"Transderm-Scop 1Patch","CDM Revenue Code":"250","Standard Price":84.7971031746032,"Note":"**"},{"Itemcode":"74106997","Description":"Clorazepate Dipotass 3.75Mg Ta","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107015","Description":"Trazodone Hcl/100Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107018","Description":"Pentoxifylline 400Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107045","Description":"Amitrip/Perphenazine 2-10 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107048","Description":"Amitrip/Perphenazine 2-25 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107054","Description":"Amitrip/Perphenazine 4-25 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107058","Description":"Paroxetine 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107060","Description":"Tridesilon 15Gm/Top Cream","CDM Revenue Code":"637","Standard Price":63.0},{"Itemcode":"74107069","Description":"D5W 250Ml Adv","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74107072","Description":"Propofol Inj 10Mg/Ml 20Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2704","Standard Price":58.5296534898314,"Note":"**"},{"Itemcode":"74107075","Description":"Erythromycin 500 MG Adv","CDM Revenue Code":"636","CDM HCPCS":"J1364","Standard Price":148.32,"Note":"**"},{"Itemcode":"74107087","Description":"Choline Mg Salicylate 750Mgtab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107108","Description":"Tuberculin Ppd 5 Unit Int Str","CDM Revenue Code":"250","Standard Price":58.9713432835821,"Note":"**"},{"Itemcode":"74107118","Description":"Levothyroxine Sod 0.125Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107120","Description":"Tums 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107153","Description":"Acetaminophen100Mg/Ml 15Mlsoln","CDM Revenue Code":"637","Standard Price":14.25},{"Itemcode":"74107159","Description":"Dibucaine Ointmetn 28 Gm","CDM Revenue Code":"637","Standard Price":14.25},{"Itemcode":"74107162","Description":"Acetaminophen/Codeine Elix 5Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107171","Description":"Acetaminophen/Codeine 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74107177","Description":"Oxycodone 5Mg/Apap 325Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107180","Description":"Tympagesic Otic Sol 15Ml","CDM Revenue Code":"637","Standard Price":39.75},{"Itemcode":"74107207","Description":"Flavoxate Hcl 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107225","Description":"Betamethasone .1% 45Gm Cr","CDM Revenue Code":"637","Standard Price":109.5,"Note":"**"},{"Itemcode":"74107243","Description":"Betamethasone .1% Ung 15G","CDM Revenue Code":"250","Standard Price":58.9909090909091,"Note":"**"},{"Itemcode":"74107246","Description":"Betamethasone .1% 45Gm Oint","CDM Revenue Code":"637","Standard Price":76.5,"Note":"**"},{"Itemcode":"74107249","Description":"Diazepam 10Mg Inj Syr","CDM Revenue Code":"636","CDM HCPCS":"J3360","Standard Price":58.4179458089669,"Note":"**"},{"Itemcode":"74107255","Description":"Diazepam 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74107273","Description":"Beclomethasone 40Mcg Oral Inh","CDM Revenue Code":"637","Standard Price":232.5},{"Itemcode":"74107276","Description":"Vancomycin 250Mg Cap","CDM Revenue Code":"637","Standard Price":160.5},{"Itemcode":"74107282","Description":"Vancomycin 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":58.9710012360939,"Note":"**"},{"Itemcode":"74107324","Description":"Enalapril 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107327","Description":"Enalapril 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107333","Description":"Enalaprilat 1.25Gm/Ml 2Ml Iv","CDM Revenue Code":"250","Standard Price":58.7954146341464,"Note":"**"},{"Itemcode":"74107342","Description":"Penicillin Vk 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74107348","Description":"Velban 10Mg/Vial","CDM Revenue Code":"636","CDM HCPCS":"J9360","Standard Price":13.39,"Note":"**"},{"Itemcode":"74107372","Description":"Etoposide 50Mg","CDM Revenue Code":"636","CDM HCPCS":"J8560","Standard Price":319.3},{"Itemcode":"74107373","Description":"Etoposide (Vp-16) 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9181","Standard Price":21.1367605633803,"Note":"**"},{"Itemcode":"74107375","Description":"Verapamil 5Mg/2Ml Inj","CDM Revenue Code":"250","Standard Price":59.1850850661625,"Note":"**"},{"Itemcode":"74107378","Description":"Verapamil 2.5Mg/Ml 4Ml Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74107390","Description":"Midazolam 10Mg/2Ml Inj","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74107393","Description":"Midazolam 1Mg/Ml 2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2250","Standard Price":58.7326031832552,"Note":"**"},{"Itemcode":"74107396","Description":"Hydrocodone 5Mg/Apap 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107414","Description":"Trifluridine 1% Ophth Sol7.5Ml","CDM Revenue Code":"637","Standard Price":387.75,"Note":"**"},{"Itemcode":"74107417","Description":"Visine 0.05%/15Ml/Drops","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107420","Description":"Pindolol 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107423","Description":"Pindolol 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107432","Description":"Vitamin E 200 Unit Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107435","Description":"Vitamin E 400 Unit Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107438","Description":"Protriptyline 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107441","Description":"Vivactil/10Mg/1Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74107456","Description":"Diclofenac Sodium 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107459","Description":"Diclofenac Sodium 75Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107471","Description":"Leucovorin/5Mg/1 Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107477","Description":"Hydrocortisone Val 0.2% 15Gm C","CDM Revenue Code":"637","Standard Price":145.5},{"Itemcode":"74107513","Description":"Alprazolam 0.25Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107516","Description":"Alprazolam 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107519","Description":"Alprazolam 0.5Mg Tablet","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74107525","Description":"Lidocaine Viscous 2% 20Ml Cup","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107528","Description":"Lidocaine 0.5% 50Ml Sdv","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"74107534","Description":"Lidocaine 1% 2Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.09625,"Note":"**"},{"Itemcode":"74107537","Description":"Lidocaine 1% 30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.7241814680796,"Note":"**"},{"Itemcode":"74107540","Description":"Lidocaine 1% With Epi 30Ml Sdv","CDM Revenue Code":"250","Standard Price":58.8940375123396,"Note":"**"},{"Itemcode":"74107546","Description":"Lidocaine 2% 2Ml Sda","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.1649039881832,"Note":"**"},{"Itemcode":"74107552","Description":"Lidocaine 2% W Epi 20Ml Vial","CDM Revenue Code":"250","Standard Price":58.9386371835443,"Note":"**"},{"Itemcode":"74107555","Description":"Lidocaine 4% 5Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.3966666666667,"Note":"**"},{"Itemcode":"74107558","Description":"Lidocaine 5%+Glucose 2Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74107567","Description":"Zanosar/1Gm/Vial","CDM Revenue Code":"636","CDM HCPCS":"J9320","Standard Price":1482.17},{"Itemcode":"74107582","Description":"Metolazone 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107585","Description":"Metolazone 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107588","Description":"Metolazone 10Mg Tab","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74107606","Description":"Acyclovir 200Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107609","Description":"Acyclovir 500Mg Injection","CDM Revenue Code":"636","CDM HCPCS":"J0133","Standard Price":59.2905067218201,"Note":"**"},{"Itemcode":"74107612","Description":"Acyclovir 5% Oint 15Gm","CDM Revenue Code":"637","Standard Price":957.0,"Note":"**"},{"Itemcode":"74107615","Description":"Carbamazepine Liq 100Mg/5Ml","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74107616","Description":"Camptosar 100Mg/5Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9206","Standard Price":69.01,"Note":"**"},{"Itemcode":"74107621","Description":"Humulin Inj 70/30 Insulin 10Ml","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":40.5},{"Itemcode":"74107626","Description":"Levothyroxine Sod 112Mcg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107630","Description":"Clindamycin 900Mg/6Ml Inj","CDM Revenue Code":"250","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"74107631","Description":"Estratab 0.625Mg Tab","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74107633","Description":"Nephro-Vite Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107634","Description":"Urocit-K/Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107637","Description":"Fluconazole 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74107638","Description":"Fluconazole 200Mg/100Ml Iv","CDM Revenue Code":"636","CDM HCPCS":"J1450","Standard Price":59.0761560693642,"Note":"**"},{"Itemcode":"74107640","Description":"Nifedipine Extended Release 90","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74107641","Description":"Bupropion Hcl 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74107644","Description":"Selegiline Hcl 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108023","Description":"Uniphyl 400Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108347","Description":"Ceftriaxone 1Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":58.736119570383,"Note":"**"},{"Itemcode":"74108348","Description":"Allopurinol 300Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108350","Description":"Alcohol Ethly Injection 5Ml","CDM Revenue Code":"250","Standard Price":156.56},{"Itemcode":"74108353","Description":"Dextran 40/Nacl 0.9% 500Ml","CDM Revenue Code":"636","CDM HCPCS":"J7100","Standard Price":115.36},{"Itemcode":"74108354","Description":"Sterile Water 250Ml","CDM Revenue Code":"258","Standard Price":58.9675,"Note":"**"},{"Itemcode":"74108356","Description":"Torsemide 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108364","Description":"Indapamide 1.25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108365","Description":"Rifampin 600Mg Vial","CDM Revenue Code":"250","Standard Price":749.975308310992,"Note":"**"},{"Itemcode":"74108368","Description":"Ben Gay Ointment","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108369","Description":"Probenecid 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108372","Description":"Temovate .05% Oint 15 Gm","CDM Revenue Code":"637","Standard Price":258.75,"Note":"**"},{"Itemcode":"74108376","Description":"Propofol Inj 10Mg/Ml 100Ml","CDM Revenue Code":"636","CDM HCPCS":"J2704","Standard Price":58.984050201539,"Note":"**"},{"Itemcode":"74108381","Description":"Terbutaline 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74108385","Description":"Metformin Hcl 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108386","Description":"Guaifenesin 600Mg+Dm 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108398","Description":"Insta-Glucose Tube","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74108401","Description":"Phenylephrine 1/4% 30Ml Drop","CDM Revenue Code":"637","Standard Price":12.0},{"Itemcode":"74108405","Description":"Lidocaine 4% Topical 50Ml","CDM Revenue Code":"250","Standard Price":59.328,"Note":"**"},{"Itemcode":"74108415","Description":"Magnesium Oxide 400Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108427","Description":"Disopyramide Po4 Cap 100Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108434","Description":"Guaifenesin Dm Syrip 10Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108437","Description":"Magnesium Cl Tab 64Mg Sr","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108440","Description":"Paraplatin 450Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9045","Standard Price":112.412068965517,"Note":"**"},{"Itemcode":"74108441","Description":"Ursodiol 300Mg Cap","CDM Revenue Code":"637","Standard Price":23.25,"Note":"**"},{"Itemcode":"74108442","Description":"Imipramine Hcl 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108443","Description":"Niacin 250Mg Sr Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108445","Description":"Medroxyprogerstone 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108446","Description":"Nortriptyline 25Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108447","Description":"Donnatal Tab","CDM Revenue Code":"637","Standard Price":28.5,"Note":"**"},{"Itemcode":"74108452","Description":"Dicloxacillin 250Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108464","Description":"Daunorubicin Hcl 20Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9150","Standard Price":500.58},{"Itemcode":"74108468","Description":"Chlorpheniramine 4Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108480","Description":"Colchicine 0.6Mg Tab","CDM Revenue Code":"637","Standard Price":20.2,"Note":"**"},{"Itemcode":"74108490","Description":"Cortisporin Ophth Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74108491","Description":"Cortone Acetate 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108493","Description":"Dantrolene 25Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108504","Description":"Efudex 5% 25Gm Cream","CDM Revenue Code":"250","Standard Price":965.11,"Note":"**"},{"Itemcode":"74108505","Description":"Mometasone Fur Cr 0.1% 15Gm","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74108511","Description":"Fleet Bisacodyl Enema","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74108514","Description":"Glycerin Supp Infant","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108523","Description":"Calcijex 1Mcg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0636","Standard Price":59.5155128205128,"Note":"**"},{"Itemcode":"74108526","Description":"Leucovorin Calcium 350Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0640","Standard Price":106.09,"Note":"**"},{"Itemcode":"74108529","Description":"Non-Formulary Nebulizer Med","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74108540","Description":"Nacl 0.9% 1000Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J7030","Standard Price":58.4919568508245,"Note":"**"},{"Itemcode":"74108544","Description":"Tobra-Dex Ophth Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":891.380565830721,"Note":"**"},{"Itemcode":"74108545","Description":"Tobra-Dex Opth Susp5Ml","CDM Revenue Code":"250","Standard Price":196.264838709677,"Note":"**"},{"Itemcode":"74108546","Description":"Clotrimazole 1% Vag Cr 45Gm","CDM Revenue Code":"637","Standard Price":12.0,"Note":"**"},{"Itemcode":"74108549","Description":"Myoflex Creme 60Gm","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74108551","Description":"Dextran 40/D5W 5Ooml","CDM Revenue Code":"636","CDM HCPCS":"J7100","Standard Price":112.27},{"Itemcode":"74108555","Description":"Primaquine 26.3 Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108557","Description":"Senna-Psyllium 100Gm","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108559","Description":"Diclofenac Potassium 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108562","Description":"Perphenazine 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108565","Description":"Glycerin Sterile Inj 5ml vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74108567","Description":"Octreotide Aceta 0.05Mg/Ml INJ","CDM Revenue Code":"636","CDM HCPCS":"J2354","Standard Price":58.6438532110092,"Note":"**"},{"Itemcode":"74108568","Description":"Zarontin 250Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108575","Description":"EpoetinNon-ESRD4000U/Ml Vl Inj","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":381.705419847328,"Note":"**"},{"Itemcode":"74108576","Description":"Muro-128 5% Ophth Soln 15Ml","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74108585","Description":"Bismuth Subsalicylate 262Mg Ta","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108594","Description":"Fluid Non Pyxis","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74108597","Description":"Carboprost Trometh 250Mcg/Ml 1","CDM Revenue Code":"250","Standard Price":1366.6418367347,"Note":"**"},{"Itemcode":"74108602","Description":"Enalapril 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108609","Description":"Toradol 60Mg Syringe","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74108610","Description":"KetorolacTromethaminInj30Mg/Ml","CDM Revenue Code":"636","CDM HCPCS":"J1885","Standard Price":58.4743634316412,"Note":"**"},{"Itemcode":"74108611","Description":"Colestid Pack","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74108613","Description":"Triamcinolone Acet 40Mg/1Ml In","CDM Revenue Code":"636","CDM HCPCS":"J3301","Standard Price":58.6026079779918,"Note":"**"},{"Itemcode":"74108616","Description":"Dapsone 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108617","Description":"Fluvastatin 20Mg Cap","CDM Revenue Code":"637","Standard Price":12.0},{"Itemcode":"74108618","Description":"Monistat Dual Pack","CDM Revenue Code":"637","Standard Price":37.5},{"Itemcode":"74108632","Description":"Sodium Bicarb 50Cc Syringe","CDM Revenue Code":"250","Standard Price":59.0971654603439,"Note":"**"},{"Itemcode":"74108636","Description":"Adenosine 6Mg/2Ml Syringe Inj","CDM Revenue Code":"636","CDM HCPCS":"J0153","Standard Price":59.0523847847848,"Note":"**"},{"Itemcode":"74108641","Description":"Thyroid 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108644","Description":"Zovirax Susp 60Ml Bottle","CDM Revenue Code":"637","Standard Price":36.75},{"Itemcode":"74108646","Description":"Ziac 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108647","Description":"Trihexyphenidyl 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108652","Description":"Lidocaine 1% 5Ml Sdv","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.9213106864275,"Note":"**"},{"Itemcode":"74108655","Description":"Methacholine Challenge","CDM Revenue Code":"250","Standard Price":224.54},{"Itemcode":"74108658","Description":"Ocuvite Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108664","Description":"Morphine PF 200Mg/20Ml","CDM Revenue Code":"636","CDM HCPCS":"J2274","Standard Price":751.213333333333,"Note":"**"},{"Itemcode":"74108665","Description":"Kerlone 10Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108666","Description":"Estradiol Vag Cr 0.01% 42.5Gm","CDM Revenue Code":"250","Standard Price":333.839928712871,"Note":"**"},{"Itemcode":"74108668","Description":"Cefuroxime 125Mg/5Ml 50Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108673","Description":"Clomipramine Hcl 25Mg Cap","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74108675","Description":"Temovate .05% 15Gm Cream","CDM Revenue Code":"637","Standard Price":105.0,"Note":"**"},{"Itemcode":"74108679","Description":"Capsaicin 0.075% Cr 30Gm","CDM Revenue Code":"637","Standard Price":33.0,"Note":"**"},{"Itemcode":"74108683","Description":"Nacl 0.65% Nas Drop 50Ml","CDM Revenue Code":"637","Standard Price":6.0},{"Itemcode":"74108684","Description":"Lithium Carbonate 300Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108686","Description":"Temovate .05% 50Ml Ssc.Ap","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74108687","Description":"Belladon 16.2Mg/Opium 30Mg Sup","CDM Revenue Code":"637","Standard Price":55.44,"Note":"**"},{"Itemcode":"74108692","Description":"Ferrous Sul 44Mg/5Ml 60Cc","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108695","Description":"Levothyroxine Sod 0.2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108701","Description":"Diazepam 5Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J3360","Standard Price":59.74},{"Itemcode":"74108702","Description":"Cyclopentolate 1% Op Sol 2Ml","CDM Revenue Code":"250","Standard Price":56.4096666666667,"Note":"**"},{"Itemcode":"74108707","Description":"Polytrim Opth Soln 10Ml","CDM Revenue Code":"637","Standard Price":30.02,"Note":"**"},{"Itemcode":"74108709","Description":"Nonform Cream/Oint","CDM Revenue Code":"637","Standard Price":18.75},{"Itemcode":"74108711","Description":"Non-Form Drug Tab/Cap","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74108712","Description":"Nonform Charge","CDM Revenue Code":"637"},{"Itemcode":"74108713","Description":"OTC Nonform Misc Charge","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74108718","Description":"Nitroglycerin 25Mg/D5W 250Ml","CDM Revenue Code":"250","Standard Price":58.9834387895461,"Note":"**"},{"Itemcode":"74108722","Description":"Dimenhydrinate 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108723","Description":"Dextrose 70% Hyperal 2000Mlchg","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74108725","Description":"MVI-Pediatrics 1Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74108727","Description":"Lisinopril 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108734","Description":"Ketoconazole 2% Shampoo 120Ml","CDM Revenue Code":"637","Standard Price":28.5,"Note":"**"},{"Itemcode":"74108736","Description":"Warfarin Sodium 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74108740","Description":"Mometasone Fur 0.1% Lot 30Ml","CDM Revenue Code":"637","Standard Price":48.75},{"Itemcode":"74108741","Description":"Emcyt 140Mg Capsule","CDM Revenue Code":"259","Standard Price":59.74},{"Itemcode":"74108745","Description":"Epinephrine 1:10000 Syr","CDM Revenue Code":"250","Standard Price":58.8237790697675,"Note":"**"},{"Itemcode":"74108746","Description":"Nitroglycerin 0.4Mg Pp25","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108749","Description":"Divalproex 125Mg/1 Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108751","Description":"Doxycycline 5Mg/Ml Liq 60Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108753","Description":"Ocufen Opth Sol 2.5Ml","CDM Revenue Code":"637"},{"Itemcode":"74108756","Description":"Doryx 100Mg Capsule","CDM Revenue Code":"637","Standard Price":31.5},{"Itemcode":"74108770","Description":"Chlorpromazine 10Mg Tab","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74108772","Description":"Vitamin A 10:000U Softgel","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108773","Description":"Bupropion Hcl 75Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108774","Description":"Zinc Gluconate 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108775","Description":"Labetalol 100Mg/20Ml Inj","CDM Revenue Code":"250","Standard Price":58.5324137931035,"Note":"**"},{"Itemcode":"74108777","Description":"Demeclocycline 300Mg Tab","CDM Revenue Code":"637","Standard Price":37.5,"Note":"**"},{"Itemcode":"74108779","Description":"Olsalazine 250Mg Cap","CDM Revenue Code":"637","Standard Price":37.5},{"Itemcode":"74108784","Description":"Proparacaine 0.5%Opth Soln15Ml","CDM Revenue Code":"250","Standard Price":58.3992117249154,"Note":"**"},{"Itemcode":"74108788","Description":"Measles-Mumps-Rubella Ii","CDM Revenue Code":"636","CDM HCPCS":"90707","Standard Price":270.134666666667,"Note":"**"},{"Itemcode":"74108795","Description":"Isosorbide Mononitrate 20Mg Ta","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108799","Description":"Ca Oyster Shell 500Mg+D 200Iu","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108806","Description":"Azithromycin 250Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108807","Description":"Tussionex 1Ml Chg","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74108808","Description":"Nicaredipine Sr 30Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108810","Description":"Empty Container 3000 Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74108813","Description":"Mesalamine 400Mg Tab","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74108814","Description":"Glyburide 1.5Mg Pres Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108825","Description":"Prostin Vr Pediatri 500Mcg Inj","CDM Revenue Code":"250","Standard Price":459.38},{"Itemcode":"74108828","Description":"Nacl 0.9% 50Ml Adv","CDM Revenue Code":"258","Standard Price":59.74,"Note":"**"},{"Itemcode":"74108829","Description":"Diltiazem Cd 120Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108831","Description":"Amlodipine 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108832","Description":"Ampicillin/Sulbactam 1.5 Adv","CDM Revenue Code":"636","CDM HCPCS":"J0295","Standard Price":59.1280334728034,"Note":"**"},{"Itemcode":"74108837","Description":"Cyanide Antidote Package","CDM Revenue Code":"250","Standard Price":3485.52,"Note":"**"},{"Itemcode":"74108838","Description":"Iron Dextran 50Mg/Ml 2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1750","Standard Price":106.180601851852,"Note":"**"},{"Itemcode":"74108839","Description":"Bupivacaine 0.5% Pf 30Ml Vl","CDM Revenue Code":"250","Standard Price":58.8139903846154,"Note":"**"},{"Itemcode":"74108847","Description":"Sterile Water 50Ml","CDM Revenue Code":"250","Standard Price":59.3224324324324,"Note":"**"},{"Itemcode":"74108849","Description":"Nacl 50Ml Vial","CDM Revenue Code":"258","Standard Price":58.9338024691358,"Note":"**"},{"Itemcode":"74108850","Description":"C0-Trimoxazole 10Ml Inj","CDM Revenue Code":"250","Standard Price":59.1605678793256,"Note":"**"},{"Itemcode":"74108852","Description":"Aspirin 81Mg Tab Enteric","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108853","Description":"Itraconazole 100Mg Cap","CDM Revenue Code":"637","Standard Price":73.5},{"Itemcode":"74108854","Description":"Cytovene 500Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J1570","Standard Price":482.04,"Note":"**"},{"Itemcode":"74108855","Description":"Fludarabine 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9185","Standard Price":258.53,"Note":"**"},{"Itemcode":"74108858","Description":"Paclitaxel 30Mg/5Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9267","Standard Price":59.2337288135593,"Note":"**"},{"Itemcode":"74108859","Description":"Nitroglycerin 2% Oint 30Gm","CDM Revenue Code":"637","Standard Price":88.5,"Note":"**"},{"Itemcode":"74108861","Description":"Pamidronate Disodium 30Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2430","Standard Price":52.4809523809523,"Note":"**"},{"Itemcode":"74108862","Description":"Atropine 1Mg/Ml 1Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0461","Standard Price":58.71,"Note":"**"},{"Itemcode":"74108863","Description":"Testosterone Cyp Inj 200Mg/Ml","CDM Revenue Code":"636","CDM HCPCS":"J1071","Standard Price":113.513828,"Note":"**"},{"Itemcode":"74108869","Description":"Diphenoxylate/Atropine 5Ml Liq","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74108871","Description":"Sotalol 80Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108872","Description":"Vancomycin 500Mg Adv Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":59.74},{"Itemcode":"74108873","Description":"Midazolam 5Mg/Ml 10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74108876","Description":"Cyanocobalamin 500Mcg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108881","Description":"Povidin-Iodin 5% 50Ml Opth Sol","CDM Revenue Code":"250","Standard Price":58.0912558935361,"Note":"**"},{"Itemcode":"74108885","Description":"Ondansetron Hcl 4Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"Q0162","Standard Price":58.2535686274509,"Note":"**"},{"Itemcode":"74108887","Description":"Morphine Oral Sol 10Mg/5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108895","Description":"Diphenhydramine 1% Cr 30 Gm","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74108896","Description":"Timolol Opth Soln. 0.25% 2.5Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74108897","Description":"Refresh Pm Eye Lub 0.4Ml Appli","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109000","Description":"Metronidazole Vag Gel0.75%70Gm","CDM Revenue Code":"637","Standard Price":366.75,"Note":"**"},{"Itemcode":"74109001","Description":"Mesalamine 1000Mg Supp","CDM Revenue Code":"637","Standard Price":92.25,"Note":"**"},{"Itemcode":"74109002","Description":"Nacl 0.9% 250Ml","CDM Revenue Code":"636","CDM HCPCS":"J7050","Standard Price":0.0},{"Itemcode":"74109004","Description":"Papaverine 30Mg/Ml 10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2440","Standard Price":59.74},{"Itemcode":"74109008","Description":"Propofol 10Mg/Ml 50Ml Vl","CDM Revenue Code":"636","CDM HCPCS":"J2704","Standard Price":58.4940085592011,"Note":"**"},{"Itemcode":"74109010","Description":"Dextrose 5% 50Ml Mb-Plus","CDM Revenue Code":"258","Standard Price":59.74,"Note":"**"},{"Itemcode":"74109011","Description":"Nacl 0.9% 50Ml","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74109012","Description":"Sumatriptan 6Mg/0.5Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J3030","Standard Price":41.54,"Note":"**"},{"Itemcode":"74109014","Description":"Phenobarbital 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109015","Description":"Fluoxetine 10Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109018","Description":"Hepatitis B Vaccine 10Mcg/0.5M","CDM Revenue Code":"636","CDM HCPCS":"90744","Standard Price":93.8208091787439,"Note":"**"},{"Itemcode":"74109020","Description":"Sulfacetamide Na 10% Opth 2Ml","CDM Revenue Code":"637","Standard Price":18.0},{"Itemcode":"74109023","Description":"Atenolol 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109024","Description":"Filgrastim-Neupogen 480Mcg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":1730.65853,"Note":"**"},{"Itemcode":"74109025","Description":"Cledcin 2% Vag Crm 40Gm","CDM Revenue Code":"637","Standard Price":249.0,"Note":"**"},{"Itemcode":"74109026","Description":"Alteplase: Recom 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":29373.231,"Note":"**"},{"Itemcode":"74109028","Description":"Finasteride 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109029","Description":"Dextrose 100Ml Minibag Pl","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74109030","Description":"Nacl 0.9% Minibag Plus 100 Ml","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74109033","Description":"Cardene Sr 45Mg Capsule","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74109035","Description":"Macrobid 100Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109040","Description":"Act Charcoal/Water 25Gm 120Ml","CDM Revenue Code":"250","Standard Price":59.2956862745098,"Note":"**"},{"Itemcode":"74109042","Description":"Etomidate 2Mg/Ml 10Ml Inj","CDM Revenue Code":"250","Standard Price":58.7824814814815,"Note":"**"},{"Itemcode":"74109043","Description":"Hycrocortisone 1% 1.5Gm Pkt","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109045","Description":"Atropine 1Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J0461","Standard Price":58.8435185185185,"Note":"**"},{"Itemcode":"74109047","Description":"Enoxaparin 30Mg/0.3Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":58.9880892023253,"Note":"**"},{"Itemcode":"74109048","Description":"Flumazenil 0.1Mg/Ml Inj 5Ml","CDM Revenue Code":"250","Standard Price":58.251040860215,"Note":"**"},{"Itemcode":"74109049","Description":"Felbatol 400Mg","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74109056","Description":"Diprosone 0.05% 15 Gm Cr","CDM Revenue Code":"637","Standard Price":126.75},{"Itemcode":"74109057","Description":"Zolpidem 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109058","Description":"Diprolene(Betamet Dip).05% Oin","CDM Revenue Code":"637","Standard Price":147.75},{"Itemcode":"74109062","Description":"Rifabutin 150Mg Cap","CDM Revenue Code":"637","Standard Price":87.0},{"Itemcode":"74109065","Description":"Ultravate Oint 50 Gm","CDM Revenue Code":"637","Standard Price":332.25},{"Itemcode":"74109570","Description":"Sterile Water 1000Ml","CDM Revenue Code":"258","Standard Price":59.1710476190476,"Note":"**"},{"Itemcode":"74109572","Description":"Viscoat Ophth O.5Ml","CDM Revenue Code":"250","Standard Price":774.56,"Note":"**"},{"Itemcode":"74109580","Description":"Dextrose 5% 100 Ml Add","CDM Revenue Code":"258","Standard Price":57.68,"Note":"**"},{"Itemcode":"74109581","Description":"Chloral Hydrate 500 Mg/5Ml Cup","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109586","Description":"Read Skin Test Misc","CDM Revenue Code":"637"},{"Itemcode":"74109597","Description":"Ketorolac Trometh 0.5% Op Sol","CDM Revenue Code":"250","Standard Price":14.335334,"Note":"**"},{"Itemcode":"74109685","Description":"Doxazosin Mesylate 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109686","Description":"Niferex-150 Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109687","Description":"Dipyridamole 5 Mg/Ml 10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1245","Standard Price":59.74},{"Itemcode":"74109690","Description":"Carbocaine 1.5% 30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0670","Standard Price":59.74},{"Itemcode":"74109692","Description":"Cyclopentolate 2% Op Sol 2Ml","CDM Revenue Code":"250","Standard Price":58.71,"Note":"**"},{"Itemcode":"74109693","Description":"Erythromycin 5Mg/Gm Oint 3.5Gm","CDM Revenue Code":"250","Standard Price":58.9847525,"Note":"**"},{"Itemcode":"74109698","Description":"Edrophonium Cl 10Mg/Ml 1Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74109699","Description":"Edrophonium Cl 10Mg/Ml 15Ml","CDM Revenue Code":"250","Standard Price":339.9},{"Itemcode":"74109702","Description":"Lidocaine 1.5% With Epi 5Mlsdv","CDM Revenue Code":"250","Standard Price":59.2646153846154,"Note":"**"},{"Itemcode":"74109714","Description":"Sterile Water Irrig 1500Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74109715","Description":"Normosol-R 1L","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74109716","Description":"Cardioplegic Soln 1000Ml","CDM Revenue Code":"258","Standard Price":221.405217391304,"Note":"**"},{"Itemcode":"74109718","Description":"Cefotaxime 500Mg Inj","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74109719","Description":"Filgrastim-Neupogen 300Mcg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":1212.31,"Note":"**"},{"Itemcode":"74109734","Description":"Novulin-R Insulin Pen 3Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":148.5},{"Itemcode":"74109737","Description":"Estazolam 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109738","Description":"Lidocaine 2% Jelly 10Ml Urojet","CDM Revenue Code":"250","Standard Price":57.4566339784946,"Note":"**"},{"Itemcode":"74109739","Description":"Lidocaine 2% Jelly 20Ml Urojet","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74109750","Description":"Opium Tincture 0.5Ml Chg","CDM Revenue Code":"637","Standard Price":6.0},{"Itemcode":"74109752","Description":"Ciprofloxacin 200Mg IV","CDM Revenue Code":"636","CDM HCPCS":"J0744","Standard Price":10.3,"Note":"**"},{"Itemcode":"74109759","Description":"Betaxolol 0.25% Op Susp 10Ml","CDM Revenue Code":"637","Standard Price":851.25},{"Itemcode":"74109768","Description":"KCL10MEQ In Sterile Water100Ml","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":59.0099112384922,"Note":"**"},{"Itemcode":"74109770","Description":"KCL20MEQ In Sterile Water100Ml","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":59.0246822625698,"Note":"**"},{"Itemcode":"74109771","Description":"KCL40MEQ In Sterile Water100Ml","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":59.0882485875706,"Note":"**"},{"Itemcode":"74109778","Description":"Ciprofloxacin 400Mg/200Ml Iv","CDM Revenue Code":"636","CDM HCPCS":"J0744","Standard Price":58.9155468377635,"Note":"**"},{"Itemcode":"74109788","Description":"Nitroglycerin 0.2Mg Patch","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109789","Description":"Nitroblycerin 0.4Mg Patch","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109790","Description":"Nitroclycerin 0.1Gm Patch","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109797","Description":"Ca Acetate 667Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109801","Description":"Isradipine 2.5Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109802","Description":"Lodine 300Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109804","Description":"Fentanyl Transdermal 25Mcg/Hr","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74109805","Description":"Epoetin NonESRD 10000U/Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":958.276873889876,"Note":"**"},{"Itemcode":"74109808","Description":"Chlorpromazine 100Mg Tab","CDM Revenue Code":"637","Standard Price":29.25},{"Itemcode":"74109809","Description":"Bupivacaine0.1%Epidur Cass100M","CDM Revenue Code":"250","Standard Price":340.93},{"Itemcode":"74109810","Description":"Vitamin A + D Oint 5Gm","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109816","Description":"Simvastatin 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109818","Description":"Phenylephrine 2.5% Ophth Sol3M","CDM Revenue Code":"250","Standard Price":58.2221052631579,"Note":"**"},{"Itemcode":"74109820","Description":"Tropicamide 1% Ophth Sol 3Ml","CDM Revenue Code":"250","Standard Price":56.4055105263158,"Note":"**"},{"Itemcode":"74109822","Description":"Co-Trimoxazole Susp 120Ml","CDM Revenue Code":"637","Standard Price":22.5},{"Itemcode":"74109823","Description":"Benazepril Hcl 5Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109825","Description":"Fosinopril 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109827","Description":"Ampicillin 2Gm Adv","CDM Revenue Code":"636","CDM HCPCS":"J0290","Standard Price":58.7140859504133,"Note":"**"},{"Itemcode":"74109828","Description":"Fentanyl Transdermal 50Mcg/Hr","CDM Revenue Code":"637","Standard Price":38.07,"Note":"**"},{"Itemcode":"74109829","Description":"Fentanyl Transdermal 75Mcg/Hr","CDM Revenue Code":"637","Standard Price":60.0,"Note":"**"},{"Itemcode":"74109832","Description":"Fentanyl Transdermal 100Mcg/Hr","CDM Revenue Code":"637","Standard Price":82.5,"Note":"**"},{"Itemcode":"74109837","Description":"Nacl 0.9%%/Kcl 40Meq 1000Ml","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":59.1292081031308,"Note":"**"},{"Itemcode":"74109838","Description":"Nacl 0.9%%/Kcl 20Meq 1000Ml","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":58.7569884991843,"Note":"**"},{"Itemcode":"74109839","Description":"D5W/Nacl 0.9%/Kcl 20Meq 1000M","CDM Revenue Code":"258","Standard Price":58.8891304347826,"Note":"**"},{"Itemcode":"74109840","Description":"D5W/Rl/Kcl 20Meq 1000Ml","CDM Revenue Code":"258","Standard Price":58.7718,"Note":"**"},{"Itemcode":"74109841","Description":"Muro-128 2% Opth Sol 15Ml","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74109856","Description":"Vasocidin Ophth Sol 5Ml","CDM Revenue Code":"637","Standard Price":32.25},{"Itemcode":"74109870","Description":"Hydrocodone Syrup 1Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109873","Description":"Octreotide Aceta 0.1Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2354","Standard Price":59.0394144144144,"Note":"**"},{"Itemcode":"74109880","Description":"Niferex-150 Forte Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109881","Description":"Acyclovir 800Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109888","Description":"Methadone 10Mg/Ml Liquid 1Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109891","Description":"Sodium Bicarbonate 4% 5 Ml Via","CDM Revenue Code":"250","Standard Price":58.7640966386555,"Note":"**"},{"Itemcode":"74109892","Description":"Albumin Human 25% 50Ml","CDM Revenue Code":"636","CDM HCPCS":"P9047","Standard Price":491.134449472096,"Note":"**"},{"Itemcode":"74109898","Description":"D5W/Nacl 0.45%/Kcl 10Meq 1000","CDM Revenue Code":"258","Standard Price":58.9091712707183,"Note":"**"},{"Itemcode":"74109899","Description":"Clarithromycin 500Mg Tab","CDM Revenue Code":"637","Standard Price":5.25,"Note":"**"},{"Itemcode":"74109904","Description":"GI Cocktail Oral Liq 30Ml Ud","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74109910","Description":"Pravastatin Sodium 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109911","Description":"Diltiazem Hcl 5Mg/Ml Inj 10Ml","CDM Revenue Code":"250","Standard Price":57.8997470119522,"Note":"**"},{"Itemcode":"74109912","Description":"Nicotine Transdermal 21Mg/Day","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74109913","Description":"Nicotine Transdermal 14Mg/Day","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74109914","Description":"Nicotine Transdermal 7Mg/Day","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74109915","Description":"D5W/Nacl 0.9%/Kcl 40Meq 1000M","CDM Revenue Code":"258","Standard Price":58.9909090909091,"Note":"**"},{"Itemcode":"74109916","Description":"Atracurium Besyl Charge 50Mg","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74109919","Description":"Hydromorphone Hp 10Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":59.74,"Note":"**"},{"Itemcode":"74109920","Description":"Morphine Sr 15Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109928","Description":"Simvastatin 5Mg/Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109929","Description":"Diltiazem Cd 180Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109931","Description":"Felodipine 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109933","Description":"Ticopidine Hcl 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109934","Description":"Diclofenac Ophth Soln 0.1% 2.5","CDM Revenue Code":"637","Standard Price":32.25,"Note":"**"},{"Itemcode":"74109937","Description":"Metoprolol Succinate 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109940","Description":"Sertraline Hcl 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109943","Description":"Quinapril 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109948","Description":"Nabumetone 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109949","Description":"Clarithromycin 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109952","Description":"Oxacillin 2Gm Adv","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74109954","Description":"Ramipril 2.5Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109959","Description":"Ethanolamine 5% 2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1430","Standard Price":1716.186,"Note":"**"},{"Itemcode":"74109960","Description":"Glyburide 3Mg Pres Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109966","Description":"Stadol Nasal Spray","CDM Revenue Code":"637","Standard Price":107.25},{"Itemcode":"74109968","Description":"Omnipaque 300 100 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":378.01},{"Itemcode":"74109970","Description":"Beta-Carotene 15Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109972","Description":"Diliazem Cd 240Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109973","Description":"Doxazosin Mesylate 4Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109976","Description":"Depakote 125Mg Sprinkle","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109977","Description":"Glyburide 1.25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109982","Description":"Etodolac 200Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74109988","Description":"Purinethol 50Mg Tab","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74109991","Description":"Sandimumune 25Mg Gel Cap","CDM Revenue Code":"636","CDM HCPCS":"J7515","Standard Price":59.3502702702702,"Note":"**"},{"Itemcode":"74109992","Description":"Carbidopa 50Mg+Levo 200Mg Cr","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109993","Description":"Levothyroxine Sod 88Mcg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74109995","Description":"Ampicillin/Sulbactam 3Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J0295","Standard Price":59.08825310559,"Note":"**"},{"Itemcode":"74109997","Description":"Sandimmune 100 Mg Capsule","CDM Revenue Code":"636","CDM HCPCS":"J7502","Standard Price":59.74,"Note":"**"},{"Itemcode":"74111124","Description":"Ampicillin 1Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J0290","Standard Price":59.0146639817629,"Note":"**"},{"Itemcode":"74111306","Description":"Lidocaine 1% 0.25Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.74},{"Itemcode":"74111318","Description":"Zemuron (Rocuronium)100Mg/10Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74111327","Description":"Epinephrine Pf 1Mg/Ml Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74111330","Description":"Vancomycin 5 Mg/0.1Ml Op Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":59.74},{"Itemcode":"74111335","Description":"Miostat 1.5Ml Opth Soln","CDM Revenue Code":"250","Standard Price":58.8467256637168,"Note":"**"},{"Itemcode":"74111343","Description":"Sterile Talc 2 Gm","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74113014","Description":"Heparin 1000 U/Ml 1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":58.9579629629629,"Note":"**"},{"Itemcode":"74113018","Description":"Erythromycin Opth Ud Oint","CDM Revenue Code":"250","Standard Price":59.0856387362637,"Note":"**"},{"Itemcode":"74114015","Description":"Nacl 0.9% 50Ml Miniplus","CDM Revenue Code":"258","Standard Price":0.0},{"Itemcode":"74118010","Description":"K Glucon 20Meq/15Ml 60Ml","CDM Revenue Code":"637"},{"Itemcode":"74118020","Description":"Vicoprofen Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118027","Description":"Warfarin Sodium 7.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118028","Description":"Warfarin Sodium 6Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118032","Description":"Vancomycin 1Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":58.9977573259052,"Note":"**"},{"Itemcode":"74118034","Description":"Albumin Human 5% 500Ml","CDM Revenue Code":"636","CDM HCPCS":"P9045","Standard Price":903.90225,"Note":"**"},{"Itemcode":"74118035","Description":"Albuterol 2Mg/5Ml Syrup 5Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118036","Description":"Alclometasone Cr 0.05% 15Gm","CDM Revenue Code":"637","Standard Price":69.75},{"Itemcode":"74118038","Description":"Venlafaxine Hcl 75Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118041","Description":"SOD. Bicarb 956Mg Effer","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118046","Description":"Stavudine 20Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118053","Description":"Stavudine 15Mg Cap","CDM Revenue Code":"637"},{"Itemcode":"74118055","Description":"Venlafaxine Hcl 50Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118056","Description":"Timolol Xe 0.25% Ophth Sol","CDM Revenue Code":"637","Standard Price":137.25},{"Itemcode":"74118076","Description":"Tobramycin 20Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3260","Standard Price":59.74},{"Itemcode":"74118077","Description":"Amlodopine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118078","Description":"Amlodipine 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118086","Description":"Trinsicon Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118091","Description":"Torsemide 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118100","Description":"Warfarin Sodium 4Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118104","Description":"Warfarin Sodium 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118106","Description":"Vitamin A + D Oint 60Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118109","Description":"Zidovudine 50Mg/5Ml Syrug 90Ml","CDM Revenue Code":"637","Standard Price":39.75},{"Itemcode":"74118110","Description":"Warfarin Sodium 3Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118111","Description":"Acetylcystein 20% 10Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118121","Description":"Acetic Acid 2% Otic Sol 60Ml","CDM Revenue Code":"637","Standard Price":172.5},{"Itemcode":"74118122","Description":"Vitamin Multi Therapeu 5Ml Liq","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118125","Description":"Warfarin Sodium 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74118126","Description":"Sterile Water 500Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74118127","Description":"Sterile Water 100Ml","CDM Revenue Code":"258","Standard Price":59.6255555555556,"Note":"**"},{"Itemcode":"74118131","Description":"Sulfasalazine 500Mg Entab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118132","Description":"Sulfacetamide Na 10% Opth 15Ml","CDM Revenue Code":"637","Standard Price":106.5},{"Itemcode":"74118134","Description":"Sucralfate Susp 1Gm/10Ml Ud","CDM Revenue Code":"637","Standard Price":25.5,"Note":"**"},{"Itemcode":"74118143","Description":"Aquaphor 454 Gm","CDM Revenue Code":"637","Standard Price":45.75,"Note":"**"},{"Itemcode":"74118146","Description":"Thrombin 5:000 Units Top","CDM Revenue Code":"250","Standard Price":303.369774919614,"Note":"**"},{"Itemcode":"74118152","Description":"Succinylcholine 20Mg/Ml 5Ml Ch","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74118157","Description":"Taxotere (Docetraxl) 20Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9171","Standard Price":234.84},{"Itemcode":"74118158","Description":"Thrombin Top Kit 20:000 Units","CDM Revenue Code":"250","Standard Price":1248.48431034483,"Note":"**"},{"Itemcode":"74118174","Description":"Synemol Cream 30 Grams","CDM Revenue Code":"637","Standard Price":9.0},{"Itemcode":"74118175","Description":"Talc For Pleurodesis 2.2Gm","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118176","Description":"Talc For Pleurodesis 5 Gm","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118184","Description":"Neomycin Oral 125Mg/5Ml 60Ml","CDM Revenue Code":"637","Standard Price":15.0},{"Itemcode":"74118185","Description":"Theophylline 400Mg/D5W 500Ml","CDM Revenue Code":"636","CDM HCPCS":"J2810","Standard Price":59.74},{"Itemcode":"74118187","Description":"Sterile Water 100Ml","CDM Revenue Code":"258","Standard Price":56.65},{"Itemcode":"74118198","Description":"Bacitracin Oint Pkt 0.9Gm","CDM Revenue Code":"250","Standard Price":6.16293623978201,"Note":"**"},{"Itemcode":"74118207","Description":"Atrovastatin 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118210","Description":"SOD .Bicarb 1916Mg/Asa 325Mg T","CDM Revenue Code":"637"},{"Itemcode":"74118212","Description":"Sargramostim 250 Mcg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2820","Standard Price":1050.6},{"Itemcode":"74118213","Description":"Benazepril Hcl 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118214","Description":"Simethicone 125Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118215","Description":"Sevoflurane (Ultane) 30Ml Chg","CDM Revenue Code":"250","Standard Price":97.5402431369869,"Note":"**"},{"Itemcode":"74118216","Description":"Nisoldipine 10Mg Tab","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74118229","Description":"Testosterone Patch 2.5Mg/Day","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74118230","Description":"Tetanus-Diphtheria Ped Tox 0.5","CDM Revenue Code":"636","CDM HCPCS":"90702","Standard Price":204.97,"Note":"**"},{"Itemcode":"74118234","Description":"Sertraline Hcl 100Mg Tablet","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74118242","Description":"Astramorph Pf 5Mg/10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2274","Standard Price":59.0181797497156,"Note":"**"},{"Itemcode":"74118243","Description":"Tetracaine Hcl 1% Inj 2Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118245","Description":"Trimethoprim 100Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118248","Description":"Promethazine + Codine 5Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118250","Description":"Preparation H Supp","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118260","Description":"Prednisolone 15Mg/5Ml Syrup","CDM Revenue Code":"636","CDM HCPCS":"J7510","Standard Price":58.9763324538259,"Note":"**"},{"Itemcode":"74118262","Description":"Ranitidine Hcl 150Mg/10Ml Ud","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74118264","Description":"Questran Light Packet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118266","Description":"Ranitidine 50Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2780","Standard Price":59.74},{"Itemcode":"74118269","Description":"Ranitidine Syrup 150Mg/10Ml 60","CDM Revenue Code":"637","Standard Price":5.25},{"Itemcode":"74118273","Description":"Prednisolone Acet 0.125% 5Ml","CDM Revenue Code":"250","Standard Price":531.717692307692,"Note":"**"},{"Itemcode":"74118277","Description":"Pyrimethamine 25Mg Tab","CDM Revenue Code":"637","Standard Price":52.5},{"Itemcode":"74118280","Description":"Carbamazepine Xr 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118287","Description":"Orajel 5Gm","CDM Revenue Code":"637","Standard Price":23.25},{"Itemcode":"74118295","Description":"Opium Tincture 1Ml Unit Dose","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74118301","Description":"Omnipaque 300 50Ml Syringe","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":350.2},{"Itemcode":"74118307","Description":"Podofiloz Topical Soln. 0.5% 3","CDM Revenue Code":"637","Standard Price":259.5},{"Itemcode":"74118326","Description":"Rimantadine Hcl 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118331","Description":"Rifamate Cap","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74118338","Description":"Pseudoephedrine 12-Hour Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118344","Description":"Quinine Sulfate 325Mg Tab","CDM Revenue Code":"637","Standard Price":19.5,"Note":"**"},{"Itemcode":"74118347","Description":"Ramipril 5Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118348","Description":"Ranitidine 150Mg Gelcap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118352","Description":"Prednisolone 1% Opth Susp 15Ml","CDM Revenue Code":"637","Standard Price":120.0},{"Itemcode":"74118356","Description":"Ringers Solution 1000Ml","CDM Revenue Code":"258","Standard Price":58.9996638778805,"Note":"**"},{"Itemcode":"74118369","Description":"Pancrease Mt16 Cap","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74118373","Description":"Parnate Tab 10Mg","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74118374","Description":"Pancrease Mt10 Cap","CDM Revenue Code":"637","Standard Price":17.25},{"Itemcode":"74118383","Description":"Pentamidine 300Mg Inhalation","CDM Revenue Code":"250","Standard Price":701.773333333333,"Note":"**"},{"Itemcode":"74118384","Description":"Penicillin G Sodium 5M Units","CDM Revenue Code":"250","Standard Price":189.52,"Note":"**"},{"Itemcode":"74118389","Description":"Oxytocin 20 Units/Rl 1000 Ml","CDM Revenue Code":"250","Standard Price":59.1143817706387,"Note":"**"},{"Itemcode":"74118396","Description":"Alpha 1 Proteinase Inhib 10Mg","CDM Revenue Code":"636","CDM HCPCS":"J0256","Standard Price":19.2757512536807,"Note":"**"},{"Itemcode":"74118399","Description":"Triamcinolone Oint 0.1% 80Gm","CDM Revenue Code":"637","Standard Price":30.75,"Note":"**"},{"Itemcode":"74118404","Description":"Triple Dye Ppk9","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118415","Description":"Rocuronium 10Mg/Ml 5Ml Inj","CDM Revenue Code":"250","Standard Price":58.7244894120964,"Note":"**"},{"Itemcode":"74118417","Description":"Triamcinolone Acet 0.1% Oint45","CDM Revenue Code":"637","Standard Price":100.5,"Note":"**"},{"Itemcode":"74118419","Description":"Triamcinolone Acet 10Mg/Ml 5Ml","CDM Revenue Code":"636","CDM HCPCS":"J3301","Standard Price":58.916,"Note":"**"},{"Itemcode":"74118425","Description":"Ceftriaxone 2Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":58.5623527830637,"Note":"**"},{"Itemcode":"74118428","Description":"Nystatin Susp 5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118430","Description":"Ceftriaxone 35Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":59.74},{"Itemcode":"74118434","Description":"Ceftriaxone 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":66.291660125261,"Note":"**"},{"Itemcode":"74118442","Description":"Nystatin Vag Tab 15","CDM Revenue Code":"637","Standard Price":24.0},{"Itemcode":"74118448","Description":"Nizatidne 150Mg Cap","CDM Revenue Code":"637","Standard Price":14.25},{"Itemcode":"74118450","Description":"Nitroclycerin 0.6Mg Pp25","CDM Revenue Code":"637","Standard Price":13.5},{"Itemcode":"74118455","Description":"Bupivacaine 0.25%W Epi 30Ml","CDM Revenue Code":"250","Standard Price":58.8819389462249,"Note":"**"},{"Itemcode":"74118456","Description":"Phenylephrine 1/8% 30Ml Drop","CDM Revenue Code":"637","Standard Price":10.5,"Note":"**"},{"Itemcode":"74118460","Description":"Pilocarpine 2% Op Sol 15Ml","CDM Revenue Code":"250","Standard Price":339.556666666667,"Note":"**"},{"Itemcode":"74118469","Description":"Bumetanide 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118470","Description":"Phenobarbital 65Mg Injection","CDM Revenue Code":"636","CDM HCPCS":"J2560","Standard Price":59.3374712643679,"Note":"**"},{"Itemcode":"74118471","Description":"Oxaprozin 600Mg Cap","CDM Revenue Code":"637","Standard Price":9.0},{"Itemcode":"74118474","Description":"Butabarbital Elix 60Mg/10Ml","CDM Revenue Code":"637","Standard Price":36.0},{"Itemcode":"74118477","Description":"Phenylephrine 1/2% 15Ml Drop","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74118480","Description":"Permethrin 5% Cream 60Gm","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74118488","Description":"Neostigmine 1-1000 5Cc Charge","CDM Revenue Code":"636","CDM HCPCS":"J2710","Standard Price":170.98},{"Itemcode":"74118494","Description":"Clindamycin/D5W 600Mg/50Ml Bag","CDM Revenue Code":"250","Standard Price":58.8643222472332,"Note":"**"},{"Itemcode":"74118495","Description":"Nicardipine Sr 60Mg Cap","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74118497","Description":"Neostigmine 1:2000 Inj 1Ml","CDM Revenue Code":"636","CDM HCPCS":"J2710","Standard Price":57.68,"Note":"**"},{"Itemcode":"74118498","Description":"Nacl 0.45% 250Ml","CDM Revenue Code":"258","Standard Price":59.74,"Note":"**"},{"Itemcode":"74118502","Description":"Neproxen Susp 25Mg/Ml 90Ml","CDM Revenue Code":"637","Standard Price":28.5},{"Itemcode":"74118503","Description":"Naproxen Na Ds 550Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118506","Description":"Neoral 25Mg Gel Cap","CDM Revenue Code":"636","CDM HCPCS":"J7515","Standard Price":6.18,"Note":"**"},{"Itemcode":"74118510","Description":"Nacl 0.45% 50Ml","CDM Revenue Code":"258","Standard Price":56.65},{"Itemcode":"74118512","Description":"Nacl 0.45% 100Ml","CDM Revenue Code":"258","Standard Price":56.65},{"Itemcode":"74118517","Description":"Cisatracurium 2Mg/Ml 5Ml Charg","CDM Revenue Code":"250","Standard Price":59.6811428571428,"Note":"**"},{"Itemcode":"74118525","Description":"Nacl 500Ml For Irrigation","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74118529","Description":"Morphine Sr 60Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118534","Description":"Murocel 1% Ophth Sol 15Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118539","Description":"Nafcillin 1Gm Inj","CDM Revenue Code":"250","Standard Price":58.5260714285714,"Note":"**"},{"Itemcode":"74118540","Description":"Navelbine 10Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9390","Standard Price":45.32},{"Itemcode":"74118541","Description":"Neoral 100Mg Gel Cap","CDM Revenue Code":"636","CDM HCPCS":"J7502","Standard Price":57.68,"Note":"**"},{"Itemcode":"74118546","Description":"Mometasone Fur 0.1% Oint 15Gm","CDM Revenue Code":"637","Standard Price":9.0},{"Itemcode":"74118548","Description":"Midazolam/Atropine Oral 3Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118553","Description":"Mepivacaine Hcl 2% 50Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0670","Standard Price":59.7225423728813,"Note":"**"},{"Itemcode":"74118559","Description":"Midazolam 5Mg/Ml 1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2250","Standard Price":59.74},{"Itemcode":"74118562","Description":"Midazolam 1Mg/1Ml 5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2250","Standard Price":58.8397288011696,"Note":"**"},{"Itemcode":"74118567","Description":"Morphine Conc 20Mg/Ml 1Ml Oral","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74118570","Description":"Mephobarbital 50Mg Tab","CDM Revenue Code":"637"},{"Itemcode":"74118571","Description":"Meperidine 10Mg/Ml 5Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118573","Description":"Medroxyprogesterone150Mg/MLINJ","CDM Revenue Code":"636","CDM HCPCS":"J1050","Standard Price":225.757272727273,"Note":"**"},{"Itemcode":"74118574","Description":"Methadone 5Mg/5Ml 500Ml","CDM Revenue Code":"637"},{"Itemcode":"74118575","Description":"HOCM: Conray 60 50Ml","CDM Revenue Code":"636","CDM HCPCS":"Q9961","Standard Price":58.8494372180451,"Note":"**"},{"Itemcode":"74118576","Description":"Methadone 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118582","Description":"Neomycin-Bac-Poly Op Oint 3.5G","CDM Revenue Code":"250","Standard Price":183.419230769231,"Note":"**"},{"Itemcode":"74118584","Description":"Methadone Oral Soln 5Mg/5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118588","Description":"Niconazole Nitrate 2% Cr 15Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118591","Description":"Menthol/Eucalyptus Loz 30","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118600","Description":"Levofloxacin 250Mg Iv","CDM Revenue Code":"636","CDM HCPCS":"J1956","Standard Price":58.8477707006369,"Note":"**"},{"Itemcode":"74118601","Description":"Midazolam/Atrop/Mep Oral 3Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118602","Description":"Magnesium Sulfate 4Gm/100Ml","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":58.9946052631579,"Note":"**"},{"Itemcode":"74118604","Description":"Magnevist 10Ml","CDM Revenue Code":"636","CDM HCPCS":"Q9951","Standard Price":227.63},{"Itemcode":"74118612","Description":"Magnesium Gluc 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118622","Description":"Lorazepam 4Mg/Ml Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118631","Description":"Lovastatin 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118632","Description":"D5W/Nacl 0.2%/Kcl 30Meq 1000M","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74118634","Description":"Lidocaine Viscous 2% 100Ml","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74118635","Description":"D5W/Kcl 10Meq 1000Ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74118637","Description":"D5W/Nacl 0.3% 1000Ml","CDM Revenue Code":"258","Standard Price":54.59,"Note":"**"},{"Itemcode":"74118642","Description":"Lidocaine 2% Jelly Per Use","CDM Revenue Code":"250","Standard Price":59.328,"Note":"**"},{"Itemcode":"74118646","Description":"Lidocaine 2% 5Ml Mpf","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.8987829912023,"Note":"**"},{"Itemcode":"74118647","Description":"Lidocaine 2% 10Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.3186,"Note":"**"},{"Itemcode":"74118657","Description":"Lidocaine 1.5% W Epi 5Ml Amp","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118663","Description":"Lidocaine 1% 20Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.1957785625774,"Note":"**"},{"Itemcode":"74118667","Description":"Lidocaine 1% 5Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.6609523809523,"Note":"**"},{"Itemcode":"74118669","Description":"Lidocaine 1% 10Ml Mpf Ezoff","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.0296551724138,"Note":"**"},{"Itemcode":"74118677","Description":"Levofloxacin 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118678","Description":"Dexamethasone 10Mg/Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":57.9836654121864,"Note":"**"},{"Itemcode":"74118679","Description":"Dexamethasone 10Mg/Ml 10Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118680","Description":"Levobunolol Hcl 0.25% 5Ml Op S","CDM Revenue Code":"637","Standard Price":5.25},{"Itemcode":"74118683","Description":"Leucovorin Calcium 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0640","Standard Price":28.737,"Note":"**"},{"Itemcode":"74118691","Description":"Lactobacillus Acidophilus Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118696","Description":"Lactobacillus Acidophilus Pkt","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118699","Description":"Lacrilube Np Opth Oint 0.7Gm","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118700","Description":"Lactulose Syrup 90Ml","CDM Revenue Code":"637","Standard Price":4.51,"Note":"**"},{"Itemcode":"74118702","Description":"Lanolin Anhydrous 36.9Gm","CDM Revenue Code":"250","Standard Price":59.172152917505,"Note":"**"},{"Itemcode":"74118707","Description":"Ketorolac Tromethamine 10Mg Tb","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118712","Description":"Labetalol 300Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118714","Description":"Ketamine 10Mg/Ml 20Ml Inj","CDM Revenue Code":"250","Standard Price":58.310301971831,"Note":"**"},{"Itemcode":"74118744","Description":"Dicyclomine 20Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118750","Description":"Isosorbide Dinitrate 30Mg Tabl","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118751","Description":"Fentanyl 250Mcg/5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":58.8128036285363,"Note":"**"},{"Itemcode":"74118756","Description":"Epinephrine 1:1000 Topical 30M","CDM Revenue Code":"637","Standard Price":281.25},{"Itemcode":"74118762","Description":"Glycopyrrolate 1Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118779","Description":"Famotidine 20Mg/2.5Ml Oral Liq","CDM Revenue Code":"637","Standard Price":27.0,"Note":"**"},{"Itemcode":"74118782","Description":"Guaifenesin Sugar-Free 120 Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118785","Description":"Guaifensein Ac 5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118796","Description":"Mitoxantrone Hcl 5Mg","CDM Revenue Code":"636","CDM HCPCS":"J9293","Standard Price":82.4},{"Itemcode":"74118800","Description":"Dipyridamole 5 Mg/Ml 2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1245","Standard Price":114.33},{"Itemcode":"74118802","Description":"Hydromorphone/Bupiv 8 Mg/100Ml","CDM Revenue Code":"258","Standard Price":89.61},{"Itemcode":"74118804","Description":"Hydromorphone 4Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118810","Description":"Interferon Alfa-2B Recomb 1Mu","CDM Revenue Code":"636","CDM HCPCS":"J9214","Standard Price":125.66},{"Itemcode":"74118813","Description":"Isoniazid Tab 100Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118817","Description":"Diltiazem 100Mg Mono Vial","CDM Revenue Code":"250","Standard Price":239.99},{"Itemcode":"74118818","Description":"Insulin Novolin R 100U/Ml 1Ml","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":42.0,"Note":"**"},{"Itemcode":"74118821","Description":"Isoflurane Charge 13Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118823","Description":"Diphenhydramine 12.5Mg/5Ml Ud","CDM Revenue Code":"636","CDM HCPCS":"Q0163","Standard Price":6.17284722222223,"Note":"**"},{"Itemcode":"74118832","Description":"Hepatitis B Immune Globulin 1M","CDM Revenue Code":"636","CDM HCPCS":"90371","Standard Price":614.91,"Note":"**"},{"Itemcode":"74118834","Description":"Donnatal Elixir 20Ml Ud","CDM Revenue Code":"637","Standard Price":73.5},{"Itemcode":"74118837","Description":"Iodine Strong Sol 30Ml","CDM Revenue Code":"250","Standard Price":58.774375,"Note":"**"},{"Itemcode":"74118846","Description":"Edrophomium/Atropine Inj 15Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118852","Description":"Doxepin 75Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118853","Description":"Edrophonium+Atropine 5Ml Chg","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118865","Description":"Flumazenil 0.1Mg/Ml Inj 10Ml","CDM Revenue Code":"250","Standard Price":58.71,"Note":"**"},{"Itemcode":"74118866","Description":"Fluconazole 200Mg/5Ml Susp","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74118870","Description":"Edrophonium Cl Charge 5Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74118879","Description":"Milrinone 20Mg In 100Ml D5W","CDM Revenue Code":"636","CDM HCPCS":"J2260","Standard Price":59.2531781140861,"Note":"**"},{"Itemcode":"74118885","Description":"Fluconazole 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118887","Description":"Fluoxetine Hcl 20Mg/5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118899","Description":"Famciclovir 250 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118908","Description":"Etodolac 400Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74118916","Description":"Gemcitabine 200Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9201","Standard Price":172.366538461539,"Note":"**"},{"Itemcode":"74118918","Description":"Enfamil Hum Milk Fortif 1 Pak","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118940","Description":"Ergocalciferol 50000U Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118941","Description":"Ergocalciferol (V-D) Drops 60M","CDM Revenue Code":"637","Standard Price":102.0},{"Itemcode":"74118948","Description":"Epoetin NonESRD 20000U/Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":1055.46866817155,"Note":"**"},{"Itemcode":"74118949","Description":"Excedrin Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74118952","Description":"Epoetin NonESRD 2000U/Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":191.58,"Note":"**"},{"Itemcode":"74118953","Description":"Eye Stream Ophth Soln 30Ml","CDM Revenue Code":"250","Standard Price":58.4564068965518,"Note":"**"},{"Itemcode":"74119563","Description":"Medication Taken At Home","CDM Revenue Code":"637"},{"Itemcode":"74120002","Description":"Ca Citrate 950Mg Tab (Ca 200Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120006","Description":"Trandolapril 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120007","Description":"Flovent Inhaler 44 Mcg/Inh","CDM Revenue Code":"637","Standard Price":465.0,"Note":"**"},{"Itemcode":"74120008","Description":"Zafirlukast 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120009","Description":"Gemzar (Gemcitabine) 1Gm/50Ml","CDM Revenue Code":"636","CDM HCPCS":"J9201","Standard Price":97.85},{"Itemcode":"74120012","Description":"Bisoprolol 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120015","Description":"Gentamycin 120 Mg Iv","CDM Revenue Code":"636","CDM HCPCS":"J1580","Standard Price":58.1812969162996,"Note":"**"},{"Itemcode":"74120016","Description":"Ferrous Subsulf(Monsel'S)60Ml","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74120020","Description":"Estradiol 0.1Mg Top Patch","CDM Revenue Code":"637","Standard Price":55.5,"Note":"**"},{"Itemcode":"74120022","Description":"Oscal 500 + Vit D (Brand) Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120023","Description":"Mirtazapine 15Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120025","Description":"Let Topical Soln 3Ml","CDM Revenue Code":"250","Standard Price":58.2150732954545,"Note":"**"},{"Itemcode":"74120029","Description":"Zinc Sulfate 220 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120032","Description":"Olanzapine 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74120033","Description":"Valacyclovir 500Mg Cap","CDM Revenue Code":"637","Standard Price":11.24,"Note":"**"},{"Itemcode":"74120034","Description":"Cisatracurium 10Mg/Ml 20 Ml","CDM Revenue Code":"250","Standard Price":1244.4975,"Note":"**"},{"Itemcode":"74120035","Description":"DobutamineINJ 1000 Mg/250Cc Pm","CDM Revenue Code":"636","CDM HCPCS":"J1250","Standard Price":94.7235398230088,"Note":"**"},{"Itemcode":"74120037","Description":"Atrovastatin 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120038","Description":"Ibuprofen 100Mg/5Ml 5Ml","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74120040","Description":"Bss Ophth Irrig 500Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120041","Description":"Fluticasone 220Mcg Inh","CDM Revenue Code":"637","Standard Price":1069.5,"Note":"**"},{"Itemcode":"74120042","Description":"Glimepiride 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120043","Description":"Misoprostol 100Mcg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74120044","Description":"Lidex (Fluocinonide) .05% 60Ml","CDM Revenue Code":"637","Standard Price":205.5},{"Itemcode":"74120045","Description":"Lidocaine 2% Jelly 5Ml","CDM Revenue Code":"250","Standard Price":59.0243064729194,"Note":"**"},{"Itemcode":"74120049","Description":"Tizanidine 4Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120050","Description":"Donepezil 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120051","Description":"Hep A Virus Vaccine Adult, IM","CDM Revenue Code":"250","CDM HCPCS":"90632","Standard Price":278.1,"Note":"**"},{"Itemcode":"74120055","Description":"Epipen (Epinephrine) 0.3Mg Syr","CDM Revenue Code":"636","CDM HCPCS":"J0171","Standard Price":143.17,"Note":"**"},{"Itemcode":"74120056","Description":"Carboxymethycell 0.4Ml Op Sol","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120057","Description":"Chlorthalidone 15 Mg Tab","CDM Revenue Code":"637","Standard Price":8.25},{"Itemcode":"74120058","Description":"Cleocin T 1% Gel 30Ml Pkg","CDM Revenue Code":"637","Standard Price":207.0},{"Itemcode":"74120060","Description":"Lac-Hydrin 12% 400 Gm Lot","CDM Revenue Code":"637","Standard Price":18.0,"Note":"**"},{"Itemcode":"74120062","Description":"Atropine Tab 0.4Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120063","Description":"Carboplatin 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9045","Standard Price":23.69},{"Itemcode":"74120065","Description":"Fosphenytoin 100Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"Q2009","Standard Price":59.633448275862,"Note":"**"},{"Itemcode":"74120066","Description":"Warfarin Sodium 5Mg Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120069","Description":"Zileuton 600Mg Tab","CDM Revenue Code":"637","Standard Price":67.5,"Note":"**"},{"Itemcode":"74120070","Description":"Fluticasone 110Mcg Inh","CDM Revenue Code":"637","Standard Price":688.5,"Note":"**"},{"Itemcode":"74120071","Description":"Ritonavir 100Mg Cap","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74120072","Description":"Carbidopa 25Mg+Levo 100Mg Cr","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120073","Description":"Fluvoximine 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120074","Description":"Lariam (Mefloquine) 250Mg Tab","CDM Revenue Code":"259","Standard Price":59.74},{"Itemcode":"74120076","Description":"Diprosone Lotion 0.05% 60Ml","CDM Revenue Code":"637","Standard Price":120.0},{"Itemcode":"74120082","Description":"Latanoprosst0.005%Op Sol 2.5Ml","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74120083","Description":"Sarna Lotion 225Ml","CDM Revenue Code":"637","Standard Price":24.0,"Note":"**"},{"Itemcode":"74120087","Description":"Azelastine 137Mcg Nasal Spy","CDM Revenue Code":"637","Standard Price":39.75,"Note":"**"},{"Itemcode":"74120088","Description":"Lamotrigine 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.47,"Note":"**"},{"Itemcode":"74120093","Description":"Valsartan 80Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120094","Description":"Ibutilide 0.1Mg/Ml 10Ml","CDM Revenue Code":"636","CDM HCPCS":"J1742","Standard Price":1918.89,"Note":"**"},{"Itemcode":"74120098","Description":"Selenium Shampoo 1% 210Ml Bot","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74120099","Description":"Sulfadiazine 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74120100","Description":"Temovate(Clobetasl).05% O 60Gm","CDM Revenue Code":"250","Standard Price":1188.62,"Note":"**"},{"Itemcode":"74120101","Description":"Anastrozole 1Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":6.18,"Note":"**"},{"Itemcode":"74120102","Description":"Naropin 0.2% 20Ml Vial (Sample","CDM Revenue Code":"250","Standard Price":59.2305376344086,"Note":"**"},{"Itemcode":"74120105","Description":"Cyanocobalamin 100Mcg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120106","Description":"Ciclopirox Olamine 1% Cr 15Gm","CDM Revenue Code":"637","Standard Price":18.0,"Note":"**"},{"Itemcode":"74120109","Description":"Lupron Depot 22.5Mg 3Mon Kit","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":9313.60333333333,"Note":"**"},{"Itemcode":"74120111","Description":"Carbamazepine Xr 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120117","Description":"MS Contin 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74120132","Description":"Midodrine 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120134","Description":"Levofloxacin 250Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120135","Description":"Antithrombin Iii (Human)500 U","CDM Revenue Code":"636","CDM HCPCS":"J7197","Standard Price":7783.00526315789,"Note":"**"},{"Itemcode":"74120136","Description":"Pilocarpine 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120137","Description":"Charcocap (Charcoal) Caplet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120139","Description":"Vasopressin 200 Unit/10Ml Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120140","Description":"Vistide 375Mg/5Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0740","Standard Price":2112.53},{"Itemcode":"74120143","Description":"Taxotere(Docetaxl) 80Mg/2Ml Vl","CDM Revenue Code":"636","CDM HCPCS":"J9171","Standard Price":938.33},{"Itemcode":"74120144","Description":"Carvediol 3.125Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120145","Description":"Visipaque 320 50 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":275.006053639847,"Note":"**"},{"Itemcode":"74120146","Description":"Carvediol 6.25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120150","Description":"Depacon (Valproat)500Mg/5Ml Vl","CDM Revenue Code":"250","Standard Price":58.61553847981,"Note":"**"},{"Itemcode":"74120156","Description":"Eye Supplies: Er","CDM Revenue Code":"250","Standard Price":75.19},{"Itemcode":"74120158","Description":"Crixivan (Indinavir) 400Mg Cap","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74120160","Description":"Desowen (Desonide) Lotion 2Oz","CDM Revenue Code":"637","Standard Price":711.0},{"Itemcode":"74120161","Description":"Lodine Xl(Etodolac) 400Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120162","Description":"Combivent Inhaler 14.7 Gm","CDM Revenue Code":"637","Standard Price":648.75},{"Itemcode":"74120163","Description":"Haldol Deconate 100Mg/1Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J1631","Standard Price":150.38,"Note":"**"},{"Itemcode":"74120164","Description":"Depo-Medrol 80Mg/1Cc Vial","CDM Revenue Code":"636","CDM HCPCS":"J1040","Standard Price":59.0217433414044,"Note":"**"},{"Itemcode":"74120170","Description":"Coly-Mycin M(Colist)150Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0770","Standard Price":117.165245202559,"Note":"**"},{"Itemcode":"74120171","Description":"Bupropion Sr 150Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120172","Description":"Vantin (Cefpodoxime) 100Mg Tab","CDM Revenue Code":"637","Standard Price":16.5},{"Itemcode":"74120175","Description":"Univasc (Moexipril) 7.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120176","Description":"Levaquin 500Mg/100 Ml Pm Bag","CDM Revenue Code":"636","CDM HCPCS":"J1956","Standard Price":58.8157121006776,"Note":"**"},{"Itemcode":"74120177","Description":"Oxycodone & Apap 5Ml Soln","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120178","Description":"Metronidazole 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120181","Description":"Viracept (Nelfinavir)250Mg Cap","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74120186","Description":"Ambisone 50Mg W/Filter Insert","CDM Revenue Code":"636","CDM HCPCS":"J0289","Standard Price":881.813639240506,"Note":"**"},{"Itemcode":"74120187","Description":"Requip (Ropinirole) 1Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120188","Description":"Azithromycin 500 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0456","Standard Price":136.46782238024,"Note":"**"},{"Itemcode":"74120189","Description":"Robinul 1Mg Per 5Ml Vial","CDM Revenue Code":"250","Standard Price":184.642851518561,"Note":"**"},{"Itemcode":"74120190","Description":"Amino Acid Tpn Chg Per 100Ml","CDM Revenue Code":"258","Standard Price":183.592241043391,"Note":"**"},{"Itemcode":"74120193","Description":"Pyridoxine 100Mg/Ml IV Charge","CDM Revenue Code":"636","CDM HCPCS":"J3415","Standard Price":59.74},{"Itemcode":"74120194","Description":"Flomax (Tamsulosin) 0.4Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120195","Description":"Albumin 25% Human 100 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"P9047","Standard Price":979.378019673829,"Note":"**"},{"Itemcode":"74120196","Description":"Albumin 5% Human 250 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"P9045","Standard Price":492.321485839907,"Note":"**"},{"Itemcode":"74120199","Description":"Nefazodone (Serzone)150Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120200","Description":"Pimozide (Orap) 2Mg Tablet","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74120202","Description":"Isoniazid 100Mg/Ml Injection","CDM Revenue Code":"250","Standard Price":1344.15},{"Itemcode":"74120207","Description":"Mometasone Fur Nasal Spray 17G","CDM Revenue Code":"637","Standard Price":754.5,"Note":"**"},{"Itemcode":"74120209","Description":"Doxorubicin Lipos 20Mg/10Ml Vl","CDM Revenue Code":"636","CDM HCPCS":"Q2050","Standard Price":4762.72},{"Itemcode":"74120210","Description":"Clopidogrel (Plavix) 75Mg Tab","CDM Revenue Code":"637","Standard Price":5.25,"Note":"**"},{"Itemcode":"74120212","Description":"Simvastatin (Zocor) 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120214","Description":"Raloxifene (Eviste)60Mg Tablet","CDM Revenue Code":"637","Standard Price":19.5,"Note":"**"},{"Itemcode":"74120221","Description":"Diazepam Rectal Gel 10Mg App","CDM Revenue Code":"250","Standard Price":1236.0},{"Itemcode":"74120222","Description":"Ketorolac Im 60Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J1885","Standard Price":11.33},{"Itemcode":"74120224","Description":"Carmustine (Gliadel)8 Wafr/Box","CDM Revenue Code":"636","Standard Price":104603.71,"Note":"**"},{"Itemcode":"74120226","Description":"Pancuronium Br 10Mg/10 Ml Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120227","Description":"Ropinirole (Requip) 0.25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120228","Description":"Montelukast (Singulair)5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120229","Description":"A-Tuss Dm Syrup 60 Ml Bottle","CDM Revenue Code":"637","Standard Price":50.25},{"Itemcode":"74120230","Description":"Fosfomycin (Monurol) 3 Gm Pkt","CDM Revenue Code":"637","Standard Price":215.7,"Note":"**"},{"Itemcode":"74120231","Description":"Sevoflurane 250 Ml Bottle","CDM Revenue Code":"250","Standard Price":1247.33},{"Itemcode":"74120235","Description":"Irbesartan (Avapro) 150Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120236","Description":"Mupirocin 2% Oint. 1 Gm Packet","CDM Revenue Code":"637","Standard Price":51.0,"Note":"**"},{"Itemcode":"74120241","Description":"Hyoscyamine (Levbid).375Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120243","Description":"Becaplermin Gel .01% 15Gm Tube","CDM Revenue Code":"637","Standard Price":3045.0},{"Itemcode":"74120244","Description":"Diphenoxylat/Atr Soln 10Ml Cup","CDM Revenue Code":"637","Standard Price":6.75,"Note":"**"},{"Itemcode":"74120250","Description":"Tolterodine (Detrol)1Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120254","Description":"Niacin Er (Niaspan) 500Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120256","Description":"Lamotrigine 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120259","Description":"Triamcinolone Cr .1% 454Gm Jar","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74120261","Description":"Cefpodoxime 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":20.25},{"Itemcode":"74120263","Description":"Folic Acid 400 Mcg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120265","Description":"Diltiazem 100Mg/Ns 100Ml Advan","CDM Revenue Code":"250","Standard Price":59.5352535496958,"Note":"**"},{"Itemcode":"74120266","Description":"Diltiazem 25Mg/5Ml Syringe","CDM Revenue Code":"250","Standard Price":58.5979682196339,"Note":"**"},{"Itemcode":"74120271","Description":"Dopamine 400 Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J1265","Standard Price":59.74},{"Itemcode":"74120274","Description":"Migranal Nasal Spry 4Mg/Ml Amp","CDM Revenue Code":"250","Standard Price":1789.11},{"Itemcode":"74120275","Description":"Propafenone Hcl 225Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120280","Description":"Paroxetine 30 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120281","Description":"Repaglinide 0.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74120282","Description":"Lepirudin (Rdna) 50 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J1945","Standard Price":2284.54},{"Itemcode":"74120286","Description":"Aluminum Hydroxide Gel 4Oz Bot","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74120287","Description":"Meperidine Syrup 50Mg/5Ml Cup","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120288","Description":"Lortab Liq 15Ml","CDM Revenue Code":"637","Standard Price":10.5},{"Itemcode":"74120289","Description":"Cadexomer-Iodine Gel 40Gm Tube","CDM Revenue Code":"250","Standard Price":472.5125,"Note":"**"},{"Itemcode":"74120290","Description":"Tricitrates Oral Soln 60Ml Bot","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120291","Description":"K Citrate/Citrc Acid Sol 60Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120292","Description":"Desmopressin 0.2 Mg Tablet","CDM Revenue Code":"637","Standard Price":6.75,"Note":"**"},{"Itemcode":"74120293","Description":"Cetirizine 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120296","Description":"Visipaque 320 100Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":445.086436972705,"Note":"**"},{"Itemcode":"74120297","Description":"Venlafaxine Xr 37.5Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120298","Description":"Oxycodone Solution 5Mg/5Ml Cup","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74120299","Description":"Tiagabine 4 Mg Tablet","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74120300","Description":"Cladribine 10Mg/10 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9065","Standard Price":772.5,"Note":"**"},{"Itemcode":"74120306","Description":"Tobramycin 300Mg/5Ml Amp Inhal","CDM Revenue Code":"250","Standard Price":272.95},{"Itemcode":"74120307","Description":"Human Factor VIII Chg Per Unit","CDM Revenue Code":"636","CDM HCPCS":"J7192","Standard Price":6.18},{"Itemcode":"74120308","Description":"Citalopram Hbr 20 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120309","Description":"Nicotine Inhaler 10Mg --168","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74120310","Description":"Eptifibatide 20Mg/10 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1327","Standard Price":731.580909090909,"Note":"**"},{"Itemcode":"74120311","Description":"Eptifibatide 75 Mg/100Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1327","Standard Price":2299.10045454545,"Note":"**"},{"Itemcode":"74120312","Description":"Naltrexone Hcl 50 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120314","Description":"Acitretin 25 Mg Capsule","CDM Revenue Code":"637","Standard Price":43.5},{"Itemcode":"74120315","Description":"Baclofen 10Mg/20Ml Inj Kit","CDM Revenue Code":"636","CDM HCPCS":"J0475","Standard Price":912.58},{"Itemcode":"74120320","Description":"Topiramate 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74120321","Description":"Simple Syrup 1 Ml Chg","CDM Revenue Code":"637"},{"Itemcode":"74120322","Description":"Niacin Er (Niaspan) 750 Mg Tab","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74120324","Description":"Baclofen 0.05 Mg/1 Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J0476","Standard Price":310.03},{"Itemcode":"74120325","Description":"Clotrimazole/Betameth 45 Gm Cr","CDM Revenue Code":"250","Standard Price":153.095454545455,"Note":"**"},{"Itemcode":"74120327","Description":"Repaglinide 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120328","Description":"Phenobarbital 20Mg/5 Ml Cup","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120329","Description":"Arava 20 Mg Tablet","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74120331","Description":"Astramorph 1Mg/1Ml 2Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2274","Standard Price":64.89},{"Itemcode":"74120336","Description":"Amitriptyline 75Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120338","Description":"Ascorbic Acid 500Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120343","Description":"Metoclopramide 5Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8597","Standard Price":6.18,"Note":"**"},{"Itemcode":"74120344","Description":"Quinapril 20Mg Tab","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74120347","Description":"Idarubicin Hcl 5 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9211","Standard Price":185.074736842105,"Note":"**"},{"Itemcode":"74120348","Description":"Gavapentin 400 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120349","Description":"Losartin 50Mg/Hctz 12.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120354","Description":"Venlafaxine 150 Mg Xr Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120355","Description":"Venlafaxine 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120357","Description":"Lansoprazole 30 Mg Capsule","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74120358","Description":"Mycophenolate 250 Mg Capsule","CDM Revenue Code":"636","CDM HCPCS":"J7517","Standard Price":6.18,"Note":"**"},{"Itemcode":"74120360","Description":"Simvastatin 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120361","Description":"Fexofenadine 60 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120363","Description":"Non Formulary IV Medication","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120364","Description":"Paricalcitol 5 Mcg/Cc Vial","CDM Revenue Code":"636","CDM HCPCS":"J2501","Standard Price":59.4266920152091,"Note":"**"},{"Itemcode":"74120365","Description":"Uniphyl 600 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120366","Description":"Isosorbide Mononitrat 30Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120367","Description":"Enoxaparin 60 Mg/0.6 Ml Syring","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":66.0605666666667,"Note":"**"},{"Itemcode":"74120368","Description":"Enoxaparin 80 Mg/0.8 Ml Syring","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":88.3525829599706,"Note":"**"},{"Itemcode":"74120369","Description":"Enoxaparin 100Mg/1 Ml Syringe","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":58.9690165947243,"Note":"**"},{"Itemcode":"74120371","Description":"Acarbose 25 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120373","Description":"Ropinirole 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120374","Description":"Ropinirole 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74120375","Description":"Midazolam 2 Mg/Ml Charge","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120376","Description":"Midazolam 10Mg/5Ml Oral Syring","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120377","Description":"Infliximab 100 Mg Inj Remicade","CDM Revenue Code":"636","CDM HCPCS":"J1745","Standard Price":4523.56356766056,"Note":"**"},{"Itemcode":"74120380","Description":"Ferrous Sulfate 25Mg/Ml 50Ml","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74120383","Description":"Oxycodone Hcl 40 Mg Cr Tablet","CDM Revenue Code":"637","Standard Price":33.0,"Note":"**"},{"Itemcode":"74120392","Description":"Losartan 50 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120393","Description":"Levothyroxine 0.137 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120396","Description":"Celecoxib 100 Mg Capsule","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74120397","Description":"Lidocaine 1.5%/Epi 1:200 10ML","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120401","Description":"Ritonavir Sol 80Mg/Ml 240Ml Bt","CDM Revenue Code":"637","Standard Price":4918.5},{"Itemcode":"74120402","Description":"Reteplase 10U Inj","CDM Revenue Code":"636","CDM HCPCS":"J2993","Standard Price":6399.39},{"Itemcode":"74120403","Description":"Ziagen 300 Mg Tablet","CDM Revenue Code":"637","Standard Price":27.75,"Note":"**"},{"Itemcode":"74120404","Description":"Efavirenz 200 Mg Capsule","CDM Revenue Code":"637","Standard Price":33.0},{"Itemcode":"74120405","Description":"Paroxetine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120406","Description":"Rituximab 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9312","Standard Price":3788.53433962264,"Note":"**"},{"Itemcode":"74120409","Description":"Amitrityline 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120416","Description":"Oxycodone 40Mg Cr Tab","CDM Revenue Code":"637","Standard Price":57.75},{"Itemcode":"74120417","Description":"Ocufloxacin 1Ml Ea","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120419","Description":"Glipizide Xl 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120421","Description":"Cipro 10 Gm/100 Ml Suspension","CDM Revenue Code":"637","Standard Price":467.25},{"Itemcode":"74120422","Description":"Midazolam 1 Mg/Ml 10 Ml Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120425","Description":"Tolterodine 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74120426","Description":"Diclofenac/Misoprostol 75Mg Tb","CDM Revenue Code":"637","Standard Price":22.5},{"Itemcode":"74120427","Description":"Hydrocodone 10Mg/Apap 325Mg Tb","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120428","Description":"Candesartan 16 Mg Tablet","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74120430","Description":"Clindamycin 300Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120431","Description":"Gentamicin Ophth Drops 5Ml","CDM Revenue Code":"250","Standard Price":58.71,"Note":"**"},{"Itemcode":"74120432","Description":"Repaglinide 1Mg Tab","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74120433","Description":"Varicella Zoster Vaccine 0.5Ml","CDM Revenue Code":"259","CDM HCPCS":"90716","Standard Price":486.16},{"Itemcode":"74120434","Description":"Hylan G-F 20 16Mg/2Ml Syringe","CDM Revenue Code":"636","CDM HCPCS":"J7325","Standard Price":1760.27},{"Itemcode":"74120436","Description":"Brinzolamide 1% Opth Soln 5Ml","CDM Revenue Code":"250","Standard Price":674.65},{"Itemcode":"74120439","Description":"Oxybutynin Cl Xl 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74120442","Description":"Ciprofloxacin 0.3% Op Oint 3.5","CDM Revenue Code":"250","Standard Price":857.99,"Note":"**"},{"Itemcode":"74120444","Description":"Lidocaine 1% Mpf 1Ml Op Inj","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.74},{"Itemcode":"74120446","Description":"Hyskon 32% Hysteroscopy Soltn","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74120447","Description":"Ciprofloxacin Hc Otic 10Ml","CDM Revenue Code":"637","Standard Price":813.75,"Note":"**"},{"Itemcode":"74120448","Description":"Levocarnitine 1000Mg/5Ml Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120449","Description":"Indocyanine Green 25Mg Inj","CDM Revenue Code":"250","Standard Price":356.151966666666,"Note":"**"},{"Itemcode":"74120450","Description":"Rosiglitazone 4 Mg Tablet","CDM Revenue Code":"637","Standard Price":16.5},{"Itemcode":"74120451","Description":"Alteplase Recombint 1Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":306.652101188831,"Note":"**"},{"Itemcode":"74120454","Description":"Paricalcitol 10 Mcg/2 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2501","Standard Price":128.75},{"Itemcode":"74120458","Description":"Oxycodone 20Mg/1Ml Oral Conc","CDM Revenue Code":"637","Standard Price":12.0,"Note":"**"},{"Itemcode":"74120459","Description":"Testosterone 4Mg Transdermal","CDM Revenue Code":"637","Standard Price":56.25},{"Itemcode":"74120460","Description":"Quetiapine Fumarate 25Mg Tab","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74120462","Description":"Fenoldopam 10Mg/1 Ml Amp","CDM Revenue Code":"250","Standard Price":1199.95},{"Itemcode":"74120463","Description":"Multivitamin Inject(Mvi12)10Ml","CDM Revenue Code":"250","Standard Price":58.7488801801802,"Note":"**"},{"Itemcode":"74120464","Description":"Octreotide Depot 20Mg Inject","CDM Revenue Code":"636","CDM HCPCS":"J2353","Standard Price":16308.5785714285,"Note":"**"},{"Itemcode":"74120465","Description":"Montelukast 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120466","Description":"Atovaquone 750Mg/5Ml 60Ml Bot","CDM Revenue Code":"637","Standard Price":1984.5},{"Itemcode":"74120467","Description":"Ofloxazin 0.3% Otic Soltn 5Ml","CDM Revenue Code":"637","Standard Price":158.06,"Note":"**"},{"Itemcode":"74120469","Description":"Lymphazurin 50mg/5 Ml 1%% Vial","CDM Revenue Code":"636","CDM HCPCS":"Q9968","Standard Price":2933.66888888889,"Note":"**"},{"Itemcode":"74120470","Description":"Cilostazol 50 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120471","Description":"Pramipexole 0.25 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120473","Description":"Topotecan 4 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9351","Standard Price":519.12,"Note":"**"},{"Itemcode":"74120474","Description":"Eye Supplies: Oto Neurology","CDM Revenue Code":"250","Standard Price":84.46},{"Itemcode":"74120476","Description":"Humalog Insulin Pen 3 Ml","CDM Revenue Code":"637","Standard Price":45.75},{"Itemcode":"74120477","Description":"Humulin N Insulin Pen 3 Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":36.75},{"Itemcode":"74120478","Description":"Humulin 70/30 Inuslin Pen 3 Ml","CDM Revenue Code":"637","Standard Price":36.75},{"Itemcode":"74120480","Description":"Rosiglitazone Mal 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":10.5},{"Itemcode":"74120482","Description":"Rizatriptan (Maxalt) 5Mg Tab","CDM Revenue Code":"637","Standard Price":109.5,"Note":"**"},{"Itemcode":"74120483","Description":"Phenol Liquid 1Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120484","Description":"Brilliant Green Solutn 1Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120487","Description":"Orlistat 120Mg Cap","CDM Revenue Code":"637","Standard Price":19.5},{"Itemcode":"74120488","Description":"Topiramate 25Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120491","Description":"Mile'S Solution 120Ml","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74120492","Description":"Pioglitazone Hcl 15 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120493","Description":"Penciclovir 1% Cream 1.5G Tube","CDM Revenue Code":"637","Standard Price":2318.25},{"Itemcode":"74120495","Description":"Palivizumab 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"90378","Standard Price":9754.1},{"Itemcode":"74120497","Description":"Temazepam 7.5 Mg Capsule","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74120498","Description":"Zaleplon 5 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120499","Description":"Gentamicin 4Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1580","Standard Price":59.74},{"Itemcode":"74120500","Description":"Bupivacaine 0.25% W/Epi 50Ml A","CDM Revenue Code":"250","Standard Price":58.8418594339622,"Note":"**"},{"Itemcode":"74120505","Description":"Ropivacaine 150Mg/30Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2795","Standard Price":118.012337008714,"Note":"**"},{"Itemcode":"74120507","Description":"Synercid 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2770","Standard Price":1722.16},{"Itemcode":"74120508","Description":"Levalbuterol .63Mg/3Ml Neb","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74120510","Description":"Olopatadine .1% Opth Drops 5Ml","CDM Revenue Code":"637","Standard Price":641.25},{"Itemcode":"74120511","Description":"Cosopt Opth Drops 5 Ml Bot","CDM Revenue Code":"637","Standard Price":150.0,"Note":"**"},{"Itemcode":"74120512","Description":"Oseltamivir 75 Mg Capsule","CDM Revenue Code":"250","Standard Price":59.2353865546218,"Note":"**"},{"Itemcode":"74120514","Description":"Enlaprilat 1.25 Mg/Ml 1Ml Vial","CDM Revenue Code":"250","Standard Price":59.5401492537313,"Note":"**"},{"Itemcode":"74120515","Description":"Epoetin NonESRD 40000U/Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":2116.40049689441,"Note":"**"},{"Itemcode":"74120517","Description":"Bupivacaine 0.75% W/Dex 2Mlamp","CDM Revenue Code":"250","Standard Price":58.9837974683544,"Note":"**"},{"Itemcode":"74120518","Description":"Zanamivir 5Mg Disk Inhaler","CDM Revenue Code":"637","Standard Price":166.5},{"Itemcode":"74120519","Description":"Halobetasol 0.05% Cr 15 Gm Tub","CDM Revenue Code":"637","Standard Price":139.5},{"Itemcode":"74120520","Description":"Metronidazole .75% Gel 1Oz Tub","CDM Revenue Code":"637","Standard Price":230.25,"Note":"**"},{"Itemcode":"74120521","Description":"Hydroxyzine Hcl 10Mg/5Ml Cups","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120523","Description":"Telmisartan 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74120525","Description":"Glipizide Er 2.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74120529","Description":"Mag Sulfate 1Gm/D5W 100Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":58.9762134350394,"Note":"**"},{"Itemcode":"74120530","Description":"Carbidopa 25 Mg Tablet","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74120531","Description":"Dipyridamol 200Mg/Asa 25Mg Tab","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74120532","Description":"Intubation Med Kit","CDM Revenue Code":"250","Standard Price":327.54},{"Itemcode":"74120533","Description":"Tobradex 0.5Ml Ophth Syringe","CDM Revenue Code":"250","Standard Price":81.37},{"Itemcode":"74120534","Description":"Adatosil 5000","CDM Revenue Code":"250","Standard Price":1516.74857142857,"Note":"**"},{"Itemcode":"74120539","Description":"Carvediol 12.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120540","Description":"Digoxin 0.05Mg/Ml Elix 2.5Ml","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74120541","Description":"Rabeprazole Na 20 Mg Tablet","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74120542","Description":"Meropenem 1 Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J2185","Standard Price":58.9219305673159,"Note":"**"},{"Itemcode":"74120543","Description":"Itraconazole 250 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J1835","Standard Price":1038.24},{"Itemcode":"74120545","Description":"Leuprolide Acet 30Mg 4 Mo (Im)","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":18394.77},{"Itemcode":"74120549","Description":"Polyethylene Glycol 17 Gm Bot","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120550","Description":"Modafinil 200Mg Tab","CDM Revenue Code":"637","Standard Price":30.0,"Note":"**"},{"Itemcode":"74120551","Description":"Tacrolimus Oral ImRel 1Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"J7507","Standard Price":6.18,"Note":"**"},{"Itemcode":"74120552","Description":"Tenecteplase 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3101","Standard Price":18542.06},{"Itemcode":"74120553","Description":"Vancomycin 125Mg Cap","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74120554","Description":"Hepatitis B Vaccine 20Mcg/1Ml","CDM Revenue Code":"636","CDM HCPCS":"90746","Standard Price":231.406666666667,"Note":"**"},{"Itemcode":"74120555","Description":"Simvastatin 80Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120556","Description":"Pantoprazole Na 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120557","Description":"Ursodiol 250 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120558","Description":"Risperidone 0.25 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120559","Description":"Ferrous Fumarate 325Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120560","Description":"Vitamin D 400 Iu Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120562","Description":"Acyclovir 200Mg/5Ml Cup","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74120563","Description":"Naproxen 220Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120564","Description":"Hyoscyamine Sulfate 0.5Mg/Ml","CDM Revenue Code":"636","CDM HCPCS":"J1980","Standard Price":231.578333333333,"Note":"**"},{"Itemcode":"74120566","Description":"Robitussin Dm 120Ml Bottle","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120567","Description":"Loratadine Reditab 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120568","Description":"Montelukast 4Mg Tab","CDM Revenue Code":"637","Standard Price":3.92,"Note":"**"},{"Itemcode":"74120570","Description":"Baclofen Inj 10Mg/5Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J0475","Standard Price":912.58},{"Itemcode":"74120571","Description":"Thymoglobulin 25Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J7511","Standard Price":3202.27},{"Itemcode":"74120573","Description":"Testosterone 5Mg Td Patch","CDM Revenue Code":"637","Standard Price":29.25},{"Itemcode":"74120574","Description":"Budesonide 0.5% Neb 2Ml Sol","CDM Revenue Code":"250","CDM HCPCS":"J7633","Standard Price":58.946199106236,"Note":"**"},{"Itemcode":"74120575","Description":"Levofloxacin 750Mg/150Ml Pm","CDM Revenue Code":"636","CDM HCPCS":"J1956","Standard Price":58.8916263547939,"Note":"**"},{"Itemcode":"74120577","Description":"Rhinocort Aq Inhaler 32Mcg","CDM Revenue Code":"637","Standard Price":255.75},{"Itemcode":"74120583","Description":"Clarithromycin Xl 500Mg Tab","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74120590","Description":"Allopurinol 500Mg Inj","CDM Revenue Code":"250","Standard Price":16918.78},{"Itemcode":"74120591","Description":"Levofloxacin 750Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120592","Description":"Nacl 0.9% 10Ml Vial","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74120593","Description":"Pegaspargase 3750Iu/5Ml","CDM Revenue Code":"636","CDM HCPCS":"J9266","Standard Price":26851.07,"Note":"**"},{"Itemcode":"74120594","Description":"Testosterone 1% Gel 5 Gm Pkt","CDM Revenue Code":"637","Standard Price":58.5,"Note":"**"},{"Itemcode":"74120595","Description":"Epoprostenol Na 0.5 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J1325","Standard Price":59.74},{"Itemcode":"74120596","Description":"Glycine Dilutent 50 Ml Vial","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74120597","Description":"Metformin Hcl Xr 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120598","Description":"Quinapril 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120599","Description":"Dofetilide 125Mcg Cap","CDM Revenue Code":"637","Standard Price":28.5,"Note":"**"},{"Itemcode":"74120600","Description":"Dofetilide 250Mcg Cap","CDM Revenue Code":"637","Standard Price":28.5,"Note":"**"},{"Itemcode":"74120603","Description":"Sumatriptan 20Mg Nasal Spray","CDM Revenue Code":"637","Standard Price":147.75,"Note":"**"},{"Itemcode":"74120604","Description":"Sumatriptan 5Mg Nasal Spray","CDM Revenue Code":"637","Standard Price":226.5},{"Itemcode":"74120605","Description":"Salmeterol Diskus 50Mcg Inhale","CDM Revenue Code":"637","Standard Price":22.5},{"Itemcode":"74120606","Description":"Bupivacaine 0.5% W/Epi30Mlvial","CDM Revenue Code":"250","Standard Price":59.0538913885899,"Note":"**"},{"Itemcode":"74120607","Description":"Topical Ophth Dilating Plegets","CDM Revenue Code":"250","Standard Price":412.0},{"Itemcode":"74120608","Description":"Beta Galactosidase 3000U Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120609","Description":"Fexfenadine+Pseudoephr 60Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120610","Description":"Progesterone Micronized 100Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120611","Description":"Buspirone 15Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120612","Description":"Sumatriptan 25Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120613","Description":"Exemestane 25Mg Tab","CDM Revenue Code":"637","Standard Price":32.25,"Note":"**"},{"Itemcode":"74120615","Description":"Perindopril 4Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120616","Description":"Rivastigmine 1.5Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120617","Description":"Fluvoxamine 50Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120618","Description":"Atorvastatin 80Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120619","Description":"Glyburide 1.25Mg-Metformin250","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120622","Description":"Linezolid (Zyvox) 600Mg Tablet","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74120624","Description":"Ramipril 10 Mg Capsule","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74120628","Description":"Leuprolide 11.25Mg 3Month (Im)","CDM Revenue Code":"636","CDM HCPCS":"J1950","Standard Price":9478.575,"Note":"**"},{"Itemcode":"74120629","Description":"Leuprolide Depot 3.75Mg Kit(Im","CDM Revenue Code":"636","CDM HCPCS":"J1950","Standard Price":3120.9,"Note":"**"},{"Itemcode":"74120630","Description":"Dofetilide 500Mcg Cap","CDM Revenue Code":"637","Standard Price":28.5,"Note":"**"},{"Itemcode":"74120631","Description":"Dexmedetomidine 200Mcg/2Ml Via","CDM Revenue Code":"250","Standard Price":58.316638095238,"Note":"**"},{"Itemcode":"74120632","Description":"Hydromorphone 5Mg/5Ml Ud Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120634","Description":"Ondansetron 8 Mg Odt Tablet","CDM Revenue Code":"636","CDM HCPCS":"Q0162","Standard Price":58.9121199272066,"Note":"**"},{"Itemcode":"74120637","Description":"Foltx (Folic Acid:B-6:B-12 Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120638","Description":"Levetiracetam 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74120641","Description":"Naratriptan Hcl 1 Mg Tablet","CDM Revenue Code":"637","Standard Price":169.5},{"Itemcode":"74120642","Description":"Alendronate Na 70 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120643","Description":"Risedronate Na 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":31.5},{"Itemcode":"74120644","Description":"Caspofungin 50 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0637","Standard Price":1433.76},{"Itemcode":"74120645","Description":"Caspofungin 70 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0637","Standard Price":1489.38},{"Itemcode":"74120646","Description":"Ferric Na Gluconate 62.5Mg/5Ml","CDM Revenue Code":"636","CDM HCPCS":"J2916","Standard Price":59.0606490739223,"Note":"**"},{"Itemcode":"74120648","Description":"Lidocaine 700 Mg Patch","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74120650","Description":"Atorvastatin 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120651","Description":"InterferonBeta-1B 0.3MgInj Kit","CDM Revenue Code":"636","CDM HCPCS":"J1830","Standard Price":1861.21,"Note":"**"},{"Itemcode":"74120653","Description":"Remifentanil 1Mg Inj","CDM Revenue Code":"250","Standard Price":258.368782608696,"Note":"**"},{"Itemcode":"74120654","Description":"Interferon Beta 1A 30Mcg(Avonx","CDM Revenue Code":"636","CDM HCPCS":"Q3027","Standard Price":20547.47},{"Itemcode":"74120657","Description":"Glatiramer 20Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1595","Standard Price":1006.31},{"Itemcode":"74120659","Description":"Topical Opth Dilating Solution","CDM Revenue Code":"250","Standard Price":59.037786163522,"Note":"**"},{"Itemcode":"74120661","Description":"Oxcarbazepine 300Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74120662","Description":"Esomeprazole","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74120664","Description":"RHO(D) Immune Globulin 5000Iu","CDM Revenue Code":"636","CDM HCPCS":"J2792","Standard Price":5520.8,"Note":"**"},{"Itemcode":"74120665","Description":"Nateglinide 60 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120666","Description":"Sevelamer 400Mg Tablet","CDM Revenue Code":"637","Standard Price":10.5},{"Itemcode":"74120667","Description":"Sevelamer 800Mg Tablet","CDM Revenue Code":"637","Standard Price":5.25,"Note":"**"},{"Itemcode":"74120669","Description":"Licocaine 1%/Epi 1:200 10Ml Vl","CDM Revenue Code":"250","Standard Price":58.963768115942,"Note":"**"},{"Itemcode":"74120670","Description":"Cefepime 2 Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J0692","Standard Price":59.1491233333333,"Note":"**"},{"Itemcode":"74120671","Description":"Entacapone 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74120672","Description":"Tolterodine La 2 Mg Capsule","CDM Revenue Code":"637","Standard Price":19.5},{"Itemcode":"74120673","Description":"Pantoprozole Sodium 40Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"C9113","Standard Price":58.9866963074873,"Note":"**"},{"Itemcode":"74120674","Description":"Imatinib Mesylate 100Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":116.39},{"Itemcode":"74120675","Description":"Amphetamine-Dextroamphet 5Mg","CDM Revenue Code":"637","Standard Price":18.0},{"Itemcode":"74120679","Description":"Insulin Glargine 10Ml 100U/Ml","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":723.75},{"Itemcode":"74120681","Description":"Xanax (Alprazolam) 0.5Mg Brand","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120682","Description":"Morphine Sulfate 15 Mg Ir Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120684","Description":"Alcoholic Beverage 1 Ea Bottle","CDM Revenue Code":"637"},{"Itemcode":"74120685","Description":"Morrhuate 5% 30Ml Vial","CDM Revenue Code":"250","Standard Price":296.64},{"Itemcode":"74120687","Description":"Tolterodine La 4Mg Capsule","CDM Revenue Code":"637","Standard Price":19.5,"Note":"**"},{"Itemcode":"74120689","Description":"Advair 100/50 Inhaler","CDM Revenue Code":"637","Standard Price":366.0,"Note":"**"},{"Itemcode":"74120691","Description":"Advair 500/50 Inhaler","CDM Revenue Code":"637","Standard Price":596.25,"Note":"**"},{"Itemcode":"74120694","Description":"Metoprolol 25 Mg Xl Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120695","Description":"Ramipril 1.25 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120698","Description":"Lactulose 10 Gm Packet","CDM Revenue Code":"637","Standard Price":20.25},{"Itemcode":"74120699","Description":"Anagrelide Hcl 0.5 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120702","Description":"Atropine 1% Ophth Soltn 5Ml","CDM Revenue Code":"250","Standard Price":58.7509566929134,"Note":"**"},{"Itemcode":"74120704","Description":"Na Citrate & Citric Acid 30 Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120705","Description":"Palivizumab 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"90378","Standard Price":6358.19},{"Itemcode":"74120706","Description":"Tacrolimus Oral ImmRel 5Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"J7507","Standard Price":59.6188235294118,"Note":"**"},{"Itemcode":"74120707","Description":"Anagrelide Hcl 1 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120708","Description":"Alteplase: Recombinant 2Mg/2Ml","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":612.029673105498,"Note":"**"},{"Itemcode":"74120709","Description":"Epirubicin 50Mg/25Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9178","Standard Price":125.66},{"Itemcode":"74120710","Description":"Cytomegalovirus Imm Glob 2.5Gm","CDM Revenue Code":"636","CDM HCPCS":"J0850","Standard Price":5452.82},{"Itemcode":"74120715","Description":"Drotrecogin Alfa 5Mg Vial","CDM Revenue Code":"250","Standard Price":1471.87},{"Itemcode":"74120716","Description":"FactorIX Recomb1iU Benefix Inj","CDM Revenue Code":"636","CDM HCPCS":"J7195","Standard Price":6.18},{"Itemcode":"74120717","Description":"Didanosine Ec 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":13.5},{"Itemcode":"74120719","Description":"Lansoprazole 30Mg Granules Pkt","CDM Revenue Code":"637","Standard Price":18.75},{"Itemcode":"74120720","Description":"Factor 7 1000Mcg","CDM Revenue Code":"636","CDM HCPCS":"J7189","Standard Price":7588.01},{"Itemcode":"74120721","Description":"Galantamine 8 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120722","Description":"Enoxaparin Na 120 Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":58.9486714727086,"Note":"**"},{"Itemcode":"74120723","Description":"Enoxaparin Na 150 Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":468.332903930131,"Note":"**"},{"Itemcode":"74120724","Description":"Oxcarbazepine 150 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120729","Description":"Colesevelam Hcl 625Mg Tab","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74120730","Description":"Risedronate Na 30Mg Tab","CDM Revenue Code":"637","Standard Price":222.75},{"Itemcode":"74120731","Description":"Zoledronic Acid 4Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3489","Standard Price":399.397647058824,"Note":"**"},{"Itemcode":"74120732","Description":"Lamivudine/Zidovudine 150/300","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74120733","Description":"Fosinopril Na 20 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120736","Description":"Perindopril 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120737","Description":"Tenofovir Disoproxil 300Mg Tab","CDM Revenue Code":"637","Standard Price":106.5,"Note":"**"},{"Itemcode":"74120740","Description":"Tramadol 37.5Mg/Apap Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120741","Description":"Fondaparinux Na 2.5Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J1652","Standard Price":134.429439252337,"Note":"**"},{"Itemcode":"74120742","Description":"Lansoprazole Granules 15Mg Pkt","CDM Revenue Code":"637","Standard Price":17.25},{"Itemcode":"74120744","Description":"Desloratadine 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120747","Description":"Lidocaine 4% Topical 5Gm Tube","CDM Revenue Code":"250","Standard Price":59.0765688913103,"Note":"**"},{"Itemcode":"74120748","Description":"Olanzapine 2.5Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120749","Description":"Argatroban 250Mg/2.5Ml","CDM Revenue Code":"636","CDM HCPCS":"J0883","Standard Price":4595.86,"Note":"**"},{"Itemcode":"74120751","Description":"Fluoxetine 90Mg Capsule","CDM Revenue Code":"637","Standard Price":108.75},{"Itemcode":"74120752","Description":"Bupropion Hcl 100Mg Sr Tablet","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74120753","Description":"Miconazole Af Powder 90Gm","CDM Revenue Code":"637","Standard Price":14.25,"Note":"**"},{"Itemcode":"74120754","Description":"Oxcarbazepine 300Mg/5Ml 60 Ml","CDM Revenue Code":"637","Standard Price":42.75},{"Itemcode":"74120756","Description":"Hydromorphone 25Mg/25Ml Pca","CDM Revenue Code":"250","Standard Price":497.002105263158,"Note":"**"},{"Itemcode":"74120757","Description":"Mycophenolate Mofetil 500Mg Vl","CDM Revenue Code":"250","Standard Price":458.35,"Note":"**"},{"Itemcode":"74120758","Description":"Azithromycin 600 Mg Tablet","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74120759","Description":"Pegfilgrastim 6Mg/0.6Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":16831.745,"Note":"**"},{"Itemcode":"74120760","Description":"Arsenic Trioxide 10Mg/10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":2739.8},{"Itemcode":"74120761","Description":"Lorazepam 2Mg/Ml Oral Conc 1Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120763","Description":"Cefazolin 2Gm Inj","CDM Revenue Code":"636","CDM HCPCS":"J0690","Standard Price":59.74,"Note":"**"},{"Itemcode":"74120764","Description":"Cefazolin 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0690","Standard Price":59.4483185840708,"Note":"**"},{"Itemcode":"74120765","Description":"Olanzapine Zydis 10 Mg Tablet","CDM Revenue Code":"637"},{"Itemcode":"74120766","Description":"Famciclovir 125 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120767","Description":"Ziprasidone Hcl 20 Mg Capsule","CDM Revenue Code":"637","Standard Price":8.28,"Note":"**"},{"Itemcode":"74120768","Description":"Ziprasidone Hcl40 Mg Capsule","CDM Revenue Code":"637","Standard Price":41.03,"Note":"**"},{"Itemcode":"74120769","Description":"Fexofenadine Hcl 180 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120770","Description":"Galantamine Hbr 4 Mg Tablet","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74120771","Description":"Asparaginase 10:000 Unit Vial","CDM Revenue Code":"636","CDM HCPCS":"J9020","Standard Price":258.53},{"Itemcode":"74120772","Description":"Paroxetine Hcl Cr 12.5 Mg Tab","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74120774","Description":"Tiagabine Hcl 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":23.25},{"Itemcode":"74120775","Description":"Chromagen Forte Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120777","Description":"Doxercalciferol 2.5 Mcg Cap","CDM Revenue Code":"637","Standard Price":101.25},{"Itemcode":"74120779","Description":"Aminocaproic Aci1000mg/4ml Liq","CDM Revenue Code":"637","Standard Price":117.0},{"Itemcode":"74120780","Description":"Divalpoex Na Er 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":16.3,"Note":"**"},{"Itemcode":"74120781","Description":"Loxapine 25 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120782","Description":"Meloxicam 7.5 Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120783","Description":"Mirtazapine Soltb 15 Mg Tablet","CDM Revenue Code":"637","Standard Price":14.25,"Note":"**"},{"Itemcode":"74120784","Description":"Capecitabine 500 Mg Capsule","CDM Revenue Code":"636","CDM HCPCS":"J8521","Standard Price":148.184175824176,"Note":"**"},{"Itemcode":"74120787","Description":"Hyoscyamine 0.125Mg/5 Ml 60Ml","CDM Revenue Code":"637","Standard Price":30.0},{"Itemcode":"74120788","Description":"Didanosine Ec 400 Mg Capsule","CDM Revenue Code":"637","Standard Price":26.25},{"Itemcode":"74120789","Description":"Magnesium Oxide 250 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120790","Description":"Augmentin 600Mg Susp 75 Ml Bot","CDM Revenue Code":"637","Standard Price":60.75},{"Itemcode":"74120791","Description":"Fulvastatin XL 80 Mg Tablet","CDM Revenue Code":"637","Standard Price":30.75},{"Itemcode":"74120792","Description":"Heparin 2000 U/2 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":59.08,"Note":"**"},{"Itemcode":"74120793","Description":"Clindamycin 900Mg/50Ml Pm","CDM Revenue Code":"250","Standard Price":59.0487087924116,"Note":"**"},{"Itemcode":"74120797","Description":"Risedronate Na 35 Mg Tablet","CDM Revenue Code":"637","Standard Price":222.75},{"Itemcode":"74120798","Description":"Oxaliplatin 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9263","Standard Price":258.53,"Note":"**"},{"Itemcode":"74120799","Description":"Hydromorphone Syrp 1 Mg/Ml Chg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120800","Description":"Thyrotropin Alfa Inj 1.1Mg","CDM Revenue Code":"636","CDM HCPCS":"J3240","Standard Price":6242.61584158416,"Note":"**"},{"Itemcode":"74120801","Description":"Racepinephrine 2.25% Inh 0.5Ml","CDM Revenue Code":"250","Standard Price":57.8085493506494,"Note":"**"},{"Itemcode":"74120803","Description":"Olanzapine 5 Mg Quick Dis Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120804","Description":"Antithymocute Globulin 250Mg","CDM Revenue Code":"636","CDM HCPCS":"J7504","Standard Price":7354.2},{"Itemcode":"74120805","Description":"Haloperidol Conc. 2Mg/1Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120806","Description":"Gatiramer Ace 20Mg/Ml Syr Inj","CDM Revenue Code":"636","CDM HCPCS":"J1595","Standard Price":953.78},{"Itemcode":"74120809","Description":"Escitalopram 10Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120810","Description":"Temozolomide 100Mg Capsule","CDM Revenue Code":"636","CDM HCPCS":"J8700","Standard Price":252.35},{"Itemcode":"74120811","Description":"Baclofen 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.49,"Note":"**"},{"Itemcode":"74120813","Description":"Cetirizine 5Mg/5Ml Syrup","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120814","Description":"Cetirizine 10Mg/10Ml Syrup","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120815","Description":"Didanosine Ec 250Mg Capsule","CDM Revenue Code":"637","Standard Price":17.25},{"Itemcode":"74120817","Description":"Methscopolamine 2.5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120818","Description":"Carbamazepine Susp 200Mg/10Ml","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74120819","Description":"Voriconazole 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":24.75,"Note":"**"},{"Itemcode":"74120820","Description":"Esmolol 2500Mg/Ns 250Ml Bag","CDM Revenue Code":"250","Standard Price":1519.353,"Note":"**"},{"Itemcode":"74120821","Description":"Niacinamide 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120822","Description":"Cilostazol 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120823","Description":"Zyvox 100Mg/5Ml 150Ml Susp","CDM Revenue Code":"637","Standard Price":1668.75},{"Itemcode":"74120824","Description":"Linezolid 600Mg/300 Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J2020","Standard Price":116.025282327586,"Note":"**"},{"Itemcode":"74120825","Description":"Fosphenytion 500 Mg/10 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"Q2009","Standard Price":57.3476474137931,"Note":"**"},{"Itemcode":"74120826","Description":"Tacrolimus Inj 5Mg/1MlAmp","CDM Revenue Code":"636","CDM HCPCS":"J7525","Standard Price":801.34},{"Itemcode":"74120827","Description":"Foscarnet Na 6000Mg/250 Ml Bot","CDM Revenue Code":"636","CDM HCPCS":"J1455","Standard Price":1589.29,"Note":"**"},{"Itemcode":"74120829","Description":"Bimatoprost.03% Opth Sol 2.5Ml","CDM Revenue Code":"637","Standard Price":492.75,"Note":"**"},{"Itemcode":"74120830","Description":"Ziprasidone Mes. 20 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J3486","Standard Price":150.781175993641,"Note":"**"},{"Itemcode":"74120831","Description":"Losartan 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74120832","Description":"Valsartan 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120833","Description":"Voriconazole 200 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J3465","Standard Price":627.474297520661,"Note":"**"},{"Itemcode":"74120834","Description":"Darbepoetin Alfa 200Mcg/1Ml","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":6001.81},{"Itemcode":"74120835","Description":"DarbepoetinAlfa100Mcg/0.5ml In","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":3000.39},{"Itemcode":"74120837","Description":"Octreotide 30Mg Depot Kit Inj","CDM Revenue Code":"636","CDM HCPCS":"J2353","Standard Price":24677.77,"Note":"**"},{"Itemcode":"74120840","Description":"Access Pak Hiv Pep Expand. Kit","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120841","Description":"Access Pak Hiv Pep Basic Kit","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120842","Description":"Modafinil 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":27.75,"Note":"**"},{"Itemcode":"74120843","Description":"Zonisamide 100 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120844","Description":"Cefotaxime 95Mg/1Ml Syringe","CDM Revenue Code":"250","Standard Price":59.0991111111111,"Note":"**"},{"Itemcode":"74120845","Description":"Metoclopramide 5Mg/1Ml Charge","CDM Revenue Code":"636","CDM HCPCS":"J2765","Standard Price":59.74},{"Itemcode":"74120846","Description":"Ertapenem Na 1 Gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J1335","Standard Price":513.906977338129,"Note":"**"},{"Itemcode":"74120847","Description":"Levofloxacin 0.5% Opth Sol 5Ml","CDM Revenue Code":"250","Standard Price":265.74},{"Itemcode":"74120848","Description":"Carvediol 25 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120850","Description":"Pentosan Polysulf Na 100Mg Cap","CDM Revenue Code":"637","Standard Price":24.75,"Note":"**"},{"Itemcode":"74120851","Description":"Vesanoid 10Mg Cap","CDM Revenue Code":"637","Standard Price":82.5,"Note":"**"},{"Itemcode":"74120852","Description":"Pimecrolimus 1% Cr 30Gm Tube","CDM Revenue Code":"637","Standard Price":776.25,"Note":"**"},{"Itemcode":"74120853","Description":"Dextrose 10% 5Ml Ampule","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74120855","Description":"Teriparatide 750Mcg/3Ml Injpen","CDM Revenue Code":"637","CDM HCPCS":"J3110","Standard Price":2214.75,"Note":"**"},{"Itemcode":"74120856","Description":"Pentobarbital 1000Mg/20Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2515","Standard Price":4583.5,"Note":"**"},{"Itemcode":"74120857","Description":"Brimodine 0.15% 0.5Ml Op Syrin","CDM Revenue Code":"637","Standard Price":39.75},{"Itemcode":"74120859","Description":"Valproate Na Syp 50Mg/1Ml 5Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120860","Description":"Dutasteride 0.5 Mg Capsule","CDM Revenue Code":"637","Standard Price":18.0,"Note":"**"},{"Itemcode":"74120861","Description":"Olmesartan Medoxomil 20Mg Tab","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74120862","Description":"Fluconazole 400Mg/200Ml Pm","CDM Revenue Code":"636","CDM HCPCS":"J1450","Standard Price":59.1404227642277,"Note":"**"},{"Itemcode":"74120863","Description":"Ezetimibe 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":31.48,"Note":"**"},{"Itemcode":"74120864","Description":"Nevirapine 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120866","Description":"Bivalirudin 250 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0583","Standard Price":4019.14412803532,"Note":"**"},{"Itemcode":"74120867","Description":"Fomepizole 1.5Gm/1.5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1451","Standard Price":2889.83666666667,"Note":"**"},{"Itemcode":"74120868","Description":"Albendazole 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":306.0,"Note":"**"},{"Itemcode":"74120870","Description":"Augmentin Xr 1000Mg Tab","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74120873","Description":"Moxifloxacin 400Mg/Ns 250MlINJ","CDM Revenue Code":"636","CDM HCPCS":"J2280","Standard Price":145.305533333333,"Note":"**"},{"Itemcode":"74120874","Description":"Letrozole 2.5Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":6.18,"Note":"**"},{"Itemcode":"74120875","Description":"Oxazepam 15 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120876","Description":"Moxifloxacin 400 Mg Tablet","CDM Revenue Code":"637","Standard Price":30.0,"Note":"**"},{"Itemcode":"74120877","Description":"Budesonide Ec 3 Mg Capsule","CDM Revenue Code":"637","Standard Price":54.75,"Note":"**"},{"Itemcode":"74120879","Description":"Granisetron 100Mcg/1Ml Syringe","CDM Revenue Code":"636","CDM HCPCS":"J1626","Standard Price":6.18},{"Itemcode":"74120881","Description":"Paroxetine Er 37.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":14.25},{"Itemcode":"74120882","Description":"Pravastatin 80 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120884","Description":"Adenosine 90Mg/30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0153","Standard Price":285.31},{"Itemcode":"74120887","Description":"Crofab Snake Antiven<=1GM Vial","CDM Revenue Code":"636","CDM HCPCS":"J0840","Standard Price":9505.64928571428,"Note":"**"},{"Itemcode":"74120888","Description":"Valganciclovir 450 Mg Tablet","CDM Revenue Code":"637","Standard Price":250.5,"Note":"**"},{"Itemcode":"74120889","Description":"Nacl 0.45%%/Kcl 20 Meq 1000 Ml","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":58.9983056668574,"Note":"**"},{"Itemcode":"74120893","Description":"Interferon Beta-1A 22Mcg(Rebif","CDM Revenue Code":"636","CDM HCPCS":"Q3027","Standard Price":2344.28},{"Itemcode":"74120894","Description":"Olmesartan Medoxomil 40Mg Tab","CDM Revenue Code":"637","Standard Price":29.25,"Note":"**"},{"Itemcode":"74120895","Description":"Caffeine Citrate 60Mg/3Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0706","Standard Price":58.71,"Note":"**"},{"Itemcode":"74120896","Description":"Caffeine Citrate 20Mg/1Ml Liq","CDM Revenue Code":"637","Standard Price":34.5,"Note":"**"},{"Itemcode":"74120897","Description":"Caffeine&Na Benzoate 500Mg/2Ml","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74120898","Description":"Adderall Xr 25Mg","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74120901","Description":"Sildenafil 50Mg Tablet","CDM Revenue Code":"637","Standard Price":175.5},{"Itemcode":"74120902","Description":"Bupivacaine O.5% W/Epi 50Ml Vl","CDM Revenue Code":"250","Standard Price":58.9912477396022,"Note":"**"},{"Itemcode":"74120904","Description":"Buproprion Xl 150Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120905","Description":"Atazanavir 200Mg Cap","CDM Revenue Code":"637","Standard Price":69.75},{"Itemcode":"74120906","Description":"Voriconazole 50Mg Tab","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74120907","Description":"Aripiprazole 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120910","Description":"Prednisone Liquid 5Mg/5 Ml Cup","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":6.18,"Note":"**"},{"Itemcode":"74120911","Description":"Quetiapine Fumarate 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120912","Description":"Quetiapine Fumarate 200 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120913","Description":"Quinapril 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74120914","Description":"Eprosartan 600 Mg Tablet","CDM Revenue Code":"637","Standard Price":8.25},{"Itemcode":"74120915","Description":"Goserelin Acetate 10.8Mg Syrin","CDM Revenue Code":"636","CDM HCPCS":"J9202","Standard Price":7702.34},{"Itemcode":"74120916","Description":"Aprepitant 125Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"J8501","Standard Price":1319.43},{"Itemcode":"74120917","Description":"Aprepitant 80Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"J8501","Standard Price":844.6},{"Itemcode":"74120918","Description":"Lamivudine Soln 25Mg/5Ml 60Ml","CDM Revenue Code":"637","Standard Price":146.25},{"Itemcode":"74120919","Description":"Bortezomib 3.5Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9041","Standard Price":6714.22666666667,"Note":"**"},{"Itemcode":"74120920","Description":"InsulinAspartProt/Aspar10MLInj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":123.75,"Note":"**"},{"Itemcode":"74120921","Description":"Insulin Novolog 1000U/10Ml Via","CDM Revenue Code":"637","Standard Price":124.5,"Note":"**"},{"Itemcode":"74120923","Description":"Stalevo 50","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74120924","Description":"Stalevo 100 Tab","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74120925","Description":"Stalevo 150","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74120926","Description":"Gefitinib 250Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8565","Standard Price":1074.29},{"Itemcode":"74120927","Description":"Aripiprazole 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120928","Description":"Aripiprazole 15Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120929","Description":"Secretin Acetate 16Mcg Vial","CDM Revenue Code":"636","CDM HCPCS":"J2850","Standard Price":2227.89},{"Itemcode":"74120930","Description":"Pramipexole 1Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120931","Description":"Pramipexole 0.125Mg Tablet","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74120932","Description":"Hepatitis A (Inac)/Hepatitis B","CDM Revenue Code":"250","Standard Price":409.94},{"Itemcode":"74120934","Description":"Dexamethasone 1Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120935","Description":"Ca Carbonate 1250Mg/5Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120936","Description":"Eplerenone 25 Mg Tablet","CDM Revenue Code":"637","Standard Price":31.5,"Note":"**"},{"Itemcode":"74120937","Description":"Calcitonin Nasal Spray 30 Dose","CDM Revenue Code":"637","Standard Price":188.25,"Note":"**"},{"Itemcode":"74120938","Description":"Mesna 400 Mg Tablet","CDM Revenue Code":"637","Standard Price":235.5},{"Itemcode":"74120939","Description":"Guaifenesin 600Mg Tbsa","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120940","Description":"Morphine Sulfate Beads 30Mg Sa","CDM Revenue Code":"637","Standard Price":13.5},{"Itemcode":"74120941","Description":"Kaletra 400/100 Liq 60 Ml Bot","CDM Revenue Code":"637","Standard Price":33.0},{"Itemcode":"74120942","Description":"Somatropin Inj 0.4 Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J2941","Standard Price":208.06},{"Itemcode":"74120944","Description":"Alfuzosin Hcl 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120945","Description":"Rosuvastatin Ca 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":26.25,"Note":"**"},{"Itemcode":"74120946","Description":"Memantine Hcl 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120947","Description":"Atazanavir Sulfate 150Mg Cap","CDM Revenue Code":"637","Standard Price":73.5,"Note":"**"},{"Itemcode":"74120948","Description":"Fosamprenavir Ca 700 Mg Tablet","CDM Revenue Code":"637","Standard Price":57.75},{"Itemcode":"74120949","Description":"Emrticitabine 200 Mg Capsule","CDM Revenue Code":"637","Standard Price":54.0,"Note":"**"},{"Itemcode":"74120950","Description":"Valsartan 320 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120951","Description":"Sirolimus 1 Mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J7520","Standard Price":59.2179452054794,"Note":"**"},{"Itemcode":"74120953","Description":"Nacl 0.9% 25Ml Bag","CDM Revenue Code":"258","Standard Price":59.0005128205128,"Note":"**"},{"Itemcode":"74120956","Description":"Magnebind-400 Tablet","CDM Revenue Code":"637","Standard Price":4.45,"Note":"**"},{"Itemcode":"74120958","Description":"Propafenone Sr 325Mg Tbsa","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74120960","Description":"Daptomycin 500 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0878","Standard Price":1864.38455223881,"Note":"**"},{"Itemcode":"74120961","Description":"Zolmitriptan Zmt 2.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":292.5,"Note":"**"},{"Itemcode":"74120962","Description":"Midazolam 100Mg/100Ml Drip","CDM Revenue Code":"636","CDM HCPCS":"J2250","Standard Price":272.36548409894,"Note":"**"},{"Itemcode":"74120963","Description":"Buprenorphine-Naloxone 8Mgsltb","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74120964","Description":"Fentanyl 2Mcg/Mlw/Marc 100Mlob","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":109.081579349817,"Note":"**"},{"Itemcode":"74120967","Description":"Lansoprazole 30 Mg Soluble Tab","CDM Revenue Code":"637","Standard Price":39.75,"Note":"**"},{"Itemcode":"74120968","Description":"Tiotropium Inhaler/5 Capsules","CDM Revenue Code":"637","Standard Price":114.0,"Note":"**"},{"Itemcode":"74120969","Description":"Palonosetron 0.25Mg/5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2469","Standard Price":618.442803738318,"Note":"**"},{"Itemcode":"74120972","Description":"Rasburicase 1.5Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2783","Standard Price":3261.37068965518,"Note":"**"},{"Itemcode":"74120973","Description":"Doxorubicin 50Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9000","Standard Price":117.186934306569,"Note":"**"},{"Itemcode":"74120975","Description":"Megestrol 400Mg/10Ml Liq Ud","CDM Revenue Code":"250","CDM HCPCS":"J9999","Standard Price":58.9068663870581,"Note":"**"},{"Itemcode":"74120976","Description":"Metronidazole 0.75% Cream 45Gm","CDM Revenue Code":"637","Standard Price":665.25,"Note":"**"},{"Itemcode":"74120977","Description":"Cyclosporine (Gengraf) 25Mg","CDM Revenue Code":"636","CDM HCPCS":"J7515","Standard Price":59.74,"Note":"**"},{"Itemcode":"74120978","Description":"Cyclosporine (Gengraf) 100Mg","CDM Revenue Code":"636","CDM HCPCS":"J7502","Standard Price":59.5683333333333,"Note":"**"},{"Itemcode":"74120979","Description":"Venlafaxine Hcl 75Mg Cpsa","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120981","Description":"Oxandrolone 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74120982","Description":"Lansoprazole 15 Mg Soluble Tab","CDM Revenue Code":"637","Standard Price":39.75},{"Itemcode":"74120983","Description":"Atovaquone Susp 750Mg/5Ml Pkt","CDM Revenue Code":"637","Standard Price":81.75,"Note":"**"},{"Itemcode":"74120984","Description":"Verapamil Pm 100Mg (Verelan)","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74120987","Description":"Alendronate 35Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74120988","Description":"Arginine Hcl 10% 300Ml","CDM Revenue Code":"250","Standard Price":146.26},{"Itemcode":"74120989","Description":"Azacitidine 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9025","Standard Price":2449.28277777777,"Note":"**"},{"Itemcode":"74120990","Description":"Acetylcysteine200Mg/ML INJ30ML","CDM Revenue Code":"636","CDM HCPCS":"J0132","Standard Price":789.9585,"Note":"**"},{"Itemcode":"74120991","Description":"SOD Bicarbonate 4.2% 5 Ml Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74120992","Description":"Metaxalone 800 Mg Tablet","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74120993","Description":"Cyclosporin Sol 100Mg/Ml 50Ml","CDM Revenue Code":"636","CDM HCPCS":"J7502","Standard Price":1843.7},{"Itemcode":"74120994","Description":"Pemetrexed 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9305","Standard Price":13457.98},{"Itemcode":"74120995","Description":"Leuprolide Acetate 22.5Mg (Sq)","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":5750.49},{"Itemcode":"74120997","Description":"Alprazolam Xr 1Mg Tbsa","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121003","Description":"Hydromorphone 1Mg/1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":58.2912990406957,"Note":"**"},{"Itemcode":"74121004","Description":"Duloxetine 30 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121005","Description":"Novolin 70/30 100Units/1Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":4.5},{"Itemcode":"74121009","Description":"Genteal Lubricant Eyegel 3.5Ml","CDM Revenue Code":"250","Standard Price":58.5005917274939,"Note":"**"},{"Itemcode":"74121010","Description":"Ketorolac 0.1Ml Ophth Syringe","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121011","Description":"Cenestin 0.3Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121014","Description":"Venofer 100Mg/5Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1756","Standard Price":125.410303030303,"Note":"**"},{"Itemcode":"74121016","Description":"Amiodarone Hcl 150Mg Syringe","CDM Revenue Code":"636","CDM HCPCS":"J0282","Standard Price":58.7481481481481,"Note":"**"},{"Itemcode":"74121017","Description":"Cetuximab 100Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9055","Standard Price":2449.34},{"Itemcode":"74121018","Description":"Cromolyn Oral Conc. 100Mg/5Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121019","Description":"Lactobacillus Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121021","Description":"Bumetanide 0.5Mg/2Ml Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121022","Description":"Amiodarone 450 Mg Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121023","Description":"Enfuvirtide 90 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J1324","Standard Price":190.55},{"Itemcode":"74121024","Description":"Adderall Xr 5Mg","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74121025","Description":"Oxybutynin 3.9Mg/24Hr Patch","CDM Revenue Code":"637","Standard Price":222.0,"Note":"**"},{"Itemcode":"74121026","Description":"Natalizumab 300Mg/15Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2323","Standard Price":19242.2655875,"Note":"**"},{"Itemcode":"74121028","Description":"Trypan Blue (Vision Blue)0.5Ml","CDM Revenue Code":"250","Standard Price":212.329389312977,"Note":"**"},{"Itemcode":"74121029","Description":"Trandolapril 4Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121031","Description":"Fenofibrate 145 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121032","Description":"VonWilbrndFctr Com Inj 1IU","CDM Revenue Code":"636","CDM HCPCS":"J7187","Standard Price":10.3592605284516,"Note":"**"},{"Itemcode":"74121033","Description":"Paclitaxel Proteinbnd Inj100Mg","CDM Revenue Code":"636","CDM HCPCS":"J9264","Standard Price":4929.58,"Note":"**"},{"Itemcode":"74121034","Description":"Olanzapine/Fluoxeti 6/25Mg Cap","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74121035","Description":"Sodium Citrate 4% 3Ml Syringe","CDM Revenue Code":"250","Standard Price":58.916,"Note":"**"},{"Itemcode":"74121036","Description":"Metformin 500Ml/5Mg Soln Ud","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121037","Description":"Baclofen Inj 40 Mg/2O Ml","CDM Revenue Code":"636","CDM HCPCS":"J0475","Standard Price":2808.81},{"Itemcode":"74121040","Description":"Fenofibrate 48Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121041","Description":"Gambro Bgk 2/0 5000Ml Bag","CDM Revenue Code":"250","Standard Price":352.26,"Note":"**"},{"Itemcode":"74121042","Description":"Gambro 4/0 5000Ml Bag","CDM Revenue Code":"250","Standard Price":82.6848936170212,"Note":"**"},{"Itemcode":"74121043","Description":"Acd Formula A 2.2% 1000Ml Bag","CDM Revenue Code":"250","Standard Price":58.9085312615613,"Note":"**"},{"Itemcode":"74121044","Description":"Ropinirole Hcl 4 Mg Tablet","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74121049","Description":"Cadexomer Iodine 10Gm Pad","CDM Revenue Code":"250","Standard Price":58.6609523809523,"Note":"**"},{"Itemcode":"74121050","Description":"Duloxetine 20Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121051","Description":"Nitazoxanide 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":241.5,"Note":"**"},{"Itemcode":"74121052","Description":"Bupivacaine 0.5% 50 Ml Vial","CDM Revenue Code":"250","Standard Price":59.098115942029,"Note":"**"},{"Itemcode":"74121053","Description":"Bupivacaine 0.25% 50 Ml Vial","CDM Revenue Code":"250","Standard Price":58.8025842696629,"Note":"**"},{"Itemcode":"74121054","Description":"Cytarabine Liposome 50Mg/5Ml","CDM Revenue Code":"636","CDM HCPCS":"J9098","Standard Price":12578.36},{"Itemcode":"74121055","Description":"Propafenone Sr 225 Mg Tablet","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74121056","Description":"Cyclosporine 0.05% Opth 0.4 Ml","CDM Revenue Code":"250","Standard Price":59.066446025641,"Note":"**"},{"Itemcode":"74121058","Description":"Phenylephrine 10%Viscous 5Mlop","CDM Revenue Code":"637"},{"Itemcode":"74121059","Description":"Cefdinir 300Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121060","Description":"Cefdinir 125Mg/5Ml 60Ml Susp","CDM Revenue Code":"637","Standard Price":6.75,"Note":"**"},{"Itemcode":"74121061","Description":"Cefdinir 250Mg/5Ml 60Ml Susp","CDM Revenue Code":"637","Standard Price":261.75},{"Itemcode":"74121062","Description":"Azithromycin 500Mg/Ns 250Ml","CDM Revenue Code":"636","CDM HCPCS":"J0456","Standard Price":224.54},{"Itemcode":"74121063","Description":"Hyaluronidase,Ovine200UnitsInj","CDM Revenue Code":"636","CDM HCPCS":"J3471","Standard Price":316.21},{"Itemcode":"74121064","Description":"Albuterol 0.5% 2.5Mg/0.5Ml Neb","CDM Revenue Code":"250","Standard Price":58.347215373643,"Note":"**"},{"Itemcode":"74121065","Description":"Senna Syrup 5 Ml Dose","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121066","Description":"Rifaximin 200Mg Tablet","CDM Revenue Code":"637","Standard Price":52.5,"Note":"**"},{"Itemcode":"74121070","Description":"Liothyronine Na 25 Mcg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121073","Description":"Loteprednol 0.5% 5 Ml Opthdrop","CDM Revenue Code":"637","Standard Price":617.25,"Note":"**"},{"Itemcode":"74121075","Description":"Definity 1.1Mg/1Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"Q9957","Standard Price":822.80826446281,"Note":"**"},{"Itemcode":"74121076","Description":"Estrogens Conjugated 0.45Mg Tb","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74121077","Description":"Tigecycline 50 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J3243","Standard Price":643.752231666667,"Note":"**"},{"Itemcode":"74121078","Description":"Ciprofloxacin-Dexam.Otic 7.5Ml","CDM Revenue Code":"637","Standard Price":595.5,"Note":"**"},{"Itemcode":"74121079","Description":"Fentanyl 5Mcg/Ml W/Marc 0.075%","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":326.175945945946,"Note":"**"},{"Itemcode":"74121080","Description":"Pregabalin 75Mg Capsule","CDM Revenue Code":"637","Standard Price":22.49,"Note":"**"},{"Itemcode":"74121081","Description":"Fentanyl Transdermal12.5Mcg/Hr","CDM Revenue Code":"637","Standard Price":24.0,"Note":"**"},{"Itemcode":"74121083","Description":"Moxifloxacin 0.5% 3Ml Opth Sol","CDM Revenue Code":"250","Standard Price":650.015833333333,"Note":"**"},{"Itemcode":"74121086","Description":"Pregabalin 25 Mg Capsule","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74121087","Description":"Cinacalcet Hcl 30 Mg Tablet","CDM Revenue Code":"637","Standard Price":81.0,"Note":"**"},{"Itemcode":"74121088","Description":"Isovue (Ioamidol) 61%% 100 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":90.8404621338913,"Note":"**"},{"Itemcode":"74121091","Description":"Pregabalin 50Mg Capsule","CDM Revenue Code":"637","Standard Price":22.48,"Note":"**"},{"Itemcode":"74121092","Description":"Penicillin G Benzathine 2.4Mu","CDM Revenue Code":"636","CDM HCPCS":"J0561","Standard Price":1150.146925,"Note":"**"},{"Itemcode":"74121093","Description":"Vancomycin 25Mg/0.25Ml Op Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":59.74},{"Itemcode":"74121095","Description":"Hydrocortisone 0.5% Oint","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121097","Description":"Sildenafil Citrate 20Mg Tab","CDM Revenue Code":"637","Standard Price":130.5,"Note":"**"},{"Itemcode":"74121098","Description":"Ramelteon 8Mg Tablet","CDM Revenue Code":"637","Standard Price":36.0,"Note":"**"},{"Itemcode":"74121099","Description":"Carbonyl Iron 45 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121100","Description":"Lithium Citrate 300Mg/5Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121101","Description":"Darifenacin Hbr 7.5Mg Tablet","CDM Revenue Code":"637","Standard Price":36.0},{"Itemcode":"74121103","Description":"Mometasone (Oral)Inh 220Mcg","CDM Revenue Code":"637","Standard Price":210.75,"Note":"**"},{"Itemcode":"74121105","Description":"Metformin Hcl Xr 750 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121107","Description":"Zonisamide 25 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121108","Description":"Ondansetron 4Mg Odt Tablet","CDM Revenue Code":"250","CDM HCPCS":"Q0162","Standard Price":58.2079790539836,"Note":"**"},{"Itemcode":"74121109","Description":"Albuterol Inhaler Per Use 1Inh","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121110","Description":"Lidocaine 1% Mpf 2Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.138795263038,"Note":"**"},{"Itemcode":"74121111","Description":"Visipaque 320Mg/Ml 200 Ml Bot","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":742.63},{"Itemcode":"74121115","Description":"Poractant Alfa 240Mg/3Ml Vial","CDM Revenue Code":"250","Standard Price":3220.01146067415,"Note":"**"},{"Itemcode":"74121116","Description":"Cefazolin/D5W 1000Mg/50Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J0690","Standard Price":58.810626458037,"Note":"**"},{"Itemcode":"74121117","Description":"Ceftriaxone/D5W 1000Mg/50Mlbag","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":59.74},{"Itemcode":"74121118","Description":"Ceftriaxone/D5W 2000Mg/50Mlbag","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"74121119","Description":"Amiodarone 400Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121120","Description":"Talc (Intrapleural) 4Gm Aer","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121121","Description":"Isradipine Cr 10Mg","CDM Revenue Code":"637","Standard Price":12.0},{"Itemcode":"74121122","Description":"Lipase-Amylase-Proteas Creon20","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74121123","Description":"Risperidone 50 Mg Im Inj Kit","CDM Revenue Code":"636","CDM HCPCS":"J2794","Standard Price":3668.86,"Note":"**"},{"Itemcode":"74121124","Description":"Ropivacaine 1% 200Mg/20Ml Amp","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121125","Description":"Ropivacaine 0.2% 200 Mg/100Ml","CDM Revenue Code":"250","Standard Price":171.403411078717,"Note":"**"},{"Itemcode":"74121126","Description":"Fluphenazine Decan 25Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2680","Standard Price":268.83},{"Itemcode":"74121128","Description":"Non-Formulary Oral Antibiotic","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74121129","Description":"Tetracaine 0.5% Ophth 5 Ml Bot","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121132","Description":"Phenol Applicator(Apdyne)0.2Ml","CDM Revenue Code":"250","Standard Price":58.0545454545455,"Note":"**"},{"Itemcode":"74121133","Description":"Etanercept 25Mg/1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1438","Standard Price":2356.64},{"Itemcode":"74121134","Description":"Etanercept 50Mg/1Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1438","Standard Price":4809.07},{"Itemcode":"74121135","Description":"Gabapentin 200Mg/4Ml Soln Chg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121137","Description":"Glycerin U.S.P. 20Ml Bottle","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121138","Description":"Exenatide 300 Mcg/1.2Ml Pen","CDM Revenue Code":"637","Standard Price":2004.75},{"Itemcode":"74121139","Description":"Lopinavir-Ritonavir 200Mg/50Mg","CDM Revenue Code":"637","Standard Price":24.0,"Note":"**"},{"Itemcode":"74121140","Description":"Trypsin W/Castor Oil&Peruv Oin","CDM Revenue Code":"637","Standard Price":166.5},{"Itemcode":"74121142","Description":"Ropivacaine Hcl 0.2% 10Ml Amp","CDM Revenue Code":"250","Standard Price":58.7628205128206,"Note":"**"},{"Itemcode":"74121143","Description":"Lamotrigine 5 Mg Chew Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121144","Description":"Levalbuterol Tart 17Gm Inhaler","CDM Revenue Code":"637","Standard Price":204.75,"Note":"**"},{"Itemcode":"74121145","Description":"Felodipine 10Mg Tabsa","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121146","Description":"Felodipine 2.5Mg Tabsa","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121147","Description":"Risperidone 1 Mg/Ml Soln Chg","CDM Revenue Code":"637","Standard Price":33.0,"Note":"**"},{"Itemcode":"74121149","Description":"Telithromycin 400Mg Tab","CDM Revenue Code":"637","Standard Price":48.75},{"Itemcode":"74121150","Description":"Acamprosate Ca 333 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121151","Description":"Emtricitabine/Tenofovir Tablet","CDM Revenue Code":"637","Standard Price":155.3,"Note":"**"},{"Itemcode":"74121156","Description":"Nacl 0.9% 10Ml Charge","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121157","Description":"Lubiprostone 24 Mcg Capsule","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74121158","Description":"Tetracycline Syrup 500Mg/20Ml","CDM Revenue Code":"637","Standard Price":354.75},{"Itemcode":"74121159","Description":"Trimethobenzamide 300Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121160","Description":"Decitabine 50Mg Inj Vial","CDM Revenue Code":"636","CDM HCPCS":"J0894","Standard Price":2988.34692307692,"Note":"**"},{"Itemcode":"74121161","Description":"Albuterol Inh Hfa 200 Inh 18Gm","CDM Revenue Code":"637","Standard Price":150.85,"Note":"**"},{"Itemcode":"74121162","Description":"Sodium Cl (Ayr)Nasal Gel 14.1G","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74121163","Description":"Cefoxitin/D5W 1Gm/50Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J0694","Standard Price":59.74},{"Itemcode":"74121164","Description":"Cefoxitin/D5W 2Gm/50Ml","CDM Revenue Code":"636","CDM HCPCS":"J0694","Standard Price":85.8333333333333,"Note":"**"},{"Itemcode":"74121165","Description":"Loteprednol 0.2% 5Ml Opth Drop","CDM Revenue Code":"637","Standard Price":585.75},{"Itemcode":"74121166","Description":"Levetiracetam 500Mg/5 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1953","Standard Price":59.0023948598131,"Note":"**"},{"Itemcode":"74121168","Description":"Isosorbide 20Mg/Hydralaz37.5Mg","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74121169","Description":"Levetiracetam 100Mg/1Ml60Mlliq","CDM Revenue Code":"637","Standard Price":45.75},{"Itemcode":"74121173","Description":"Candesartan 8Mg Tablet","CDM Revenue Code":"637","Standard Price":9.75},{"Itemcode":"74121174","Description":"Bismuth Subgallate 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121175","Description":"Amoxicillin 875Mg Tablets","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121177","Description":"Bupivacaine 0.75% 30Ml Mpf Via","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74121178","Description":"Vecuronium 20Mg Inj","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74121179","Description":"Phenylephrine 1% 50Mg/5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2370","Standard Price":117.36412735849,"Note":"**"},{"Itemcode":"74121180","Description":"Multivitamin Childrens Chew Fe","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121181","Description":"Multivitamin Childrens Chew","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121185","Description":"Insulin Glargine 100U/Ml 3Ml","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":223.5,"Note":"**"},{"Itemcode":"74121186","Description":"Novolog70/30Mix 100U/Ml 3MLInj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":44.94,"Note":"**"},{"Itemcode":"74121187","Description":"NovologInsulin 100U/Ml 3Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":44.95,"Note":"**"},{"Itemcode":"74121189","Description":"Isradipine Er 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74121190","Description":"Levalbuterol 1.25Mg/0.5Ml Neb","CDM Revenue Code":"250","Standard Price":58.9692111182935,"Note":"**"},{"Itemcode":"74121191","Description":"Eszopiclone 1Mg Tablet","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74121192","Description":"Eszopiclone 2Mg Tablet","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74121193","Description":"Amoxicillin Susp 400Mg/5Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121194","Description":"Varenicline 0.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":19.5,"Note":"**"},{"Itemcode":"74121195","Description":"Lanthanum Carbonate 500Mg Chew","CDM Revenue Code":"637","Standard Price":36.0,"Note":"**"},{"Itemcode":"74121196","Description":"Rasagiline Mes. 0.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":69.75,"Note":"**"},{"Itemcode":"74121197","Description":"Omega 3 Acid 1 Gm Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121198","Description":"Lidocaine 4% Topical Per Use","CDM Revenue Code":"250","Standard Price":59.0721954288111,"Note":"**"},{"Itemcode":"74121199","Description":"Panitubumab 100Mg Injection","CDM Revenue Code":"636","CDM HCPCS":"J9303","Standard Price":4659.72},{"Itemcode":"74121201","Description":"Rasagiline 1Mg Tab","CDM Revenue Code":"637","Standard Price":36.75,"Note":"**"},{"Itemcode":"74121202","Description":"Cimetidine 200Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121203","Description":"Methylprednisolone 2000Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2930","Standard Price":326.51},{"Itemcode":"74121205","Description":"Oxychlorosene Na Powder 2 Gm","CDM Revenue Code":"637","Standard Price":30.0},{"Itemcode":"74121207","Description":"Atripla Tablet","CDM Revenue Code":"637","Standard Price":203.42,"Note":"**"},{"Itemcode":"74121208","Description":"Torsemide 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121209","Description":"Vitamin E 1000 Intntunits Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121211","Description":"Telmisartan 20Mg Tab","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74121212","Description":"Estradiol 0.075Mg Pat","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74121213","Description":"Estradiol 0.025Mg Pat","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74121214","Description":"Pramoxine 1%/Hc 1% 30Gm Cream","CDM Revenue Code":"637","Standard Price":174.0,"Note":"**"},{"Itemcode":"74121215","Description":"Pramoxone 2.5%/Hc 1% Crm 30Gm","CDM Revenue Code":"637","Standard Price":321.0,"Note":"**"},{"Itemcode":"74121216","Description":"Niacin 250Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121217","Description":"Saquinavir 500 Mg Tablet","CDM Revenue Code":"637","Standard Price":30.0},{"Itemcode":"74121218","Description":"Melphalan 50Mg Inj Vial","CDM Revenue Code":"636","CDM HCPCS":"J9245","Standard Price":0.0},{"Itemcode":"74121220","Description":"Cetaphil Cream 454Gm","CDM Revenue Code":"637","Standard Price":33.75,"Note":"**"},{"Itemcode":"74121221","Description":"Cetaphil Compounding Veh 453Gm","CDM Revenue Code":"637","Standard Price":38.25,"Note":"**"},{"Itemcode":"74121222","Description":"Cromolyn Na 4% Ophth 10Ml","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74121223","Description":"Carbamide Peroxide Liq 60Ml","CDM Revenue Code":"637","Standard Price":23.25,"Note":"**"},{"Itemcode":"74121225","Description":"Solifenacin Succinate 5Mg Tab","CDM Revenue Code":"637","Standard Price":31.5,"Note":"**"},{"Itemcode":"74121227","Description":"Sitagliptin Phosphate 50Mg Tab","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74121228","Description":"Fat Emulsion 30% 500 Ml Bottle","CDM Revenue Code":"258","Standard Price":230.72},{"Itemcode":"74121229","Description":"Nacl With Aloe Nasal Swab (Ayr","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121230","Description":"Morphine 1Mg/1Ml 100Ml Epi Cas","CDM Revenue Code":"258","Standard Price":122.57},{"Itemcode":"74121231","Description":"Hydromorphone 0.1Mg/1Ml 100Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121232","Description":"Sitagliptin 25Mg Tablet","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74121233","Description":"Sitagliptin 100Mg Tablet","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74121234","Description":"Risperidone 37.5 Mg Im Inj Kit","CDM Revenue Code":"636","CDM HCPCS":"J2794","Standard Price":2562.64},{"Itemcode":"74121238","Description":"Heparin Lock Flush 500U/5Ml Vl","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":28.9892901597676,"Note":"**"},{"Itemcode":"74121239","Description":"Heparin LockFlush 300U/3Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":58.3487813953488,"Note":"**"},{"Itemcode":"74121240","Description":"Linezolid Susp 600Mg/30 Ml Chg","CDM Revenue Code":"637","Standard Price":227.25,"Note":"**"},{"Itemcode":"74121241","Description":"Meperidine 10Mg/Ml 25Ml PCA","CDM Revenue Code":"250","Standard Price":59.0596330275229,"Note":"**"},{"Itemcode":"74121242","Description":"Dextroamphetamine Er 5Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121243","Description":"Ropivacaine 0.2% Cassett 100Ml","CDM Revenue Code":"250","Standard Price":521.695,"Note":"**"},{"Itemcode":"74121246","Description":"Fentanyl Pca 1250Mcg/25Ml Syrg","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":110.115589782119,"Note":"**"},{"Itemcode":"74121247","Description":"Gambro 4/2.5 5000 Ml Bag","CDM Revenue Code":"250","Standard Price":374.92},{"Itemcode":"74121248","Description":"HOCM: Gastrograffin 30 Ml Soln","CDM Revenue Code":"255","CDM HCPCS":"Q9963","Standard Price":59.0280528745645,"Note":"**"},{"Itemcode":"74121249","Description":"Triple Nipple Cream 45Gm","CDM Revenue Code":"637","Standard Price":201.75,"Note":"**"},{"Itemcode":"74121250","Description":"Adalimumab 40Mg/0.8Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0135","Standard Price":9422.44,"Note":"**"},{"Itemcode":"74121252","Description":"Carvediol Er 10 Mg Capsule","CDM Revenue Code":"637","Standard Price":27.75,"Note":"**"},{"Itemcode":"74121253","Description":"Tropsium Cl 20 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121256","Description":"Ondansetron 4Mg/5Ml Liq Ud","CDM Revenue Code":"636","CDM HCPCS":"Q0162","Standard Price":59.74,"Note":"**"},{"Itemcode":"74121257","Description":"Ondansetron 2Mg/2.5Ml Ud Liq","CDM Revenue Code":"636","CDM HCPCS":"J8597","Standard Price":77.25},{"Itemcode":"74121259","Description":"Carvediol Er 40 Mg Capsule","CDM Revenue Code":"637","Standard Price":27.75,"Note":"**"},{"Itemcode":"74121260","Description":"Aliskiren 150Mg Tablet","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74121261","Description":"Levetiracetam 500Mg/5Ml Cup","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121262","Description":"Lamivudine 100Mg Tablet","CDM Revenue Code":"637","Standard Price":48.75,"Note":"**"},{"Itemcode":"74121263","Description":"Paliperidone 9Mg Tbsa","CDM Revenue Code":"637","Standard Price":152.25},{"Itemcode":"74121265","Description":"Fondaparinux 7.5Mg/0.6Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1652","Standard Price":399.983333333333,"Note":"**"},{"Itemcode":"74121267","Description":"Olanzapine 10Mg Inj Vial","CDM Revenue Code":"250","Standard Price":138.408697524753,"Note":"**"},{"Itemcode":"74121268","Description":"Amantadine Syrup 50Mg/5Ml Cup","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74121269","Description":"Acetic Acid 0.25% Irr 500Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121270","Description":"Exenatide 600 Mcg/2.4Ml Pen","CDM Revenue Code":"637","Standard Price":2004.75},{"Itemcode":"74121271","Description":"Tipranavir 250Mg Capsule","CDM Revenue Code":"637","Standard Price":37.5},{"Itemcode":"74121272","Description":"Lanthanum Carbonate 1000Mg Chw","CDM Revenue Code":"637","Standard Price":36.0},{"Itemcode":"74121274","Description":"Torsemide 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121276","Description":"Leflunomide 10Mg Tablet","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74121277","Description":"Riboflavin 100Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121278","Description":"Clozapine 25Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121279","Description":"Ranolazine 500Mg Tbsa","CDM Revenue Code":"637","Standard Price":17.99,"Note":"**"},{"Itemcode":"74121280","Description":"Lidocaine 1% 1Ml Syringe","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":57.6835273972602,"Note":"**"},{"Itemcode":"74121283","Description":"Lidocaine 4% Topical 50Ml Nc","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74121284","Description":"Ropivacaine 100Mg/20Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2795","Standard Price":58.3022040816327,"Note":"**"},{"Itemcode":"74121285","Description":"Budesibude 90Mcg Powder Flxhle","CDM Revenue Code":"637","Standard Price":485.25,"Note":"**"},{"Itemcode":"74121286","Description":"Candesartan 4 Mg Tablet","CDM Revenue Code":"637","Standard Price":9.75,"Note":"**"},{"Itemcode":"74121287","Description":"Ethacrynic Acid 25Mg Tablet","CDM Revenue Code":"637","Standard Price":63.75},{"Itemcode":"74121288","Description":"Diphenhydramine 2% Cream 30Gm","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121289","Description":"Prosed Ds (Urised Ds) 1 Ea Tab","CDM Revenue Code":"637","Standard Price":8.25},{"Itemcode":"74121290","Description":"Cyanocobalamin 1000Mcg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121292","Description":"Epoprostenol Na 1.5 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J1325","Standard Price":186.43,"Note":"**"},{"Itemcode":"74121293","Description":"Omnipaque 180Mg/Ml 10 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"Q9965","Standard Price":163.253811538461,"Note":"**"},{"Itemcode":"74121296","Description":"Omnipaque 300 Mg/Ml 200 Ml Via","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":1179.35},{"Itemcode":"74121298","Description":"Omnipaque 350 Mg/Ml 50 Ml Vial","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":381.1},{"Itemcode":"74121299","Description":"Omnipaque 350 Mg/Ml 100 Ml Via","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":428.48},{"Itemcode":"74121300","Description":"Omnipaque 350 Mg/Ml 125 Ml Via","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":0.0},{"Itemcode":"74121301","Description":"Omnipaque 350 Mg/Ml 150 Ml Via","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":591.22},{"Itemcode":"74121303","Description":"Piroxicam 10Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121304","Description":"Budesonide 180 Mcg Inhaler","CDM Revenue Code":"637","Standard Price":649.5,"Note":"**"},{"Itemcode":"74121305","Description":"Gelfilm 12.5 Sq/Cm Pad","CDM Revenue Code":"250","Standard Price":868.29},{"Itemcode":"74121306","Description":"Gelfoam (12 - 7 Mm) 12 Sq/Cm","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121307","Description":"Balzalazide 750 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121308","Description":"Arformoterol 15Mcg/2Ml Neb","CDM Revenue Code":"250","Standard Price":59.5555223880597,"Note":"**"},{"Itemcode":"74121310","Description":"Symbicort 80/4.5 Mcg 6Gm Inh","CDM Revenue Code":"637","Standard Price":546.75,"Note":"**"},{"Itemcode":"74121311","Description":"Symbicort 160/4.5 Mcg 6Gm Inh","CDM Revenue Code":"637","Standard Price":629.25,"Note":"**"},{"Itemcode":"74121316","Description":"Tretinoin 0.1% Cream 20gm tube","CDM Revenue Code":"637","Standard Price":328.5,"Note":"**"},{"Itemcode":"74121317","Description":"Polymyxin B 100000 Unit/Ns 5Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121318","Description":"Temsirolimus 25Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9330","Standard Price":7146.14},{"Itemcode":"74121319","Description":"Fenofibrate 200Mg Capsule","CDM Revenue Code":"637","Standard Price":6.75,"Note":"**"},{"Itemcode":"74121320","Description":"Fenofibrate 67Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121321","Description":"Fenofibrate 134Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121322","Description":"Dornase Alfa Neb. Sol 1 Mg/Ml","CDM Revenue Code":"250","Standard Price":456.0325,"Note":"**"},{"Itemcode":"74121323","Description":"Retisert 0.59Mg Implant","CDM Revenue Code":"636","CDM HCPCS":"J7311","Standard Price":64641.255,"Note":"**"},{"Itemcode":"74121324","Description":"Mycophenolate 1000Mg/5Ml Susp","CDM Revenue Code":"636","CDM HCPCS":"J7517","Standard Price":166.86,"Note":"**"},{"Itemcode":"74121325","Description":"Metoprolol Tartrate 25 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121326","Description":"Nepafenac 0.1% Opth Soln 5Ml","CDM Revenue Code":"637","Standard Price":741.75},{"Itemcode":"74121329","Description":"Sulfur Soap 10 % Bar","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74121330","Description":"Adefovir Dipivoxil 10 Mg Tab","CDM Revenue Code":"637","Standard Price":73.5},{"Itemcode":"74121332","Description":"Abatacept 250 Mg/10 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0129","Standard Price":2305.89416949152,"Note":"**"},{"Itemcode":"74121333","Description":"Ixabepilone 15 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9207","Standard Price":4768.9},{"Itemcode":"74121335","Description":"Rivastigmine 4.6 Mg Patch","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74121336","Description":"Cevimeline Hcl 30 Mg Capsule","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74121337","Description":"Insulin Detemir 300 U/3Ml INJ","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":102.0},{"Itemcode":"74121338","Description":"Retapamulin 1% Oint 15 Gm Tube","CDM Revenue Code":"637","Standard Price":714.0},{"Itemcode":"74121339","Description":"Methenamine Mandelate 0.5 Gm","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121340","Description":"Mesalamine 1.2 Gm Tab","CDM Revenue Code":"637","Standard Price":27.75,"Note":"**"},{"Itemcode":"74121341","Description":"Rivastigmine 9.5 Mg Patch","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74121342","Description":"Benzocaine-Glycerin Spr .75 Oz","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74121343","Description":"Doxycycline 100Mg/Ns 250Ml","CDM Revenue Code":"250","Standard Price":59.0792452830188,"Note":"**"},{"Itemcode":"74121344","Description":"Erlotinib 100 Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":1005.28},{"Itemcode":"74121345","Description":"Erlotinib 150 Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":1106.22},{"Itemcode":"74121346","Description":"Tramadol Er 100Mg Tbsa","CDM Revenue Code":"637","Standard Price":8.25},{"Itemcode":"74121347","Description":"Raltegravir 400Mg Tab","CDM Revenue Code":"637","Standard Price":69.6,"Note":"**"},{"Itemcode":"74121348","Description":"Esmomeprazole 40Mg Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121349","Description":"Rosuvastatin 5Mg Tab","CDM Revenue Code":"637","Standard Price":26.25,"Note":"**"},{"Itemcode":"74121350","Description":"Temozolomide 20 Mg Capsule","CDM Revenue Code":"636","CDM HCPCS":"J8700","Standard Price":164.8},{"Itemcode":"74121351","Description":"Rosuvastatin Ca 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":26.25,"Note":"**"},{"Itemcode":"74121352","Description":"Stalevo 200 Tablet","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74121355","Description":"Esomeprazole 20 Mg Cap","CDM Revenue Code":"637","Standard Price":24.75},{"Itemcode":"74121356","Description":"Carbidopa/Levo 25/100 1 Ea Odt","CDM Revenue Code":"637","Standard Price":4.51,"Note":"**"},{"Itemcode":"74121357","Description":"Clopidogrel 300 Mg Tablet","CDM Revenue Code":"250","Standard Price":59.1011392405063,"Note":"**"},{"Itemcode":"74121358","Description":"Omalizumab 150 Mg/1.2 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2357","Standard Price":4297.63449438202,"Note":"**"},{"Itemcode":"74121359","Description":"Tiotropium Inhaler 30 Capsules","CDM Revenue Code":"637","Standard Price":777.0,"Note":"**"},{"Itemcode":"74121363","Description":"Heparin 30,000 UnitS/30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":58.8650965250965,"Note":"**"},{"Itemcode":"74121364","Description":"Cefotetan/D5W 1 Gm/50 Ml Bag","CDM Revenue Code":"250","Standard Price":58.5838775510204,"Note":"**"},{"Itemcode":"74121365","Description":"Cefotetan/D5W 2Gm/50Ml Bag","CDM Revenue Code":"250","Standard Price":58.9577215189873,"Note":"**"},{"Itemcode":"74121366","Description":"Nebivolol 5Mg Tablet","CDM Revenue Code":"637","Standard Price":12.0,"Note":"**"},{"Itemcode":"74121368","Description":"Triesence 40Mg/Ml Ophth Inj","CDM Revenue Code":"636","CDM HCPCS":"J3300","Standard Price":638.6,"Note":"**"},{"Itemcode":"74121369","Description":"Erlotinib 25Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":356.38},{"Itemcode":"74121370","Description":"Galantamine Hydrobrom Er 8 Mg","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74121371","Description":"Galantamine Hydrobrom Er 16 Mg","CDM Revenue Code":"637","Standard Price":32.25},{"Itemcode":"74121372","Description":"Caphosol Artificial Saliva30Ml","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74121373","Description":"Anti-Inhibitor Coag 1 Unit Chg","CDM Revenue Code":"636","CDM HCPCS":"J7198","Standard Price":6.18,"Note":"**"},{"Itemcode":"74121374","Description":"Dalteparin Sodium 2500 Units","CDM Revenue Code":"636","CDM HCPCS":"J1645","Standard Price":107.12},{"Itemcode":"74121375","Description":"Adderal Xr 10Mg","CDM Revenue Code":"637","Standard Price":21.0},{"Itemcode":"74121376","Description":"Paliperidone 3 Mg Tbsa","CDM Revenue Code":"637","Standard Price":102.0,"Note":"**"},{"Itemcode":"74121377","Description":"Entecavir 0.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":137.25,"Note":"**"},{"Itemcode":"74121378","Description":"Etomidate 2 Mg/Ml 20 Ml Vial","CDM Revenue Code":"250","Standard Price":58.6215932021467,"Note":"**"},{"Itemcode":"74121380","Description":"Regadenoson 0.4 Mg/5Ml Syringe","CDM Revenue Code":"636","CDM HCPCS":"J2785","Standard Price":994.080129464286,"Note":"**"},{"Itemcode":"74121381","Description":"Lidocaine 4% 4 Ml Kit","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74121382","Description":"Bendamustine Hcl 100 Mg/20 Ml","CDM Revenue Code":"636","CDM HCPCS":"J9033","Standard Price":12611.32},{"Itemcode":"74121383","Description":"Poole'S Diaper Rash Cream120Gm","CDM Revenue Code":"637","Standard Price":45.0,"Note":"**"},{"Itemcode":"74121384","Description":"Dalteparin Sodium 12500 Units","CDM Revenue Code":"636","CDM HCPCS":"J1645","Standard Price":434.66},{"Itemcode":"74121385","Description":"Dalteparin Sodium 15000 Units","CDM Revenue Code":"636","CDM HCPCS":"J1645","Standard Price":522.21},{"Itemcode":"74121386","Description":"Dalteparin Sodium 18000 Units","CDM Revenue Code":"636","CDM HCPCS":"J1645","Standard Price":627.27},{"Itemcode":"74121387","Description":"Dalteparin Sodium 5000 Units","CDM Revenue Code":"636","CDM HCPCS":"J1645","Standard Price":174.07},{"Itemcode":"74121388","Description":"Dalteparin Sodium 10000 Units","CDM Revenue Code":"636","CDM HCPCS":"J1645","Standard Price":348.14},{"Itemcode":"74121389","Description":"Dalteparin Sodium 7500 Units","CDM Revenue Code":"636","CDM HCPCS":"J1645","Standard Price":260.59},{"Itemcode":"74121390","Description":"Meropenem 500 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J2185","Standard Price":59.0662455406078,"Note":"**"},{"Itemcode":"74121391","Description":"Maraviroc 150Mg Tablet","CDM Revenue Code":"637","Standard Price":46.5},{"Itemcode":"74121392","Description":"Amphetamine-Dextroamphet 20Mg","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121393","Description":"Amphetamine-Dextroamphet 10Mg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121394","Description":"Fondaparinux Na 5 Mg/0.4 Ml","CDM Revenue Code":"636","CDM HCPCS":"J1652","Standard Price":403.76,"Note":"**"},{"Itemcode":"74121395","Description":"Clofarabine 20 Mg/20 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9027","Standard Price":6365.4,"Note":"**"},{"Itemcode":"74121396","Description":"Zolpidem 12.5Mg Tbsa","CDM Revenue Code":"637","Standard Price":50.25},{"Itemcode":"74121397","Description":"Nisoldipine 8.5 Mg Er Tablet","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74121398","Description":"Ca Gluconate 650Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121399","Description":"Morphine 5Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":59.74},{"Itemcode":"74121400","Description":"Advair 250/50 Mcg 14 Dose Inh","CDM Revenue Code":"637","Standard Price":363.26,"Note":"**"},{"Itemcode":"74121401","Description":"Micafungin Sodium 100 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J2248","Standard Price":265.041328671328,"Note":"**"},{"Itemcode":"74121403","Description":"Diclofenac 1% Gel 100 Gm Tube","CDM Revenue Code":"637","Standard Price":153.0,"Note":"**"},{"Itemcode":"74121404","Description":"Insulin Reg Hum 500 U/Ml 20ML","CDM Revenue Code":"636","CDM HCPCS":"J1815","Standard Price":296.64,"Note":"**"},{"Itemcode":"74121405","Description":"Cabergoline 0.5 Mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J8515","Standard Price":68.5522222222223,"Note":"**"},{"Itemcode":"74121406","Description":"Dimethyl Sulfoxide 50% 50 Ml","CDM Revenue Code":"636","CDM HCPCS":"J1212","Standard Price":2228.92,"Note":"**"},{"Itemcode":"74121407","Description":"Hyaluronidase 150 Mg/1Ml/Vial","CDM Revenue Code":"636","CDM HCPCS":"J3470","Standard Price":151.41},{"Itemcode":"74121408","Description":"Levetiracetam Xr 500Mg Tab","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74121409","Description":"Lubiprostone 8 Mcg Capsule","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74121410","Description":"Clindamycin 300 Mg/50Ml Premix","CDM Revenue Code":"250","Standard Price":58.8146224343675,"Note":"**"},{"Itemcode":"74121411","Description":"Cefazolin 2 Gm/100 Ml Premix","CDM Revenue Code":"250","Standard Price":59.0080301564164,"Note":"**"},{"Itemcode":"74121412","Description":"Tussionex Syrup 5 Ml Dose","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74121413","Description":"Budesonide 0.25% Neb Soln","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121414","Description":"Alvimopan 12Mg Cap","CDM Revenue Code":"637","Standard Price":396.0,"Note":"**"},{"Itemcode":"74121415","Description":"Desvenlafaxine 50Mg Tablet","CDM Revenue Code":"637","Standard Price":24.75,"Note":"**"},{"Itemcode":"74121416","Description":"Tetan/Diph/Acel Tdap 0.5ml Inj","CDM Revenue Code":"636","CDM HCPCS":"90715","Standard Price":168.646228168421,"Note":"**"},{"Itemcode":"74121418","Description":"Daclizumab 25 Mg/5 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J7513","Standard Price":2942.71},{"Itemcode":"74121419","Description":"Febuxostat 40Mg Tablet","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74121420","Description":"Hyaluronidase (Hylenex)150Unit","CDM Revenue Code":"636","CDM HCPCS":"J3473","Standard Price":234.846242424243,"Note":"**"},{"Itemcode":"74121422","Description":"Estradiol 0.1 Mg Pat (Vivelle)","CDM Revenue Code":"637","Standard Price":66.0,"Note":"**"},{"Itemcode":"74121423","Description":"Estradiol 0.075 Mg Pat (Vivell","CDM Revenue Code":"637","Standard Price":66.0},{"Itemcode":"74121424","Description":"Estradiol 0.0375 Mg Pat (Vivel","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74121425","Description":"Pantoprazole Sodium 40 Mg Pkt","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74121426","Description":"Somatropin 8.8 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J2941","Standard Price":4926.49},{"Itemcode":"74121428","Description":"Fluocinolone Ace. Shampoo Bot","CDM Revenue Code":"637","Standard Price":1127.25},{"Itemcode":"74121429","Description":"Didanosine Ec 125 Mg Capsule","CDM Revenue Code":"637","Standard Price":13.5},{"Itemcode":"74121431","Description":"Insulin Glulisine 300 Unit/3Ml","CDM Revenue Code":"637","Standard Price":295.5},{"Itemcode":"74121432","Description":"Beclomethasone Hfa Oral 80Mcg","CDM Revenue Code":"637","Standard Price":248.25,"Note":"**"},{"Itemcode":"74121433","Description":"Teniposide 50 Mg/5 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"Q2017","Standard Price":10592.52},{"Itemcode":"74121434","Description":"Methadone 5Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121435","Description":"Posaconazole 105Ml 200 Mg/5Ml","CDM Revenue Code":"250","Standard Price":3973.74},{"Itemcode":"74121436","Description":"Guaifen-Phenyle 400Mg/10Mgtab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121437","Description":"Guaife-Phenyle 100Mg/7.5Mg-5Ml","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74121438","Description":"Iothalamate Meglumine 250 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9958","Standard Price":59.0464509174312,"Note":"**"},{"Itemcode":"74121439","Description":"Darunavir 400 Mg Tab","CDM Revenue Code":"637","Standard Price":63.0},{"Itemcode":"74121440","Description":"Darunavir 600 Mg Tab","CDM Revenue Code":"637","Standard Price":73.5,"Note":"**"},{"Itemcode":"74121441","Description":"Phenylephrine-Chlorphen-Dm60Ml","CDM Revenue Code":"637","Standard Price":28.5},{"Itemcode":"74121442","Description":"Etravirine 100 Mg Tab","CDM Revenue Code":"637","Standard Price":29.25,"Note":"**"},{"Itemcode":"74121443","Description":"Clozapine 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":5.25,"Note":"**"},{"Itemcode":"74121444","Description":"Dapsone 100Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121446","Description":"Cadexomer Iodine Sterile 5 Gm","CDM Revenue Code":"250","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"74121453","Description":"Cadexomer Iodine 40 Gm Nocharg","CDM Revenue Code":"250","Standard Price":0.0},{"Itemcode":"74121454","Description":"Hydromorphone Hcl 8 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121455","Description":"Tapentadol 50 Mg Tab","CDM Revenue Code":"637","Standard Price":15.75,"Note":"**"},{"Itemcode":"74121456","Description":"Permethrin 1 % Lotion 60Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121457","Description":"Na Hyaluronate 25 Mg/2.5Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"J7321","Standard Price":977.47},{"Itemcode":"74121458","Description":"Norepinephrine/D5W 16Mg/250Mg","CDM Revenue Code":"250","Standard Price":242.652437694704,"Note":"**"},{"Itemcode":"74121459","Description":"Remifentanil Hcl 2Mg Injection","CDM Revenue Code":"250","Standard Price":520.15},{"Itemcode":"74121460","Description":"Imatinib Mesylate 400 Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":488.677777777777,"Note":"**"},{"Itemcode":"74121461","Description":"Non Formulary Liquid 60Ml","CDM Revenue Code":"637","Standard Price":63.0},{"Itemcode":"74121462","Description":"Selegiline 6 Mg/24 Hr Pat","CDM Revenue Code":"637","Standard Price":156.75,"Note":"**"},{"Itemcode":"74121463","Description":"Non-Formulary Drug 5 Ml Syra","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121465","Description":"Dizoxide Oral 50 Mg/Ml Dose","CDM Revenue Code":"637","Standard Price":28.5},{"Itemcode":"74121466","Description":"Humalog 50/50 300 Unit/3Ml Pen","CDM Revenue Code":"637","Standard Price":57.0},{"Itemcode":"74121467","Description":"Fulvestrant 250 Mg/5 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9395","Standard Price":3818.21},{"Itemcode":"74121468","Description":"Ferumoxytol 510 Mg/17 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"Q0138","Standard Price":3016.01782647058,"Note":"**"},{"Itemcode":"74121469","Description":"Risedronate Na 150 Mg Tab","CDM Revenue Code":"637","Standard Price":964.5},{"Itemcode":"74121470","Description":"Quetiapine Xr 300 Mg Tbsa","CDM Revenue Code":"637","Standard Price":60.4,"Note":"**"},{"Itemcode":"74121471","Description":"Alum & Mag Hydrox-Sim 30Ml Cup","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121472","Description":"Proteinase Inhibitor 1Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0256","Standard Price":6.18},{"Itemcode":"74121474","Description":"Posaconazole Susp 200Mg/5Ml Ud","CDM Revenue Code":"637","Standard Price":188.25,"Note":"**"},{"Itemcode":"74121475","Description":"Prasugrel 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":45.75,"Note":"**"},{"Itemcode":"74121476","Description":"Prasugrel 10 Mg Tablet","CDM Revenue Code":"250","Standard Price":59.0822022022022,"Note":"**"},{"Itemcode":"74121478","Description":"Dronedarone Hcl 400 Mg Tablet","CDM Revenue Code":"637","Standard Price":30.0,"Note":"**"},{"Itemcode":"74121479","Description":"Aztreonam 1 Gm/50 Ml Bag","CDM Revenue Code":"250","Standard Price":141.11},{"Itemcode":"74121480","Description":"Aztreonam 2 Gm/50 Ml Bag","CDM Revenue Code":"250","Standard Price":283.25},{"Itemcode":"74121481","Description":"Vancomycin/D5W 1Gm/200 Ml Ivpb","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":59.74},{"Itemcode":"74121482","Description":"Memantine Hcl 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74121484","Description":"Cocaine 4% 10Ml Solution","CDM Revenue Code":"250","Standard Price":1799.41},{"Itemcode":"74121485","Description":"Lidocaine Hcl 3.5 %/5 Ml Gel","CDM Revenue Code":"250","Standard Price":58.916,"Note":"**"},{"Itemcode":"74121486","Description":"Cyanocobalamin 250 Mcg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121487","Description":"Pyridostigmine 60 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74121488","Description":"Hydromorphone 30 Mg/30 Ml Syrd","CDM Revenue Code":"250","Standard Price":947.6},{"Itemcode":"74121489","Description":"Cocaine 4% 4 Ml Solution","CDM Revenue Code":"250","Standard Price":718.94,"Note":"**"},{"Itemcode":"74121490","Description":"Nitroglycerin 50 Mg/D5W 500Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74121491","Description":"Clonazepam 0.5 Mg Odt","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74121492","Description":"Interferon Beta-1A 44Mcg/0.5Ml","CDM Revenue Code":"250","CDM HCPCS":"Q3028","Standard Price":2344.28},{"Itemcode":"74121493","Description":"Zoledronic Acid 5Mg/100Ml Bot","CDM Revenue Code":"636","CDM HCPCS":"J3489","Standard Price":4585.56,"Note":"**"},{"Itemcode":"74121494","Description":"Adenosine 90 Mg/Ns 90 Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J0153","Standard Price":281.464666666667,"Note":"**"},{"Itemcode":"74121495","Description":"Ranolazine 1000 Mg Tbsa","CDM Revenue Code":"637","Standard Price":29.25,"Note":"**"},{"Itemcode":"74121496","Description":"Diclofenac Epolamine 1.3 % Pat","CDM Revenue Code":"637","Standard Price":35.25,"Note":"**"},{"Itemcode":"74121997","Description":"Azelastine Hcl Opth 0.05% 6 Ml","CDM Revenue Code":"637","Standard Price":27.75,"Note":"**"},{"Itemcode":"74121998","Description":"Conivaptan/D5W 20 Mg/100Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"C9488","Standard Price":2546.16},{"Itemcode":"74121999","Description":"Vancomycin 250Mg/5 Ml Oral Sol","CDM Revenue Code":"637","Standard Price":5.25,"Note":"**"},{"Itemcode":"74122000","Description":"Paricalcitol 1 Mcg Cap","CDM Revenue Code":"637","Standard Price":26.25},{"Itemcode":"74122002","Description":"Pseudoephedrine W/ Dm-Gg 10 Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122003","Description":"Prednisolone 10Mg Odt Tablet","CDM Revenue Code":"637","Standard Price":34.5,"Note":"**"},{"Itemcode":"74122004","Description":"Prednisolone 15Mg Odt Tablet","CDM Revenue Code":"637","Standard Price":57.75,"Note":"**"},{"Itemcode":"74122005","Description":"Prednisolone 15Mg/5Ml Soltn","CDM Revenue Code":"636","CDM HCPCS":"J7510","Standard Price":293.55},{"Itemcode":"74122008","Description":"Buprenorphine Sl 8Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122009","Description":"Fluconazole 100Mg/50 Ml Pm","CDM Revenue Code":"636","CDM HCPCS":"J1450","Standard Price":59.74},{"Itemcode":"74122010","Description":"Mannitol 15% 75 Gm/500 Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J2150","Standard Price":150.590866141732,"Note":"**"},{"Itemcode":"74122011","Description":"Diazepam 2.5Mg Rectal Gel","CDM Revenue Code":"637","Standard Price":782.25},{"Itemcode":"74122012","Description":"Albuterol Hfa Inh 60Inh 8Gm","CDM Revenue Code":"637","Standard Price":66.0,"Note":"**"},{"Itemcode":"74122013","Description":"Pralatrexate 40 Mg/2 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9307","Standard Price":34809.88},{"Itemcode":"74122014","Description":"Sodium Cl/Bicarb Sinus Rinse","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74122015","Description":"Tacrolimus Orl ImRel 0.5Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"J7507","Standard Price":6.18,"Note":"**"},{"Itemcode":"74122016","Description":"Trospium Chloride Xr 60 Mg Cap","CDM Revenue Code":"637","Standard Price":16.5},{"Itemcode":"74122017","Description":"Atomoxetine Hcl 60Mg Cap","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122018","Description":"Triptorelin Depot 3.75Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3315","Standard Price":2529.68},{"Itemcode":"74122019","Description":"Nicardipine/Ns 40 Mg/200Ml Iv","CDM Revenue Code":"250","Standard Price":794.985377736549,"Note":"**"},{"Itemcode":"74122020","Description":"Pravastatin Na 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122021","Description":"Miconzole Powder 1.5 Oz Bot","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122022","Description":"Tadalafil 5 Mg Tab","CDM Revenue Code":"637","Standard Price":30.75,"Note":"**"},{"Itemcode":"74122023","Description":"Lipase-Protease-Amyla Creondr6","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122024","Description":"Lipas-Proteas-Amyla Zenpepdr20","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74122025","Description":"Nebivolol Hcl 2.5 Mg Tab","CDM Revenue Code":"637","Standard Price":12.0,"Note":"**"},{"Itemcode":"74122026","Description":"Ibandronate Sodium 3Mg/3Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1740","Standard Price":2238.19},{"Itemcode":"74122027","Description":"Ibandronate Sodium 150 Mg Tab","CDM Revenue Code":"637","Standard Price":333.0},{"Itemcode":"74122029","Description":"Cholecalciferol 50Ml 400U/Mllq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122030","Description":"Immune Globulin (Gamunex) 1 Gm","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":359.47,"Note":"**"},{"Itemcode":"74122031","Description":"Immune Globulin (Privigen) 1Gm","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":333.417717391304,"Note":"**"},{"Itemcode":"74122032","Description":"Immune Globulin (Gammagard)1Gm","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":358.20421686747,"Note":"**"},{"Itemcode":"74122033","Description":"Triptorelin Depot 11.25Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3315","Standard Price":7586.98},{"Itemcode":"74122037","Description":"Erythromycin 400 Mg/5 Ml Ud","CDM Revenue Code":"637","Standard Price":61.5,"Note":"**"},{"Itemcode":"74122038","Description":"Sertraline 20Mg/Ml ORAL Syr","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122039","Description":"Ofatumumab 100 Mg/5 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9302","Standard Price":2251.20396825397,"Note":"**"},{"Itemcode":"74122040","Description":"Acetaminophen 80 Mg/0.8Ml Liq","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122041","Description":"Ferric Subsulfate (Monsel) 8Ml","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122042","Description":"Iloprost 10 Mcg/Ml Neb Soln","CDM Revenue Code":"250","Standard Price":525.3},{"Itemcode":"74122043","Description":"Quetiapine Xr 50 Mg Tab","CDM Revenue Code":"637","Standard Price":24.66,"Note":"**"},{"Itemcode":"74122044","Description":"Quetiaapine Xr 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":47.87,"Note":"**"},{"Itemcode":"74122045","Description":"Saxagliptin Hcl 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":38.25,"Note":"**"},{"Itemcode":"74122046","Description":"Liraglttide 18 Mcg/3 Ml Pen","CDM Revenue Code":"637","Standard Price":807.0,"Note":"**"},{"Itemcode":"74122047","Description":"Sevelamer Carbonate 2.4 Gm Pkt","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122048","Description":"Lacosamide 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":41.97,"Note":"**"},{"Itemcode":"74122049","Description":"Fesoterodine 8 Mg Er Tablet","CDM Revenue Code":"637","Standard Price":30.0},{"Itemcode":"74122050","Description":"Milnacipran 50Mg Tablet","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74122051","Description":"Gatifloxacin Opth 0.5% 2.5Ml","CDM Revenue Code":"637","Standard Price":499.5},{"Itemcode":"74122052","Description":"Rufinamide 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":28.5},{"Itemcode":"74122053","Description":"Aripiprazole 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122054","Description":"Cabazitaxel 60 Mg/1.5 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9043","Standard Price":33409.08},{"Itemcode":"74122055","Description":"Milnacipran Hcl 25 Mg Tablet","CDM Revenue Code":"637","Standard Price":15.75,"Note":"**"},{"Itemcode":"74122056","Description":"Milnacipran Hcl 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74122057","Description":"Azithromycin 200 Mg/5 Ml Syro","CDM Revenue Code":"637","Standard Price":26.25,"Note":"**"},{"Itemcode":"74122058","Description":"Heparin Na 20000 Unit Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122059","Description":"Rifaximin 550 Mg Tablet","CDM Revenue Code":"637","Standard Price":99.75,"Note":"**"},{"Itemcode":"74122060","Description":"Oseltamivir 6 Mg/1Ml Liq","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74122061","Description":"Pravastatin 40 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122062","Description":"Denosumab 60 Mg/Ml Inj. Syra","CDM Revenue Code":"636","CDM HCPCS":"J0897","Standard Price":4496.37748263625,"Note":"**"},{"Itemcode":"74122064","Description":"Lipase-Protease-Amylase 10500U","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74122065","Description":"Fat Emulsion 20% 250 Ml Bag","CDM Revenue Code":"258","Standard Price":58.863073047859,"Note":"**"},{"Itemcode":"74122066","Description":"Gentamicin In Ns 100 Mg/100 Ml","CDM Revenue Code":"636","CDM HCPCS":"J1580","Standard Price":59.0863461538461,"Note":"**"},{"Itemcode":"74122067","Description":"Torsemide 50 Mg/5 Ml Vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122068","Description":"Lamivudine 25 Mg/5 Ml Soltn","CDM Revenue Code":"637","Standard Price":15.0},{"Itemcode":"74122069","Description":"Micro. Collagen Hemostat 1 Gm","CDM Revenue Code":"250","Standard Price":806.49},{"Itemcode":"74122070","Description":"Doxercalciferol 4 Mcg/2Ml Vial","CDM Revenue Code":"250","CDM HCPCS":"J1270","Standard Price":58.752011023622,"Note":"**"},{"Itemcode":"74122071","Description":"Dabigatran Eiexilat 150 Mg Cap","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74122072","Description":"Lamivudine 50 Mg/5 Ml Solution","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122075","Description":"Tranexamic Acid 1000Mg/10Ml Am","CDM Revenue Code":"250","Standard Price":209.987487977502,"Note":"**"},{"Itemcode":"74122076","Description":"Meningococcal Vac (Menactra)","CDM Revenue Code":"636","CDM HCPCS":"90733","Standard Price":467.826,"Note":"**"},{"Itemcode":"74122077","Description":"Etoposide Phosphate 100 Mg Via","CDM Revenue Code":"636","CDM HCPCS":"J9181","Standard Price":21.63},{"Itemcode":"74122079","Description":"Dabigatran Etexilate 75Mg Tab","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74122080","Description":"Rabies Vaccine, Pcec 2.5 Intun","CDM Revenue Code":"636","CDM HCPCS":"90675","Standard Price":1288.50455294118,"Note":"**"},{"Itemcode":"74122081","Description":"Desmopressin 0.1 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122083","Description":"Mag Sulfate 20Gm/Water 500Ml","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":59.1210762331839,"Note":"**"},{"Itemcode":"74122084","Description":"Cholecalciferol 1000 Units Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122085","Description":"Hydrocodone 5Mg/Apap 325Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122087","Description":"Oxycodone 10Mg/Apap 325Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122088","Description":"Cetaphil Moisturizing Lot 16Oz","CDM Revenue Code":"637","Standard Price":53.25},{"Itemcode":"74122089","Description":"Cetaphil Skin Cleanser 8 Oz","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74122090","Description":"Lacosamide 50 Mg/5 Ml Syro","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74122091","Description":"Lacosamide 100 Mg/10 Ml Syro","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122092","Description":"Octreotide Depot 10 Mg Inject","CDM Revenue Code":"636","CDM HCPCS":"J2353","Standard Price":8240.0},{"Itemcode":"74122093","Description":"Methylnaltrexone 12Mg/0.6Mlinj","CDM Revenue Code":"636","CDM HCPCS":"J2212","Standard Price":411.21308,"Note":"**"},{"Itemcode":"74122094","Description":"Mexiletime Hcl 250 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122095","Description":"Eribulin Mesylate 1 Mg/2 Mlinj","CDM Revenue Code":"636","CDM HCPCS":"J9179","Standard Price":4617.49},{"Itemcode":"74122097","Description":"Benzocaine 20%% 0.5Ml Spray","CDM Revenue Code":"250","Standard Price":58.9830579531442,"Note":"**"},{"Itemcode":"74122098","Description":"Pain Ease Topical Anest 1 Ea","CDM Revenue Code":"637","Standard Price":4.45,"Note":"**"},{"Itemcode":"74122099","Description":"Lidocaine 1% Mpf Polyamp 10Ml","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122104","Description":"Lacosamide 200 Mg/20 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"C9254","Standard Price":152.700759493671,"Note":"**"},{"Itemcode":"74122105","Description":"Ceftaroline Fosamil 600Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0712","Standard Price":515.632045454545,"Note":"**"},{"Itemcode":"74122106","Description":"Sevelamer Carbonate 0.8 Gm Pkt","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122107","Description":"Gadobenate Dim(Multihance)10Ml","CDM Revenue Code":"255","CDM HCPCS":"A9577","Standard Price":157.893554380665,"Note":"**"},{"Itemcode":"74122108","Description":"Bupivacaine 0.25% 100 Ml Cass","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122109","Description":"Ropivacaine 0.2% On-Q Pump 500","CDM Revenue Code":"250","Standard Price":711.327990762125,"Note":"**"},{"Itemcode":"74122110","Description":"Hydroxyurea 200 Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122111","Description":"Bupivacaine 0.5% On-Q 100Ml","CDM Revenue Code":"250","Standard Price":284.28},{"Itemcode":"74122112","Description":"Bupivacaine 0.25% On-Q 100Ml","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122114","Description":"Bupivacaine 0.25% On-Q 400Ml","CDM Revenue Code":"250","Standard Price":315.18},{"Itemcode":"74122116","Description":"Amiodarone 360 Mg/200 Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J0282","Standard Price":194.420783612868,"Note":"**"},{"Itemcode":"74122117","Description":"Phenylephrine 500 Mcg/5 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2370","Standard Price":59.74},{"Itemcode":"74122118","Description":"Thiothixene 10 Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122119","Description":"Mesalamine 800 Mg Tablet","CDM Revenue Code":"637","Standard Price":27.0,"Note":"**"},{"Itemcode":"74122120","Description":"Fixodent 21Gm Cream","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122121","Description":"Fesoterodine Fumurate 4Mg Tab","CDM Revenue Code":"637","Standard Price":30.0,"Note":"**"},{"Itemcode":"74122122","Description":"Dulera 200 Mcg/5 Mcg Inhaler","CDM Revenue Code":"637","Standard Price":714.75},{"Itemcode":"74122123","Description":"Colesevelam Powder 3.75 Gm Pkt","CDM Revenue Code":"637","Standard Price":59.25,"Note":"**"},{"Itemcode":"74122124","Description":"Levetiracetam 750 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122125","Description":"Fidaxomicin 200 Mg Tab","CDM Revenue Code":"637","Standard Price":528.0,"Note":"**"},{"Itemcode":"74122126","Description":"Dextromethorphan Poli 30Mg/5Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122128","Description":"Dextromethorphan Hbr 30Mg/10Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122129","Description":"Dextrometh/Quinidine 20Mg/10Mg","CDM Revenue Code":"637","Standard Price":37.5,"Note":"**"},{"Itemcode":"74122131","Description":"Lidocaine 2% 10 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":58.5920341880342,"Note":"**"},{"Itemcode":"74122132","Description":"Magnesium Sulfate 2 Gm/50Ml Sw","CDM Revenue Code":"250","CDM HCPCS":"J3475","Standard Price":59.0194670644391,"Note":"**"},{"Itemcode":"74122133","Description":"Hydroxyzine 25Mg/1 Ml Vial","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122134","Description":"Fosaprepitant 150Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1453","Standard Price":1346.47218181819,"Note":"**"},{"Itemcode":"74122135","Description":"Tolvaptan 15 Mg Tab","CDM Revenue Code":"637","Standard Price":1172.25,"Note":"**"},{"Itemcode":"74122138","Description":"Nelfinavir Mesylate 625 Mg Tab","CDM Revenue Code":"637","Standard Price":27.75},{"Itemcode":"74122139","Description":"Donepezil Hcl 23 Mg Tablet","CDM Revenue Code":"637","Standard Price":6.75,"Note":"**"},{"Itemcode":"74122140","Description":"Methylene Blue 1%% 1Mg/Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"Q9968","Standard Price":59.74},{"Itemcode":"74122141","Description":"Acetaminophen 1000Mg/100Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0131","Standard Price":222.664710118833,"Note":"**"},{"Itemcode":"74122142","Description":"Zoster Vaccine Live 0.65Ml Inj","CDM Revenue Code":"250","Standard Price":946.57},{"Itemcode":"74122143","Description":"Trastuzumab 21 Mg/1 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":872.41,"Note":"**"},{"Itemcode":"74122145","Description":"Lidocaine 1% With Epi 10Ml Via","CDM Revenue Code":"250","Standard Price":58.9909090909091,"Note":"**"},{"Itemcode":"74122146","Description":"Plasma-Lyte A 1000 Ml Bag","CDM Revenue Code":"250","Standard Price":58.8334948979592,"Note":"**"},{"Itemcode":"74122147","Description":"Denosumab Inj 120 Mg","CDM Revenue Code":"636","CDM HCPCS":"J0897","Standard Price":9112.41},{"Itemcode":"74122148","Description":"Rivaroxaban 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":41.9,"Note":"**"},{"Itemcode":"74122149","Description":"Chlorhexidine Gluc 0.12% 15Ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122150","Description":"Advair 230-21 Mcg Hfa 8Gm Inh","CDM Revenue Code":"637","Standard Price":867.0,"Note":"**"},{"Itemcode":"74122151","Description":"Epoprostenol (Veletri)1.5Mg Vl","CDM Revenue Code":"636","CDM HCPCS":"J1325","Standard Price":347.664615384616,"Note":"**"},{"Itemcode":"74122152","Description":"Silodosin 8 Mg Capsule","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74122153","Description":"Oxymorphone Hcl 5 Mg Tab","CDM Revenue Code":"637","Standard Price":18.75},{"Itemcode":"74122154","Description":"Levothyroine Na 100 Mcg Vial","CDM Revenue Code":"250","Standard Price":384.897594728171,"Note":"**"},{"Itemcode":"74122156","Description":"Camphor-Eucalyptus-Mentho 50Gm","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122158","Description":"Tocilizumab 20 Mg/1 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3262","Standard Price":417.546153846153,"Note":"**"},{"Itemcode":"74122159","Description":"Pilocarpine 1% Opth Soln 15 Ml","CDM Revenue Code":"250","Standard Price":333.72,"Note":"**"},{"Itemcode":"74122162","Description":"Belimumab 80 Mg/1 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0490","Standard Price":1768.07098360655,"Note":"**"},{"Itemcode":"74122163","Description":"Calcium W/ Vitamin D 200 Mg Ta","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122164","Description":"Isovue 300 Mg/Ml 50 Ml Vial","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":59.74},{"Itemcode":"74122165","Description":"Levofloxacin 250 Mg/10 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1956","Standard Price":19.57},{"Itemcode":"74122168","Description":"Gadobenate Dim(Multihance)15Ml","CDM Revenue Code":"255","CDM HCPCS":"A9577","Standard Price":352.448320456708,"Note":"**"},{"Itemcode":"74122169","Description":"Gadobenate Dim(Multihance)20Ml","CDM Revenue Code":"255","CDM HCPCS":"A9577","Standard Price":438.714635075493,"Note":"**"},{"Itemcode":"74122172","Description":"Isovue 370 100 Ml Vial","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":58.9974689265536,"Note":"**"},{"Itemcode":"74122173","Description":"Isovue 370 150 Ml Bot","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":141.800705882353,"Note":"**"},{"Itemcode":"74122174","Description":"Isovue-M 200 10 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"Q9966","Standard Price":133.797,"Note":"**"},{"Itemcode":"74122175","Description":"Isovue 300 200 Ml Bot","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":163.427579456194,"Note":"**"},{"Itemcode":"74122176","Description":"Isovue-M 200 20 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"Q9966","Standard Price":366.445388888889,"Note":"**"},{"Itemcode":"74122177","Description":"Isovue 370 50 Mlvial","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":58.0037142857143,"Note":"**"},{"Itemcode":"74122179","Description":"Benzoin Tincture 4Oz Spray","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122180","Description":"Sunitinib Maleate 25 Mg Capsul","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":1411.1},{"Itemcode":"74122182","Description":"Hydrocodone/Apap 5Mg/325Mg Cup","CDM Revenue Code":"637","Standard Price":9.75},{"Itemcode":"74122183","Description":"Romiplostim 250 Mcg/0.5 Ml Via","CDM Revenue Code":"636","CDM HCPCS":"J2796","Standard Price":7257.174,"Note":"**"},{"Itemcode":"74122184","Description":"Bevacizumab 10 Mg/0.4 Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9035","Standard Price":324.248624489796,"Note":"**"},{"Itemcode":"74122185","Description":"Ropivacaine 1% 100 Mg/10 Mlinj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122186","Description":"Dulera 100Mcg/5Mcg Inhaler","CDM Revenue Code":"637","Standard Price":893.25,"Note":"**"},{"Itemcode":"74122187","Description":"Diclofenac 1.5% Top Soln 150Ml","CDM Revenue Code":"637","Standard Price":571.5},{"Itemcode":"74122188","Description":"Roflumilast 500 Mcg Tablet","CDM Revenue Code":"637","Standard Price":32.25,"Note":"**"},{"Itemcode":"74122189","Description":"Silikon 1000 Ophth","CDM Revenue Code":"250","Standard Price":2063.82571428572,"Note":"**"},{"Itemcode":"74122190","Description":"Rivaroxaban 15 Mg Tablet","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122191","Description":"Dextrose 20% 500 Ml Bag","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"74122192","Description":"Milk Of Magnesia 10Ml Concentr","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122193","Description":"SOD . Thiosulfate 25% 50Ml Via","CDM Revenue Code":"250","Standard Price":422.842105263158,"Note":"**"},{"Itemcode":"74122194","Description":"Interferon Gamma 1B 100Mcg Via","CDM Revenue Code":"637","Standard Price":1119.0},{"Itemcode":"74122195","Description":"Ticagrelor 90 Mg Tablet","CDM Revenue Code":"637","Standard Price":16.49,"Note":"**"},{"Itemcode":"74122196","Description":"Efavirenz 600 Mg Tablet","CDM Revenue Code":"637","Standard Price":98.25,"Note":"**"},{"Itemcode":"74122197","Description":"Argatroban 50 Mg/50 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J0883","Standard Price":942.022926829269,"Note":"**"},{"Itemcode":"74122198","Description":"Linagliptin 5 Mg Tablet","CDM Revenue Code":"637","Standard Price":38.25,"Note":"**"},{"Itemcode":"74122199","Description":"Dasatinib 100 Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":1707.74},{"Itemcode":"74122201","Description":"Lidocaine Hc1 1% 50 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.74},{"Itemcode":"74122202","Description":"Lenalidomide 10Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":0.0},{"Itemcode":"74122203","Description":"Lenalidomide 15Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":0.0},{"Itemcode":"74122204","Description":"Lenalidomide 25Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":2950.95},{"Itemcode":"74122205","Description":"Penicillin Gk 2.5Mu/Ns 100Ml","CDM Revenue Code":"636","CDM HCPCS":"J2540","Standard Price":151.41},{"Itemcode":"74122206","Description":"Duke'S Mouthwash 237Mlbottle","CDM Revenue Code":"637","Standard Price":111.75,"Note":"**"},{"Itemcode":"74122207","Description":"Mouthwash Blm 237 Ml","CDM Revenue Code":"637","Standard Price":73.5,"Note":"**"},{"Itemcode":"74122208","Description":"Potassium Chl. 40Meq/20 Ml Liq","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74122209","Description":"Ritonavir 100 Mg Tab","CDM Revenue Code":"637","Standard Price":25.5,"Note":"**"},{"Itemcode":"74122210","Description":"Lidocaine 2% 50 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":59.74},{"Itemcode":"74122211","Description":"Rivaroxaban 20 Mg Tab","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122213","Description":"Bupivacaine Liposome 1.3% 20Ml","CDM Revenue Code":"636","CDM HCPCS":"C9290","Standard Price":2072.41386459144,"Note":"**"},{"Itemcode":"74122214","Description":"Glycopyrrolate 0.4 Mg/2 Ml Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122215","Description":"Hydrocodone 7.5Mg/Apap 325Mg T","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122216","Description":"Mannitol Inh Powder Test Kit","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122217","Description":"Gabapentin Enacarbil Er Tab","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122219","Description":"Formoterol 20 Mcq/2 Ml Neb Sol","CDM Revenue Code":"250","Standard Price":59.1728886376484,"Note":"**"},{"Itemcode":"74122220","Description":"Vancomycin 1250Mg/Ns 250Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":138.504800456413,"Note":"**"},{"Itemcode":"74122221","Description":"Vancomycin 1500Mg/Ns 300Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":138.518279255596,"Note":"**"},{"Itemcode":"74122222","Description":"Lansoprazole Sus 3Mg/Ml 90Ml","CDM Revenue Code":"637","Standard Price":108.75,"Note":"**"},{"Itemcode":"74122223","Description":"Vancomycin 750Mg/Ns 250Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":121.609243697479,"Note":"**"},{"Itemcode":"74122224","Description":"Vilazodone Hcl 20 Mg Tablet","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74122225","Description":"Pitavastatin Ca 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":24.75,"Note":"**"},{"Itemcode":"74122226","Description":"Ribavirin 200 Mg Tablet","CDM Revenue Code":"637","Standard Price":24.0},{"Itemcode":"74122227","Description":"Brimonidine/Timolol Opth 5 Ml","CDM Revenue Code":"637","Standard Price":441.0,"Note":"**"},{"Itemcode":"74122229","Description":"Levetiracetam/Ns 500 Mg/100Ml","CDM Revenue Code":"636","CDM HCPCS":"J1953","Standard Price":59.0787923728813,"Note":"**"},{"Itemcode":"74122230","Description":"Levetiracetam/Ns 1000Mg/100Ml","CDM Revenue Code":"636","CDM HCPCS":"J1953","Standard Price":130.309027237354,"Note":"**"},{"Itemcode":"74122231","Description":"Vilazodone Hcl 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":22.5},{"Itemcode":"74122232","Description":"Rotigotine 1 Mg/24 Hr Patch","CDM Revenue Code":"637","Standard Price":62.25,"Note":"**"},{"Itemcode":"74122233","Description":"Levetiracetam Xr 750 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122234","Description":"Metoclopramide 5 Mg Odt Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122235","Description":"Ferrous Sufate Er 140Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122238","Description":"Fluzone-Intradermal 0.1Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90630","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122239","Description":"Fluzone-High Dose 0.5Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90662","Standard Price":155.493700440529,"Note":"**"},{"Itemcode":"74122240","Description":"Ibuprofen 800 Mg/8Ml Injection","CDM Revenue Code":"636","CDM HCPCS":"J1741","Standard Price":58.6636036036036,"Note":"**"},{"Itemcode":"74122241","Description":"Abatacept 125 Mg/1 Ml Syringe","CDM Revenue Code":"636","CDM HCPCS":"J0129","Standard Price":4062.32},{"Itemcode":"74122242","Description":"Ceftaroline Fosamil 400Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0712","Standard Price":514.612077922078,"Note":"**"},{"Itemcode":"74122243","Description":"Lidocaine 1%-Phenyleph1.5% Inj","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122244","Description":"Saxagliptin Hcl 2.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":38.25,"Note":"**"},{"Itemcode":"74122245","Description":"Terconazole 0.8% Vag Cr 20Gm","CDM Revenue Code":"637","Standard Price":91.5,"Note":"**"},{"Itemcode":"74122246","Description":"Terconazole 0.4% Vag Cr 45Gm","CDM Revenue Code":"637","Standard Price":88.5},{"Itemcode":"74122248","Description":"Magnesium Hydroxide 311 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122249","Description":"Tapentadol Er 100Mg Tablet","CDM Revenue Code":"637","Standard Price":31.5},{"Itemcode":"74122250","Description":"Eculizumab 300Mg/30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1300","Standard Price":15065.925875,"Note":"**"},{"Itemcode":"74122251","Description":"Docusate Na 60Mg/15Ml Liq","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122252","Description":"Carfilzomib 60Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9047","Standard Price":8693.2,"Note":"**"},{"Itemcode":"74122253","Description":"Docusate 150Mg/15Ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122254","Description":"Pertuzumab 30 Mg/Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9306","Standard Price":1474.96},{"Itemcode":"74122255","Description":"Atropine 0.4Mg/Ml 2Ml Syringe","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122257","Description":"Oseltamivir Phosphate 30Mg Cap","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122258","Description":"Oseltamivir Phosphate 45Mg Cap","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122260","Description":"Brinzolamide 1% Opth Soln 10Ml","CDM Revenue Code":"250","Standard Price":1165.96,"Note":"**"},{"Itemcode":"74122261","Description":"Timolol Opth Soln 0.25% 5Ml","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74122262","Description":"Lidocaine 1% 50Mg/5Ml Syringe","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122265","Description":"Alpha Prot Inhib 1000Mg/50Ml","CDM Revenue Code":"636","CDM HCPCS":"J0257","Standard Price":2206.26},{"Itemcode":"74122267","Description":"Sumatriptan-Naproxen 85-500Mg","CDM Revenue Code":"637","Standard Price":279.0},{"Itemcode":"74122268","Description":"Ranitidine 15Mg/Ml Oral Syr","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122269","Description":"Brentuximab 50Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9042","Standard Price":24473.83,"Note":"**"},{"Itemcode":"74122270","Description":"Cefazolin/D5 2 Gm/50 Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J0690","Standard Price":57.8275270154832,"Note":"**"},{"Itemcode":"74122271","Description":"Calcitriol 1Mcg/Ml Oral Sol","CDM Revenue Code":"637","Standard Price":28.5,"Note":"**"},{"Itemcode":"74122272","Description":"Complera Tablet","CDM Revenue Code":"637","Standard Price":267.75,"Note":"**"},{"Itemcode":"74122273","Description":"Ambrisentan (Letairis) 5Mg Tab","CDM Revenue Code":"637","Standard Price":925.5,"Note":"**"},{"Itemcode":"74122274","Description":"Dexilant 30Mg Capsule","CDM Revenue Code":"637","Standard Price":25.5},{"Itemcode":"74122275","Description":"Combivent Respimat 4Gm Inh","CDM Revenue Code":"637","Standard Price":1035.0,"Note":"**"},{"Itemcode":"74122276","Description":"Isovue 370 125 Ml Bot","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":98.88},{"Itemcode":"74122277","Description":"Acthrel 100Mcg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0795","Standard Price":3370.16},{"Itemcode":"74122278","Description":"Immune Globulin (Octagam) 1 Gm","CDM Revenue Code":"636","CDM HCPCS":"J1568","Standard Price":438.78},{"Itemcode":"74122279","Description":"Augmentin 250Mg/5Ml Suspension","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122280","Description":"Acyclovir 5% 5 Gm Cream","CDM Revenue Code":"637","Standard Price":2192.25,"Note":"**"},{"Itemcode":"74122281","Description":"Kadcyla 100Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9354","Standard Price":12491.84},{"Itemcode":"74122282","Description":"Certolizmab 200 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0717","Standard Price":5427.07},{"Itemcode":"74122283","Description":"Nxstage Rfp 453 5000 Ml Bag","CDM Revenue Code":"250","Standard Price":82.7512442396314,"Note":"**"},{"Itemcode":"74122284","Description":"Nxstage Rfp 401 5000 Ml Bag","CDM Revenue Code":"250","Standard Price":151.41},{"Itemcode":"74122285","Description":"Nxstage Rfp 454 5000 Ml Bag","CDM Revenue Code":"250","Standard Price":151.41},{"Itemcode":"74122286","Description":"Linaclotide 145 Mcg Capsule","CDM Revenue Code":"637","Standard Price":38.86,"Note":"**"},{"Itemcode":"74122287","Description":"Oxymorphone Hcl Er 10 Tablet","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74122288","Description":"Clobazam 10 Mg Tablet","CDM Revenue Code":"637","Standard Price":50.25,"Note":"**"},{"Itemcode":"74122289","Description":"Hydroxyprogesterone 250Mg/1Ml","CDM Revenue Code":"636","CDM HCPCS":"J1726","Standard Price":3243.47},{"Itemcode":"74122290","Description":"Daunorubicin 20Mg/4Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9150","Standard Price":560.251333333333,"Note":"**"},{"Itemcode":"74122291","Description":"Dexmedetomidin 400Mcg/100Ml Vl","CDM Revenue Code":"250","Standard Price":349.981515151515,"Note":"**"},{"Itemcode":"74122292","Description":"Gelfoam 1 Gm Powder","CDM Revenue Code":"250","Standard Price":312.09,"Note":"**"},{"Itemcode":"74122293","Description":"Doxercalciferol 0.5 Mcg Tablet","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74122294","Description":"Lurasidone Hcl 40 Mg Tablet","CDM Revenue Code":"637","Standard Price":113.25,"Note":"**"},{"Itemcode":"74122295","Description":"Apixaban 2.5 Mg Tab","CDM Revenue Code":"637","Standard Price":19.5,"Note":"**"},{"Itemcode":"74122296","Description":"Linaclotide Base 290 Mcg Cap","CDM Revenue Code":"637","Standard Price":35.25,"Note":"**"},{"Itemcode":"74122297","Description":"Rivastigmine 13.3 Patch","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74122298","Description":"Ambrisentan 10 Mg Tab","CDM Revenue Code":"637","Standard Price":925.5,"Note":"**"},{"Itemcode":"74122299","Description":"Treprostinil 50Mg/20Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3285","Standard Price":16576.82,"Note":"**"},{"Itemcode":"74122300","Description":"Dextrose 70% 50 Ml Syrd","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122301","Description":"Calcium Citrate 950 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122302","Description":"Isovue 300 150 Ml Bottle","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":105.774133333333,"Note":"**"},{"Itemcode":"74122303","Description":"Riluzole 50 Mg Tab","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74122304","Description":"Risperidone 0.5 Mg Odt Tablet","CDM Revenue Code":"637","Standard Price":10.5},{"Itemcode":"74122305","Description":"Silodosin 4 Mg Cap","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74122306","Description":"Carisoproldol 250 Mg Tablet","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74122307","Description":"Ipilimumab 200 Mg/40 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9228","Standard Price":56227.7},{"Itemcode":"74122308","Description":"Ipilimumab 50 Mg/10 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9228","Standard Price":14057.44},{"Itemcode":"74122309","Description":"SOD Phosphat 20 Mmol/20 Ml Via","CDM Revenue Code":"250","Standard Price":58.4785759493671,"Note":"**"},{"Itemcode":"74122310","Description":"Saccharomyces Bou. 250 Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122312","Description":"Diatrizone Na/Meg 100 Ml Bot","CDM Revenue Code":"255","Standard Price":59.74},{"Itemcode":"74122313","Description":"Ritonavir 80 Mg/1 Ml Solution","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74122315","Description":"Hydromorphone 0.5 Mg/0.5 Mlinj","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":58.7485526277533,"Note":"**"},{"Itemcode":"74122316","Description":"Besifloxacin 0.6% 5 Ml Bot","CDM Revenue Code":"637","Standard Price":439.5,"Note":"**"},{"Itemcode":"74122317","Description":"Loteprednol0.5%/Tobramycin0.3%","CDM Revenue Code":"637","Standard Price":642.0},{"Itemcode":"74122318","Description":"Urea 10% Cr 85 Gm Tube","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74122319","Description":"Hyaluronate Na 4 Mg/0.4 Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"J7321","Standard Price":155.53},{"Itemcode":"74122321","Description":"Dexlansoprazole 60 Mg Capusule","CDM Revenue Code":"637","Standard Price":25.5,"Note":"**"},{"Itemcode":"74122322","Description":"Stalevo 75 Tablet","CDM Revenue Code":"637","Standard Price":9.0},{"Itemcode":"74122323","Description":"Ropinirole Er 2 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122324","Description":"Aclidinium 400Mcg/Dose Inhaler","CDM Revenue Code":"637","Standard Price":892.5,"Note":"**"},{"Itemcode":"74122325","Description":"Buprenorphin2Mg/Nalox0.5Mgfilm","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74122327","Description":"Darunavir 800 Mg Tablet","CDM Revenue Code":"637","Standard Price":146.25,"Note":"**"},{"Itemcode":"74122328","Description":"Nimodipine 60 Mg/20Ml Solution","CDM Revenue Code":"637","Standard Price":234.0,"Note":"**"},{"Itemcode":"74122329","Description":"Phenylephrine 1% 15 Ml Spray","CDM Revenue Code":"637","Standard Price":12.0,"Note":"**"},{"Itemcode":"74122330","Description":"Tetracaine 0.5% 0.6Ml Opth Sol","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122331","Description":"Doxycycline 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122332","Description":"Mineral Oil Lt Sterile 25 Ml","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122333","Description":"Rifampin 150 Mg Capsule","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122334","Description":"Ceftazidime 500 Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J0713","Standard Price":59.328,"Note":"**"},{"Itemcode":"74122336","Description":"Rimexolone 1% Opth Soln 5 Ml","CDM Revenue Code":"637","Standard Price":255.75},{"Itemcode":"74122337","Description":"Nacl 0.9% Cold 1000Ml Bag","CDM Revenue Code":"636","CDM HCPCS":"J7030","Standard Price":58.5628571428572,"Note":"**"},{"Itemcode":"74122338","Description":"Oxymetazoline/Lidocaine Nasal","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122339","Description":"Darbepoetin Alfa 500Mcg/1Ml","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":15002.98},{"Itemcode":"74122341","Description":"Lidocaine 2% Jelly 1 Ml Chg","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122342","Description":"Hydromorphone/Bupiv 4Mg/100Ml","CDM Revenue Code":"250","Standard Price":89.61},{"Itemcode":"74122343","Description":"Non-Formulary IV Antibiotic","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122344","Description":"Midazolam Syrup 10 Mg/5Ml","CDM Revenue Code":"637","Standard Price":17.42,"Note":"**"},{"Itemcode":"74122345","Description":"Clindamycin 75Mg/5Ml Liq 100Ml","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74122346","Description":"Cefotetan 1Gm/50 Ml Ns Bag","CDM Revenue Code":"250","Standard Price":93.73},{"Itemcode":"74122347","Description":"Levofloxaxin 750 Mg Vial","CDM Revenue Code":"250","Standard Price":227.63},{"Itemcode":"74122348","Description":"Pseudoephedrine 60 Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122349","Description":"Sodium Bicarbonate 50Meq Vial","CDM Revenue Code":"250","Standard Price":59.1267257559958,"Note":"**"},{"Itemcode":"74122350","Description":"Metronidazole 500 Mg Iv","CDM Revenue Code":"250","Standard Price":58.9946052631579,"Note":"**"},{"Itemcode":"74122351","Description":"Tetracaine 0.5% Opth Sol 1 App","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122352","Description":"Non-Formulary Chemo Oral","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122353","Description":"Sodium Chloride 0.9% 10Ml Vial","CDM Revenue Code":"250","Standard Price":6.18,"Note":"**"},{"Itemcode":"74122355","Description":"Non-Formulary Opth/Otic/Inhalr","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122356","Description":"Oxybutynin 10% Gel 1 Gm Packet","CDM Revenue Code":"637","Standard Price":34.5},{"Itemcode":"74122357","Description":"Wound Dressing-Ca Alginate Pad","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122358","Description":"Fingolimod Hydrochloride 0.5Mg","CDM Revenue Code":"637","Standard Price":800.25,"Note":"**"},{"Itemcode":"74122359","Description":"Canagliflozin 100 Mg Tablet","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122360","Description":"Hydrocod-Acetaminoph Cup 7.5Mg","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74122361","Description":"Escitalopram 10Mg/10Ml Soln","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74122362","Description":"Nxstage Rfp 404 5000 Ml Bag","CDM Revenue Code":"250","Standard Price":82.6008455565142,"Note":"**"},{"Itemcode":"74122363","Description":"Advair 115/21 Mcg Hfa Inhaler","CDM Revenue Code":"637","Standard Price":1084.5,"Note":"**"},{"Itemcode":"74122364","Description":"Vaganciclovir 450 Mg/9 Ml Soln","CDM Revenue Code":"637","Standard Price":309.75},{"Itemcode":"74122365","Description":"DEXMEDETOMIDINE 200MCG/50ML VL","CDM Revenue Code":"250","Standard Price":196.73},{"Itemcode":"74122366","Description":"Magnesium Cl 10,000mg/50 ml vl","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122367","Description":"TOBRAMYCIN 300 MG NEBULIZER","CDM Revenue Code":"250","Standard Price":59.0592274678111,"Note":"**"},{"Itemcode":"74122368","Description":"MORPHINE 10MG CPSA KADIAN","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74122369","Description":"ISOVUE-IOPAMIDOL 370 200ML BOT","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":178.9946875,"Note":"**"},{"Itemcode":"74122370","Description":"CONRAY 43 250 ML VIAL","CDM Revenue Code":"255","CDM HCPCS":"Q9960","Standard Price":53.045},{"Itemcode":"74122371","Description":"VANCOMYCIN 1750MG/350ML IV BAG","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":138.456826036982,"Note":"**"},{"Itemcode":"74122372","Description":"VANCOMYCIN 2000MG/400ML IV BAG","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":127.993677988691,"Note":"**"},{"Itemcode":"74122374","Description":"DIGOXIN 0.05 MG/ML 5ML CUP","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74122375","Description":"Pnuemoccocal 13 vaccine","CDM Revenue Code":"636","CDM HCPCS":"90670","Standard Price":709.036153846154,"Note":"**"},{"Itemcode":"74122376","Description":"Indomethacin 50 mg rec supp.","CDM Revenue Code":"637","Standard Price":290.98,"Note":"**"},{"Itemcode":"74122377","Description":"Prothrombin Com(KCentra)1 unit","CDM Revenue Code":"636","CDM HCPCS":"C9132","Standard Price":6.18,"Note":"**"},{"Itemcode":"74122378","Description":"Cadexomer Iodine Gel 10gm tube","CDM Revenue Code":"250","Standard Price":59.1781818181819,"Note":"**"},{"Itemcode":"74122379","Description":"Gentamicin0.1% cream 15gm tube","CDM Revenue Code":"637","Standard Price":66.75,"Note":"**"},{"Itemcode":"74122380","Description":"BELATACEPT(NULOJIX) 250MG VIAL","CDM Revenue Code":"636","CDM HCPCS":"J0485","Standard Price":3980.23347826087,"Note":"**"},{"Itemcode":"74122382","Description":"Ciclesonide 80mcg/actu inhaler","CDM Revenue Code":"637","Standard Price":687.0},{"Itemcode":"74122383","Description":"Carboxymethylcel. op gel .02ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122384","Description":"Mirabegron","CDM Revenue Code":"637","Standard Price":32.25,"Note":"**"},{"Itemcode":"74122385","Description":"Phenylephrine2.5% Opth sol 5ml","CDM Revenue Code":"250","Standard Price":131.84},{"Itemcode":"74122386","Description":"Bumetanide 2.5 mg/10 ml vial","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122387","Description":"Ferric Carboxyma 750mg/15ml IV","CDM Revenue Code":"636","CDM HCPCS":"J1439","Standard Price":3275.24638623327,"Note":"**"},{"Itemcode":"74122388","Description":"Filgrastim TBO-Grani300MCG Inj","CDM Revenue Code":"636","CDM HCPCS":"J1447","Standard Price":662.735169491526,"Note":"**"},{"Itemcode":"74122389","Description":"Filgrastim TBO Grani480MCG Inj","CDM Revenue Code":"636","CDM HCPCS":"J1447","Standard Price":1055.20845360824,"Note":"**"},{"Itemcode":"74122391","Description":"Famotidine in NS 20 mg/50ml PM","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122392","Description":"Augmentin susp. 400mg/5ml 5ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122393","Description":"NA Nitrite/NA Thiosulfate Kit","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122395","Description":"Morphine Conc. 10mg/0.5ML Oral","CDM Revenue Code":"637","Standard Price":10.5,"Note":"**"},{"Itemcode":"74122396","Description":"Phenylephrine 2.5% 15 ML OP","CDM Revenue Code":"250","Standard Price":370.8,"Note":"**"},{"Itemcode":"74122398","Description":"Vedolizumab 300 MG","CDM Revenue Code":"636","CDM HCPCS":"J3380","Standard Price":24288.8692043189,"Note":"**"},{"Itemcode":"74122399","Description":"Aclidinum 400 MCG/ACT 30 Puff","CDM Revenue Code":"637","Standard Price":216.0,"Note":"**"},{"Itemcode":"74122400","Description":"Augmentin 125 mg/5ml oral dose","CDM Revenue Code":"637","Standard Price":79.5},{"Itemcode":"74122401","Description":"Augmentin 600 mg/5ml oral dose","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122402","Description":"Ciprofloxacin 500mg/5ml oral","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74122403","Description":"Naproxen 125 mg/5 ml oral dose","CDM Revenue Code":"637","Standard Price":12.75},{"Itemcode":"74122404","Description":"Idursulfase 6mg/3ml vial","CDM Revenue Code":"250","Standard Price":13306.57},{"Itemcode":"74122405","Description":"Micafungin Sodium 50 mg vial","CDM Revenue Code":"636","CDM HCPCS":"J2248","Standard Price":132.632307692308,"Note":"**"},{"Itemcode":"74122406","Description":"Prepen 1ML INJ","CDM Revenue Code":"250","Standard Price":419.416,"Note":"**"},{"Itemcode":"74122407","Description":"Histamine Positive Control 1ML","CDM Revenue Code":"250","Standard Price":59.122,"Note":"**"},{"Itemcode":"74122408","Description":"Penicillin 10,000 Units Inj.","CDM Revenue Code":"250","Standard Price":58.916,"Note":"**"},{"Itemcode":"74122409","Description":"SALINE NEGATIVE CONTROL 1ML S","CDM Revenue Code":"250","Standard Price":6.18,"Note":"**"},{"Itemcode":"74122410","Description":"Methylnaltrexone 8mg/0.4ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2212","Standard Price":420.060869565218,"Note":"**"},{"Itemcode":"74122411","Description":"Pamidronate 90 mg vial","CDM Revenue Code":"636","CDM HCPCS":"J2430","Standard Price":157.933333333333,"Note":"**"},{"Itemcode":"74122412","Description":"Phenylephrine OPTH 0.5ML OPSY","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122416","Description":"EPHEDrine Sulfate 25mg/5ml syr","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122417","Description":"Acyclovir 5% ointment 5gm tube","CDM Revenue Code":"637","Standard Price":318.75,"Note":"**"},{"Itemcode":"74122418","Description":"Piperacillian/Tazobactam 13.5g","CDM Revenue Code":"636","CDM HCPCS":"J2543","Standard Price":234.601590381679,"Note":"**"},{"Itemcode":"74122419","Description":"Triamcinolone 0.025% LOT 60ml","CDM Revenue Code":"637","Standard Price":87.0,"Note":"**"},{"Itemcode":"74122420","Description":"Clotrimazole 1% CR 30gm tube","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122421","Description":"Phenylephrine 2.5% 0.5 ML OP","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122422","Description":"DOXOrubicin 10 mg vial","CDM Revenue Code":"636","CDM HCPCS":"J9000","Standard Price":23.69,"Note":"**"},{"Itemcode":"74122423","Description":"NAFCILLIN 12 GM","CDM Revenue Code":"250","Standard Price":236.8470437018,"Note":"**"},{"Itemcode":"74122424","Description":"PSEUDOEPH-BROM-DM 20ML LIQ","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122425","Description":"Conray 43 50ml vial","CDM Revenue Code":"636","CDM HCPCS":"Q9960","Standard Price":57.886,"Note":"**"},{"Itemcode":"74122426","Description":"MEDIHONEY WOUND PASTE 44ML TUB","CDM Revenue Code":"637","Standard Price":42.0},{"Itemcode":"74122427","Description":"Gabapentin soln 300 mg/6ml cup","CDM Revenue Code":"637","Standard Price":6.0},{"Itemcode":"74122428","Description":"Memantine HCl ER 28mg capsule","CDM Revenue Code":"637","Standard Price":39.0,"Note":"**"},{"Itemcode":"74122429","Description":"Memantine HCL ER 7mg capsule","CDM Revenue Code":"637","Standard Price":39.0,"Note":"**"},{"Itemcode":"74122430","Description":"LevETIRAcetam/NS 1500mg/100ml","CDM Revenue Code":"636","CDM HCPCS":"J1953","Standard Price":168.981990740741,"Note":"**"},{"Itemcode":"74122431","Description":"Vancomycin Retent Enema 1000MG","CDM Revenue Code":"636","Standard Price":57.9154285714285,"Note":"**"},{"Itemcode":"74122432","Description":"Dulera 200mcg/5mcg 60 puff inh","CDM Revenue Code":"637","Standard Price":604.5,"Note":"**"},{"Itemcode":"74122433","Description":"Tacrolimus 0.03% ointment 30gm","CDM Revenue Code":"637","Standard Price":729.0},{"Itemcode":"74122434","Description":"Tacrolimus 0.1% ointment 30gm","CDM Revenue Code":"637","Standard Price":729.0},{"Itemcode":"74122435","Description":"Eletriptan 20 mg tablet","CDM Revenue Code":"637","Standard Price":171.0},{"Itemcode":"74122436","Description":"Acyclovir 1000 mg injection","CDM Revenue Code":"636","CDM HCPCS":"J0133","Standard Price":59.74},{"Itemcode":"74122437","Description":"RID COMPLETE 1-2-3 LICE KIT","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122438","Description":"Cefotaxime 2 gm vial","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122439","Description":"Pyridostigmine 60 mg/5ml syrup","CDM Revenue Code":"637","Standard Price":33.75,"Note":"**"},{"Itemcode":"74122440","Description":"Calcium Acetate 667mg/5ml soln","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122441","Description":"Treprostinil 100 mg/20 ml vial","CDM Revenue Code":"636","CDM HCPCS":"J3285","Standard Price":20326.02},{"Itemcode":"74122442","Description":"Tromethamine 36mg/ml 500ml bot","CDM Revenue Code":"250","Standard Price":1028.97},{"Itemcode":"74122443","Description":"Apixaban 5 mg tablet","CDM Revenue Code":"637","Standard Price":19.5,"Note":"**"},{"Itemcode":"74122444","Description":"Telbivudine 600mg tablet","CDM Revenue Code":"637","Standard Price":107.25},{"Itemcode":"74122445","Description":"Boceprevir 200 mg capsule","CDM Revenue Code":"637","Standard Price":60.0},{"Itemcode":"74122446","Description":"Trizivir tablet","CDM Revenue Code":"637","Standard Price":69.75},{"Itemcode":"74122447","Description":"Rilpivirine 25 mg tablet","CDM Revenue Code":"637","Standard Price":96.75,"Note":"**"},{"Itemcode":"74122448","Description":"Epzicom tablet","CDM Revenue Code":"637","Standard Price":129.0,"Note":"**"},{"Itemcode":"74122449","Description":"Rotigotine 4mg/24HR TD Patch","CDM Revenue Code":"637","Standard Price":62.25,"Note":"**"},{"Itemcode":"74122450","Description":"Dolutegravir Na 50 mg tablet","CDM Revenue Code":"637","Standard Price":146.25,"Note":"**"},{"Itemcode":"74122451","Description":"Dapagliflozin 5 mg tablet","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122452","Description":"Tadalafil 20 mg tablet","CDM Revenue Code":"637","Standard Price":173.25,"Note":"**"},{"Itemcode":"74122453","Description":"Memantine XR 21 mg capsule","CDM Revenue Code":"637","Standard Price":39.0},{"Itemcode":"74122454","Description":"Memantine XR 14 mg capsule","CDM Revenue Code":"637","Standard Price":39.0,"Note":"**"},{"Itemcode":"74122455","Description":"Selenium 2.5% lotion 118ml bot","CDM Revenue Code":"637","Standard Price":30.0},{"Itemcode":"74122456","Description":"Tenofovir 40mg oral powder","CDM Revenue Code":"637","Standard Price":29.25},{"Itemcode":"74122457","Description":"Nystatin&Triamcinolone Cr 60gm","CDM Revenue Code":"637","Standard Price":135.75,"Note":"**"},{"Itemcode":"74122458","Description":"Pylera packet of 3 capsules","CDM Revenue Code":"637","Standard Price":20.25},{"Itemcode":"74122459","Description":"Docosanol 10% cream 2gm tube","CDM Revenue Code":"637","Standard Price":46.5,"Note":"**"},{"Itemcode":"74122460","Description":"ATROPINE 1% 15ML BOTTLE","CDM Revenue Code":"250","Standard Price":323.42},{"Itemcode":"74122461","Description":"Pyrimethamine 25 mg tablet","CDM Revenue Code":"637","Standard Price":2250.0},{"Itemcode":"74122462","Description":"Stalevo 125 tablet","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74122463","Description":"Ivermection 3 mg tablet","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74122464","Description":"Selegiline HCl 1.25mg tablet","CDM Revenue Code":"637","Standard Price":193.5},{"Itemcode":"74122465","Description":"Saliva stimulant oral spray","CDM Revenue Code":"637","Standard Price":13.5,"Note":"**"},{"Itemcode":"74122466","Description":"Mometasone 0.1%cream 45gm tube","CDM Revenue Code":"637","Standard Price":30.0},{"Itemcode":"74122467","Description":"Fluocinonide 0.05% Cr 60gmtube","CDM Revenue Code":"637","Standard Price":151.5,"Note":"**"},{"Itemcode":"74122468","Description":"Ciprofloxacin 0.3% opth 2.5ml","CDM Revenue Code":"250","Standard Price":59.0533333333333,"Note":"**"},{"Itemcode":"74122469","Description":"MEROPENEM 2GM VIAL","CDM Revenue Code":"636","CDM HCPCS":"J2185","Standard Price":136.152523364485,"Note":"**"},{"Itemcode":"74122470","Description":"FLUCONAZOLE 2MG/ML SYR (NUR)","CDM Revenue Code":"636","CDM HCPCS":"J1450","Standard Price":59.74},{"Itemcode":"74122471","Description":"ACYCLOVIR 5MG/ML SYR (NURSERY)","CDM Revenue Code":"636","CDM HCPCS":"J0133","Standard Price":19.5258571428572,"Note":"**"},{"Itemcode":"74122472","Description":"CLINDAMYCIN 6MG/ML SYR (NUR)","CDM Revenue Code":"250","Standard Price":32.5022222222223,"Note":"**"},{"Itemcode":"74122473","Description":"GENTAMICIN 4MG/ML SYR (NUR)","CDM Revenue Code":"636","CDM HCPCS":"J1580","Standard Price":59.3294158075601,"Note":"**"},{"Itemcode":"74122474","Description":"metroNIDAZOLE 5MG/ML SYR (NUR)","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122475","Description":"PENICILLIN 100,000 UNITS SYR","CDM Revenue Code":"636","CDM HCPCS":"J2540","Standard Price":59.0337142857143,"Note":"**"},{"Itemcode":"74122476","Description":"VANCOMYCIN 5 MG/ML SYR (NUR)","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":58.9530337078652,"Note":"**"},{"Itemcode":"74122477","Description":"ZIDOVUDINE 4MG/ML SYR (NUR)","CDM Revenue Code":"636","CDM HCPCS":"J3485","Standard Price":59.74},{"Itemcode":"74122478","Description":"NAFCILLIN 40MG/ML SYR (NUR)","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122479","Description":"THIORIDAZINE HCL 10MG TABLET","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122480","Description":"PEGLOTICASE 8MG/ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J2507","Standard Price":50124.5538461539,"Note":"**"},{"Itemcode":"74122481","Description":"Malarone 250-100 mg Tablet","CDM Revenue Code":"637","Standard Price":20.25},{"Itemcode":"74122482","Description":"Magnesium Sulf. 40meq/10ml syr","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":59.74},{"Itemcode":"74122483","Description":"Benzocaine 20% gel 7.5ml tube","CDM Revenue Code":"637","Standard Price":27.0,"Note":"**"},{"Itemcode":"74122484","Description":"Rifaximin 200mg/10ml Oral Susp","CDM Revenue Code":"637","Standard Price":52.5,"Note":"**"},{"Itemcode":"74122485","Description":"STIBILD tabl(150-150-200-300)","CDM Revenue Code":"637","Standard Price":294.0},{"Itemcode":"74122486","Description":"Dalbavancin HCl 500 mg vial","CDM Revenue Code":"636","CDM HCPCS":"J0875","Standard Price":5707.02408583333,"Note":"**"},{"Itemcode":"74122487","Description":"Celecoxib 50 mg capsule","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122488","Description":"Tedizolid Phosphat 200mg tabl","CDM Revenue Code":"250","Standard Price":1365.78},{"Itemcode":"74122489","Description":"Tedizolid Phosphate 200mg vial","CDM Revenue Code":"636","CDM HCPCS":"J3090","Standard Price":1088.71},{"Itemcode":"74122490","Description":"Gabapentin soln 250 mg/5ml cup","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122491","Description":"Anoro 62.5/25mcg 7dose inhaler","CDM Revenue Code":"637","Standard Price":201.75,"Note":"**"},{"Itemcode":"74122492","Description":"Azilsartan Medoxomil 40mg tabl","CDM Revenue Code":"637","Standard Price":18.0,"Note":"**"},{"Itemcode":"74122493","Description":"Pentoxifylline Susp 400mg/20ml","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122494","Description":"Eltrombopaq 12.5 mg tablet","CDM Revenue Code":"637","Standard Price":456.0},{"Itemcode":"74122495","Description":"Opium tincture 6mg/0.6ml","CDM Revenue Code":"637","Standard Price":6.75},{"Itemcode":"74122496","Description":"KETORALAC 15MG/ML INJ","CDM Revenue Code":"636","CDM HCPCS":"J1885","Standard Price":59.3966666666667,"Note":"**"},{"Itemcode":"74122497","Description":"Hydroxyurea 500mg/12.5 ml oral","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122499","Description":"GOLIMUMAB 50 MG/4 ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J1602","Standard Price":6673.79916666667,"Note":"**"},{"Itemcode":"74122500","Description":"Amiodarone/D5W 150mg/100ml bag","CDM Revenue Code":"636","CDM HCPCS":"J0282","Standard Price":146.13350877193,"Note":"**"},{"Itemcode":"74122501","Description":"Meningococ Vac (Menomune)","CDM Revenue Code":"636","CDM HCPCS":"90733","Standard Price":520.15},{"Itemcode":"74122502","Description":"Epinephrine PF sulf fr 1mg amp","CDM Revenue Code":"250","Standard Price":58.9556774916014,"Note":"**"},{"Itemcode":"74122504","Description":"DICLEGIS DR Tablet","CDM Revenue Code":"637","Standard Price":18.75,"Note":"**"},{"Itemcode":"74122505","Description":"Ketamine/NS 50 mg/5 ml syringe","CDM Revenue Code":"250","Standard Price":59.0631428571428,"Note":"**"},{"Itemcode":"74122506","Description":"OXYBUTYNIN syrup 5mg/5ml oral","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122507","Description":"ceFEPime/D5w 16m/50ml bag","CDM Revenue Code":"636","CDM HCPCS":"J0692","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122508","Description":"Ramucirumab 100 Mg/10 mL Inj","CDM Revenue Code":"636","CDM HCPCS":"J9308","Standard Price":4709.16},{"Itemcode":"74122509","Description":"Methylphenidate 20Mg Tab","CDM Revenue Code":"637","Standard Price":4.48,"Note":"**"},{"Itemcode":"74122510","Description":"Mesalamine 0.375 gm Cap","CDM Revenue Code":"637","Standard Price":12.0,"Note":"**"},{"Itemcode":"74122511","Description":"TELAVANCIN (VIBATIV) 750MG","CDM Revenue Code":"636","CDM HCPCS":"J3095","Standard Price":1732.39941176471,"Note":"**"},{"Itemcode":"74122512","Description":"ORITAVANCIN (ORBACTIV) 400 MG","CDM Revenue Code":"636","CDM HCPCS":"J2407","Standard Price":4102.49},{"Itemcode":"74122513","Description":"Paiperidone 234mg/1.5ml syr","CDM Revenue Code":"636","CDM HCPCS":"J2426","Standard Price":10119.75},{"Itemcode":"74122514","Description":"Dexmedetomidine/NS 80mcg/20ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122515","Description":"Estradiol Valerate 20mg/2mlInj","CDM Revenue Code":"636","CDM HCPCS":"J1380","Standard Price":112.27},{"Itemcode":"74122516","Description":"Riociguat (Adempas) 0.5mg tab","CDM Revenue Code":"637","Standard Price":306.75},{"Itemcode":"74122517","Description":"Lubriderm 6oz bottle","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122518","Description":"Isovue-Iopamidol-370 100ml chg","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":98.496765182469,"Note":"**"},{"Itemcode":"74122520","Description":"Fibrin Sealant Kit 2ml- EVICEL","CDM Revenue Code":"250","Standard Price":910.764696132596,"Note":"**"},{"Itemcode":"74122521","Description":"NS 0.9% 50ML Charge","CDM Revenue Code":"258","Standard Price":57.6023401546157,"Note":"**"},{"Itemcode":"74122522","Description":"Ganciclovir 0.15% opth gel 5gm","CDM Revenue Code":"637","Standard Price":912.0,"Note":"**"},{"Itemcode":"74122523","Description":"Senna syrup 528 mg/15ml cup","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122524","Description":"FECAL MICROBIOTA PREPARATION","CDM Revenue Code":"250","Standard Price":1625.68333333333,"Note":"**"},{"Itemcode":"74122525","Description":"Heparin 500U 0.45% NACL500ml","CDM Revenue Code":"636","Standard Price":59.74},{"Itemcode":"74122526","Description":"Breo Ellipta 100/25mcg 14 dose","CDM Revenue Code":"637","Standard Price":196.01,"Note":"**"},{"Itemcode":"74122528","Description":"Amino Acid 10%% 500ml Neonate","CDM Revenue Code":"250","Standard Price":59.328,"Note":"**"},{"Itemcode":"74122529","Description":"Lisinopril 2.5mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122530","Description":"TELVANCIN (VIBATIV)","CDM Revenue Code":"636","CDM HCPCS":"J3095","Standard Price":886.83},{"Itemcode":"74122531","Description":"Morphine 0.4mg/ml Oral Solutn","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122532","Description":"Naloxegol Oxalate 25 mg tablet","CDM Revenue Code":"637","Standard Price":31.5,"Note":"**"},{"Itemcode":"74122533","Description":"Epinephrine Intraocular 1mg/ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122534","Description":"Vancomycin 10mg/1ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122535","Description":"cefTAZadime 20mg/1ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J0713","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122536","Description":"Vancomycin 100mg/1ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122537","Description":"Propranolol 20mg/5ml Oral SYR","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122538","Description":"Dexamethasone 4mg/1ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":58.3666666666667,"Note":"**"},{"Itemcode":"74122539","Description":"cefTAZadime 200mg/1ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J0713","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122540","Description":"Vancomycin 5mg/1ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J7999","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122541","Description":"Vancomycin 500mg/10ml opth bot","CDM Revenue Code":"250","Standard Price":58.3666666666667,"Note":"**"},{"Itemcode":"74122542","Description":"cefTAZidime 500mg/10ml op bott","CDM Revenue Code":"250","Standard Price":58.3666666666667,"Note":"**"},{"Itemcode":"74122543","Description":"DIGOXIN 100MCG/ML NEONATE INJ","CDM Revenue Code":"636","CDM HCPCS":"J1160","Standard Price":328.57},{"Itemcode":"74122544","Description":"DIGOXIN 10MCG/ML NEONATE INJ","CDM Revenue Code":"636","CDM HCPCS":"J1160","Standard Price":328.57},{"Itemcode":"74122545","Description":"Posaconazole 100 mg tablet","CDM Revenue Code":"637","Standard Price":188.25,"Note":"**"},{"Itemcode":"74122546","Description":"Amikacin 2mg/ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J0278","Standard Price":59.74},{"Itemcode":"74122547","Description":"Amikacin 1mg/ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J0278","Standard Price":59.74},{"Itemcode":"74122548","Description":"Amikacin 80mg/ml opth Inj","CDM Revenue Code":"636","CDM HCPCS":"J0278","Standard Price":59.74},{"Itemcode":"74122549","Description":"Digoxin 0.5mg/ml Oral Syringe","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122550","Description":"Phenylephrine2.5% opth sol 2ml","CDM Revenue Code":"250","Standard Price":58.0222861003861,"Note":"**"},{"Itemcode":"74122551","Description":"Propranolol 4mg/ml Oral Syr","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122552","Description":"Propranolol 0.1mg/ml syr (Neo)","CDM Revenue Code":"636","CDM HCPCS":"J1800","Standard Price":59.74},{"Itemcode":"74122553","Description":"PHENobarbital 10mg/ml IV (Neo)","CDM Revenue Code":"636","CDM HCPCS":"J2560","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122554","Description":"FentANYL 10mcg/ml - Neonate","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122555","Description":"Neostigmine 4mg/4ml inj","CDM Revenue Code":"636","CDM HCPCS":"J2710","Standard Price":170.98},{"Itemcode":"74122556","Description":"Indomethacin 1mg/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":1427.58},{"Itemcode":"74122557","Description":"DOCEtaxel 10MG/ML INJ","CDM Revenue Code":"636","CDM HCPCS":"J9171","Standard Price":116.87925,"Note":"**"},{"Itemcode":"74122558","Description":"CEFTAZIDIME/AVIBACTAM 2.5GM IV","CDM Revenue Code":"636","CDM HCPCS":"J0714","Standard Price":1249.35417391304,"Note":"**"},{"Itemcode":"74122559","Description":"Thrombin Top. 20,000 unit vial","CDM Revenue Code":"250","Standard Price":1178.00645357687,"Note":"**"},{"Itemcode":"74122560","Description":"Furosemide oral 10mg/1 ml cup","CDM Revenue Code":"637","Standard Price":6.0,"Note":"**"},{"Itemcode":"74122561","Description":"IdaruCIZUMAB 2.5gm/50ml vial","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":7173.95,"Note":"**"},{"Itemcode":"74122562","Description":"Ivabradine 5 mg tablet","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74122564","Description":"Entresto 24mg/26mg tablet","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74122565","Description":"Mugard oral rinse 240ml bottle","CDM Revenue Code":"637","Standard Price":1590.0},{"Itemcode":"74122566","Description":"Cefazolin/NS 3000mg/100ml bag","CDM Revenue Code":"636","CDM HCPCS":"J0690","Standard Price":59.141935483871,"Note":"**"},{"Itemcode":"74122567","Description":"DARUNAVIR/COBICISTAT TABLET","CDM Revenue Code":"637","Standard Price":167.25,"Note":"**"},{"Itemcode":"74122568","Description":"Enzalutamide (Xtandi) 40mg cap","CDM Revenue Code":"637"},{"Itemcode":"74122569","Description":"Suvorexant (Belsomra) 10mg tab","CDM Revenue Code":"637","Standard Price":30.75,"Note":"**"},{"Itemcode":"74122570","Description":"Armodafinil (Nuvigil) 50mg tab","CDM Revenue Code":"637","Standard Price":21.75},{"Itemcode":"74122571","Description":"Phenyleprine& Ketorolac 4ml vl","CDM Revenue Code":"636","CDM HCPCS":"J1097","Standard Price":1969.22491803279,"Note":"**"},{"Itemcode":"74122572","Description":"Tobramycin 5mg/ml Lock Soltn","CDM Revenue Code":"636","CDM HCPCS":"J3260","Standard Price":59.74},{"Itemcode":"74122573","Description":"Epinephrine-LidocainePFSF 2ml","CDM Revenue Code":"636","CDM HCPCS":"J0171","Standard Price":84.7973362445415,"Note":"**"},{"Itemcode":"74122574","Description":"Palbociclib(Ibrance) 125mg cap","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":2215.53},{"Itemcode":"74122575","Description":"Ponatinib(Iclusig) 45mg tab","CDM Revenue Code":"637","Standard Price":957.75},{"Itemcode":"74122576","Description":"Olopatadine HCL 30.5gm Nasinh","CDM Revenue Code":"637","Standard Price":827.25},{"Itemcode":"74122577","Description":"Ergoloid Mesylates 1mg tablet","CDM Revenue Code":"637","Standard Price":19.5},{"Itemcode":"74122578","Description":"NEPAFENAC/ILEVRO 0.3%% 3ML OPT","CDM Revenue Code":"637","Standard Price":741.75},{"Itemcode":"74122579","Description":"Isavuconazonium 372mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1833","Standard Price":1158.75},{"Itemcode":"74122580","Description":"Blephamide eye oint 3.5gm tube","CDM Revenue Code":"637","Standard Price":361.5},{"Itemcode":"74122581","Description":"FLOVENT DISKUS 50MCG","CDM Revenue Code":"637","Standard Price":441.0,"Note":"**"},{"Itemcode":"74122582","Description":"Vortioxetine HBR 10 mg tablet","CDM Revenue Code":"637","Standard Price":34.5,"Note":"**"},{"Itemcode":"74122583","Description":"Lamotrigine ODT 100 mg tablet","CDM Revenue Code":"637","Standard Price":24.0},{"Itemcode":"74122584","Description":"NELARABINE 250MG/50ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9261","Standard Price":3119.87},{"Itemcode":"74122585","Description":"Abiraterone (Zytiga) 250mg tab","CDM Revenue Code":"637","Standard Price":234.75},{"Itemcode":"74122586","Description":"Cytarabine 100mg/5ml PF vial","CDM Revenue Code":"636","CDM HCPCS":"J9100","Standard Price":26.2880597014925,"Note":"**"},{"Itemcode":"74122587","Description":"Cytarabine 2GM/20ml PF vial","CDM Revenue Code":"636","CDM HCPCS":"J9100","Standard Price":92.464414893617,"Note":"**"},{"Itemcode":"74122588","Description":"Fluocinolone 0.01% 60ml soln","CDM Revenue Code":"637","Standard Price":228.0},{"Itemcode":"74122589","Description":"Nivolumab 40 mg/4ml vial","CDM Revenue Code":"636","CDM HCPCS":"J9299","Standard Price":4384.71},{"Itemcode":"74122590","Description":"Nivolumab 100mg/10ml vial","CDM Revenue Code":"636","CDM HCPCS":"J9299","Standard Price":10962.29},{"Itemcode":"74122591","Description":"Rytary ER 36.25/145mg cap","CDM Revenue Code":"637","Standard Price":7.5},{"Itemcode":"74122592","Description":"RYTARY ER 23.75-95 MG CAPSULE","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74122593","Description":"DARUNAVIR 100 MG/ML ORAL SUSP","CDM Revenue Code":"637","Standard Price":12.0},{"Itemcode":"74122594","Description":"Vorapaxar Sulfate 2.08 mg tab","CDM Revenue Code":"637","Standard Price":28.5},{"Itemcode":"74122595","Description":"Zerbaxa 1.5 gm vial","CDM Revenue Code":"636","CDM HCPCS":"J0695","Standard Price":403.78641025641,"Note":"**"},{"Itemcode":"74122596","Description":"Palbociclib 100mg caps","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":2215.53},{"Itemcode":"74122597","Description":"Palbociclib 75mg caps","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":2215.53},{"Itemcode":"74122598","Description":"Harvoni 90-400mg tab","CDM Revenue Code":"637","Standard Price":3375.0},{"Itemcode":"74122599","Description":"DARBEPOETIN ALFA 100 MCG/MLINJ","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":3000.39},{"Itemcode":"74122600","Description":"Trypsin W/Castor Oil&Peruv CAN","CDM Revenue Code":"637","Standard Price":33.75},{"Itemcode":"74122601","Description":"Ursodiol Susp 60mg/ml Syr oral","CDM Revenue Code":"637","Standard Price":18.0},{"Itemcode":"74122602","Description":"Aquadeks Ped 60ml drops","CDM Revenue Code":"637","Standard Price":63.0},{"Itemcode":"74122603","Description":"Hyaluronate Na 20 mg/2 ml vial","CDM Revenue Code":"636","CDM HCPCS":"J7321","Standard Price":801.752,"Note":"**"},{"Itemcode":"74122605","Description":"Breo Ellipta 200/25mcg 14 dose","CDM Revenue Code":"637","Standard Price":196.28,"Note":"**"},{"Itemcode":"74122606","Description":"Risperidone 25 Mg Im Inj Kit","CDM Revenue Code":"636","Standard Price":1834.43,"Note":"**"},{"Itemcode":"74122607","Description":"Cadexomer 5gm Pad","CDM Revenue Code":"637","Standard Price":48.0,"Note":"**"},{"Itemcode":"74122608","Description":"Gelclair oral 15ml gel pack","CDM Revenue Code":"637","Standard Price":114.0},{"Itemcode":"74122609","Description":"Dymista nasal spray","CDM Revenue Code":"637","Standard Price":536.25,"Note":"**"},{"Itemcode":"74122610","Description":"Tacrolimus XL EXREL 1mg cap","CDM Revenue Code":"636","CDM HCPCS":"J7508","Standard Price":18.54,"Note":"**"},{"Itemcode":"74122612","Description":"Peramivir 200mg/20ml vial","CDM Revenue Code":"636","CDM HCPCS":"J2547","Standard Price":1344.15,"Note":"**"},{"Itemcode":"74122614","Description":"Cholecalciferol 5000 Units Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122615","Description":"Tapentadol Er 50Mg Tablet","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74122616","Description":"Dextrose 50%% 500ml bag","CDM Revenue Code":"250","CDM HCPCS":"J7799","Standard Price":58.9495348837209,"Note":"**"},{"Itemcode":"74122617","Description":"Iodine tincture 30ml bottle","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122618","Description":"Bendamustine (BENDEKA) 25MG/ML","CDM Revenue Code":"636","CDM HCPCS":"J9034","Standard Price":2442.13},{"Itemcode":"74122619","Description":"Olmesartan Medoxomil 5mg tab","CDM Revenue Code":"637","Standard Price":17.25,"Note":"**"},{"Itemcode":"74122620","Description":"Dasatinib Chemo RX140mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":1707.74},{"Itemcode":"74122621","Description":"Tyvaso 1.74mg/2.9ml neb","CDM Revenue Code":"250","Standard Price":784.86},{"Itemcode":"74122622","Description":"Ofloxacin 0.3% Opth 10ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122623","Description":"Diclofenac Sodium 37.5 mg vial","CDM Revenue Code":"636","CDM HCPCS":"J1130","Standard Price":59.74},{"Itemcode":"74122624","Description":"Teriparatide 600mcg/2.4ml INJ","CDM Revenue Code":"637","CDM HCPCS":"J3110","Standard Price":8994.0,"Note":"**"},{"Itemcode":"74122625","Description":"Genvoya tablet","CDM Revenue Code":"637","Standard Price":275.25,"Note":"**"},{"Itemcode":"74122626","Description":"Cobicistat 150 mg tablet","CDM Revenue Code":"637","Standard Price":20.25},{"Itemcode":"74122627","Description":"Elvitegravir 85 mg tablet","CDM Revenue Code":"637","Standard Price":120.75},{"Itemcode":"74122628","Description":"Elvitegravir 150 mg tablet","CDM Revenue Code":"637","Standard Price":120.75},{"Itemcode":"74122630","Description":"Sugammadex Na 200mg/2ml vial","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":487.984448111744,"Note":"**"},{"Itemcode":"74122631","Description":"Ciprofloxacin 60mg/ml Inj Susp","CDM Revenue Code":"636","CDM HCPCS":"J7342","Standard Price":1159.55786333333,"Note":"**"},{"Itemcode":"74122632","Description":"Mepolizumab 100mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J2182","Standard Price":8519.8353939394,"Note":"**"},{"Itemcode":"74122633","Description":"Daratumumab 100mg/5ml SDV","CDM Revenue Code":"636","CDM HCPCS":"J9145","Standard Price":2042.76688172043,"Note":"**"},{"Itemcode":"74122634","Description":"Daratumumab 400mg/20ml SDV","CDM Revenue Code":"636","CDM HCPCS":"J9145","Standard Price":8208.07},{"Itemcode":"74122635","Description":"Ketoconazole 2%% Cr 30Gm","CDM Revenue Code":"637","Standard Price":125.25},{"Itemcode":"74122637","Description":"Lurasidone HCl 20mg Tablet","CDM Revenue Code":"637","Standard Price":113.25,"Note":"**"},{"Itemcode":"74122638","Description":"Bourdreaux's butt paste","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122639","Description":"Lansoprazole Sus 3mg/ml Oral","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122640","Description":"Tranexamic Acid 650mg Tablet","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74122641","Description":"Reslizumab 100mg/10ml vial","CDM Revenue Code":"636","CDM HCPCS":"J2786","Standard Price":3605.17336633663,"Note":"**"},{"Itemcode":"74122642","Description":"Heparin 30U INJ 1/2NS 30ml Syr","CDM Revenue Code":"636","Standard Price":59.2539325842696,"Note":"**"},{"Itemcode":"74122643","Description":"Heparin 30U IV 1/2NaACE 30mlSy","CDM Revenue Code":"250","Standard Price":59.61125,"Note":"**"},{"Itemcode":"74122644","Description":"Cangrelor 50 mg vial","CDM Revenue Code":"636","CDM HCPCS":"C9460","Standard Price":3178.58},{"Itemcode":"74122645","Description":"Gemcitabine 1000MG/26.3ml vial","CDM Revenue Code":"636","CDM HCPCS":"J9201","Standard Price":598.43},{"Itemcode":"74122646","Description":"Ketorolac 0.5%% 3 ml Op Sol","CDM Revenue Code":"250","Standard Price":14.42,"Note":"**"},{"Itemcode":"74122647","Description":"Ibrutinib 140mg capsule","CDM Revenue Code":"637","Standard Price":369.75},{"Itemcode":"74122648","Description":"Ruxolitinib 10mg tablet","CDM Revenue Code":"637","Standard Price":577.5},{"Itemcode":"74122649","Description":"Dobutamine Inj 500Mg/250ml","CDM Revenue Code":"636","CDM HCPCS":"J1250","Standard Price":59.74},{"Itemcode":"74122650","Description":"Dopamine 400Mg Inj D5W 250Ml","CDM Revenue Code":"636","CDM HCPCS":"J1265","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122651","Description":"Ibuprofen 800 Mg/100Ml IV Bag","CDM Revenue Code":"636","CDM HCPCS":"J1741","Standard Price":58.8849056603773,"Note":"**"},{"Itemcode":"74122652","Description":"Mifepristone 300mg tablet","CDM Revenue Code":"637","Standard Price":1296.0},{"Itemcode":"74122653","Description":"Sorafenib Tosylate 200mg tab","CDM Revenue Code":"637","Standard Price":411.75},{"Itemcode":"74122654","Description":"Triumeq tablet","CDM Revenue Code":"637","Standard Price":246.75,"Note":"**"},{"Itemcode":"74122655","Description":"Brimonidine 0.2%% Opth Sol 5Ml","CDM Revenue Code":"250","Standard Price":59.033137254902,"Note":"**"},{"Itemcode":"74122656","Description":"Edoxaban 30 Mg Tablet","CDM Revenue Code":"637","Standard Price":22.5,"Note":"**"},{"Itemcode":"74122657","Description":"Zerbaxa 4.5 gm vial","CDM Revenue Code":"636","CDM HCPCS":"J0695","Standard Price":1146.07975903614,"Note":"**"},{"Itemcode":"74122658","Description":"Heparin 500Units D10W500ml INJ","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":59.74},{"Itemcode":"74122659","Description":"MEDIHONEY WOUND GEL 15 ML TUBE","CDM Revenue Code":"637","Standard Price":14.25},{"Itemcode":"74122660","Description":"Raltegravir 100Mg Chew tab","CDM Revenue Code":"637","Standard Price":17.25},{"Itemcode":"74122661","Description":"Apremilast 30 mg Tablet","CDM Revenue Code":"637","Standard Price":147.75},{"Itemcode":"74122662","Description":"Nabumetone 500mgTablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122663","Description":"Factor 7 2000Mcg","CDM Revenue Code":"636","CDM HCPCS":"J7189","Standard Price":14598.19},{"Itemcode":"74122664","Description":"Factor 7 5000Mcg","CDM Revenue Code":"636","CDM HCPCS":"J7189","Standard Price":36494.96},{"Itemcode":"74122665","Description":"Factor 7 8000Mcg","CDM Revenue Code":"636","CDM HCPCS":"J7189","Standard Price":58391.73},{"Itemcode":"74122666","Description":"Oxymorphone Hcl Er 5mgTablet","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122668","Description":"Atezolizumab 1200mg/20ml SDV","CDM Revenue Code":"636","CDM HCPCS":"J9022","Standard Price":30166.64},{"Itemcode":"74122669","Description":"Etravirine 200 Mg Tab","CDM Revenue Code":"637","Standard Price":58.5},{"Itemcode":"74122670","Description":"Oxycodone 15 Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122671","Description":"Raltegravir 100Mg powder pack","CDM Revenue Code":"637","Standard Price":17.25},{"Itemcode":"74122672","Description":"Clonidine 20 mcg/ml ORAL SYR","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122673","Description":"Tapentadol Er 250Mg Tablet","CDM Revenue Code":"637","Standard Price":64.5},{"Itemcode":"74122674","Description":"Brivaracetam 50 mg/5ml vial","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":181.28},{"Itemcode":"74122675","Description":"Atomoxetine Hcl 80Mg Cap","CDM Revenue Code":"637","Standard Price":46.5},{"Itemcode":"74122676","Description":"Alogliptin 25 mf tablet","CDM Revenue Code":"637","Standard Price":37.5},{"Itemcode":"74122677","Description":"Vortioxetine HBR 5 mg tablet","CDM Revenue Code":"637","Standard Price":34.5,"Note":"**"},{"Itemcode":"74122678","Description":"Patiromer Ca Sorbitex8.4gm pkt","CDM Revenue Code":"637","Standard Price":89.25,"Note":"**"},{"Itemcode":"74122680","Description":"LOCM Visipaque 320MGI 150 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":633.45},{"Itemcode":"74122681","Description":"Insulin Degludec 300 Unit/3Ml","CDM Revenue Code":"637","Standard Price":88.5,"Note":"**"},{"Itemcode":"74122682","Description":"Phytonadione (K1) 5Mg /0.5ml","CDM Revenue Code":"637","Standard Price":50.25,"Note":"**"},{"Itemcode":"74122683","Description":"ceFEPime/D5w 2000mg/50ml bag","CDM Revenue Code":"636","CDM HCPCS":"J0692","Standard Price":59.74},{"Itemcode":"74122684","Description":"Estazolam 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122685","Description":"USTEKINUMAB IV INJ 130MG/26ML","CDM Revenue Code":"636","CDM HCPCS":"J3358","Standard Price":6683.27384615384,"Note":"**"},{"Itemcode":"74122686","Description":"Ustekinumab 45mg/0.5ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3357","Standard Price":32887.9},{"Itemcode":"74122687","Description":"Ustekinumab 90mg/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3357","Standard Price":65202.09,"Note":"**"},{"Itemcode":"74122688","Description":"Dehydrated alcohol 5Ml VIAL","CDM Revenue Code":"250","Standard Price":398.61,"Note":"**"},{"Itemcode":"74122689","Description":"Phytonadione (K1) 1Mg /0.5ml","CDM Revenue Code":"637","Standard Price":44.33,"Note":"**"},{"Itemcode":"74122690","Description":"Dasatinib 50 Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":948.63},{"Itemcode":"74122691","Description":"Ruxolitinib 5mg tablet","CDM Revenue Code":"637","Standard Price":546.75},{"Itemcode":"74122692","Description":"Theophylline Sa 100Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122693","Description":"Theophylline Sa 200Mg Tab","CDM Revenue Code":"637","Standard Price":8.25,"Note":"**"},{"Itemcode":"74122694","Description":"Ryanodex 250mg vial","CDM Revenue Code":"250","CDM HCPCS":"J3490","Standard Price":7744.57,"Note":"**"},{"Itemcode":"74122695","Description":"Vemurafenib 240mg tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":191.58},{"Itemcode":"74122696","Description":"Sildenafil 2.5mg/ml syringe","CDM Revenue Code":"637","Standard Price":15.75},{"Itemcode":"74122697","Description":"Ticagrelor 60 Mg Tablet","CDM Revenue Code":"637","Standard Price":16.5,"Note":"**"},{"Itemcode":"74122698","Description":"Incruse Ellipta 7dose inhaler","CDM Revenue Code":"637","Standard Price":118.04,"Note":"**"},{"Itemcode":"74122699","Description":"Triamcinalone 025%% Cr 454GM","CDM Revenue Code":"637","Standard Price":40.5,"Note":"**"},{"Itemcode":"74122700","Description":"Mycophenolate 500 Mg Capsule","CDM Revenue Code":"636","CDM HCPCS":"J7517","Standard Price":59.0991541353384,"Note":"**"},{"Itemcode":"74122701","Description":"Neulasta Inj Delivery Kit 6mg","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":20480.52},{"Itemcode":"74122702","Description":"Oral GLucose 3ml syr","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122703","Description":"Ferrous Sulfate 15Mg/Ml SYR","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122704","Description":"Isovue (Ioamidol) 61%% 100 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":59.4104},{"Itemcode":"74122705","Description":"Fluocinolone Ace.0.01%%Oil Bo","CDM Revenue Code":"637","Standard Price":529.5},{"Itemcode":"74122706","Description":"Tetracaine 0.5%% 4Ml Opth Sol","CDM Revenue Code":"250","Standard Price":58.8585416359617,"Note":"**"},{"Itemcode":"74122708","Description":"Gammagard 30gm vial","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":10690.6275,"Note":"**"},{"Itemcode":"74122709","Description":"Gammagard 20Gm vial","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":7113.25999666667,"Note":"**"},{"Itemcode":"74122710","Description":"Gammagard 10gm vial","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":3466.50561142857,"Note":"**"},{"Itemcode":"74122711","Description":"Gammagard Liquid 5gm vial","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":1659.65872340426,"Note":"**"},{"Itemcode":"74122712","Description":"Dexamethasone 10Mg/Ml PF Neo","CDM Revenue Code":"250","Standard Price":54.59,"Note":"**"},{"Itemcode":"74122713","Description":"ChemoTher-Pazopanib 200mg tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":389.34},{"Itemcode":"74122714","Description":"Privigen 5 gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":1527.48715862069,"Note":"**"},{"Itemcode":"74122715","Description":"Ketotifen 0.25%%Opth 5Ml/Drops","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74122716","Description":"Privigen 40gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":13146.3940425532,"Note":"**"},{"Itemcode":"74122717","Description":"Privigen 20gm Vial","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":6197.22196785714,"Note":"**"},{"Itemcode":"74122718","Description":"Privigen 10gm vial","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":3156.89100909091,"Note":"**"},{"Itemcode":"74122719","Description":"Pentacel Vaccine 0.5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"90698","Standard Price":355.35,"Note":"**"},{"Itemcode":"74122720","Description":"Sucralfate Susp 0.1Gm/1 Ml syr","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122722","Description":"Trabectedin 1mg vial","CDM Revenue Code":"636","CDM HCPCS":"J9352","Standard Price":11920.19},{"Itemcode":"74122723","Description":"Temozolomide 250Mg Capsule Orl","CDM Revenue Code":"636","CDM HCPCS":"J8700","Standard Price":1718.04},{"Itemcode":"74122725","Description":"Naloxegol Oxalate 12.5 mg Tab","CDM Revenue Code":"637","Standard Price":31.5,"Note":"**"},{"Itemcode":"74122726","Description":"Lifitegrast 5%% Opth 0.2 ml","CDM Revenue Code":"250","Standard Price":58.3666666666667,"Note":"**"},{"Itemcode":"74122727","Description":"LOCM Isovue 300 1 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":1.03000730203854,"Note":"**"},{"Itemcode":"74122728","Description":"LOCM Visipaque 320 1 Ml","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":6.18,"Note":"**"},{"Itemcode":"74122729","Description":"Albuterol/Ipratrop2.5/0.5MGNeb","CDM Revenue Code":"250","Standard Price":58.8528229778068,"Note":"**"},{"Itemcode":"74122730","Description":"Pomalidomide 1Mg Cap","CDM Revenue Code":"637","Standard Price":2457.0},{"Itemcode":"74122731","Description":"Eluxadoline 100 mg tablet","CDM Revenue Code":"637","Standard Price":42.0,"Note":"**"},{"Itemcode":"74122732","Description":"Albuterol 0.5%% 2.5Mg/3 Ml Neb","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122733","Description":"Amphotericin B 50mcg/ml Op Syr","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122735","Description":"Tenofovir Alafenamide 25MgTab","CDM Revenue Code":"637","Standard Price":99.75,"Note":"**"},{"Itemcode":"74122736","Description":"Hydrocortisone 2%% 28Gm Oint","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122738","Description":"Insulin Detemir 100 U/1Ml Inj","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":27.0,"Note":"**"},{"Itemcode":"74122739","Description":"Doxercalciferol 2 Mcg/1Ml Vial","CDM Revenue Code":"250","CDM HCPCS":"J1270","Standard Price":58.9675,"Note":"**"},{"Itemcode":"74122740","Description":"Cefazolin 6000mg IV Soltn","CDM Revenue Code":"636","CDM HCPCS":"J0690","Standard Price":59.1667826086957,"Note":"**"},{"Itemcode":"74122741","Description":"Meningococcal B Vac (Bexero)","CDM Revenue Code":"636","CDM HCPCS":"90620","Standard Price":541.0075,"Note":"**"},{"Itemcode":"74122742","Description":"Lidocaine 5%% Oint 1 APP Charg","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122743","Description":"Infliximab-Dyyb100Mg Inflectra","CDM Revenue Code":"636","CDM HCPCS":"Q5103","Standard Price":2761.726125,"Note":"**"},{"Itemcode":"74122744","Description":"Ocrelizumab 300mg/10ml vial","CDM Revenue Code":"636","CDM HCPCS":"J2350","Standard Price":50128.1354105263,"Note":"**"},{"Itemcode":"74122745","Description":"C1 Esterase Berin Inh 500U Inj","CDM Revenue Code":"636","CDM HCPCS":"J0597","Standard Price":9705.69},{"Itemcode":"74122746","Description":"Levothyroxine 25mcg/ml sus syr","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122747","Description":"Top Opth Dilating SolNO Tetrac","CDM Revenue Code":"250","Standard Price":110.109512195122,"Note":"**"},{"Itemcode":"74122748","Description":"Morphine 0.5MG/ML Inj","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":59.3966666666667,"Note":"**"},{"Itemcode":"74122749","Description":"Pembrolizumab 100mg/4ml vial","CDM Revenue Code":"636","CDM HCPCS":"J9271","Standard Price":18873.72,"Note":"**"},{"Itemcode":"74122752","Description":"Methylene Blue INJ 50MG/10Ml","CDM Revenue Code":"636","CDM HCPCS":"Q9968","Standard Price":633.774741509434,"Note":"**"},{"Itemcode":"74122753","Description":"Bicitra 1Ml SYR","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122754","Description":"Nevirapine 50MG/5ML Susp","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74122755","Description":"Minocycline 100Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2265","Standard Price":656.11,"Note":"**"},{"Itemcode":"74122756","Description":"Gamunex Immune Glob Inj 10 Gm","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":3696.63038461539,"Note":"**"},{"Itemcode":"74122757","Description":"Gamunex Immune Glob Inj 20 Gm","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":7401.58,"Note":"**"},{"Itemcode":"74122758","Description":"Gamunex Immune Glob Inj 5 Gm","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":1846.90444444444,"Note":"**"},{"Itemcode":"74122759","Description":"Perit Dia Dex 4.25%% 2000mll","CDM Revenue Code":"250","Standard Price":58.4594594594595,"Note":"**"},{"Itemcode":"74122760","Description":"Diazepam 2 Mg Inj Syr","CDM Revenue Code":"636","CDM HCPCS":"J3360","Standard Price":59.4457142857143,"Note":"**"},{"Itemcode":"74122761","Description":"Perit Dia Dex 4.25%% SS 2000ml","CDM Revenue Code":"250","Standard Price":59.3966666666667,"Note":"**"},{"Itemcode":"74122762","Description":"Perit Dia Dex 4.25%% 5000mll","CDM Revenue Code":"250","Standard Price":58.9863414634146,"Note":"**"},{"Itemcode":"74122763","Description":"Perit Dia Dex 2.5%% SS 2000mll","CDM Revenue Code":"250","Standard Price":58.6206632653061,"Note":"**"},{"Itemcode":"74122764","Description":"Perit Dia Dex 2.5%% SS 2000mll","CDM Revenue Code":"250","Standard Price":58.916,"Note":"**"},{"Itemcode":"74122765","Description":"Perit Dia Dex 2.5%% 5000mll","CDM Revenue Code":"250","Standard Price":59.0213350125945,"Note":"**"},{"Itemcode":"74122766","Description":"Perit Dia Dex 1.5% 2000ml","CDM Revenue Code":"250","Standard Price":58.9523529411765,"Note":"**"},{"Itemcode":"74122767","Description":"Perit Dia Dex 1.5%% SS 2000mll","CDM Revenue Code":"250","Standard Price":59.0925714285714,"Note":"**"},{"Itemcode":"74122768","Description":"Perit Dia Dex 1.5%% SS 5000mll","CDM Revenue Code":"250","Standard Price":59.1748125937032,"Note":"**"},{"Itemcode":"74122769","Description":"Midostaurin 25mg capsule","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":567.53,"Note":"**"},{"Itemcode":"74122770","Description":"Isavuconazonium 186mg caps","CDM Revenue Code":"637","Standard Price":240.0,"Note":"**"},{"Itemcode":"74122772","Description":"Dexmedetomidine 400Mcg/4Ml Via","CDM Revenue Code":"250","Standard Price":126.516729635393,"Note":"**"},{"Itemcode":"74122773","Description":"Chemo RX,Trametinib 2mg caps","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":1482.17},{"Itemcode":"74122774","Description":"Lidocaine 1.5%%/Epi 1:200 30ML","CDM Revenue Code":"250","Standard Price":59.205925925926,"Note":"**"},{"Itemcode":"74122776","Description":"Hyaluronate 7.7 Mg/0.55 Ml Sy","CDM Revenue Code":"250","Standard Price":445.372,"Note":"**"},{"Itemcode":"74122777","Description":"Dronabinol 5mg/1ml soln","CDM Revenue Code":"637","Standard Price":87.75},{"Itemcode":"74122778","Description":"Chemo RX, Dabrafenib 75mg caps","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":341.96},{"Itemcode":"74122779","Description":"Topiramate 25Mg Sprinkle","CDM Revenue Code":"637","Standard Price":17.25},{"Itemcode":"74122780","Description":"Albuterol Inh Hfa 200Inh 8.5Gm","CDM Revenue Code":"637","Standard Price":155.25,"Note":"**"},{"Itemcode":"74122781","Description":"Clevipidine 25mg/50ml vial","CDM Revenue Code":"636","CDM HCPCS":"C9248","Standard Price":259.756741573034,"Note":"**"},{"Itemcode":"74122782","Description":"Volumen 450Ml","CDM Revenue Code":"255","Standard Price":26.4107547169812,"Note":"**"},{"Itemcode":"74122783","Description":"Bezlotoxumab 1000mg/40ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0565","Standard Price":12975.2533333333,"Note":"**"},{"Itemcode":"74122784","Description":"Gelfilm 125 mm sheet","CDM Revenue Code":"250","Standard Price":7452.05},{"Itemcode":"74122785","Description":"ELIGARD 7.5 MG SYR (SQ)","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":580.92,"Note":"**"},{"Itemcode":"74122786","Description":"Copanlisib 60mg vial","CDM Revenue Code":"636","CDM HCPCS":"J9057","Standard Price":14481.8},{"Itemcode":"74122787","Description":"Chlorhexidine Gluc 0.12%% 118M","CDM Revenue Code":"637","Standard Price":20.25,"Note":"**"},{"Itemcode":"74122788","Description":"Temozolomide 140Mg Oral Cap","CDM Revenue Code":"636","CDM HCPCS":"J8700","Standard Price":228.66},{"Itemcode":"74122789","Description":"Mycophenolate 180mg tablet DR","CDM Revenue Code":"636","CDM HCPCS":"J7518","Standard Price":20.5078861788618,"Note":"**"},{"Itemcode":"74122791","Description":"Lidocaine 1%% With Epi 50Ml","CDM Revenue Code":"250","CDM HCPCS":"J3490","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122792","Description":"Itraconazole Sol 50mg/5ml dose","CDM Revenue Code":"637","Standard Price":28.5},{"Itemcode":"74122793","Description":"Obinutuzumab 1000mg/40ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J9301","Standard Price":21394.13},{"Itemcode":"74122794","Description":"Hemin 350mg/50ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J1640","Standard Price":24933.21,"Note":"**"},{"Itemcode":"74122795","Description":"Cyclopentolate 1%% Op Sol 10Ml","CDM Revenue Code":"250","Standard Price":57.68},{"Itemcode":"74122796","Description":"Difluprednate 0.05%% Opth 5ml","CDM Revenue Code":"250","Standard Price":656.23875,"Note":"**"},{"Itemcode":"74122797","Description":"Insulin Reg Hum 1500 Unit/3Ml","CDM Revenue Code":"636","CDM HCPCS":"J1815","Standard Price":1140.828,"Note":"**"},{"Itemcode":"74122798","Description":"Tobramycin Sulfate 4MG/ML Inj","CDM Revenue Code":"636","CDM HCPCS":"J3260","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122799","Description":"Heparin 2000 U/NS 1000ML","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122800","Description":"Urea 15 gm powder pkt","CDM Revenue Code":"637","Standard Price":11.25,"Note":"**"},{"Itemcode":"74122801","Description":"Oxcarbazepine 300Mg/5Ml oral","CDM Revenue Code":"637","Standard Price":7.5,"Note":"**"},{"Itemcode":"74122804","Description":"Empagliflozin 25Mg Tablet","CDM Revenue Code":"637","Standard Price":44.25,"Note":"**"},{"Itemcode":"74122805","Description":"Empagliffozin 10Mg Tablet","CDM Revenue Code":"637","Standard Price":44.25,"Note":"**"},{"Itemcode":"74122806","Description":"Immune Globulin INJ 200MG/1ML","CDM Revenue Code":"636","Standard Price":79.31},{"Itemcode":"74122808","Description":"Vancomycin 1000mg/250ml PM INJ","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":78.5823853211009,"Note":"**"},{"Itemcode":"74122809","Description":"Degarelix 80mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9155","Standard Price":1223.64},{"Itemcode":"74122810","Description":"Benralizumab 30mg/ml syr","CDM Revenue Code":"636","Standard Price":16242.5595049505,"Note":"**"},{"Itemcode":"74122811","Description":"Vyxeos 44mg/100ml Vial","CDM Revenue Code":"636","Standard Price":26722.32,"Note":"**"},{"Itemcode":"74122812","Description":"Tropicamide 0.5%% Opth 15Ml","CDM Revenue Code":"250","Standard Price":25.9216666666667,"Note":"**"},{"Itemcode":"74122813","Description":"Regorafenib 40mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":788.98},{"Itemcode":"74122814","Description":"Alteplase-Recomb 1Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":306.885935397039,"Note":"**"},{"Itemcode":"74122815","Description":"Abacavir son 300mg/15ml","CDM Revenue Code":"637","Standard Price":26.25},{"Itemcode":"74122816","Description":"Entresto 49mg/51mg tablet","CDM Revenue Code":"637","Standard Price":21.75,"Note":"**"},{"Itemcode":"74122817","Description":"Betamethasone Val 0.1%% Lt 60m","CDM Revenue Code":"637","Standard Price":106.5,"Note":"**"},{"Itemcode":"74122818","Description":"Radicava 30mg/100ml bag","CDM Revenue Code":"636","CDM HCPCS":"J1301","Standard Price":2270.43088414634,"Note":"**"},{"Itemcode":"74122819","Description":"Acetic Acid 0.25%% Irr 1000Ml","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122820","Description":"Asenapine 5 Mg SL Tab","CDM Revenue Code":"637","Standard Price":57.0},{"Itemcode":"74122821","Description":"Submucosal Endo Composite 10ml","CDM Revenue Code":"250","Standard Price":326.546352941176,"Note":"**"},{"Itemcode":"74122823","Description":"Nacl Conc 2.5Meq Per Ml Chg","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122824","Description":"Novolin-N 100U/1ML INJ","CDM Revenue Code":"637","CDM HCPCS":"J1815","Standard Price":6.0,"Note":"**"},{"Itemcode":"74122825","Description":"Lidocaine 2%% W Epi 50Ml Vial","CDM Revenue Code":"250","Standard Price":58.8940535947712,"Note":"**"},{"Itemcode":"74122826","Description":"Topiramate 25Mg ER capsule","CDM Revenue Code":"637","Standard Price":25.5,"Note":"**"},{"Itemcode":"74122827","Description":"TRELEGY ELLIPTA INH","CDM Revenue Code":"637","Standard Price":389.25,"Note":"**"},{"Itemcode":"74122828","Description":"Morphine 2Mg/2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":59.74},{"Itemcode":"74122829","Description":"Vitamin Multi Therap 15Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122830","Description":"Lidocaine 1%% With Epi 30Ml","CDM Revenue Code":"250","CDM HCPCS":"J3490","Standard Price":59.1985375494072,"Note":"**"},{"Itemcode":"74122832","Description":"Talc For Intrapleural 4Gm","CDM Revenue Code":"250","Standard Price":588.661612903226,"Note":"**"},{"Itemcode":"74122833","Description":"Nifedipine 30mg/7.5ml","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74122834","Description":"Alemtuzumab 12mg/1.2ml vial","CDM Revenue Code":"636","CDM HCPCS":"J0202","Standard Price":75166.31},{"Itemcode":"74122835","Description":"Fentanyl .05Mg/Ml 50Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":65.92,"Note":"**"},{"Itemcode":"74122836","Description":"Potassium Acetate 100Meq Inj.","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122837","Description":"Venetoclax 10mg Tab (Chemo)","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":39.14},{"Itemcode":"74122838","Description":"Venetoclax 50 mg tab (Chemo)","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":197.76},{"Itemcode":"74122839","Description":"Clonazepam 1 Mg Odt","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122840","Description":"Crizotinib 250mg Capsule","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":1137.12},{"Itemcode":"74122841","Description":"Heparin Flush 5 Unit/5Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":59.74},{"Itemcode":"74122842","Description":"Sirolimus 1 Mg/1Ml solution","CDM Revenue Code":"636","CDM HCPCS":"J7520","Standard Price":118.45},{"Itemcode":"74122843","Description":"Delafloxacin 450 Mg Tablet","CDM Revenue Code":"637","Standard Price":193.5,"Note":"**"},{"Itemcode":"74122844","Description":"Anakinra 100mg/0.67ml Syringe","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":593.28},{"Itemcode":"74122845","Description":"Fondaparinux 10Mg/0.8Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1652","Standard Price":504.7},{"Itemcode":"74122846","Description":"Cabozantinib 40mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":2418.44},{"Itemcode":"74122847","Description":"Nintedanib 100mg Capsule","CDM Revenue Code":"637","Standard Price":459.0},{"Itemcode":"74122848","Description":"Nintedanib 150mg Capsule","CDM Revenue Code":"637","Standard Price":459.0},{"Itemcode":"74122849","Description":"Progesterone 100mg Vag Supp","CDM Revenue Code":"637","Standard Price":11.25},{"Itemcode":"74122850","Description":"Ceftriaxone 35Mg/ML Inj","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":6.18,"Note":"**"},{"Itemcode":"74122851","Description":"Rabies Immune Glob 300Unit/1Ml","CDM Revenue Code":"636","CDM HCPCS":"90376","Standard Price":2676.62666666667,"Note":"**"},{"Itemcode":"74122852","Description":"Rabies ImmuneGlob1500Unit/5Ml","CDM Revenue Code":"636","CDM HCPCS":"90376","Standard Price":10665.0076966292,"Note":"**"},{"Itemcode":"74122853","Description":"Patiromer Sorbitex16.8gm pkt","CDM Revenue Code":"637","Standard Price":89.25,"Note":"**"},{"Itemcode":"74122854","Description":"Lithium Carbonate 300Mg ERTab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122855","Description":"Dextrose 15gm Oral Gel","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74122856","Description":"Linaclotide 72 Mcg Capsule","CDM Revenue Code":"637","Standard Price":36.75,"Note":"**"},{"Itemcode":"74122857","Description":"TIOTROPIUM/OLODATEROL 60 INH","CDM Revenue Code":"637","Standard Price":739.5,"Note":"**"},{"Itemcode":"74122858","Description":"Sirolimus 0.5 Mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J7520","Standard Price":21.6986666666667,"Note":"**"},{"Itemcode":"74122859","Description":"Crysvita 10 mg/ml syringe","CDM Revenue Code":"636","CDM HCPCS":"J0584","Standard Price":11723.46},{"Itemcode":"74122860","Description":"Crysvita 20 mg/ml syr","CDM Revenue Code":"636","CDM HCPCS":"J0584","Standard Price":23445.89,"Note":"**"},{"Itemcode":"74122861","Description":"Crysvita 30 mg/ml syr","CDM Revenue Code":"636","CDM HCPCS":"J0584","Standard Price":35169.35,"Note":"**"},{"Itemcode":"74122862","Description":"Mepivacaine Hcl 1%% 50Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0670","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122863","Description":"Descovy 200-25mg Tablet","CDM Revenue Code":"637","Standard Price":160.5,"Note":"**"},{"Itemcode":"74122864","Description":"Hydrocortisone2.5%%Pram 1%%30G","CDM Revenue Code":"637","Standard Price":350.25,"Note":"**"},{"Itemcode":"74122865","Description":"Tiotropium 2.5mcg Inh 4 gm","CDM Revenue Code":"637","Standard Price":112.5,"Note":"**"},{"Itemcode":"74122866","Description":"Dulera 100Mcg/5Mcg 50puf Inh","CDM Revenue Code":"637","Standard Price":604.5,"Note":"**"},{"Itemcode":"74122867","Description":"Maraviroc 300Mg Tablet","CDM Revenue Code":"637","Standard Price":46.5},{"Itemcode":"74122868","Description":"Ritonavir 100mg powder Pkt","CDM Revenue Code":"637","Standard Price":24.75},{"Itemcode":"74122869","Description":"Vortioxetine HBR 20 mg tablet","CDM Revenue Code":"637","Standard Price":36.0,"Note":"**"},{"Itemcode":"74122870","Description":"Arsenic Trioxide 12Mg/6Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":3596.76,"Note":"**"},{"Itemcode":"74122871","Description":"Erythromycin 25mg/ml 90ml Top","CDM Revenue Code":"637","Standard Price":82.5,"Note":"**"},{"Itemcode":"74122872","Description":"FluBlok 0.5ml syringe","CDM Revenue Code":"636","CDM HCPCS":"90682","Standard Price":188.49},{"Itemcode":"74122873","Description":"Factor XA,Inactiva 100mg vial","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":9482.18},{"Itemcode":"74122874","Description":"Lamotrigine ODT 50 mg tablet","CDM Revenue Code":"637","Standard Price":21.0,"Note":"**"},{"Itemcode":"74122875","Description":"Polymyxin B 500000 Unit/Ns 5Ml","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"74122876","Description":"Clotrimazole 1%% Sol 30ml","CDM Revenue Code":"637","Standard Price":135.75,"Note":"**"},{"Itemcode":"74122877","Description":"Lenalidomide 10 Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":2950.95,"Note":"**"},{"Itemcode":"74122878","Description":"Lenalidomide 15Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":2950.95},{"Itemcode":"74122879","Description":"Lenalidomide 20Mg Cap","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":2950.95},{"Itemcode":"74122880","Description":"Carboplatin 10mg/ml","CDM Revenue Code":"636","CDM HCPCS":"J9045","Standard Price":5.15},{"Itemcode":"74122881","Description":"Eltrombopaq 50mg tablet","CDM Revenue Code":"637","Standard Price":825.0},{"Itemcode":"74122882","Description":"Alprazolam Xr 0.5 Mg Tbsa","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122883","Description":"TOUJEO INSULIN 450 U/1.5ML","CDM Revenue Code":"636","CDM HCPCS":"J1815","Standard Price":352.26,"Note":"**"},{"Itemcode":"74122884","Description":"Nevirapine ER 400 Mg Tablet","CDM Revenue Code":"637","Standard Price":15.0},{"Itemcode":"74122885","Description":"RomiDEPsin 10mg/2ML","CDM Revenue Code":"636","CDM HCPCS":"J9315","Standard Price":10573.98},{"Itemcode":"74122887","Description":"Desvenlafaxine 25Mg Tablet","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122888","Description":"VABOMERE 2GM IV","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":637.57},{"Itemcode":"74122889","Description":"Rivaroxaban 2.5 Mg Tablet","CDM Revenue Code":"637","Standard Price":15.0,"Note":"**"},{"Itemcode":"74122890","Description":"ERAVACYCLINE DI-HCL 50MG IV","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":182.183643122676,"Note":"**"},{"Itemcode":"74122891","Description":"Improvue Surg Ophth 2ml","CDM Revenue Code":"250","Standard Price":138.959720218579,"Note":"**"},{"Itemcode":"74122892","Description":"Eltrombopaq 75mg tablet","CDM Revenue Code":"637","Standard Price":1238.25},{"Itemcode":"74122893","Description":"Danocrine 200Mg Cap","CDM Revenue Code":"637","Standard Price":12.75,"Note":"**"},{"Itemcode":"74122894","Description":"PLAZOMICIN SULFATE 500MG/10ML","CDM Revenue Code":"636","CDM HCPCS":"J0291","Standard Price":1297.8},{"Itemcode":"74122895","Description":"Nystatin-Triamcinolone Cr 30Gm","CDM Revenue Code":"637","Standard Price":88.5,"Note":"**"},{"Itemcode":"74122896","Description":"Buspirone 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122897","Description":"Antihemo FVIII NovoEight 1unit","CDM Revenue Code":"636","Standard Price":4.12},{"Itemcode":"74122898","Description":"Carbidopa 10Mg++Levo 100Mg ODT","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122899","Description":"Omacetaxine 3.5mg vial","CDM Revenue Code":"636","Standard Price":4251.84},{"Itemcode":"74122900","Description":"Alglucosidase 50mg/10ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0221","Standard Price":2786.15},{"Itemcode":"74122901","Description":"Factor XA,Inactiva 200mg vial","CDM Revenue Code":"636","CDM HCPCS":"C9041","Standard Price":18905.8216666667,"Note":"**"},{"Itemcode":"74122902","Description":"Venetoclax 100 mg tab (Chemo)","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":383.16,"Note":"**"},{"Itemcode":"74122903","Description":"Submucosal Lifting Aget 20ml","CDM Revenue Code":"250","Standard Price":703.833333333333,"Note":"**"},{"Itemcode":"74122904","Description":"Ethiodized Oil 10ml Amp","CDM Revenue Code":"250","Standard Price":4507.28,"Note":"**"},{"Itemcode":"74122905","Description":"Lithium Carbonate 150Mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122906","Description":"TILDRAKIZUMAB-ASMIN 100MG/ML","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":44374.46,"Note":"**"},{"Itemcode":"74122907","Description":"Gemtuzumab 4.5mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9203","Standard Price":28696.315,"Note":"**"},{"Itemcode":"74122908","Description":"Cariprazine 1.5MG Capsule","CDM Revenue Code":"637","Standard Price":114.75,"Note":"**"},{"Itemcode":"74122909","Description":"Semaglutide 2mg/1.5ml Pen","CDM Revenue Code":"637","CDM HCPCS":"C9399","Standard Price":1109.25,"Note":"**"},{"Itemcode":"74122910","Description":"Guaifensein Ac 10Ml Ud","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122911","Description":"Topiramate 200Mg ER capsule","CDM Revenue Code":"637","Standard Price":96.75,"Note":"**"},{"Itemcode":"74122912","Description":"Abiraterone (Zytiga) 500mg tab","CDM Revenue Code":"637","Standard Price":521.25},{"Itemcode":"74122913","Description":"Oxytocin 30 Units/Rl 500 Ml","CDM Revenue Code":"250","Standard Price":57.68},{"Itemcode":"74122914","Description":"DULAGLUTIDE 1.5MG/0.5ML PEN","CDM Revenue Code":"636","Standard Price":748.81},{"Itemcode":"74122915","Description":"CALCIFEDIOL 30 Mcg Cap","CDM Revenue Code":"637","Standard Price":103.5},{"Itemcode":"74122916","Description":"Dexamethasone 0.2mg/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":57.68},{"Itemcode":"74122917","Description":"INFLIXIMAB-ABDA INJ 100MG","CDM Revenue Code":"636","CDM HCPCS":"Q5104","Standard Price":1676.01421730769,"Note":"**"},{"Itemcode":"74122918","Description":"ROMOSOZUMAG 105mg/1.17ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3111","Standard Price":3759.5,"Note":"**"},{"Itemcode":"74122919","Description":"cefTAZadime 22.5mg/1ml Op Inj","CDM Revenue Code":"636","CDM HCPCS":"J0713","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122921","Description":"Sodium Acetate 400Meq/100Ml","CDM Revenue Code":"250","Standard Price":57.68,"Note":"**"},{"Itemcode":"74122922","Description":"Omadacycline 100mg vial","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":1421.4,"Note":"**"},{"Itemcode":"74122923","Description":"Pomalidomide 4Mg Cap","CDM Revenue Code":"637","Standard Price":2457.0},{"Itemcode":"74122924","Description":"Epoetin EPBX NonESRD 2000U/Ml","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":74.16,"Note":"**"},{"Itemcode":"74122925","Description":"Epoetin EPBX NonESRD 3000U/Ml","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":111.24},{"Itemcode":"74122926","Description":"Epoetin EPBX NonESRD 4000U/Ml","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":149.35,"Note":"**"},{"Itemcode":"74122927","Description":"Epoetin EPBX NonESRD 10000U/Ml","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":371.243441777509,"Note":"**"},{"Itemcode":"74122928","Description":"Epoetin EPBX NonESRD 40000U/Ml","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":1488.35,"Note":"**"},{"Itemcode":"74122929","Description":"Cannabidiol (CBD) 100mg/ml Liq","CDM Revenue Code":"637","Standard Price":36.75},{"Itemcode":"74122930","Description":"Fluticasone Furoate 100mcg Inh","CDM Revenue Code":"637","Standard Price":196.5,"Note":"**"},{"Itemcode":"74122931","Description":"Fluticasone Furoate 200mcg Inh","CDM Revenue Code":"637","Standard Price":262.5,"Note":"**"},{"Itemcode":"74122932","Description":"Azathioprine 75Mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"J7500","Standard Price":65.92,"Note":"**"},{"Itemcode":"74122933","Description":"Loperamide 2 Mg/15 Ml Cup","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122934","Description":"CIDOFOVIR 1%% TOP CM 40GM","CDM Revenue Code":"637","Standard Price":1538.25},{"Itemcode":"74122935","Description":"Gamunex Immune Glob Inj 40 Gm","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":12798.78,"Note":"**"},{"Itemcode":"74122936","Description":"Gammagard 2.5GM Vial","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":900.22,"Note":"**"},{"Itemcode":"74122937","Description":"Lamotrigine 50Mg XRTab","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74122938","Description":"Bosutinib 100mg Tab","CDM Revenue Code":"637","CDM HCPCS":"C9399","Standard Price":373.5},{"Itemcode":"74122939","Description":"LUMASON 25MG/5ML INJ VIAL","CDM Revenue Code":"636","CDM HCPCS":"Q9950","Standard Price":552.08,"Note":"**"},{"Itemcode":"74122940","Description":"DarbepoetinAlfa60Mcg/0.3ml In","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":1791.17,"Note":"**"},{"Itemcode":"74122941","Description":"Thrombin 5:000 Units Top Kit","CDM Revenue Code":"250","Standard Price":193.64,"Note":"**"},{"Itemcode":"74122942","Description":"Penicillin G Procaine 600000U","CDM Revenue Code":"636","CDM HCPCS":"J2510","Standard Price":128.75,"Note":"**"},{"Itemcode":"74122943","Description":"Arsenic Trioxide 10Mg/10Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":457.32},{"Itemcode":"74122944","Description":"DEXMEDETOMIDINE 12MCG/3 ML","CDM Revenue Code":"250","Standard Price":56.4652912751678,"Note":"**"},{"Itemcode":"74122945","Description":"Biktarvy 50-200-25mg Tab","CDM Revenue Code":"637","Standard Price":301.5,"Note":"**"},{"Itemcode":"74122948","Description":"Risperidone 12.5 Mg Kit IM","CDM Revenue Code":"636","CDM HCPCS":"J2794","Standard Price":922.88,"Note":"**"},{"Itemcode":"74122949","Description":"Cal Gluconate 2GM/100ML bag","CDM Revenue Code":"636","CDM HCPCS":"J0610","Standard Price":79.31,"Note":"**"},{"Itemcode":"74122950","Description":"Hydrocortisone 5Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122951","Description":"Phenobarbital 4Mg/1 Ml Liq","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122952","Description":"Hyaluronate 13.3 Mg/0.85 Ml","CDM Revenue Code":"250","Standard Price":585.04},{"Itemcode":"74122953","Description":"Liothyronine Na 10 Mcg vial","CDM Revenue Code":"250","Standard Price":1164.93,"Note":"**"},{"Itemcode":"74122955","Description":"LONSURF 15/6.14MG TAB","CDM Revenue Code":"637","Standard Price":495.0},{"Itemcode":"74122956","Description":"LONSURF 20/8.19MG TAB","CDM Revenue Code":"637","Standard Price":660.0},{"Itemcode":"74122957","Description":"Sunitinib Maleate 50 Mg Capsul","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":2628.56},{"Itemcode":"74122958","Description":"COPPER CHLORIDE 4MG/10ML","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":79.31,"Note":"**"},{"Itemcode":"74122959","Description":"SYMTUZA COMBO TAB","CDM Revenue Code":"637","Standard Price":363.0,"Note":"**"},{"Itemcode":"74122960","Description":"Copper Gluconate 2mg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122961","Description":"Entresto 97mg/103mg tablet","CDM Revenue Code":"637","Standard Price":24.0,"Note":"**"},{"Itemcode":"74122962","Description":"Apalutamide 60mg Tablet","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":400.67},{"Itemcode":"74122963","Description":"Calcitriol 0.5Mcg Cap","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122964","Description":"Trastuzumab-anns 21 Mg/1 Ml","CDM Revenue Code":"636","CDM HCPCS":"Q5117","Standard Price":735.42,"Note":"**"},{"Itemcode":"74122965","Description":"Methotrexate 1000mg/20ml vial","CDM Revenue Code":"636","CDM HCPCS":"J9260","Standard Price":247.2,"Note":"**"},{"Itemcode":"74122968","Description":"Ibuprofen 800 Mg/200Ml IV Bag","CDM Revenue Code":"636","CDM HCPCS":"J1741","Standard Price":81.37,"Note":"**"},{"Itemcode":"74122969","Description":"Famotidine 10Mg Tab","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"74122970","Description":"Diliazem CP 420Mg Cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122972","Description":"Simethicone Drops 20Mg/0.3Ml","CDM Revenue Code":"637","Standard Price":9.0,"Note":"**"},{"Itemcode":"74122973","Description":"Cal Gluconate 1GM/50ML bag","CDM Revenue Code":"636","CDM HCPCS":"J0610","Standard Price":59.74,"Note":"**"},{"Itemcode":"74122974","Description":"DULAGLUTIDE 0.75MG/0.5ML PEN","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":737.48},{"Itemcode":"74122975","Description":"Vanicream 454 Gm","CDM Revenue Code":"637","Standard Price":31.5,"Note":"**"},{"Itemcode":"74122976","Description":"Roflumilast 250 Mcg Tablet","CDM Revenue Code":"637","Standard Price":31.5,"Note":"**"},{"Itemcode":"74122977","Description":"VANCOMYCIN 2250MG/500ML IV BAG","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":140.08,"Note":"**"},{"Itemcode":"74122978","Description":"VANCOMYCIN 2500MG/500ML IV BAG","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":140.08,"Note":"**"},{"Itemcode":"74122979","Description":"Dasatinib 80 Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":1937.43},{"Itemcode":"74122980","Description":"Pomalidomide 2 Mg Cap","CDM Revenue Code":"636","Standard Price":3578.22},{"Itemcode":"74122981","Description":"Carfilzomib 10Mg Vial","CDM Revenue Code":"636","CDM HCPCS":"J9047","Standard Price":1672.72},{"Itemcode":"74122982","Description":"Mesalamine 400Mg DR cap","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"74122983","Description":"Osimertinib 40mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":2047.64},{"Itemcode":"74122984","Description":"Osimertinib 80 Mg Tab","CDM Revenue Code":"636","CDM HCPCS":"J8999","Standard Price":2047.64},{"Itemcode":"74122985","Description":"Recarbrio 1.25 G","CDM Revenue Code":"636","CDM HCPCS":"C9399","Standard Price":1102.1},{"Itemcode":"75385621","Description":"OASIS ULTRA 5X7CM 306813000013","CDM Revenue Code":"636","CDM HCPCS":"Q4124","Standard Price":1327.67},{"Itemcode":"76970196","Description":"Albumin 5%% Human 250 Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"P9045","Standard Price":318.27},{"Itemcode":"76970425","Description":"Meningococcal (A,C,Y&W-135)Pol","CDM Revenue Code":"636","CDM HCPCS":"90733","Standard Price":640.66},{"Itemcode":"76970511","Description":"Fluzone-High Dose 0.5Ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90662","Standard Price":47.38},{"Itemcode":"76971282","Description":"Ascorbic Acid 500Mg/ 1Ml","CDM Revenue Code":"250","Standard Price":59.74,"Note":"**"},{"Itemcode":"76971492","Description":"Prochlorperazine 10Mg2Ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J0780","Standard Price":30.9,"Note":"**"},{"Itemcode":"76972018","Description":"Hydrocodone 5MG/APAP 325MG TAB","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"76972019","Description":"HYDRALAZINE 20 MG/ML","CDM Revenue Code":"636","CDM HCPCS":"J0360","Standard Price":59.74},{"Itemcode":"76972020","Description":"TUBERCULIN VL 5TU/0.1ML","CDM Revenue Code":"254","Standard Price":59.74},{"Itemcode":"76972021","Description":"IPOL","CDM Revenue Code":"636","CDM HCPCS":"90713","Standard Price":128.4925,"Note":"**"},{"Itemcode":"76972022","Description":"ISOVUE EA 1ML","CDM Revenue Code":"255","CDM HCPCS":"Q9967","Standard Price":1.03},{"Itemcode":"76972023","Description":"LABETALOL 20MG/4ML","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"76972024","Description":"LOPERAMIDE 2 MG CAPSULE","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"76972026","Description":"METOCLOPRPAMIDE 10MG/2ML INJ","CDM Revenue Code":"636","CDM HCPCS":"J2765","Standard Price":59.74},{"Itemcode":"76972027","Description":"METOCLOPRAMIDE 10MG 1TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972028","Description":"MEASLES-MUMPS-RUBELLA II","CDM Revenue Code":"636","CDM HCPCS":"90707","Standard Price":269.654,"Note":"**"},{"Itemcode":"76972029","Description":"OXYCODONE 5MG TAB","CDM Revenue Code":"637","Standard Price":3.0},{"Itemcode":"76972030","Description":"OXYCODONE 5MG/APAP 325MG TAB","CDM Revenue Code":"637","Standard Price":4.35,"Note":"**"},{"Itemcode":"76972031","Description":"PROBENECID 500MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972032","Description":"PROCHLORPERAZINE Oral ea 5mg","CDM Revenue Code":"636","CDM HCPCS":"Q0164","Standard Price":6.18},{"Itemcode":"76972033","Description":"PROMETHAZINE 25MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972034","Description":"BELIMUMAB/BENLYSTA INJ 10MG","CDM Revenue Code":"636","CDM HCPCS":"J0490","Standard Price":178.19},{"Itemcode":"76972035","Description":"SODIUM POLYSTYRENE SULF ORAL","CDM Revenue Code":"637","Standard Price":18.0},{"Itemcode":"76972036","Description":"SOD. THIOSULFATE 25% 50ML VIAL","CDM Revenue Code":"250","Standard Price":14.42},{"Itemcode":"76972037","Description":"ALBUTEROL INHALER PER USE 1INH","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972038","Description":"LORATADINE 10MG TAB","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"76972039","Description":"CALCIUM GLUCONATE 10ML INJ","CDM Revenue Code":"636","CDM HCPCS":"J0610","Standard Price":54.6487705882353,"Note":"**"},{"Itemcode":"76972041","Description":"DIPHENOXYLATE/ATROPIN 2.5MGTAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972043","Description":"PREDNISONE 5 MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972044","Description":"PEDAXHIB VACCINE 7.5ug / 0.5mL","CDM Revenue Code":"636","CDM HCPCS":"90647","Standard Price":100.94},{"Itemcode":"76972045","Description":"PREVNAR 13 SYRINGE","CDM Revenue Code":"636","CDM HCPCS":"90670","Standard Price":59.09625,"Note":"**"},{"Itemcode":"76972046","Description":"PROMETHAZINE UP TO 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J2550","Standard Price":47.1722034883721,"Note":"**"},{"Itemcode":"76972047","Description":"SODIUM BICARB 8.4% VIAL","CDM Revenue Code":"250","Standard Price":59.74},{"Itemcode":"76972048","Description":"NACL 0.45% 1000ML","CDM Revenue Code":"258","Standard Price":59.74,"Note":"**"},{"Itemcode":"76972049","Description":"HYDROCORTISONE NA SUC 100MGINJ","CDM Revenue Code":"636","CDM HCPCS":"J1720","Standard Price":4.4702,"Note":"**"},{"Itemcode":"76972051","Description":"WINRHO EACH 100 IU","CDM Revenue Code":"636","CDM HCPCS":"J2792","Standard Price":99.91},{"Itemcode":"76972052","Description":"PHYTONADIONE/VIT K EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J3430","Standard Price":6.18},{"Itemcode":"76972053","Description":"HepB Vac 20mcg/1ml","CDM Revenue Code":"636","CDM HCPCS":"90747","Standard Price":96.82,"Note":"**"},{"Itemcode":"76972054","Description":"TDAP VACCINE","CDM Revenue Code":"636","CDM HCPCS":"90715","Standard Price":170.7225,"Note":"**"},{"Itemcode":"76972055","Description":"ARSENIC TRIOX(6ML VL) 1 MG EA","CDM Revenue Code":"636","CDM HCPCS":"J9017","Standard Price":165.83},{"Itemcode":"76972057","Description":"HYDROMORPHONE 4 MG","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":58.916,"Note":"**"},{"Itemcode":"76972058","Description":"GLUCAGEN INJ 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1610","Standard Price":717.91},{"Itemcode":"76972059","Description":"TRIPTORELIN DEPO 3.75 MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J3315","Standard Price":2529.68},{"Itemcode":"76972060","Description":"GOSERELIN ACETATE EA 3.6 MG","CDM Revenue Code":"636","CDM HCPCS":"J9202","Standard Price":2541.63695652174,"Note":"**"},{"Itemcode":"76972061","Description":"ALBUTEROL HFA MDI 60INH 8GM","CDM Revenue Code":"636","CDM HCPCS":"J3535","Standard Price":81.37},{"Itemcode":"76972062","Description":"TEMOZOLOMIDE ORAL EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J8700","Standard Price":13.39},{"Itemcode":"76972063","Description":"LACTATED RINGERS 500 ML","CDM Revenue Code":"258","CDM HCPCS":"J7120","Standard Price":57.68,"Note":"**"},{"Itemcode":"76972064","Description":"LACTATED RINGERS 1000 ML","CDM Revenue Code":"258","CDM HCPCS":"J7120","Standard Price":59.74,"Note":"**"},{"Itemcode":"76972065","Description":"Hydromorphone HCL 1MG/ML Inj","CDM Revenue Code":"636","CDM HCPCS":"J1170","Standard Price":59.74},{"Itemcode":"76972066","Description":"Hydrocodon/Aceto10mg/325mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972068","Description":"GRANISETRON HCL 1 MG TAB","CDM Revenue Code":"636","CDM HCPCS":"Q0166","Standard Price":5.15},{"Itemcode":"76972069","Description":"FUROSEMIDE 20 MG TAB","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"76972070","Description":"FLUMAZENIL 0.1MG/ML 5ML INJ MD","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":16.48},{"Itemcode":"76972072","Description":"ASPARAGINASE 10,000 UNITS","CDM Revenue Code":"636","CDM HCPCS":"J9020","Standard Price":421.27},{"Itemcode":"76972073","Description":"D5W 500 ML","CDM Revenue Code":"636","CDM HCPCS":"J7060","Standard Price":55.5429161290323,"Note":"**"},{"Itemcode":"76972074","Description":"D5W 1000 ML","CDM Revenue Code":"636","CDM HCPCS":"J7070","Standard Price":56.65},{"Itemcode":"76972075","Description":"D5W/NACL 0.9%% 500ML","CDM Revenue Code":"636","CDM HCPCS":"J7042","Standard Price":59.2646153846154,"Note":"**"},{"Itemcode":"76972076","Description":"D5W/NACL 0.45% 1000 ML","CDM Revenue Code":"258","Standard Price":59.74,"Note":"**"},{"Itemcode":"76972078","Description":"DEFEROXAMINE 500 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J0895","Standard Price":54.59,"Note":"**"},{"Itemcode":"76972079","Description":"CYTARABINE 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J9100","Standard Price":25.75,"Note":"**"},{"Itemcode":"76972080","Description":"INSULIN Flex Pen EA 5U INJ","CDM Revenue Code":"636","CDM HCPCS":"J1815","Standard Price":3.09},{"Itemcode":"76972081","Description":"MANVEO VACCINE","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":536.63,"Note":"**"},{"Itemcode":"76972082","Description":"ActHIB VACCIN 4DoseIM","CDM Revenue Code":"636","CDM HCPCS":"90648","Standard Price":149.968,"Note":"**"},{"Itemcode":"76972083","Description":"Hylenex Inj Ea 1.0 USP Unit","CDM Revenue Code":"636","CDM HCPCS":"J3473","Standard Price":2.06},{"Itemcode":"76972084","Description":"Pneumococcal 23 Vac Conj 0.5ml","CDM Revenue Code":"636","CDM HCPCS":"90732","Standard Price":371.212,"Note":"**"},{"Itemcode":"76972085","Description":"NACL 0.45%500 ML","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"76972086","Description":"ENOXAPARIN EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1650","Standard Price":12.36},{"Itemcode":"76972087","Description":"LEUPROLIDE ACETATE INJ 3.75MG","CDM Revenue Code":"636","CDM HCPCS":"J1950","Standard Price":4754.83051212121,"Note":"**"},{"Itemcode":"76972088","Description":"MEPERIDINE UP TO 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J2175","Standard Price":51.3293142857143,"Note":"**"},{"Itemcode":"76972089","Description":"MORPHINE INJ EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J2270","Standard Price":58.9909090909091,"Note":"**"},{"Itemcode":"76972090","Description":"ECULIZUMAB EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1300","Standard Price":499.884054054054,"Note":"**"},{"Itemcode":"76972091","Description":"RANITIDINE/ZANTAC EA 25 MG","CDM Revenue Code":"636","CDM HCPCS":"J2780","Standard Price":28.84},{"Itemcode":"76972092","Description":"IDARUBICIN EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9211","Standard Price":186.43},{"Itemcode":"76972093","Description":"Dexamethasone 2Mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972094","Description":"CEFTRIAXONE EA 250 MG","CDM Revenue Code":"636","CDM HCPCS":"J0696","Standard Price":33.6154545454545,"Note":"**"},{"Itemcode":"76972095","Description":"VISTIDE 375 MG","CDM Revenue Code":"636","CDM HCPCS":"J0740","Standard Price":2877.82},{"Itemcode":"76972097","Description":"CORTROSYN 0.25 MG","CDM Revenue Code":"636","CDM HCPCS":"J0834","Standard Price":78.9666666666667,"Note":"**"},{"Itemcode":"76972098","Description":"DACTINOMYCIN 0.5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9120","Standard Price":2625.47},{"Itemcode":"76972099","Description":"OLARATUMAB 500MG/50ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":10014.69},{"Itemcode":"76972100","Description":"LIBATAYO 350 MG/7 ML VIAL","CDM Revenue Code":"636","Standard Price":7207.837,"Note":"**"},{"Itemcode":"76972102","Description":"ZIPRASIDONE MESYLATE EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J3486","Standard Price":79.31},{"Itemcode":"76972103","Description":"KETOROLAC TROMETHAMINE 15MG LC","CDM Revenue Code":"636","CDM HCPCS":"J1885","Standard Price":45.1357771428572,"Note":"**"},{"Itemcode":"76972105","Description":"Heparin Sodium per 10 unit inj","CDM Revenue Code":"636","CDM HCPCS":"J1642","Standard Price":1.19537014616802,"Note":"**"},{"Itemcode":"76972106","Description":"NORMAL SALINE 1000 CC","CDM Revenue Code":"636","CDM HCPCS":"J7030","Standard Price":19.2140108416548,"Note":"**"},{"Itemcode":"76972107","Description":"NORMAL SALINE 500ML","CDM Revenue Code":"258","CDM HCPCS":"J7040","Standard Price":18.5477697960408,"Note":"**"},{"Itemcode":"76972108","Description":"Normal Saline 250 Cc","CDM Revenue Code":"636","CDM HCPCS":"J7050","Standard Price":19.57,"Note":"**"},{"Itemcode":"76972109","Description":"Lipidox Ea 10 Mg","CDM Revenue Code":"636","CDM HCPCS":"Q2049","Standard Price":1455.39},{"Itemcode":"76972111","Description":"Interferon Alfa 2B 1 M Units","CDM Revenue Code":"636","CDM HCPCS":"J9214","Standard Price":125.66},{"Itemcode":"76972112","Description":"Gammagard Ea 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J1569","Standard Price":210.683806153847,"Note":"**"},{"Itemcode":"76972113","Description":"BAVENCIO 200 MG/10 ML VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9023","Standard Price":1603.08323404255,"Note":"**"},{"Itemcode":"76972116","Description":"Ipilimumab Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9228","Standard Price":483.886793002916,"Note":"**"},{"Itemcode":"76972117","Description":"Solumedrol Up to 125 MG","CDM Revenue Code":"636","CDM HCPCS":"J2930","Standard Price":58.81506,"Note":"**"},{"Itemcode":"76972118","Description":"Furosemide/Lasix Ea 20 MG","CDM Revenue Code":"636","CDM HCPCS":"J1940","Standard Price":58.775744680851,"Note":"**"},{"Itemcode":"76972119","Description":"Iron Sucrose Ea 1 Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1756","Standard Price":5.15},{"Itemcode":"76972120","Description":"Carf Ilzomib/kyprolis 1MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J9047","Standard Price":138.688108108108,"Note":"**"},{"Itemcode":"76972121","Description":"DECITABINE/DACOGEN Inj EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J0894","Standard Price":60.1542391304348,"Note":"**"},{"Itemcode":"76972122","Description":"Sipuleucel-T/Provenge Per Vial","CDM Revenue Code":"636","CDM HCPCS":"Q2043","Standard Price":77714.53},{"Itemcode":"76972123","Description":"Vincristine Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9370","Standard Price":58.3899771929824,"Note":"**"},{"Itemcode":"76972126","Description":"Dexrazoxane/Zinecard 250 Mg","CDM Revenue Code":"636","CDM HCPCS":"J1190","Standard Price":554.14},{"Itemcode":"76972127","Description":"Vinblastine Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9360","Standard Price":13.39,"Note":"**"},{"Itemcode":"76972128","Description":"GAMUNEX INJ EA 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J1561","Standard Price":184.37,"Note":"**"},{"Itemcode":"76972129","Description":"ONDANSETRON/ZOFRAN EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J2405","Standard Price":7.03137864575479,"Note":"**"},{"Itemcode":"76972130","Description":"Cladribine/Leustatin Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9065","Standard Price":77.25},{"Itemcode":"76972132","Description":"ZOLEDRONIC ACID IV-ea 1mg","CDM Revenue Code":"636","Standard Price":895.317686997636,"Note":"**"},{"Itemcode":"76972135","Description":"D5W 250 Ml","CDM Revenue Code":"258","Standard Price":19.57},{"Itemcode":"76972138","Description":"PANITUMUMAB EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J9303","Standard Price":461.507763157895,"Note":"**"},{"Itemcode":"76972139","Description":"LORAZEPAM TABLET 0.5mg Tab","CDM Revenue Code":"637","Standard Price":3.75,"Note":"**"},{"Itemcode":"76972140","Description":"ONDANSETRON TABLET EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"Q0162","Standard Price":5.15,"Note":"**"},{"Itemcode":"76972141","Description":"KADCYLA EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9354","Standard Price":100.32784989858,"Note":"**"},{"Itemcode":"76972142","Description":"DOXORUBICIN/DOXIL EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"Q2050","Standard Price":2301.47708540925,"Note":"**"},{"Itemcode":"76972143","Description":"BRENTUXIMAB/ADCETRIS EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9042","Standard Price":456.876307692308,"Note":"**"},{"Itemcode":"76972144","Description":"CLOFARABINE/CLOLAR EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9027","Standard Price":600.49},{"Itemcode":"76972145","Description":"FILGRAMSTIM(G-CSG) EA1MCG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":5.15,"Note":"**"},{"Itemcode":"76972146","Description":"PERTUZUMAB/PERJETA EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9306","Standard Price":48.0261977186312,"Note":"**"},{"Itemcode":"76972147","Description":"GRANIX/TBO-FILGRASTIM Inj 1Mcg","CDM Revenue Code":"636","CDM HCPCS":"J1447","Standard Price":19.57},{"Itemcode":"76972148","Description":"TOPOTECAN EA 0.1 MG LCRP","CDM Revenue Code":"636","CDM HCPCS":"J9351","Standard Price":13.39,"Note":"**"},{"Itemcode":"76972149","Description":"Lorazepam Ea 2mg","CDM Revenue Code":"636","CDM HCPCS":"J2060","Standard Price":59.1307042253522,"Note":"**"},{"Itemcode":"76972150","Description":"DEXTROSE 5%/0.45% NACL 500ml","CDM Revenue Code":"258","Standard Price":59.74},{"Itemcode":"76972151","Description":"EPINEPHRINE 0.1 MG","CDM Revenue Code":"636","CDM HCPCS":"J0171","Standard Price":6.18},{"Itemcode":"76972152","Description":"PACLITAXEL PROTEIN BND 1MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9264","Standard Price":50.0385745614035,"Note":"**"},{"Itemcode":"76972153","Description":"Fluorouracil 500MG","CDM Revenue Code":"636","CDM HCPCS":"J9190","Standard Price":57.1471909397388,"Note":"**"},{"Itemcode":"76972154","Description":"PEMETREXED/ALIMTA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9305","Standard Price":204.397242463,"Note":"**"},{"Itemcode":"76972155","Description":"PALONOSETRON/ALOXI 25MCG","CDM Revenue Code":"636","CDM HCPCS":"J2469","Standard Price":62.496602807971,"Note":"**"},{"Itemcode":"76972156","Description":"ATROPINE SULFATE 0.01 MG","CDM Revenue Code":"636","CDM HCPCS":"J0461","Standard Price":4.88950785585345,"Note":"**"},{"Itemcode":"76972157","Description":"Bevacizumab 10MG Inj LCRP","CDM Revenue Code":"636","CDM HCPCS":"J9035","Standard Price":310.04522248996,"Note":"**"},{"Itemcode":"76972158","Description":"Bleomycin Sulfate 15Units Inj","CDM Revenue Code":"636","CDM HCPCS":"J9040","Standard Price":139.421475409836,"Note":"**"},{"Itemcode":"76972160","Description":"IRINOTECAN 20 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9206","Standard Price":13.3080154381085,"Note":"**"},{"Itemcode":"76972161","Description":"Carboplatin Ea 50MG","CDM Revenue Code":"636","CDM HCPCS":"J9045","Standard Price":54.2004071931956,"Note":"**"},{"Itemcode":"76972162","Description":"Alteplase 1 MG Inj LCRP","CDM Revenue Code":"636","CDM HCPCS":"J2997","Standard Price":299.650648430494,"Note":"**"},{"Itemcode":"76972163","Description":"Cisplatin EA 10 MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J9060","Standard Price":12.36,"Note":"**"},{"Itemcode":"76972165","Description":"B-12 INJ Up to 1000 MCG","CDM Revenue Code":"636","CDM HCPCS":"J3420","Standard Price":53.840026618705,"Note":"**"},{"Itemcode":"76972166","Description":"CYCLOPHOSPHAMIDE 100 MG LCRP","CDM Revenue Code":"636","CDM HCPCS":"J9070","Standard Price":172.901236884803,"Note":"**"},{"Itemcode":"76972167","Description":"DACARBAZINE/DTIC 100 MG LCRP","CDM Revenue Code":"636","CDM HCPCS":"J9130","Standard Price":29.5228412256268,"Note":"**"},{"Itemcode":"76972169","Description":"DEXAMETHASONE EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1100","Standard Price":6.00549079101502,"Note":"**"},{"Itemcode":"76972170","Description":"Diphenhydramine HCL Up To 50MG","CDM Revenue Code":"636","CDM HCPCS":"J1200","Standard Price":56.3272545614808,"Note":"**"},{"Itemcode":"76972171","Description":"DOCETAXEL 1 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9171","Standard Price":11.9593810935738,"Note":"**"},{"Itemcode":"76972172","Description":"DOXORUBICIN HCL 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J9000","Standard Price":22.7477448648649,"Note":"**"},{"Itemcode":"76972173","Description":"FOSAPREPITANT EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1453","Standard Price":9.03986349471341,"Note":"**"},{"Itemcode":"76972174","Description":"EPIRUBICIN HCL 2 MG","CDM Revenue Code":"636","CDM HCPCS":"J9178","Standard Price":14.42},{"Itemcode":"76972175","Description":"CETUXIMAB 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9055","Standard Price":231.259279276811,"Note":"**"},{"Itemcode":"76972176","Description":"Famotidine ea 20mg","CDM Revenue Code":"250","Standard Price":55.6638487470167,"Note":"**"},{"Itemcode":"76972177","Description":"ERIBULIN MESYLATE 0.1 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9179","Standard Price":429.48779830639,"Note":"**"},{"Itemcode":"76972178","Description":"ROMIPLOSTIM/NPLATE 10MCG","CDM Revenue Code":"636","Standard Price":242.572471643366,"Note":"**"},{"Itemcode":"76972179","Description":"DENOSUMAB Inj EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J0897","Standard Price":74.0159141274238,"Note":"**"},{"Itemcode":"76972180","Description":"OCTREOTIDE DEPOT IM INJ EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J2353","Standard Price":583.907,"Note":"**"},{"Itemcode":"76972181","Description":"Bortizomib / Velcade Ea 0.1MG","CDM Revenue Code":"636","CDM HCPCS":"J9041","Standard Price":192.290221032049,"Note":"**"},{"Itemcode":"76972182","Description":"Azacitidine Ea 1 Mg","CDM Revenue Code":"636","CDM HCPCS":"J9025","Standard Price":24.4371592379769,"Note":"**"},{"Itemcode":"76972183","Description":"DARBEPOETIN ALFA EA 1 MCG","CDM Revenue Code":"636","CDM HCPCS":"J0881","Standard Price":29.87},{"Itemcode":"76972184","Description":"Mesna ea 200 MG LCRP","CDM Revenue Code":"636","CDM HCPCS":"J9209","Standard Price":26.13625,"Note":"**"},{"Itemcode":"76972185","Description":"IXABEPILONE 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9207","Standard Price":318.27},{"Itemcode":"76972186","Description":"Cabazitaxel 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9043","Standard Price":550.548918918919,"Note":"**"},{"Itemcode":"76972187","Description":"Methotrexate Ea 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J9260","Standard Price":10.3,"Note":"**"},{"Itemcode":"76972188","Description":"EPO INJ NonESRD EA 1000Units","CDM Revenue Code":"636","CDM HCPCS":"J0885","Standard Price":112.34981961458,"Note":"**"},{"Itemcode":"76972192","Description":"FLUDARBINE EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J9185","Standard Price":258.53},{"Itemcode":"76972193","Description":"GEMCITABINE Inj EA 200 MG","CDM Revenue Code":"636","CDM HCPCS":"J9201","Standard Price":159.241833790738,"Note":"**"},{"Itemcode":"76972194","Description":"InjectAFer EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J1439","Standard Price":6.15024022140221,"Note":"**"},{"Itemcode":"76972195","Description":"GRANISETRON HCL EA 100 MCG","CDM Revenue Code":"636","CDM HCPCS":"J1626","Standard Price":6.18,"Note":"**"},{"Itemcode":"76972196","Description":"Neulasta/Pegfilgramsim 6MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":16239.5994609929,"Note":"**"},{"Itemcode":"76972197","Description":"Pamidronate 30 MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J2430","Standard Price":52.53,"Note":"**"},{"Itemcode":"76972198","Description":"RITUXAN EA 100 MG INJ","CDM Revenue Code":"636","Standard Price":3727.57682119206,"Note":"**"},{"Itemcode":"76972199","Description":"VINORELBINE/NAVELB 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9390","Standard Price":58.1656910569106,"Note":"**"},{"Itemcode":"76972200","Description":"Copper, 0.4mg/ml, Inj","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":153.34350877193,"Note":"**"},{"Itemcode":"76972201","Description":"IFOSFAMIDE/IFEX 1 GM","CDM Revenue Code":"636","CDM HCPCS":"J9208","Standard Price":133.9},{"Itemcode":"76972204","Description":"MITOXANTRONE HCL 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9293","Standard Price":82.4,"Note":"**"},{"Itemcode":"76972205","Description":"Magnesium Citrate","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972206","Description":"KCL 20 MEQ /15 ML ORAL","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"76972208","Description":"DESMOPRESSIN ACETATE 1 MCG","CDM Revenue Code":"636","CDM HCPCS":"J2597","Standard Price":46.5417931034482,"Note":"**"},{"Itemcode":"76972209","Description":"FULVESTRANT/FASLODEX 25 MG","CDM Revenue Code":"636","CDM HCPCS":"J9395","Standard Price":365.930390868212,"Note":"**"},{"Itemcode":"76972210","Description":"FERUMOXYTOL 1 MG","CDM Revenue Code":"636","CDM HCPCS":"Q0138","Standard Price":5.88888947368421,"Note":"**"},{"Itemcode":"76972211","Description":"FERRIC NA GLUCONATE 12.5 MG","CDM Revenue Code":"636","CDM HCPCS":"J2916","Standard Price":10.6677658914729,"Note":"**"},{"Itemcode":"76972212","Description":"TRASTUZUMAB/HERCE MDV 10 MGINJ","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":342.99,"Note":"**"},{"Itemcode":"76972213","Description":"KCL 2 mEq","CDM Revenue Code":"636","CDM HCPCS":"J3480","Standard Price":19.0700548112059,"Note":"**"},{"Itemcode":"76972214","Description":"Acetaminophen 10Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J0131","Standard Price":2.06},{"Itemcode":"76972216","Description":"FLUZONE VACCINE V4","CDM Revenue Code":"636","CDM HCPCS":"90686","Standard Price":77.25,"Note":"**"},{"Itemcode":"76972218","Description":"Cyramza Ea 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9308","Standard Price":232.300228013029,"Note":"**"},{"Itemcode":"76972219","Description":"ELELYSO EA 10 UNITS","CDM Revenue Code":"636","CDM HCPCS":"J3060","Standard Price":165.83},{"Itemcode":"76972220","Description":"Meningococcal Vac IM 0.5ml Inj","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":469.68},{"Itemcode":"76972223","Description":"TRANSDERM-SCOP 1PATCH","CDM Revenue Code":"637","Standard Price":61.5},{"Itemcode":"76972224","Description":"TEMSIROLIMUS/TORISEL 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9330","Standard Price":285.31,"Note":"**"},{"Itemcode":"76972225","Description":"BENDAMUSTINE/TREANDA EA 1 MG","CDM Revenue Code":"636","CDM HCPCS":"J9033","Standard Price":126.69},{"Itemcode":"76972226","Description":"Etoposide/Toposar 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J9181","Standard Price":6.18,"Note":"**"},{"Itemcode":"76972227","Description":"PRIVIGEN EA 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J1459","Standard Price":165.914411508283,"Note":"**"},{"Itemcode":"76972228","Description":"PACLITAXEL 1.0 MG","CDM Revenue Code":"636","CDM HCPCS":"J9267","Standard Price":20.631018809558,"Note":"**"},{"Itemcode":"76972229","Description":"PROCHLORPERAZINE <=10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J0780","Standard Price":64.89,"Note":"**"},{"Itemcode":"76972230","Description":"OXALIPLATIN INJ 0.5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9263","Standard Price":5.02439167616876,"Note":"**"},{"Itemcode":"76972231","Description":"SARGRAMOSTIM INJ EA 50 MCG","CDM Revenue Code":"636","CDM HCPCS":"J2820","Standard Price":130.81},{"Itemcode":"76972232","Description":"TESTOSTERONE CYPIONATE 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1071","Standard Price":59.0283636363636,"Note":"**"},{"Itemcode":"76972233","Description":"BICNU 100 MG","CDM Revenue Code":"636","CDM HCPCS":"J9050","Standard Price":728.21,"Note":"**"},{"Itemcode":"76972234","Description":"MITOMYCIN 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J9280","Standard Price":554.8816,"Note":"**"},{"Itemcode":"76972235","Description":"MANNITOL 25%, 50ml VIAL","CDM Revenue Code":"636","CDM HCPCS":"J2150","Standard Price":19.2744347826087,"Note":"**"},{"Itemcode":"76972236","Description":"MG SULFATE 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J3475","Standard Price":19.1339830047587,"Note":"**"},{"Itemcode":"76972237","Description":"LEUCOVORIN CALCIUM INJ EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J0640","Standard Price":27.4708312963617,"Note":"**"},{"Itemcode":"76972238","Description":"INFED/IRON DEXTRAN EA 50 MG","CDM Revenue Code":"636","CDM HCPCS":"J1750","Standard Price":79.6805534779357,"Note":"**"},{"Itemcode":"76972239","Description":"HEPARIN PER 1000 UNITS INJ","CDM Revenue Code":"636","CDM HCPCS":"J1644","Standard Price":58.195,"Note":"**"},{"Itemcode":"76972240","Description":"ZIV-AFLIBERCEPT/ZALTRAP EA 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9400","Standard Price":92.7},{"Itemcode":"76972241","Description":"Neulasta Delivery Kit 6mg INJ","CDM Revenue Code":"636","CDM HCPCS":"J2505","Standard Price":15402.6404901333,"Note":"**"},{"Itemcode":"76972242","Description":"Keytruda Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J9271","Standard Price":191.984011310846,"Note":"**"},{"Itemcode":"76972243","Description":"Mycafungin - Micamine ea 1MG","CDM Revenue Code":"636","CDM HCPCS":"J2248","Standard Price":3.09},{"Itemcode":"76972244","Description":"ZARXIO,FILGRSTM(G-CSF) BS 1MCG","CDM Revenue Code":"636","CDM HCPCS":"Q5101","Standard Price":6.18,"Note":"**"},{"Itemcode":"76972245","Description":"Trabectedin/Yondelis 0.1MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9352","Standard Price":1172.72857142857,"Note":"**"},{"Itemcode":"76972246","Description":"Pentostatin/Nipent Inj 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9268","Standard Price":8357.42},{"Itemcode":"76972247","Description":"Pegaspargase Inj SDV 3750IU5ml","CDM Revenue Code":"636","CDM HCPCS":"J9266","Standard Price":55517.0,"Note":"**"},{"Itemcode":"76972248","Description":"CIPROFLOXACIN 500MG ORAL TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972250","Description":"Gazyva / Obinutuzumab 10MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J9301","Standard Price":187.842266037736,"Note":"**"},{"Itemcode":"76972251","Description":"Gammaplex Inj 500mg","CDM Revenue Code":"636","CDM HCPCS":"J1557","Standard Price":160.68},{"Itemcode":"76972252","Description":"Aminocaproic Acid 250mg/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":6.18},{"Itemcode":"76972253","Description":"Albuterol-Nebulizer NonCom 1mg","CDM Revenue Code":"250","CDM HCPCS":"J7611","Standard Price":6.18,"Note":"**"},{"Itemcode":"76972254","Description":"Iron Sucrose Comp Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J1756","Standard Price":6.18,"Note":"**"},{"Itemcode":"76972255","Description":"BENDAMUSTINE/BENDEKA 1MG MDV","CDM Revenue Code":"636","CDM HCPCS":"J9034","Standard Price":85.0585807067021,"Note":"**"},{"Itemcode":"76972256","Description":"Ertapenem Na Inj 500 mg","CDM Revenue Code":"636","CDM HCPCS":"J1335","Standard Price":2597.66},{"Itemcode":"76972257","Description":"ISTODAX/RomiDEPsin pwdr 1mg","CDM Revenue Code":"636","CDM HCPCS":"J9315","Standard Price":1244.24},{"Itemcode":"76972258","Description":"DEXAMETHASONE ORAL EA 0.25MG","CDM Revenue Code":"636","CDM HCPCS":"J8540","Standard Price":3.09,"Note":"**"},{"Itemcode":"76972259","Description":"IMLYGIC/TalLah 1M PFU/ml Inj","CDM Revenue Code":"636","CDM HCPCS":"J9325","Standard Price":197.76},{"Itemcode":"76972260","Description":"IMLYGIC 100XM PFU Inj EA Vial","CDM Revenue Code":"636","CDM HCPCS":"J9325","Standard Price":96.82},{"Itemcode":"76972261","Description":"Engerix-B 10mcg/0.5 ml Ped SDV","CDM Revenue Code":"636","CDM HCPCS":"90744","Standard Price":94.76},{"Itemcode":"76972262","Description":"Amlodipine 5MG Oral Tab","CDM Revenue Code":"637","Standard Price":2.25},{"Itemcode":"76972263","Description":"Darzalex 10mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9145","Standard Price":202.67679245283,"Note":"**"},{"Itemcode":"76972266","Description":"CIPROFLOXACIN 200MG IV INJ","CDM Revenue Code":"636","CDM HCPCS":"J0744","Standard Price":10.3},{"Itemcode":"76972267","Description":"HEP A VACC PED/ADOL 2DSE IMINJ","CDM Revenue Code":"636","CDM HCPCS":"90633","Standard Price":125.66},{"Itemcode":"76972268","Description":"PREDNISONE IR/DR ORAL 1MG TAB","CDM Revenue Code":"636","CDM HCPCS":"J7512","Standard Price":5.15},{"Itemcode":"76972269","Description":"ARRANON INJ EA 50MG","CDM Revenue Code":"636","CDM HCPCS":"J9261","Standard Price":596.37},{"Itemcode":"76972270","Description":"CYCLOPHOSPHAMIDE CAP EA 25MG","CDM Revenue Code":"636","CDM HCPCS":"J8530","Standard Price":23.69},{"Itemcode":"76972271","Description":"EMEND CAP EA 5 MG","CDM Revenue Code":"636","CDM HCPCS":"J8501","Standard Price":43.26},{"Itemcode":"76972272","Description":"Rasburicase/Elitek 0.5mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J2783","Standard Price":1061.24333333333,"Note":"**"},{"Itemcode":"76972273","Description":"Leuprolide Acet/Eligard 7.5Mg","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":1858.12,"Note":"**"},{"Itemcode":"76972275","Description":"GANCICLOVIR 500MG PWVL","CDM Revenue Code":"636","CDM HCPCS":"J1570","Standard Price":339.9},{"Itemcode":"76972277","Description":"ELOTUZUMAB/EMPLICITI INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9176","Standard Price":26.3818545900046,"Note":"**"},{"Itemcode":"76972278","Description":"MENACWY VACCINE IM SDV","CDM Revenue Code":"636","CDM HCPCS":"90734","Standard Price":456.496,"Note":"**"},{"Itemcode":"76972279","Description":"CIPROFLOXACIN 250MG ORAL TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"76972280","Description":"Bleomycin 15 Un Inj (Imported)","CDM Revenue Code":"636","CDM HCPCS":"J9040","Standard Price":612.85},{"Itemcode":"76972281","Description":"PEGINTERFERON ALFA2A 180MCG/ML","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":4016.691,"Note":"**"},{"Itemcode":"76972282","Description":"HYDROCORTISONE NONCHEMO10MGTAB","CDM Revenue Code":"636","CDM HCPCS":"J8499","Standard Price":6.18},{"Itemcode":"76972283","Description":"TECENTRIQ/ATEZOLIZUMAB INJ10MG","CDM Revenue Code":"636","CDM HCPCS":"J9022","Standard Price":246.852166216216,"Note":"**"},{"Itemcode":"76972284","Description":"Vancomycin HCL 500Mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J3370","Standard Price":81.37},{"Itemcode":"76972285","Description":"Chlorpromazine HCL Inj to 50MG","CDM Revenue Code":"636","CDM HCPCS":"J3230","Standard Price":115.36},{"Itemcode":"76972286","Description":"SUSTOL INJ 10MG/0.4ML INJ","CDM Revenue Code":"636","Standard Price":2153.73},{"Itemcode":"76972287","Description":"Tranexamic Acid 10ml IV","CDM Revenue Code":"250","Standard Price":218.36},{"Itemcode":"76972288","Description":"Infanrix DTAP Peds 0.5ml Syr","CDM Revenue Code":"636","CDM HCPCS":"90700","Standard Price":92.57125,"Note":"**"},{"Itemcode":"76972289","Description":"Ofatumumab/Arzerra 10mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9302","Standard Price":213.004,"Note":"**"},{"Itemcode":"76972290","Description":"ALBUTEROL HFA MDI 200INH 18GM","CDM Revenue Code":"636","CDM HCPCS":"J3535","Standard Price":184.37},{"Itemcode":"76972292","Description":"Fentanyl Ptch-Xtd Rel 25mcg/hr","CDM Revenue Code":"637","Standard Price":9.0},{"Itemcode":"76972293","Description":"HYQVIA IMMUNGLOBULIN INJ 100MG","CDM Revenue Code":"636","CDM HCPCS":"J1575","Standard Price":9251.46},{"Itemcode":"76972294","Description":"FLUCONAZOLE/DIFLUCAN INJ 200MG","CDM Revenue Code":"636","CDM HCPCS":"J1450","Standard Price":29.1833333333333,"Note":"**"},{"Itemcode":"76972295","Description":"Hydralazine 25Mg Tab","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"76972296","Description":"ELOSULFASEALFA,VIMIZIM INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1322","Standard Price":973.35},{"Itemcode":"76972297","Description":"GALSULFASE/NAGLAZYM INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J1458","Standard Price":1554.27},{"Itemcode":"76972298","Description":"ImmuneGlobul-Octagam 500mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J1568","Standard Price":220.42},{"Itemcode":"76972299","Description":"Varubi Inj 166.5mg/92.5ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":1251.45},{"Itemcode":"76972301","Description":"Degarelix/Firmagon Inj 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9155","Standard Price":15.45,"Note":"**"},{"Itemcode":"76972322","Description":"DEPO_MEDROL 40 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1030","Standard Price":27.81,"Note":"**"},{"Itemcode":"76972345","Description":"Filgrastim-Neupogen Inj 1Mcg","CDM Revenue Code":"636","CDM HCPCS":"J1442","Standard Price":4.87599031561753,"Note":"**"},{"Itemcode":"76972346","Description":"Montelukast Sod 10mg Tab","CDM Revenue Code":"637","Standard Price":4.0,"Note":"**"},{"Itemcode":"76972352","Description":"ALLOPURINOL 300MG TAB","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972353","Description":"ALLOPURINOL 100MG TAB","CDM Revenue Code":"637","Standard Price":4.5,"Note":"**"},{"Itemcode":"76972354","Description":"NIVOLUMAB / OPDIVO, INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9299","Standard Price":107.758671240194,"Note":"**"},{"Itemcode":"76972355","Description":"Somatuline Depot ea 1mg, Inj","CDM Revenue Code":"636","CDM HCPCS":"J1930","Standard Price":263.353781432048,"Note":"**"},{"Itemcode":"76972356","Description":"ALEMTUZUMAB/CAMPATH Inj 1mg","CDM Revenue Code":"636","CDM HCPCS":"J0202","Standard Price":0.0},{"Itemcode":"76972357","Description":"Levoleucovorin Calcm Inj 0.5mg","CDM Revenue Code":"636","CDM HCPCS":"J0641","Standard Price":8.24},{"Itemcode":"76972358","Description":"CARPUJET,MORPH SULF 4MG/ML INJ","CDM Revenue Code":"250","Standard Price":75.19,"Note":"**"},{"Itemcode":"76972359","Description":"OLARATUMAB INJ 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9285","Standard Price":204.97},{"Itemcode":"76972360","Description":"Sustol Inj ea 0.1mg","CDM Revenue Code":"636","CDM HCPCS":"J1627","Standard Price":2260.85},{"Itemcode":"76972361","Description":"TRASTUZUMAB/HER INJ SDV 10MG","CDM Revenue Code":"636","CDM HCPCS":"J9355","Standard Price":415.714924163876,"Note":"**"},{"Itemcode":"76972362","Description":"IRINOTECAN LIP/ONIVYDE INJ 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9205","Standard Price":167.89,"Note":"**"},{"Itemcode":"76972363","Description":"FLEBOGAMMA IG 5%%DIF 500MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J1572","Standard Price":172.01},{"Itemcode":"76972364","Description":"Fentanyl 100mcg/2Ml Inj SDV","CDM Revenue Code":"636","CDM HCPCS":"J3010","Standard Price":59.74},{"Itemcode":"76972365","Description":"Copanlisib/Aliqopa 1mg Inj","CDM Revenue Code":"636","CDM HCPCS":"J9057","Standard Price":17823.12},{"Itemcode":"76972366","Description":"DURVALUMAB/IMFINZI INJ 10MG","CDM Revenue Code":"636","Standard Price":239.291319767995,"Note":"**"},{"Itemcode":"76972367","Description":"IMMUNE GLOBULIN POWDER 500 MG","CDM Revenue Code":"636","CDM HCPCS":"J1566","Standard Price":122.57},{"Itemcode":"76972368","Description":"Vedolizumab/Entyvio Inj, 1mg","CDM Revenue Code":"636","CDM HCPCS":"J3380","Standard Price":82.4},{"Itemcode":"76972369","Description":"GEMTUZUMAB OZOGAMICIN IN 0.1MG","CDM Revenue Code":"636","CDM HCPCS":"J9203","Standard Price":772.5},{"Itemcode":"76972370","Description":"AMLODIPENE BESYLATE 10MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"76972371","Description":"METOPROLOL TARTRATE 100MG TAB","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"76972372","Description":"HAVRIX 1440U/ 1ML SYR INJ","CDM Revenue Code":"250","Standard Price":263.886,"Note":"**"},{"Itemcode":"76972373","Description":"9VHPVGARDASIL VAC2-3D 0.5MLINJ","CDM Revenue Code":"636","CDM HCPCS":"90651","Standard Price":805.46},{"Itemcode":"76972400","Description":"RITUXAN EA 10 MG INJ","CDM Revenue Code":"636","CDM HCPCS":"J9312","Standard Price":372.242,"Note":"**"},{"Itemcode":"76972424","Description":"Magnesium Cl 10,000mg/50 ml vl","CDM Revenue Code":"250","Standard Price":13.39},{"Itemcode":"76972425","Description":"Emicizumab-KXWH 0.5 mg","CDM Revenue Code":"636","CDM HCPCS":"J7170","Standard Price":153.1404},{"Itemcode":"76972450","Description":"Cemiplimab-rwlc (Libtayo) 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9119","Standard Price":75.5316166666667,"Note":"**"},{"Itemcode":"76972451","Description":"Fulphila 0.5mg inj","CDM Revenue Code":"636","CDM HCPCS":"Q5108","Standard Price":1118.58,"Note":"**"},{"Itemcode":"76972452","Description":"Metoprolol 5mg/5ml vial","CDM Revenue Code":"250","Standard Price":57.68},{"Itemcode":"76972454","Description":"Mogamulizumab--kpkc 1 mg EA","CDM Revenue Code":"636","CDM HCPCS":"J9204","Standard Price":364.428372093023,"Note":"**"},{"Itemcode":"76972455","Description":"POLATUZUMAB 1 MG VIAL","CDM Revenue Code":"636","CDM HCPCS":"J9999","Standard Price":358.44},{"Itemcode":"76972456","Description":"PENTAMIDINE ISET 300MG INH PWD","CDM Revenue Code":"250","CDM HCPCS":"J2545","Standard Price":418.18,"Note":"**"},{"Itemcode":"76972457","Description":"Carvedilol 12.5MG Oral Tab","CDM Revenue Code":"637","Standard Price":3.75},{"Itemcode":"76972458","Description":"Ravulizumab-CWVZ EA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"J1303","Standard Price":714.82,"Note":"**"},{"Itemcode":"76972459","Description":"Romosozumab-AQQG 1mg ea","CDM Revenue Code":"636","CDM HCPCS":"J3111","Standard Price":35.02},{"Itemcode":"76972460","Description":"Bevacizumab-AWWB 10mg (MVASI)","CDM Revenue Code":"636","CDM HCPCS":"Q5107","Standard Price":268.83},{"Itemcode":"76972461","Description":"TRASTUZ-ANNS (KANJINTI) 10MG","CDM Revenue Code":"636","CDM HCPCS":"Q5117","Standard Price":284.28,"Note":"**"},{"Itemcode":"76972462","Description":"Clindamycin 300mg/50ml IVPB","CDM Revenue Code":"636","CDM HCPCS":"J3490","Standard Price":54.59,"Note":"**"},{"Itemcode":"76972463","Description":"Magnesium Hydroxide Oral 30ml","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972464","Description":"NaPhos 45mmol/15ml vial","CDM Revenue Code":"250","Standard Price":131.84},{"Itemcode":"76972465","Description":"Pentam 300mg INJ pwd vial","CDM Revenue Code":"250","Standard Price":647.87},{"Itemcode":"76972466","Description":"Enfortumab Vedotin-ejfv 1mg","CDM Revenue Code":"636","CDM HCPCS":"J3590","Standard Price":353.29,"Note":"**"},{"Itemcode":"76972467","Description":"Melphalan HCL 50mg vial","CDM Revenue Code":"636","CDM HCPCS":"J9245","Standard Price":2008.5,"Note":"**"},{"Itemcode":"76972468","Description":"TRUXIMA 10 MG","CDM Revenue Code":"636","CDM HCPCS":"Q5115","Standard Price":264.71},{"Itemcode":"76972469","Description":"Reblozyl 1mg inj","CDM Revenue Code":"636","CDM HCPCS":"J3590","Standard Price":460.41},{"Itemcode":"76972471","Description":"Varicella-Zoster GE 0.5ml","CDM Revenue Code":"636","CDM HCPCS":"90750","Standard Price":575.77,"Note":"**"},{"Itemcode":"76972500","Description":"Abatacept 10mg SDV INJ","CDM Revenue Code":"636","CDM HCPCS":"J0129","Standard Price":159.65},{"Itemcode":"76972501","Description":"Amifostine 500mg","CDM Revenue Code":"636","CDM HCPCS":"J0207","Standard Price":1494.53},{"Itemcode":"76972502","Description":"Amikacin Sulfate 100mg","CDM Revenue Code":"636","CDM HCPCS":"J0278","Standard Price":56.65},{"Itemcode":"76972504","Description":"Cerezyme (Imiglucerase) 10Unit","CDM Revenue Code":"636","CDM HCPCS":"J1786","Standard Price":168.92},{"Itemcode":"76972505","Description":"Methylprednisolone 40MG Inj","CDM Revenue Code":"636","CDM HCPCS":"J2920","Standard Price":58.575652173913,"Note":"**"},{"Itemcode":"76972506","Description":"Leuprolide Depot Ea 7.5Mg","CDM Revenue Code":"636","CDM HCPCS":"J9217","Standard Price":5845.86682509506,"Note":"**"},{"Itemcode":"76972508","Description":"Vitamin K (Mephyton) ea 5mg","CDM Revenue Code":"250","Standard Price":237.93},{"Itemcode":"76972509","Description":"Folic Acid ea 1mg","CDM Revenue Code":"250","Standard Price":6.18},{"Itemcode":"76972510","Description":"Levofloxacin/Levaquin 250 mg","CDM Revenue Code":"636","CDM HCPCS":"J1956","Standard Price":19.57},{"Itemcode":"76972511","Description":"Magnesium Oxide 400mg Tab","CDM Revenue Code":"637","Standard Price":4.5},{"Itemcode":"76972512","Description":"Praltrexate / Folotyn ea 1MG","CDM Revenue Code":"636","CDM HCPCS":"J9307","Standard Price":870.35},{"Itemcode":"76972513","Description":"Cefepime/Maxepine Inj ea 500MG","CDM Revenue Code":"636","CDM HCPCS":"J0692","Standard Price":15.45},{"Itemcode":"76972516","Description":"Tetanus-Diptheria (Tenivac)0.5","CDM Revenue Code":"636","CDM HCPCS":"90714","Standard Price":93.73,"Note":"**"},{"Itemcode":"76972517","Description":"ADDAMEL N INJ10ML AMP (TRA ME)","CDM Revenue Code":"250","Standard Price":64.89},{"Itemcode":"76972518","Description":"Velaglucerase Alfa/VPRIV100UIn","CDM Revenue Code":"636","CDM HCPCS":"J3385","Standard Price":1445.85130434782,"Note":"**"},{"Itemcode":"76972638","Description":"Gammagard S/D 500 mg Powder","CDM Revenue Code":"636","CDM HCPCS":"J1566","Standard Price":254.41},{"Itemcode":"76972646","Description":"EPOETIN ALFA -EBX 1000U","CDM Revenue Code":"636","CDM HCPCS":"Q5106","Standard Price":10.6605,"Note":"**"},{"Itemcode":"76972899","Description":"OMACETAXINE 0.01 MG","CDM Revenue Code":"636","CDM HCPCS":"J9262","Standard Price":11.7935,"Note":"**"},{"Itemcode":"76977534","Description":"Lidocaine 1%% 2Ml Amp","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":51.5},{"Itemcode":"76977537","Description":"Lidocaine 1%% 30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":2.06},{"Itemcode":"76977538","Description":"Lidocaine 1%% 30Ml Vial","CDM Revenue Code":"636","CDM HCPCS":"J2001","Standard Price":2.06},{"Itemcode":"76979017","Description":"ARSENIC TRIOXIDE 10MG/10ML VL","CDM Revenue Code":"636","Standard Price":5861.73},{"Itemcode":"76979467","Description":"RITUXIMAB/HYALURONIDASE","CDM Revenue Code":"636","CDM HCPCS":"J9311","Standard Price":6977.22},{"Itemcode":"76979468","Description":"RITUXIMAB/HYALURONIDASE","CDM Revenue Code":"636","CDM HCPCS":"J9311","Standard Price":677.3795,"Note":"**"},{"Itemcode":"J7182","Description":"ANTIHEMO FVIII NovoEight 1 Uni","CDM Revenue Code":"636","Standard Price":4.12},{"Itemcode":"0040","Description":"Device Emb LC Beads 100-300","CDM Revenue Code":"278","Standard Price":7851.96},{"Itemcode":"0091","Description":"Clip Localization / Marker","CDM Revenue Code":"272","Standard Price":524.28,"Note":"**"},{"Itemcode":"6103","Description":"MW PMTA APPLICATOR 14,19CM","CDM Revenue Code":"272","Standard Price":8503.74},{"Itemcode":"61502880","Description":"Circumcisio-D","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"61550194","Description":"ARISTA Adhesn Barrier 1 GM","CDM Revenue Code":"272","Standard Price":559.98,"Note":"**"},{"Itemcode":"61550195","Description":"ARISTA Adhesn Barrier 3 GM","CDM Revenue Code":"272","Standard Price":1112.82,"Note":"**"},{"Itemcode":"61550196","Description":"ARISTA Adhesn Barrier 5 GM","CDM Revenue Code":"272","Standard Price":1464.72},{"Itemcode":"61552820","Description":"Resuscitation: Neonate Comp-D","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"61554278","Description":"BALLOON POSTPARTUM","CDM Revenue Code":"272","Standard Price":1295.4},{"Itemcode":"61554670","Description":"Pack: Resuscitation Neo Comple","CDM Revenue Code":"272","Standard Price":466.14},{"Itemcode":"61557535","Description":"Filshie Clips","CDM Revenue Code":"278","Standard Price":483.48,"Note":"**"},{"Itemcode":"61557930","Description":"Interceed Adhesion Barrier","CDM Revenue Code":"278","Standard Price":1047.54,"Note":"**"},{"Itemcode":"61600097","Description":"Bili Mask","CDM Revenue Code":"270","Standard Price":29.58},{"Itemcode":"61800055","Description":"Arctic Sun Gel Pad Set","CDM Revenue Code":"272","Standard Price":3776.04},{"Itemcode":"61800056","Description":"Arctic Sun Universal Gel Pad","CDM Revenue Code":"272","Standard Price":1417.8},{"Itemcode":"61900600","Description":"Kit: ICP Monitor & Drain","CDM Revenue Code":"272","Standard Price":3363.96},{"Itemcode":"61900602","Description":"Bag: Icp/Lumbar Drainage Repl","CDM Revenue Code":"272","Standard Price":184.62},{"Itemcode":"61900603","Description":"Drainage System: Icp/Lumbar","CDM Revenue Code":"272","Standard Price":698.7},{"Itemcode":"61900605","Description":"Cath: Icp Drainage Only","CDM Revenue Code":"278","Standard Price":618.12},{"Itemcode":"61900608","Description":"Kit: ICP Cranial Access","CDM Revenue Code":"272","Standard Price":1162.8},{"Itemcode":"61901600","Description":"Kit: ICP Drain Only-D","CDM Revenue Code":"272","Standard Price":0.0},{"Itemcode":"63148666","Description":"TIP YANK WAVEGUIDE","CDM Revenue Code":"272","Standard Price":1368.84},{"Itemcode":"63300010","Description":"Cast Light Long Leg","CDM Revenue Code":"270","Standard Price":1075.08},{"Itemcode":"63300011","Description":"Cast Light Short Leg","CDM Revenue Code":"270","Standard Price":624.24},{"Itemcode":"63300088","Description":"Trac Russills","CDM Revenue Code":"270","Standard Price":207.06},{"Itemcode":"63301098","Description":"Splint Post - Fiberglass Arm","CDM Revenue Code":"270","Standard Price":218.28},{"Itemcode":"63301099","Description":"Splint Post - Fiberglass Leg","CDM Revenue Code":"270","Standard Price":252.96},{"Itemcode":"63301186","Description":"BACKSUPPORT ULTRALIGN++LSO","CDM Revenue Code":"274","CDM HCPCS":"L0637","Standard Price":1451.46},{"Itemcode":"63301187","Description":"BACK SUPPORT SAG RIGID PRECST","CDM Revenue Code":"274","CDM HCPCS":"L0627","Standard Price":468.18},{"Itemcode":"63301188","Description":"AFO MULTI-PODUS PRE CST","CDM Revenue Code":"274","CDM HCPCS":"L4396","Standard Price":513.06},{"Itemcode":"63301189","Description":"COLLAR, ASPEN","CDM Revenue Code":"274","CDM HCPCS":"L0172","Standard Price":146.88},{"Itemcode":"63302482","Description":"TLSO Aspen","CDM Revenue Code":"274","CDM HCPCS":"L0462","Standard Price":2414.34},{"Itemcode":"63302484","Description":"LSO Aspen L/Prof","CDM Revenue Code":"274","CDM HCPCS":"L0631","Standard Price":1288.26},{"Itemcode":"63302485","Description":"LSO Aspen","CDM Revenue Code":"274","CDM HCPCS":"L0631","Standard Price":1901.28},{"Itemcode":"63304000","Description":"TLSO Rigid Frame Hyperex Pre","CDM Revenue Code":"274","CDM HCPCS":"L0472","Standard Price":2213.4},{"Itemcode":"63304001","Description":"TLSO Rigid Plastic Cust Fab","CDM Revenue Code":"274","CDM HCPCS":"L0484","Standard Price":7218.54},{"Itemcode":"63304002","Description":"TLSO Rigidlined Cust Fab Two","CDM Revenue Code":"274","CDM HCPCS":"L0486","Standard Price":7149.18},{"Itemcode":"63304003","Description":"Lo Sagitt Rigid Panel Prefab","CDM Revenue Code":"274","CDM HCPCS":"L0627","Standard Price":2125.68},{"Itemcode":"63304004","Description":"LSO Sag-Coro Rigid Frame Pre","CDM Revenue Code":"274","CDM HCPCS":"L0631","Standard Price":4188.12},{"Itemcode":"63304005","Description":"Ho Post-Op Hip Abduction","CDM Revenue Code":"274","CDM HCPCS":"L1686","Standard Price":3780.12},{"Itemcode":"63304007","Description":"KO Adj Jnt Pos Rigid Support","CDM Revenue Code":"274","CDM HCPCS":"L1832","Standard Price":3074.28},{"Itemcode":"63304009","Description":"AFO Rig Ant Tib Prefab Tcf/=","CDM Revenue Code":"274","CDM HCPCS":"L1932","Standard Price":3641.4},{"Itemcode":"63304012","Description":"AFO Pos Solid Ank Plastic Mo","CDM Revenue Code":"274","CDM HCPCS":"L1960","Standard Price":2664.24},{"Itemcode":"63304013","Description":"AFO Plastic Molded W/Ankle J","CDM Revenue Code":"274","CDM HCPCS":"L1970","Standard Price":3111.0},{"Itemcode":"63304014","Description":"Kafo Fem Fx Cast Molded To P","CDM Revenue Code":"274","CDM HCPCS":"L2128","Standard Price":6504.54},{"Itemcode":"63304016","Description":"Plastic Mod Low Ext Pad/Line","CDM Revenue Code":"274","CDM HCPCS":"L2275","Standard Price":631.38},{"Itemcode":"63304018","Description":"Hip Adj Flex Ext Abduct Cont","CDM Revenue Code":"274","CDM HCPCS":"L2624","Standard Price":2006.34},{"Itemcode":"63304019","Description":"Soft Interface Below Knee Se","CDM Revenue Code":"274","CDM HCPCS":"L2820","Standard Price":507.96},{"Itemcode":"63304020","Description":"Acromio/Clavicular Canvas&We","CDM Revenue Code":"274","CDM HCPCS":"L3670","Standard Price":673.2},{"Itemcode":"63304021","Description":"Wrist Cock-Up Non-Molded","CDM Revenue Code":"274","CDM HCPCS":"L3908","Standard Price":340.68},{"Itemcode":"63304022","Description":"Pneumati Walking Boot Prefab","CDM Revenue Code":"274","CDM HCPCS":"L4360","Standard Price":1414.74},{"Itemcode":"63304023","Description":"Non-Pneum Walk Boot Prefab","CDM Revenue Code":"274","CDM HCPCS":"L4386","Standard Price":822.12},{"Itemcode":"63304024","Description":"Static Afo","CDM Revenue Code":"274","CDM HCPCS":"L4396","Standard Price":867.0},{"Itemcode":"63304025","Description":"Postop App Non-Wgt Bear Dsg","CDM Revenue Code":"274","CDM HCPCS":"L5450","Standard Price":2097.12},{"Itemcode":"63304029","Description":"Shrinker Below Knee","CDM Revenue Code":"274","CDM HCPCS":"L8440","Standard Price":0.0},{"Itemcode":"63304030","Description":"Shrinker Below Knee","CDM Revenue Code":"274","CDM HCPCS":"L8460","Standard Price":0.0},{"Itemcode":"64100047","Description":"Pacemaker Gen Single Grp1","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":10820.16},{"Itemcode":"64100070","Description":"Rezoom Conventional Iol","CDM Revenue Code":"276","Standard Price":872.1},{"Itemcode":"64100071","Description":"Rezoom Presbyopia Lens -D","CDM Revenue Code":"276","Standard Price":0.0},{"Itemcode":"64100073","Description":"Toric Lens -D","CDM Revenue Code":"276","Standard Price":2627.52},{"Itemcode":"64100074","Description":"Toric Conventional Iol","CDM Revenue Code":"276","Standard Price":872.1},{"Itemcode":"64100077","Description":"Lens Toric A-C Function","CDM Revenue Code":"276","CDM HCPCS":"V2787","Standard Price":619.14,"Note":"**"},{"Itemcode":"64100084","Description":"Encore Inflation Dev 15-105","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":221.34},{"Itemcode":"64100135","Description":"Pacer Enrythm Gen & Leads D","CDM Revenue Code":"275","Standard Price":19950.18},{"Itemcode":"64100179","Description":"Rod Group 5","CDM Revenue Code":"278","Standard Price":4213.62},{"Itemcode":"64100181","Description":"Pacemaker System Versa -D","CDM Revenue Code":"275","Standard Price":19151.52},{"Itemcode":"64100187","Description":"Defib Virtuoso Sgl D154Vwc","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":72324.12},{"Itemcode":"64100191","Description":"Alloderm Tissue 6X16 102196","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":10661.04},{"Itemcode":"64100192","Description":"Alloderm 6X16 Xthick 982196","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":11004.78},{"Itemcode":"64100194","Description":"Alloderm 6X12 102072","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":10172.46},{"Itemcode":"64100232","Description":"Alloderm 8X16 Xthick 982128","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":14674.74},{"Itemcode":"64100233","Description":"Alloderm 2X4","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":1327.02},{"Itemcode":"64100235","Description":"Graftjacket Mesh 4X04 CM","CDM Revenue Code":"278","CDM HCPCS":"Q4107","Standard Price":6460.68},{"Itemcode":"64100238","Description":"Graftjacket Mesh 86Tm-4X08","CDM Revenue Code":"278","CDM HCPCS":"Q4107","Standard Price":9214.68},{"Itemcode":"64100239","Description":"Graftjacket 5X5 8600-5X05","CDM Revenue Code":"278","CDM HCPCS":"Q4107","Standard Price":35260.38},{"Itemcode":"64100240","Description":"GraftJacket 4X7 86Um-4X07","CDM Revenue Code":"278","CDM HCPCS":"Q4107","Standard Price":35260.38},{"Itemcode":"64100242","Description":"GraftJacket 4X7Cm 8600-4X07","CDM Revenue Code":"278","CDM HCPCS":"Q4107","Standard Price":35260.38},{"Itemcode":"64100245","Description":"Sealant Surg/Closure Dev Grp 1","CDM Revenue Code":"272","Standard Price":940.44,"Note":"**"},{"Itemcode":"64100246","Description":"Sealant Surg/Closure Dev Grp 2","CDM Revenue Code":"272","Standard Price":2093.04,"Note":"**"},{"Itemcode":"64100247","Description":"Graft Vascular Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":629.34},{"Itemcode":"64100248","Description":"Graft Vascular Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":925.14,"Note":"**"},{"Itemcode":"64100249","Description":"Graft Vascular Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":1559.58,"Note":"**"},{"Itemcode":"64100250","Description":"Graft Vascular Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":2258.28,"Note":"**"},{"Itemcode":"64100253","Description":"Graft Vascular Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":2567.34,"Note":"**"},{"Itemcode":"64100254","Description":"Graft Vascular Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":5127.54,"Note":"**"},{"Itemcode":"64100257","Description":"Graft Vascular Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":9496.2,"Note":"**"},{"Itemcode":"64100258","Description":"Graft Vascular Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":9937.86,"Note":"**"},{"Itemcode":"64100259","Description":"Graft Vascular Grp 11","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":31446.6,"Note":"**"},{"Itemcode":"64100260","Description":"Gamma Graft 12X30 Cm2 Gg400","CDM Revenue Code":"278","CDM HCPCS":"Q4111","Standard Price":1060.8},{"Itemcode":"64100261","Description":"Cath Guiding Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":908.82,"Note":"**"},{"Itemcode":"64100263","Description":"Cath Guiding Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":1698.3,"Note":"**"},{"Itemcode":"64100264","Description":"Pacemaker Sys Adpata Addrs1-D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"64100265","Description":"Gen Addrs1","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":17575.62},{"Itemcode":"64100269","Description":"Spinal Cage/Spacer Grp 1","CDM Revenue Code":"278","Standard Price":3797.46,"Note":"**"},{"Itemcode":"64100270","Description":"Spinal Cage/Spacer Grp 2","CDM Revenue Code":"278","Standard Price":3720.96,"Note":"**"},{"Itemcode":"64100271","Description":"Spinal Cage/Spacer Grp 3","CDM Revenue Code":"278","Standard Price":5185.68,"Note":"**"},{"Itemcode":"64100272","Description":"Spinal Cage/Spacer Grp 4","CDM Revenue Code":"278","Standard Price":9546.18,"Note":"**"},{"Itemcode":"64100273","Description":"Spinal Cage/Spacer Grp 5","CDM Revenue Code":"278","Standard Price":10146.96,"Note":"**"},{"Itemcode":"64100274","Description":"Spinal Cage/Spacer Grp 6","CDM Revenue Code":"278","Standard Price":12410.34,"Note":"**"},{"Itemcode":"64100275","Description":"Spinal Cage/Spacer Grp 7","CDM Revenue Code":"278","Standard Price":14138.22,"Note":"**"},{"Itemcode":"64100276","Description":"Spinal Cage/Spacer Grp 8","CDM Revenue Code":"278","Standard Price":15796.74,"Note":"**"},{"Itemcode":"64100279","Description":"Rod Grp 6","CDM Revenue Code":"278","Standard Price":6168.96,"Note":"**"},{"Itemcode":"64100280","Description":"Sizer Mammary Grp","CDM Revenue Code":"272","Standard Price":278.46},{"Itemcode":"64100287","Description":"Cath Coronary Grp 2","CDM Revenue Code":"272","Standard Price":4774.62},{"Itemcode":"64100293","Description":"Morcellator","CDM Revenue Code":"272","CDM HCPCS":"C1782","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64100296","Description":"Elevate Anterior 720093-01","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":7970.28},{"Itemcode":"64100301","Description":"Alloderm 4X12 Cm","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":4907.22},{"Itemcode":"64100302","Description":"Bone Morphogenic Protein","CDM Revenue Code":"278","Standard Price":16557.66},{"Itemcode":"64100303","Description":"Bone Osteogenic Protein","CDM Revenue Code":"278","Standard Price":16906.5},{"Itemcode":"64100308","Description":"Gen Zephyr Xl Dr 5826","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":23851.68},{"Itemcode":"64100314","Description":"Pacer Zephyr Xl Dr 5826 Sys-D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"64100317","Description":"Cath Atherectomy","CDM Revenue Code":"272","CDM HCPCS":"C1724","Standard Price":11394.42,"Note":"**"},{"Itemcode":"64100359","Description":"Cath Relieva Sinus Balloon","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":2832.54,"Note":"**"},{"Itemcode":"64100386","Description":"Stent Non Cov/No Deliv","CDM Revenue Code":"278","CDM HCPCS":"C1877","Standard Price":8113.08},{"Itemcode":"64100389","Description":"Cement Bone Group 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2896.8,"Note":"**"},{"Itemcode":"64100392","Description":"Contigen","CDM Revenue Code":"278","CDM HCPCS":"L8603","Standard Price":2145.06},{"Itemcode":"64100393","Description":"Cath Intradiscal (Idet)","CDM Revenue Code":"272","CDM HCPCS":"C1754","Standard Price":5460.06},{"Itemcode":"64100394","Description":"Gen Prime Advanced Neurostim","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":19415.7},{"Itemcode":"64100395","Description":"Lead Kit Neurostim 39565","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":18932.22},{"Itemcode":"64100396","Description":"Programmer Impl Neurostim","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":3298.68},{"Itemcode":"64100397","Description":"Cement Bone Group 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":971.04,"Note":"**"},{"Itemcode":"64100398","Description":"Ablator Sys Atricure Disp","CDM Revenue Code":"272","Standard Price":10653.9,"Note":"**"},{"Itemcode":"64100401","Description":"Cath Occlusion","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":1924.74},{"Itemcode":"64100405","Description":"Pacemaker Sys Empulse E2Dr01-D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"64100406","Description":"Bmp Infuse Xsm","CDM Revenue Code":"278","Standard Price":7657.14,"Note":"**"},{"Itemcode":"64100407","Description":"Bmp Infuse Xxsm","CDM Revenue Code":"278","Standard Price":3831.12},{"Itemcode":"64100487","Description":"Suture Guide Heart Gfs-10","CDM Revenue Code":"272","Standard Price":334.56,"Note":"**"},{"Itemcode":"64100495","Description":"Knife Bayonet 9560659","CDM Revenue Code":"272","Standard Price":1384.14,"Note":"**"},{"Itemcode":"64100509","Description":"Lead Locking Device","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2507.16},{"Itemcode":"64100532","Description":"Gen Nuerostim Sc-1110-02","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":52256.64},{"Itemcode":"64100534","Description":"Spacer Relieva Sinus System","CDM Revenue Code":"272","Standard Price":3391.5},{"Itemcode":"64100575","Description":"Rod Axia Lif Interbody Device","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":26274.18},{"Itemcode":"64100579","Description":"Plate Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":15022.56,"Note":"**"},{"Itemcode":"64100595","Description":"Plate Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7105.32,"Note":"**"},{"Itemcode":"64100596","Description":"Plate Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9054.54,"Note":"**"},{"Itemcode":"64100600","Description":"Sling No Cost C1771","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":1.02},{"Itemcode":"64100616","Description":"Cath Guiding Acclarent","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2401.08},{"Itemcode":"64100658","Description":"No Cost Mesh C1781","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1.02},{"Itemcode":"64100684","Description":"Sealant Duraseal 202050","CDM Revenue Code":"278","Standard Price":3610.8,"Note":"**"},{"Itemcode":"64100706","Description":"Lead Coronary Sinus","CDM Revenue Code":"275","CDM HCPCS":"C1900","Standard Price":10077.6},{"Itemcode":"64100731","Description":"Prowler Cath Neuro Embolectomy","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":3708.72},{"Itemcode":"64100759","Description":"Pacer Sys Adsr01 -D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"64100765","Description":"Stent Palmaz","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":7276.68,"Note":"**"},{"Itemcode":"64100795","Description":"Stent Graft Conlat - Endurant","CDM Revenue Code":"278","Standard Price":21747.42,"Note":"**"},{"Itemcode":"64100796","Description":"Prosth Penile Reservoir-TITAN","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":7615.32,"Note":"**"},{"Itemcode":"64100797","Description":"Prosth Penile Reservr-100ML IZ","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":8901.42666666667,"Note":"**"},{"Itemcode":"64100798","Description":"BLADE DISPOSABLE GRP 6","CDM Revenue Code":"272","Standard Price":3641.4,"Note":"**"},{"Itemcode":"64100799","Description":"Protector Nerve 7mmX2Cm NW720","CDM Revenue Code":"278","CDM HCPCS":"C9353","Standard Price":8425.2},{"Itemcode":"64100808","Description":"Cath Turbohawk Atherectomy","CDM Revenue Code":"272","CDM HCPCS":"C1714","Standard Price":10805.88},{"Itemcode":"64100850","Description":"Sling Avaulta","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":6927.84},{"Itemcode":"64100860","Description":"Pacer System Altrua S401 -D","CDM Revenue Code":"275","Standard Price":13491.54},{"Itemcode":"64100866","Description":"Pacer Altrua S403 Dr -D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"64100869","Description":"Pacer Gen Altrua S403 Dr","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14201.46},{"Itemcode":"64100871","Description":"Fascia Lata Tissue Implant GR2","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":6987.0},{"Itemcode":"64100874","Description":"Xenograft Implant","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":7087.98},{"Itemcode":"64100876","Description":"Anchor Bone Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2545.92,"Note":"**"},{"Itemcode":"64100878","Description":"Inforce Matrix-CnTiss Nonhuman","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":10204.08,"Note":"**"},{"Itemcode":"64100889","Description":"Pacemaker Contak Renewal","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":28902.72},{"Itemcode":"64100912","Description":"BMP Infuse Small","CDM Revenue Code":"278","Standard Price":12134.94,"Note":"**"},{"Itemcode":"64100913","Description":"BMP Infuse Medium","CDM Revenue Code":"278","Standard Price":16900.38,"Note":"**"},{"Itemcode":"64100914","Description":"BMP Infuse Large","CDM Revenue Code":"278","Standard Price":19110.72,"Note":"**"},{"Itemcode":"64100915","Description":"Prosthes Penile-AccesryKit 800","CDM Revenue Code":"272","Standard Price":4999.02,"Note":"**"},{"Itemcode":"64100916","Description":"GraftJacket 2X4 8600-2X04","CDM Revenue Code":"278","CDM HCPCS":"Q4107","Standard Price":5494.74},{"Itemcode":"64100922","Description":"NS Kit Lead Trial 50cm","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":5118.36},{"Itemcode":"64100926","Description":"External Fixator Cmpnts Grp 3A","CDM Revenue Code":"272","Standard Price":3896.4,"Note":"**"},{"Itemcode":"64100930","Description":"External Fixator Cmpnts Grp 3B","CDM Revenue Code":"272","Standard Price":4760.34,"Note":"**"},{"Itemcode":"64100939","Description":"Plate Grp 5A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4968.42,"Note":"**"},{"Itemcode":"64100956","Description":"Graft Vascular Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":15255.12,"Note":"**"},{"Itemcode":"64100957","Description":"Graft Vascular Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":21640.32,"Note":"**"},{"Itemcode":"64100958","Description":"Graft Vascular Grp 12","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":38650.86,"Note":"**"},{"Itemcode":"64100961","Description":"Nail, Ortho Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7500.06,"Note":"**"},{"Itemcode":"64100962","Description":"Nail, Ortho Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8453.76,"Note":"**"},{"Itemcode":"64101013","Description":"Sys Fem Filter Recover Rf-310F","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":6326.04},{"Itemcode":"64101053","Description":"Nerve Locator/Stimulator","CDM Revenue Code":"272","Standard Price":319.26,"Note":"**"},{"Itemcode":"64101054","Description":"Stimulator Test Interstim 3625","CDM Revenue Code":"272","Standard Price":3391.5},{"Itemcode":"64101062","Description":"Stent Complete Se","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":5758.92},{"Itemcode":"64101092","Description":"Neurostim Interstim 3023-101","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":29755.44},{"Itemcode":"64101093","Description":"Neurostim Itrel 2 7425","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":26357.82},{"Itemcode":"64101095","Description":"Lead Icd Sprint Quattro 6721S","CDM Revenue Code":"275","CDM HCPCS":"C1896","Standard Price":4478.82},{"Itemcode":"64101100","Description":"Attain Cath Venogram 6215","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":853.74},{"Itemcode":"64101170","Description":"FORCEP BIPOLAR, INTUITIVE","CDM Revenue Code":"272","Standard Price":10820.16},{"Itemcode":"64101189","Description":"Impl NS Lead Test Kit","CDM Revenue Code":"278","CDM HCPCS":"C1897","Standard Price":6378.06,"Note":"**"},{"Itemcode":"64101194","Description":"Fixator Circular Sidekick","CDM Revenue Code":"272","Standard Price":18976.08},{"Itemcode":"64101198","Description":"Primatrix 4X4 Sq Cm","CDM Revenue Code":"278","CDM HCPCS":"Q4110","Standard Price":2745.84},{"Itemcode":"64101206","Description":"Primatrix 6X6 Sq Cm","CDM Revenue Code":"278","CDM HCPCS":"Q4110","Standard Price":4837.86},{"Itemcode":"64101226","Description":"PriMatrix 8X8 Sq Cm","CDM Revenue Code":"278","CDM HCPCS":"Q4110","Standard Price":9876.66},{"Itemcode":"64101230","Description":"Kit Platelet","CDM Revenue Code":"272","Standard Price":929.22,"Note":"**"},{"Itemcode":"64101237","Description":"Brachytherapy Needle Fn18","CDM Revenue Code":"278","CDM HCPCS":"C1715","Standard Price":664.02,"Note":"**"},{"Itemcode":"64101239","Description":"Artelon Tissue Implant","CDM Revenue Code":"278","CDM HCPCS":"L8658","Standard Price":10653.9},{"Itemcode":"64101240","Description":"Crystalens -D","CDM Revenue Code":"276","Standard Price":0.0},{"Itemcode":"64101242","Description":"Crystalens Presby-C Functn","CDM Revenue Code":"276","CDM HCPCS":"V2788","Standard Price":1301.52},{"Itemcode":"64101246","Description":"Vein Saphenous Lp230-39Cm","CDM Revenue Code":"278","Standard Price":35906.04},{"Itemcode":"64101247","Description":"Vein Saphenous V010","CDM Revenue Code":"278","Standard Price":34556.58,"Note":"**"},{"Itemcode":"64101248","Description":"Vein Saphenous Cv46-60","CDM Revenue Code":"278","Standard Price":19595.22},{"Itemcode":"64101249","Description":"Guidewire Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":643.62,"Note":"**"},{"Itemcode":"64101251","Description":"Screw Group 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4975.56,"Note":"**"},{"Itemcode":"64101252","Description":"Screw Group 8","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5930.28,"Note":"**"},{"Itemcode":"64101255","Description":"Prosthesis Breast Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":5707.92,"Note":"**"},{"Itemcode":"64101270","Description":"Allograft Orth/Neuro Grp7","CDM Revenue Code":"278","Standard Price":9845.04,"Note":"**"},{"Itemcode":"64101271","Description":"Allograft Orth/Neuro Grp8","CDM Revenue Code":"278","Standard Price":14440.14,"Note":"**"},{"Itemcode":"64101272","Description":"Allograft Oats 268003","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":21978.96},{"Itemcode":"64101273","Description":"Allograft Human 268021","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":22148.28,"Note":"**"},{"Itemcode":"64101355","Description":"Aigisrx Pm Antibacterial Envel","CDM Revenue Code":"278","Standard Price":2965.14},{"Itemcode":"64101511","Description":"MatrixWnd w/Mesh 5x5cm Mwm2021","CDM Revenue Code":"278","CDM HCPCS":"C9363","Standard Price":7379.7},{"Itemcode":"64101547","Description":"Anchor Kit - Neurostim","CDM Revenue Code":"278","Standard Price":1990.02,"Note":"**"},{"Itemcode":"64101548","Description":"Flexhd 6X16 Derm Tissue 471616","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":10643.7},{"Itemcode":"64101549","Description":"Flexhd 6X12 Cm Derm Tissue","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":8802.6},{"Itemcode":"64101552","Description":"Flexhd 2X4 Cm Derm Tissue","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":2408.22},{"Itemcode":"64101553","Description":"Repliform","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":2875.38},{"Itemcode":"64101555","Description":"Spacer Mold Hip Cement","CDM Revenue Code":"278","Standard Price":1173.0},{"Itemcode":"64101569","Description":"ICD Gen Incepta Vr He E160","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":54328.26},{"Itemcode":"64101576","Description":"ICD Gen Contak Renew Biv H215","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":82953.54},{"Itemcode":"64101579","Description":"Ams Spectra Penile Prosthesis","CDM Revenue Code":"278","CDM HCPCS":"C2622","Standard Price":17787.78,"Note":"**"},{"Itemcode":"64101663","Description":"Coupler Gem Vasc Anastomoses","CDM Revenue Code":"272","Standard Price":1836.0,"Note":"**"},{"Itemcode":"64101668","Description":"Screw Cover, Ext Cochlear","CDM Revenue Code":"272","Standard Price":834.36,"Note":"**"},{"Itemcode":"64101670","Description":"Gen NS-Restore 37712","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":61800.78},{"Itemcode":"64101671","Description":"Lead Neurostim","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":3047.76},{"Itemcode":"64101674","Description":"Disk Artificial","CDM Revenue Code":"278","Standard Price":15216.36},{"Itemcode":"64101675","Description":"Spacer Anterior Stt36110-12Lt","CDM Revenue Code":"278","Standard Price":22316.58},{"Itemcode":"64101677","Description":"Cage Pillar Alif","CDM Revenue Code":"278","Standard Price":22418.58},{"Itemcode":"64101678","Description":"Spacer Alif Xsm 364.009","CDM Revenue Code":"278","Standard Price":26566.92},{"Itemcode":"64101679","Description":"SCREW EXTRACTION 309.510","CDM Revenue Code":"272","Standard Price":533.46},{"Itemcode":"64101682","Description":"BOLT EXTRACTION 4.5MM","CDM Revenue Code":"272","Standard Price":643.62},{"Itemcode":"64101683","Description":"SCREW CONICAL EXTRACTION","CDM Revenue Code":"272","Standard Price":864.96},{"Itemcode":"64101687","Description":"GUIDE PIN, NON IMPLNT GR 3","CDM Revenue Code":"272","Standard Price":2985.54,"Note":"**"},{"Itemcode":"64101689","Description":"Allograft BiofixFlow 0.5CC","CDM Revenue Code":"278","CDM HCPCS":"Q4162","Standard Price":10237.74},{"Itemcode":"64101691","Description":"ALLGRFT AMNIO MEM BIOFIX 4X4CM","CDM Revenue Code":"278","CDM HCPCS":"Q4163","Standard Price":10549.86},{"Itemcode":"64101700","Description":"NS EXT PT RECHARG SYSTEM REPL","CDM Revenue Code":"274","CDM HCPCS":"L8689","Standard Price":8957.64},{"Itemcode":"64101701","Description":"ALLOGRAFT BIOFIX FLOW 1CC BFA","CDM Revenue Code":"278","CDM HCPCS":"Q4162","Standard Price":11766.72},{"Itemcode":"64101703","Description":"Plate Grp 9A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10986.42,"Note":"**"},{"Itemcode":"64101704","Description":"Plug, Acetabular","CDM Revenue Code":"278","Standard Price":483.48,"Note":"**"},{"Itemcode":"64101707","Description":"DEVICE,INFLATION-ENCORE 26","CDM Revenue Code":"272","Standard Price":463.08},{"Itemcode":"64101708","Description":"Cytology Brush Sheathed","CDM Revenue Code":"272","Standard Price":712.98},{"Itemcode":"64101709","Description":"Pin Guide, Tibia 25mm","CDM Revenue Code":"272","Standard Price":161.16},{"Itemcode":"64101710","Description":"Prosthesis Penile Pump Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":32876.64,"Note":"**"},{"Itemcode":"64101711","Description":"Intro/Sheath,Fixed,Peel-Away","CDM Revenue Code":"272","CDM HCPCS":"C1892","Standard Price":419.22,"Note":"**"},{"Itemcode":"64101712","Description":"SPINE ROD TRIAL IMPLANT","CDM Revenue Code":"278","Standard Price":572.22,"Note":"**"},{"Itemcode":"64101715","Description":"SPINE ROD CURVED 65MM","CDM Revenue Code":"278","Standard Price":540.6},{"Itemcode":"64101716","Description":"SPINE ROD GRP 1","CDM Revenue Code":"278","Standard Price":617.1},{"Itemcode":"64101717","Description":"SPINE ROD GRP 2","CDM Revenue Code":"278","Standard Price":822.12,"Note":"**"},{"Itemcode":"64101738","Description":"SPINE ROD GRP 3","CDM Revenue Code":"278","Standard Price":1040.4,"Note":"**"},{"Itemcode":"64101739","Description":"SPINE ROD GRP 4","CDM Revenue Code":"278","Standard Price":1248.48,"Note":"**"},{"Itemcode":"64101741","Description":"Valvulotome-Expandable","CDM Revenue Code":"272","Standard Price":8697.54,"Note":"**"},{"Itemcode":"64101745","Description":"Neurawrap Nerve Protector 2Cm","CDM Revenue Code":"278","CDM HCPCS":"C9353","Standard Price":4638.96},{"Itemcode":"64101746","Description":"Neurawrap Nerve Protector","CDM Revenue Code":"278","CDM HCPCS":"C9353","Standard Price":6762.6,"Note":"**"},{"Itemcode":"64101747","Description":"Neuragen Nerve Guide 2 Cm","CDM Revenue Code":"278","CDM HCPCS":"C9352","Standard Price":6094.5},{"Itemcode":"64101748","Description":"Neuragen Nerve Guide 3 Cm","CDM Revenue Code":"278","CDM HCPCS":"C9352","Standard Price":8193.66,"Note":"**"},{"Itemcode":"64101749","Description":"SPINE ROD GRP 5","CDM Revenue Code":"278","Standard Price":1560.6,"Note":"**"},{"Itemcode":"64101752","Description":"SPINE ROD GRP 6","CDM Revenue Code":"278","Standard Price":1904.34,"Note":"**"},{"Itemcode":"64101756","Description":"SPINE ROD GRP 7","CDM Revenue Code":"278","Standard Price":2330.7,"Note":"**"},{"Itemcode":"64101778","Description":"SPINE ROD GRP 8","CDM Revenue Code":"278","Standard Price":2856.0,"Note":"**"},{"Itemcode":"64101779","Description":"SPINE ROD GRP 9","CDM Revenue Code":"278","Standard Price":3490.44},{"Itemcode":"64101780","Description":"SPINE ROD GRP 10","CDM Revenue Code":"278","Standard Price":4265.64,"Note":"**"},{"Itemcode":"64101784","Description":"SPINE ROD GRP 11","CDM Revenue Code":"278","Standard Price":5202.0},{"Itemcode":"64101786","Description":"SPINE ROD GRP 12","CDM Revenue Code":"278","Standard Price":6366.84,"Note":"**"},{"Itemcode":"64101788","Description":"SPINE ROD OFFSET 20MM","CDM Revenue Code":"278","Standard Price":7678.56},{"Itemcode":"64101789","Description":"SPINE ROD W CORD 152.XXXX","CDM Revenue Code":"278","Standard Price":9467.64},{"Itemcode":"64101793","Description":"SPINE ROD W/TUBING 40MM","CDM Revenue Code":"278","Standard Price":10143.9},{"Itemcode":"64101794","Description":"Connector Orth/Neuro Grp 2A","CDM Revenue Code":"278","Standard Price":2601.0,"Note":"**"},{"Itemcode":"64101801","Description":"Stackhouse Filter Lfs-103","CDM Revenue Code":"272","Standard Price":422.28},{"Itemcode":"64101805","Description":"SPINE STAB-TRANS SPOOL 152.202","CDM Revenue Code":"278","Standard Price":322.32},{"Itemcode":"64101806","Description":"NS Kit PatientTrial SC-6500-32","CDM Revenue Code":"272","Standard Price":451.86},{"Itemcode":"64101810","Description":"Kit,Rotation w/Tendon Stples","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4126.92},{"Itemcode":"64101813","Description":"Introducer/Sheath Grp 2B","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":792.54,"Note":"**"},{"Itemcode":"64101819","Description":"Introducer Sheath 14FR X 28CM","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":1060.8,"Note":"**"},{"Itemcode":"64101821","Description":"Cath Balloon Angioplasty Grp1C","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1284.18,"Note":"**"},{"Itemcode":"64101822","Description":"Cath Balloon Angioplasty Grp1E","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1570.8,"Note":"**"},{"Itemcode":"64101826","Description":"Dermis Hmatrix 5X4 Cm 208032","CDM Revenue Code":"278","CDM HCPCS":"Q4134","Standard Price":2700.96},{"Itemcode":"64101828","Description":"PICO 10X20Cm Ns Pump 66800951","CDM Revenue Code":"272","Standard Price":1171.98,"Note":"**"},{"Itemcode":"64101832","Description":"Bony Void Filler Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":14493.18,"Note":"**"},{"Itemcode":"64101833","Description":"ORTHOCORD","CDM Revenue Code":"272","Standard Price":176.46,"Note":"**"},{"Itemcode":"64101836","Description":"Screw Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1008.78,"Note":"**"},{"Itemcode":"64101838","Description":"Screw Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1639.14,"Note":"**"},{"Itemcode":"64101842","Description":"Patch Fibrin Sealant 2x4in","CDM Revenue Code":"278","Standard Price":3306.84,"Note":"**"},{"Itemcode":"64101845","Description":"Rod Humeral 8x240","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10420.32,"Note":"**"},{"Itemcode":"64101847","Description":"NAIL VALOR 11.5X250","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":14253.48},{"Itemcode":"64101848","Description":"COMP FEM OXNM SZ3","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":23390.64},{"Itemcode":"64101850","Description":"Allogrft Tiss-Cartilage Denovo","CDM Revenue Code":"278","Standard Price":16094.58,"Note":"**"},{"Itemcode":"64101852","Description":"NS Kit, Lead Introducer","CDM Revenue Code":"272","Standard Price":451.86},{"Itemcode":"64101853","Description":"Wire Ortho Supply Grp 1A","CDM Revenue Code":"272","Standard Price":457.98},{"Itemcode":"64101854","Description":"Wire Ortho Supply Grp 1B","CDM Revenue Code":"272","Standard Price":572.22,"Note":"**"},{"Itemcode":"64101855","Description":"Wire Ortho Supply Grp 1C","CDM Revenue Code":"272","Standard Price":692.58,"Note":"**"},{"Itemcode":"64101860","Description":"Burr Grp 2B","CDM Revenue Code":"272","Standard Price":1077.12},{"Itemcode":"64101861","Description":"Burr Grp 2C","CDM Revenue Code":"272","Standard Price":1310.7,"Note":"**"},{"Itemcode":"64101865","Description":"Bit Drill Grp 2A","CDM Revenue Code":"272","Standard Price":931.26,"Note":"**"},{"Itemcode":"64101866","Description":"Bit Drill Grp 2B","CDM Revenue Code":"272","Standard Price":1139.34,"Note":"**"},{"Itemcode":"64101867","Description":"Implant Joint Grp 5A","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":3933.12,"Note":"**"},{"Itemcode":"64101868","Description":"Implant Hammerlock 20mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4798.08,"Note":"**"},{"Itemcode":"64101872","Description":"DBS/NS Adaptor Pocket 1x4","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":2627.52},{"Itemcode":"64101875","Description":"Bone Stimulator 01-203-0001","CDM Revenue Code":"278","Standard Price":8572.08},{"Itemcode":"64101879","Description":"KIT JUGGER KNOT SZ1 OR 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2729.52,"Note":"**"},{"Itemcode":"64101880","Description":"Prosthesis Ams Cuff W/IH, OCCL","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":19125.0,"Note":"**"},{"Itemcode":"64101882","Description":"Plate Grp 3 A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1337.22,"Note":"**"},{"Itemcode":"64101883","Description":"Plate Grp 3 B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1633.02,"Note":"**"},{"Itemcode":"64101884","Description":"Staple Bone Grp 3 D","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4525.74},{"Itemcode":"64101885","Description":"Plate Grp 3 C","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1992.06,"Note":"**"},{"Itemcode":"64101887","Description":"Plate Grp 3 D","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2434.74,"Note":"**"},{"Itemcode":"64101888","Description":"Port Power 8FR SGL","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":1246.44,"Note":"**"},{"Itemcode":"64101889","Description":"Sternalock Plate - GR 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1756.44},{"Itemcode":"64101896","Description":"Sternalock Plate - GR 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2788.68},{"Itemcode":"64101897","Description":"Valve Heart MAGNA 330TFX25","CDM Revenue Code":"278","Standard Price":33475.38},{"Itemcode":"64101898","Description":"Plate Grp 9 B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13515.0,"Note":"**"},{"Itemcode":"64101908","Description":"Bit Drill 16mm Synthes","CDM Revenue Code":"272","Standard Price":4289.1,"Note":"**"},{"Itemcode":"64101910","Description":"Mesh Genl Surg C1781 Grp 5 A","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":5072.46,"Note":"**"},{"Itemcode":"64101915","Description":"Cath Central Venous Grp 2 A","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":2060.4},{"Itemcode":"64101918","Description":"Cath Central Venous Grp 2 B","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":2517.36,"Note":"**"},{"Itemcode":"64101921","Description":"Prosthesis Kit Penile/Uri GR2","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":2960.04,"Note":"**"},{"Itemcode":"64101925","Description":"Prosthesis Kit Penile/Uri GR3","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":3621.0},{"Itemcode":"64101927","Description":"Graft Vascular Grp 6 A","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":6262.8,"Note":"**"},{"Itemcode":"64101929","Description":"Bit Drill Grp 4 A","CDM Revenue Code":"272","Standard Price":2746.86,"Note":"**"},{"Itemcode":"64101935","Description":"GUIDE PIN, NON IMPLNT GR 1","CDM Revenue Code":"272","Standard Price":1997.16},{"Itemcode":"64101938","Description":"GUIDE PIN, NON IMPLNT GR 2","CDM Revenue Code":"272","Standard Price":2444.94},{"Itemcode":"64101940","Description":"External Fixator Cmpnts Grp2A","CDM Revenue Code":"272","Standard Price":1300.5},{"Itemcode":"64101942","Description":"External Fixator Cmpnts Grp2C","CDM Revenue Code":"272","Standard Price":1945.14},{"Itemcode":"64101944","Description":"Bony Void Filler Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3490.44,"Note":"**"},{"Itemcode":"64101945","Description":"Valve Heart Grp A","CDM Revenue Code":"278","Standard Price":12900.96},{"Itemcode":"64101946","Description":"Mesh Genl Surg C1781 Grp 4A","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":3292.56,"Note":"**"},{"Itemcode":"64101947","Description":"Mesh Genl Surg C1781 Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1893.12,"Note":"**"},{"Itemcode":"64101948","Description":"Mesh Genl Surg C1781 Grp 3B","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":2315.4,"Note":"**"},{"Itemcode":"64101950","Description":"IMP TRAY TIBIAL ROTATG PLTFRM","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":24137.28},{"Itemcode":"64101951","Description":"Cath Balloon Angioplasty Grp1A","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1050.6,"Note":"**"},{"Itemcode":"64101954","Description":"Cath Balloon Angioplasty Grp1D","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1285.2},{"Itemcode":"64101955","Description":"Cannula OH FEM/VEN 23/25FR","CDM Revenue Code":"272","Standard Price":1866.6,"Note":"**"},{"Itemcode":"64101956","Description":"Implant-Ossicular Ti 636-080","CDM Revenue Code":"278","CDM HCPCS":"L8613","Standard Price":694.62,"Note":"**"},{"Itemcode":"64101957","Description":"Imp Cath Port C1788 Grp A","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":1008.78,"Note":"**"},{"Itemcode":"64101958","Description":"Mesh Hernia Phasix 20X25CM","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":28234.62},{"Itemcode":"64101959","Description":"Allograft Orth/Neuro Grp 6B","CDM Revenue Code":"278","Standard Price":9883.8,"Note":"**"},{"Itemcode":"64101961","Description":"Bony Void Filler Actifuse","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":14118.84},{"Itemcode":"64101962","Description":"Prodense 87Sr-Ck15 Bone Filler","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":18822.06,"Note":"**"},{"Itemcode":"64101963","Description":"Prodense 87Sr-0420 Bone Filler","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":15141.9,"Note":"**"},{"Itemcode":"64101967","Description":"Bony Void Filler Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":880.26,"Note":"**"},{"Itemcode":"64101972","Description":"Bony Void Filler Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2045.1,"Note":"**"},{"Itemcode":"64101973","Description":"Bony Void Filler Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2854.98,"Note":"**"},{"Itemcode":"64101974","Description":"Bony Void Filler Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4486.98,"Note":"**"},{"Itemcode":"64101975","Description":"Bony Void Filler Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5416.2,"Note":"**"},{"Itemcode":"64101976","Description":"Bony Void Filler Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6631.02,"Note":"**"},{"Itemcode":"64101977","Description":"Bony Void Filler Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10263.24,"Note":"**"},{"Itemcode":"64101978","Description":"Cannula FlwPrt, Hip Arthros","CDM Revenue Code":"272","Standard Price":2095.08,"Note":"**"},{"Itemcode":"64101979","Description":"Impl, Pin Bone Fixation","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6582.06,"Note":"**"},{"Itemcode":"64101980","Description":"Valve, Tracheostomy Speaking","CDM Revenue Code":"274","CDM HCPCS":"L8501","Standard Price":231.54},{"Itemcode":"64101981","Description":"IMPLANT HIP HELICAL GRP 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4822.56},{"Itemcode":"64101982","Description":"Cath Infusion, MidLine","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":1262.76,"Note":"**"},{"Itemcode":"64101983","Description":"Mesh Genl Surg C1781 Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1830.9,"Note":"**"},{"Itemcode":"64101987","Description":"Mesh Genl Surg C1781 Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1087.32,"Note":"**"},{"Itemcode":"64101988","Description":"Mesh Genl Surg C1781 Grp 2B","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1332.12,"Note":"**"},{"Itemcode":"64101989","Description":"Prosthesis Ear GR 2","CDM Revenue Code":"278","CDM HCPCS":"L8613","Standard Price":1758.48,"Note":"**"},{"Itemcode":"64101991","Description":"Prosthesis Ear GR 3","CDM Revenue Code":"278","CDM HCPCS":"L8613","Standard Price":2148.12,"Note":"**"},{"Itemcode":"64101992","Description":"Impl, Blade, Helical 90-95mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4812.36,"Note":"**"},{"Itemcode":"64101993","Description":"Sheath, Endograft, Steerable","CDM Revenue Code":"272","Standard Price":2453.1,"Note":"**"},{"Itemcode":"64101994","Description":"Pin Guide Fixation/Temp","CDM Revenue Code":"272","Standard Price":1847.22},{"Itemcode":"64101996","Description":"Restrctr/Spacer Cement","CDM Revenue Code":"278","Standard Price":322.32,"Note":"**"},{"Itemcode":"64101997","Description":"KIT MENISCAL REPAIR AR-4550","CDM Revenue Code":"278","Standard Price":4245.24},{"Itemcode":"64101998","Description":"KIT ACCESSORY PENILE PROSTH","CDM Revenue Code":"272","Standard Price":3579.47142857142,"Note":"**"},{"Itemcode":"64101999","Description":"BonyVoidFiller-Osteosponge10mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1804.38},{"Itemcode":"64102000","Description":"Mesh Genl Surg Marlex 3x6","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":643.62,"Note":"**"},{"Itemcode":"64102001","Description":"Bony Void Filler Grp 1A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1077.12},{"Itemcode":"64102002","Description":"Screw Grp 3B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2003.28,"Note":"**"},{"Itemcode":"64102003","Description":"Cath Balloon Dil Non-Vasc Grp3","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":1607.52,"Note":"**"},{"Itemcode":"64102004","Description":"Plate Grp 1A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":442.68},{"Itemcode":"64102005","Description":"Plate Grp 1B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":542.64},{"Itemcode":"64102006","Description":"Staple Bone Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":915.96,"Note":"**"},{"Itemcode":"64102007","Description":"Staple Bone Grp 2B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1118.94},{"Itemcode":"64102008","Description":"Screw Grp 1A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":572.22,"Note":"**"},{"Itemcode":"64102009","Description":"Cable Ortho Grp 4A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3100.8},{"Itemcode":"64102010","Description":"CABLE FIXATION W/CLAMP","CDM Revenue Code":"272","Standard Price":2913.12,"Note":"**"},{"Itemcode":"64102012","Description":"Low Cost Screw Grp 11","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":447.78,"Note":"**"},{"Itemcode":"64102014","Description":"Implant Joint Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":693.6,"Note":"**"},{"Itemcode":"64102015","Description":"Implant Joint Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":1032.24,"Note":"**"},{"Itemcode":"64102016","Description":"Implant Joint Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":1659.54,"Note":"**"},{"Itemcode":"64102017","Description":"Implant Joint Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":2521.44,"Note":"**"},{"Itemcode":"64102018","Description":"Implant Joint Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":3219.12,"Note":"**"},{"Itemcode":"64102019","Description":"Implant Joint Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":4217.7,"Note":"**"},{"Itemcode":"64102020","Description":"Implant Joint Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":5941.5,"Note":"**"},{"Itemcode":"64102021","Description":"Implant Joint Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":6764.64,"Note":"**"},{"Itemcode":"64102022","Description":"Implant Joint Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":9655.32,"Note":"**"},{"Itemcode":"64102023","Description":"Implant Joint Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":9834.84,"Note":"**"},{"Itemcode":"64102024","Description":"Implant Joint Grp 11","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":10908.9,"Note":"**"},{"Itemcode":"64102025","Description":"Implant Joint Grp 12","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12638.82,"Note":"**"},{"Itemcode":"64102026","Description":"Implant Joint Grp 13","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":17190.06,"Note":"**"},{"Itemcode":"64102028","Description":"Pacemaker Sys Enpulse E2Sr01-D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"64102032","Description":"Implant Joint Grp 14","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":19728.84,"Note":"**"},{"Itemcode":"64102033","Description":"Cath Embolectomy C1757 Grp 1A","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":481.44},{"Itemcode":"64102035","Description":"Cath Embolectomy C1757 Grp 1B","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":587.52,"Note":"**"},{"Itemcode":"64102036","Description":"Pin Fixation Hammertoe","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4529.82},{"Itemcode":"64102038","Description":"Cath Vascular Bern 4FR","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":164.22},{"Itemcode":"64102039","Description":"Screw Grp 1B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":698.7,"Note":"**"},{"Itemcode":"64102040","Description":"LowCost-Cath Baln Angio Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":348.84},{"Itemcode":"64102042","Description":"Set Colonic Decompression","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1320.9},{"Itemcode":"64102044","Description":"LowCost-Cath Baln Angio Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":426.36},{"Itemcode":"64102045","Description":"LowCost-Cath Baln Angio Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":525.3},{"Itemcode":"64102050","Description":"Stapler-Reloads Disp. Grp 2A","CDM Revenue Code":"272","Standard Price":941.46,"Note":"**"},{"Itemcode":"64102051","Description":"Electrode Disposable Grp 2A","CDM Revenue Code":"272","Standard Price":1389.24},{"Itemcode":"64102052","Description":"Electrode Disposable Grp 2B","CDM Revenue Code":"272","Standard Price":1696.26,"Note":"**"},{"Itemcode":"64102053","Description":"Spinal Cage/Spacer Grp 1A","CDM Revenue Code":"278","Standard Price":2798.88,"Note":"**"},{"Itemcode":"64102054","Description":"Spinal Cage/Spacer Grp 1B","CDM Revenue Code":"278","Standard Price":3423.12,"Note":"**"},{"Itemcode":"64102056","Description":"Screw Grp 2B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1233.18,"Note":"**"},{"Itemcode":"64102057","Description":"Anchor Bone Grp 1A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1456.56},{"Itemcode":"64102058","Description":"Anchor Bone Grp 1B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1778.88,"Note":"**"},{"Itemcode":"64102059","Description":"Spinal Cage/Spacer Grp 3E","CDM Revenue Code":"278","Standard Price":9410.52},{"Itemcode":"64102060","Description":"Allograft Orth/Neuro Grp 2A","CDM Revenue Code":"278","Standard Price":2387.82,"Note":"**"},{"Itemcode":"64102061","Description":"Nail, Ortho Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4369.68,"Note":"**"},{"Itemcode":"64102062","Description":"Sternalock Screw","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":576.3,"Note":"**"},{"Itemcode":"64102063","Description":"Sternalock Plate GR 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2731.56,"Note":"**"},{"Itemcode":"64102064","Description":"Shears Harmonic 36cm HARHD","CDM Revenue Code":"272","Standard Price":2967.18,"Note":"**"},{"Itemcode":"64102065","Description":"Stapler-Reloads Disp. Grp 3A","CDM Revenue Code":"272","Standard Price":1456.56,"Note":"**"},{"Itemcode":"64102066","Description":"Stapler-Reloads Disp. Grp 3B","CDM Revenue Code":"272","Standard Price":1783.98,"Note":"**"},{"Itemcode":"64102067","Description":"Stapler-Reloads Disp. Grp 3C","CDM Revenue Code":"272","Standard Price":2179.74,"Note":"**"},{"Itemcode":"64102068","Description":"Stapler-Reloads Disp. Grp 1A","CDM Revenue Code":"272","Standard Price":525.3,"Note":"**"},{"Itemcode":"64102070","Description":"Guidewire Grp 2A","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":788.46},{"Itemcode":"64102071","Description":"Bit Drill Grp 3A","CDM Revenue Code":"272","Standard Price":1726.86,"Note":"**"},{"Itemcode":"64102072","Description":"RELIEVA SPINPLUS BALLN SYS","CDM Revenue Code":"278","CDM HCPCS":"C1726","Standard Price":8318.1,"Note":"**"},{"Itemcode":"64102073","Description":"Bit Drill Grp 1A","CDM Revenue Code":"272","Standard Price":660.96,"Note":"**"},{"Itemcode":"64102074","Description":"Tube Trach Cuffless","CDM Revenue Code":"272","CDM HCPCS":"A7520","Standard Price":259.08,"Note":"**"},{"Itemcode":"64102075","Description":"Guidewire Vasc Runthru 300cm","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":516.12,"Note":"**"},{"Itemcode":"64102076","Description":"Arthowand Group 5","CDM Revenue Code":"272","Standard Price":2328.66},{"Itemcode":"64102077","Description":"Spinal Cage/Spacer Grp 3C","CDM Revenue Code":"278","Standard Price":6236.28,"Note":"**"},{"Itemcode":"64102078","Description":"Allograft Orth/Neuro Grp 5A","CDM Revenue Code":"278","Standard Price":5884.38},{"Itemcode":"64102079","Description":"Pacemaker DR MRI Advisa A2DR01","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":17582.76},{"Itemcode":"64102081","Description":"Screw, Blade Helical 80mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2363.34},{"Itemcode":"64102084","Description":"Guidewire Grp 1C","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":395.76},{"Itemcode":"64102085","Description":"Nail, Ortho Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2117.52,"Note":"**"},{"Itemcode":"64102086","Description":"Nail, Ortho Grp 2B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2590.8},{"Itemcode":"64102087","Description":"Clip Applier- LAPRA-TY","CDM Revenue Code":"272","Standard Price":9119.82},{"Itemcode":"64102088","Description":"Coil Embolization Gr 2","CDM Revenue Code":"278","Standard Price":542.64,"Note":"**"},{"Itemcode":"64102089","Description":"LowCost-Cath Baln Angio Grp 5","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":642.6},{"Itemcode":"64102090","Description":"StentUretal Temp WODel Sys GrA","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":603.84,"Note":"**"},{"Itemcode":"64102091","Description":"StentUretal Temp WODel Sys Gr2","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":946.56,"Note":"**"},{"Itemcode":"64102092","Description":"Washer Grp 2","CDM Revenue Code":"278","Standard Price":205.02,"Note":"**"},{"Itemcode":"64102093","Description":"Washer Grp 3","CDM Revenue Code":"278","Standard Price":270.3},{"Itemcode":"64102094","Description":"Washer Grp 4","CDM Revenue Code":"278","Standard Price":353.94,"Note":"**"},{"Itemcode":"64102096","Description":"Washer Grp 5","CDM Revenue Code":"278","Standard Price":463.08,"Note":"**"},{"Itemcode":"64102097","Description":"Washer Threaded 3mm","CDM Revenue Code":"278","Standard Price":1188.3},{"Itemcode":"64102098","Description":"Washer STBL LOK NUT 5.0MM","CDM Revenue Code":"278","Standard Price":1920.66},{"Itemcode":"64102099","Description":"Washer Bfly 21.7mm","CDM Revenue Code":"278","Standard Price":884.34},{"Itemcode":"64102100","Description":"Washer 2mm","CDM Revenue Code":"278","Standard Price":80.58},{"Itemcode":"64102101","Description":"Allograft Orth/Neuro Grp 4A","CDM Revenue Code":"278","Standard Price":5002.08,"Note":"**"},{"Itemcode":"64102102","Description":"ALLOGRAFT CEL MTRX-VIVIGEN 5CC","CDM Revenue Code":"278","Standard Price":8104.92},{"Itemcode":"64102103","Description":"Plate Grp 1C","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":666.06,"Note":"**"},{"Itemcode":"64102104","Description":"Sizer Mammary Grp 1","CDM Revenue Code":"272","Standard Price":1176.06,"Note":"**"},{"Itemcode":"64102105","Description":"Plate GR 4A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3844.38,"Note":"**"},{"Itemcode":"64102106","Description":"Fascia Lata Tissue Implant GR1","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":5717.1,"Note":"**"},{"Itemcode":"64102107","Description":"Allograft Orth/Neuro Grp 1A","CDM Revenue Code":"278","Standard Price":1181.16,"Note":"**"},{"Itemcode":"64102108","Description":"Burr Grp 1A","CDM Revenue Code":"272","Standard Price":587.52,"Note":"**"},{"Itemcode":"64102109","Description":"Burr Grp A","CDM Revenue Code":"272","Standard Price":327.42,"Note":"**"},{"Itemcode":"64102110","Description":"Guidewire Grp 1A","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":265.2},{"Itemcode":"64102111","Description":"Cath Brachytherapy Admin Seed","CDM Revenue Code":"272","CDM HCPCS":"C1728","Standard Price":580.38},{"Itemcode":"64102112","Description":"Fixator Finger,BadiaHinge","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":66.3},{"Itemcode":"64102114","Description":"Prosthesis Penile SPECTRA","CDM Revenue Code":"278","CDM HCPCS":"C2622","Standard Price":29235.24},{"Itemcode":"64102115","Description":"NAIL, ORTHO GRP 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13358.94,"Note":"**"},{"Itemcode":"64102116","Description":"Plate Grp 8A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8682.24,"Note":"**"},{"Itemcode":"64102117","Description":"Pin Fixation/Temp GR1","CDM Revenue Code":"272","Standard Price":562.02,"Note":"**"},{"Itemcode":"64102118","Description":"Cath Baln Angio-Sterling GR1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1060.8,"Note":"**"},{"Itemcode":"64102119","Description":"Cap Bone/Neuro Grp 2A","CDM Revenue Code":"278","Standard Price":1129.14},{"Itemcode":"64102120","Description":"Cap Bone/Neuro Grp 2B","CDM Revenue Code":"278","Standard Price":1384.14,"Note":"**"},{"Itemcode":"64102121","Description":"Plate Grp 7A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6450.48,"Note":"**"},{"Itemcode":"64102122","Description":"Graft Vascular Grp 6 C","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":8479.26},{"Itemcode":"64102124","Description":"GRAFT ENDOVASCULAR-EXTENSN GR1","CDM Revenue Code":"278","Standard Price":9155.52},{"Itemcode":"64102125","Description":"GRAFT ENDOVASCULAR-EXTENSN GR2","CDM Revenue Code":"278","Standard Price":11199.6},{"Itemcode":"64102126","Description":"Bony Void Filler Grp 2B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2496.96,"Note":"**"},{"Itemcode":"64102127","Description":"Screw, Temporary Fixation","CDM Revenue Code":"278","Standard Price":599.76,"Note":"**"},{"Itemcode":"64102128","Description":"LowCost-Cath Baln Angio Grp 6","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":770.1},{"Itemcode":"64102129","Description":"Guidewire Grp 1D","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":479.4},{"Itemcode":"64102130","Description":"Guidewire Grp 1E","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":586.5,"Note":"**"},{"Itemcode":"64102131","Description":"Implant Joint Grp 16","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":24930.84},{"Itemcode":"64102309","Description":"IOL - Posterior Chamber-MA6","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":640.0},{"Itemcode":"64102310","Description":"IOL - Post Chmbr-ZA,SN,MN,ZCB","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":760.0,"Note":"**"},{"Itemcode":"64102312","Description":"IOL - Posterio Chamber- Sensar","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":893.0},{"Itemcode":"64102411","Description":"GUIDE SZING COMP SPEED IMPLANT","CDM Revenue Code":"278","Standard Price":314.16},{"Itemcode":"64102420","Description":"Tap Grp 3","CDM Revenue Code":"272","Standard Price":3391.5},{"Itemcode":"64102421","Description":"Kit Introducer MicroNonL 7272v","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":157.08,"Note":"**"},{"Itemcode":"64102431","Description":"GUIDEWIRE VASC VIPER","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1008.78},{"Itemcode":"64102450","Description":"Connector Crosslink Grp 4","CDM Revenue Code":"278","Standard Price":6604.5},{"Itemcode":"64102452","Description":"Connector Crosslink Grp 5","CDM Revenue Code":"278","Standard Price":7811.16},{"Itemcode":"64102466","Description":"Valve Csf Grp 3","CDM Revenue Code":"278","Standard Price":5110.2},{"Itemcode":"64102467","Description":"Programmer Trial Neuro 3510","CDM Revenue Code":"272","Standard Price":5950.68},{"Itemcode":"64102488","Description":"IOL- ANTERIOR CHAMBER","CDM Revenue Code":"276","CDM HCPCS":"V2630","Standard Price":527.0,"Note":"**"},{"Itemcode":"64102489","Description":"IOL - Posterior Chamber-SN6","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":538.0,"Note":"**"},{"Itemcode":"64102710","Description":"PEG DISTAL FEM,FIXATN","CDM Revenue Code":"278","Standard Price":312.12},{"Itemcode":"64102711","Description":"Spacer Cement Restrictor","CDM Revenue Code":"278","Standard Price":322.32,"Note":"**"},{"Itemcode":"64102712","Description":"Valvulotome EZ Site","CDM Revenue Code":"272","Standard Price":3622.02},{"Itemcode":"64102713","Description":"Washer Spiked,Ortho 14mm","CDM Revenue Code":"278","Standard Price":758.88,"Note":"**"},{"Itemcode":"64102714","Description":"Sealant Surg/Closure Dev Grp 3","CDM Revenue Code":"272","Standard Price":2601.0,"Note":"**"},{"Itemcode":"64102715","Description":"Trocar Optical 5mm","CDM Revenue Code":"272","Standard Price":147.9,"Note":"**"},{"Itemcode":"64102716","Description":"Trocar Optical Airseal","CDM Revenue Code":"272","Standard Price":565.08},{"Itemcode":"64102717","Description":"Tissue Expander Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":7803.0,"Note":"**"},{"Itemcode":"64102718","Description":"SysGen,Neurostim MRI Imp-Restr","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":73712.34},{"Itemcode":"64102719","Description":"Spinal Cage/Spacer Grp 3D","CDM Revenue Code":"278","Standard Price":7698.96,"Note":"**"},{"Itemcode":"64102720","Description":"Cath Balln Occlusion 26FR","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":774.18},{"Itemcode":"64102721","Description":"GRAFIX PRIME 3X4CM","CDM Revenue Code":"278","CDM HCPCS":"Q4133","Standard Price":4565.52},{"Itemcode":"64102722","Description":"Clip Suture, Lapra Ty","CDM Revenue Code":"278","Standard Price":1414.74,"Note":"**"},{"Itemcode":"64102723","Description":"Rod, Reaming 2.5mm","CDM Revenue Code":"272","Standard Price":923.1,"Note":"**"},{"Itemcode":"64102724","Description":"Bone Graft Sub-Formagraft 10CC","CDM Revenue Code":"278","Standard Price":4431.9,"Note":"**"},{"Itemcode":"64102725","Description":"Bone Grft Sub-Formagraft Block","CDM Revenue Code":"278","Standard Price":5642.64,"Note":"**"},{"Itemcode":"64102726","Description":"Stapler-Reloads Ech Flx 60mm","CDM Revenue Code":"272","Standard Price":5426.4},{"Itemcode":"64102727","Description":"Driver Pin/Tap","CDM Revenue Code":"272","Standard Price":1458.6,"Note":"**"},{"Itemcode":"64102728","Description":"Bolt Spinal 5.5x50mm Lrg","CDM Revenue Code":"278","Standard Price":2132.82},{"Itemcode":"64102729","Description":"GEL DBM 10CC XEMPLI","CDM Revenue Code":"278","Standard Price":5246.88,"Note":"**"},{"Itemcode":"64102730","Description":"Kit Suturetak Disp","CDM Revenue Code":"272","Standard Price":1327.02,"Note":"**"},{"Itemcode":"64102731","Description":"Cath Angio 5FR, Soft-Vu","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":100.98},{"Itemcode":"64102732","Description":"Central Venous Cath Group 1B","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":702.78},{"Itemcode":"64102733","Description":"Bony Void Filler Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":11860.56,"Note":"**"},{"Itemcode":"64102734","Description":"Patch Soft Tissue 2mmx15cm","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":8480.28},{"Itemcode":"64102735","Description":"GUIDE PIN Ti 2mm","CDM Revenue Code":"272","Standard Price":270.3},{"Itemcode":"64102736","Description":"ARISTA Adhesn Barrier 1 GM","CDM Revenue Code":"272","Standard Price":559.98,"Note":"**"},{"Itemcode":"64102737","Description":"Introducer/Sheath Grp 2C","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":1025.1,"Note":"**"},{"Itemcode":"64102738","Description":"Cath Bln Occlusion 6 FR","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":258.06},{"Itemcode":"64102739","Description":"Staple Bone Grp 3E","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5202.0,"Note":"**"},{"Itemcode":"64102740","Description":"Stent Aero Tracheobronchial","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8453.76},{"Itemcode":"64102741","Description":"Introducer/Sheath NonLsr Grp2A","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":686.46,"Note":"**"},{"Itemcode":"64102742","Description":"Mesh Genl Sur 30x20cm Symbotex","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":5410.08,"Note":"**"},{"Itemcode":"64102743","Description":"Cement Bone Group 2A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1176.06,"Note":"**"},{"Itemcode":"64102744","Description":"Cement Bone Group 2B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1424.94,"Note":"**"},{"Itemcode":"64102745","Description":"Screw Grp 4A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2496.96,"Note":"**"},{"Itemcode":"64102746","Description":"Stapler-Reloads Disp. Grp 3F","CDM Revenue Code":"272","Standard Price":2601.0,"Note":"**"},{"Itemcode":"64102747","Description":"Stapler-Reloads Disp. Grp 5","CDM Revenue Code":"272","Standard Price":4265.64,"Note":"**"},{"Itemcode":"64102748","Description":"Probe Grp A","CDM Revenue Code":"272","Standard Price":580.38,"Note":"**"},{"Itemcode":"64102749","Description":"Cath Balloon Angioplasty Grp1B","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1060.8,"Note":"**"},{"Itemcode":"64102750","Description":"Burr Grp 2A","CDM Revenue Code":"272","Standard Price":884.34,"Note":"**"},{"Itemcode":"64102751","Description":"Laser Fiber Grp 3","CDM Revenue Code":"272","Standard Price":7386.84},{"Itemcode":"64102752","Description":"Laser Fiber Grp 4","CDM Revenue Code":"272","Standard Price":8947.44,"Note":"**"},{"Itemcode":"64102753","Description":"Laser Fiber Grp 1A","CDM Revenue Code":"272","Standard Price":2601.0,"Note":"**"},{"Itemcode":"64102754","Description":"Laser Fiber Greenlight","CDM Revenue Code":"272","Standard Price":5143.86},{"Itemcode":"64102755","Description":"PLATE, STERNAL CABLE","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2184.84},{"Itemcode":"64102756","Description":"Spinal Cage/Spacer Grp 2A","CDM Revenue Code":"278","Standard Price":4502.28,"Note":"**"},{"Itemcode":"64102757","Description":"Allogrft Biocartilage Mtrx 1cc","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":4179.96},{"Itemcode":"64102758","Description":"Cover Screw 3mm-Cochlear Imp","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":5874.18,"Note":"**"},{"Itemcode":"64102759","Description":"Washer Rnd 12.7mm 71101690","CDM Revenue Code":"278","Standard Price":593.64},{"Itemcode":"64102760","Description":"Guide Rod Ball Tip 3.0mm","CDM Revenue Code":"272","Standard Price":1023.06,"Note":"**"},{"Itemcode":"64102761","Description":"External Fixator Cmpnts Grp2D","CDM Revenue Code":"272","Standard Price":2288.88,"Note":"**"},{"Itemcode":"64102762","Description":"Laser Fiber Grp 1B","CDM Revenue Code":"272","Standard Price":3173.22},{"Itemcode":"64102763","Description":"Mesh Genl Surg C1781 Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":8427.24,"Note":"**"},{"Itemcode":"64102764","Description":"Suture Anchor SpdbrgeSwvlk4.75","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8598.6},{"Itemcode":"64102765","Description":"Wire Spider LRG 6.0 Spd2Us-060","CDM Revenue Code":"272","CDM HCPCS":"C1884","Standard Price":6824.82},{"Itemcode":"64102766","Description":"Implant Joint Grp 2B","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":1248.48,"Note":"**"},{"Itemcode":"64102767","Description":"Screw Grp 4B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3043.68,"Note":"**"},{"Itemcode":"64102768","Description":"Custom Cutting Block Low Cost","CDM Revenue Code":"272","Standard Price":2122.62,"Note":"**"},{"Itemcode":"64102769","Description":"Graft Vascular Grp 5A","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":3121.2,"Note":"**"},{"Itemcode":"64102770","Description":"Implant Joint Grp 6A","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":5097.96,"Note":"**"},{"Itemcode":"64102771","Description":"Allograft Orth/Neuro Grp 6A","CDM Revenue Code":"278","Standard Price":8089.62,"Note":"**"},{"Itemcode":"64102772","Description":"Cath Hemodialysis LT 43","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":595.68},{"Itemcode":"64102774","Description":"Rod Polars Pls 8x220","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10420.32},{"Itemcode":"64102775","Description":"Cath/Introducer Passiv Stealth","CDM Revenue Code":"272","Standard Price":2420.46,"Note":"**"},{"Itemcode":"64102776","Description":"Tightrope Mini AR 8912/13","CDM Revenue Code":"278","Standard Price":3849.48},{"Itemcode":"64102777","Description":"Stent Graft Endopros-Endurant","CDM Revenue Code":"278","Standard Price":21640.32,"Note":"**"},{"Itemcode":"64102778","Description":"Imp Hip-Slv AdaptrC-Taper2.5mm","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":322.32},{"Itemcode":"64102779","Description":"Cannula OH Dual Lumen 23FR","CDM Revenue Code":"272","Standard Price":10024.56,"Note":"**"},{"Itemcode":"64102780","Description":"Inflation Device Sinus","CDM Revenue Code":"272","Standard Price":1031.22,"Note":"**"},{"Itemcode":"64102781","Description":"DISSECTOR-SONICISION","CDM Revenue Code":"272","Standard Price":2097.12,"Note":"**"},{"Itemcode":"64102782","Description":"THR Neck Standard","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":258.06,"Note":"**"},{"Itemcode":"64102783","Description":"Cannula Arterial 16FR","CDM Revenue Code":"272","Standard Price":1138.32},{"Itemcode":"64102784","Description":"Cath: Temporary Pacing","CDM Revenue Code":"272","Standard Price":928.2},{"Itemcode":"64102785","Description":"Anchor Kit - Neurostim N300","CDM Revenue Code":"278","Standard Price":806.82},{"Itemcode":"64102786","Description":"Implant Joint Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":2060.4,"Note":"**"},{"Itemcode":"64102787","Description":"Implant Joint Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":1248.48,"Note":"**"},{"Itemcode":"64102788","Description":"Stent Biliary - Express","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4052.46,"Note":"**"},{"Itemcode":"64102789","Description":"Lead NeuroStim-Contact 50-70cm","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":7746.9,"Note":"**"},{"Itemcode":"64102790","Description":"Bony Void Filler Grp 6A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8104.92,"Note":"**"},{"Itemcode":"64102791","Description":"Burr Grp 1A","CDM Revenue Code":"272","Standard Price":582.42,"Note":"**"},{"Itemcode":"64102812","Description":"Graft Vascular Grp 5 A","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":2824.38},{"Itemcode":"64102813","Description":"Graft Vascular Grp 5 B","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":3107.94,"Note":"**"},{"Itemcode":"64102814","Description":"Graft Vascular Grp 5 C","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":3418.02},{"Itemcode":"64102815","Description":"Graft Vascular Grp 5 D","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":3760.74},{"Itemcode":"64102816","Description":"Graft Vascular Grp 5 E","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":4138.14},{"Itemcode":"64102817","Description":"Graft Vascular Grp 5 F","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":4552.26,"Note":"**"},{"Itemcode":"64102818","Description":"Graft Vascular Grp 5 G","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":5007.18},{"Itemcode":"64102819","Description":"Cath Ureteral Wedge 5Fr","CDM Revenue Code":"272","CDM HCPCS":"C1758","Standard Price":94.86,"Note":"**"},{"Itemcode":"64102820","Description":"CATH DRN BIL BALN PROBE 5FR","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":335.58,"Note":"**"},{"Itemcode":"64102821","Description":"Cath Drainage Thor 24/28Fr","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":44.88,"Note":"**"},{"Itemcode":"64102888","Description":"ALLGRFT BONE-CANC CHIPS 30CC","CDM Revenue Code":"278","Standard Price":2132.82,"Note":"**"},{"Itemcode":"64102965","Description":"Allograft Orth/Neuro Grp7A","CDM Revenue Code":"278","Standard Price":10830.36,"Note":"**"},{"Itemcode":"64102966","Description":"Allograft Orth/Neuro Grp7B","CDM Revenue Code":"278","Standard Price":11912.58,"Note":"**"},{"Itemcode":"64102967","Description":"Allograft Orth/Neuro Grp7C","CDM Revenue Code":"278","Standard Price":13103.94},{"Itemcode":"64102968","Description":"Stent Endopros AAA-ENDURANT","CDM Revenue Code":"278","Standard Price":16061.94,"Note":"**"},{"Itemcode":"64102969","Description":"Implant Joint Grp 8 A","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":7441.92,"Note":"**"},{"Itemcode":"64102970","Description":"Implant Joint Grp 8 B","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":8185.5,"Note":"**"},{"Itemcode":"64102971","Description":"Implant Joint Grp 8 C","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":9004.56,"Note":"**"},{"Itemcode":"64102972","Description":"Implant Joint Grp 12 A","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":13903.62,"Note":"**"},{"Itemcode":"64102973","Description":"Implant Joint Grp 12 B","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":15293.88,"Note":"**"},{"Itemcode":"64102974","Description":"Implant Joint Grp 12 C","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16822.86,"Note":"**"},{"Itemcode":"64102975","Description":"Kit Kyphoplasty VBRX","CDM Revenue Code":"278","Standard Price":9331.98},{"Itemcode":"64102982","Description":"Cath Infusion Midline 7FR","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":2486.76},{"Itemcode":"64102983","Description":"Cath Infusion Midline 8FR","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":2913.12},{"Itemcode":"64103000","Description":"Washer Grp 6","CDM Revenue Code":"278","Standard Price":765.0},{"Itemcode":"64103121","Description":"Wire Ortho Supply Grp 4","CDM Revenue Code":"272","Standard Price":1511.64,"Note":"**"},{"Itemcode":"64103122","Description":"Countersink 3 in 1","CDM Revenue Code":"272","Standard Price":1552.44},{"Itemcode":"64103123","Description":"BUTTON CERCLAGE 4.5MM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":189.72},{"Itemcode":"64103124","Description":"Wire Ortho Supply Grp 5","CDM Revenue Code":"272","Standard Price":1622.82,"Note":"**"},{"Itemcode":"64103160","Description":"Wire Ortho Bayonet Olive","CDM Revenue Code":"272","Standard Price":2548.98,"Note":"**"},{"Itemcode":"64103161","Description":"Wire Ortho Y,K FC-xxxx","CDM Revenue Code":"272","Standard Price":2559.18},{"Itemcode":"64103162","Description":"Wire Ortho iO-NCW","CDM Revenue Code":"272","Standard Price":4880.7},{"Itemcode":"64103163","Description":"Prosthesis Ams 800 Balloon GR2","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":9095.34,"Note":"**"},{"Itemcode":"64103164","Description":"Pin Guide, Tibial PSI","CDM Revenue Code":"272","Standard Price":2122.62,"Note":"**"},{"Itemcode":"64103165","Description":"GRAFT BONE SUB 20CC-KINEX","CDM Revenue Code":"278","Standard Price":9867.48},{"Itemcode":"64103166","Description":"STENT K WART 6FR","CDM Revenue Code":"278","CDM HCPCS":"C2625","Standard Price":619.14},{"Itemcode":"64103167","Description":"Impl: Cover, Hole for Screw","CDM Revenue Code":"278","Standard Price":386.58,"Note":"**"},{"Itemcode":"64103168","Description":"Cath: Diagnostic Grp 1","CDM Revenue Code":"272","Standard Price":66.3,"Note":"**"},{"Itemcode":"64103169","Description":"Cath Baln Angio-Sterling GR2","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1698.3},{"Itemcode":"64103170","Description":"CathAbla Tiss,XtraVas-Novasure","CDM Revenue Code":"278","CDM HCPCS":"C1886","Standard Price":4671.6,"Note":"**"},{"Itemcode":"64103171","Description":"AnchorSys Implt-AC ReprAR-2271","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6859.5,"Note":"**"},{"Itemcode":"64103172","Description":"ALLGRFT AMNIO MEM BIOFIX 2X4CM","CDM Revenue Code":"278","CDM HCPCS":"Q4163","Standard Price":5972.1},{"Itemcode":"64103188","Description":"PLATE STRAIGHT TUBULAR","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2538.78},{"Itemcode":"64103189","Description":"KIT BIOSUTURE TAK 2.4","CDM Revenue Code":"272","Standard Price":1327.02,"Note":"**"},{"Itemcode":"64103975","Description":"Spinal Cord Stimulator Gen","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":40145.16},{"Itemcode":"64103977","Description":"PLATE QUARTER TUBULAR W/COLLAR","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":608.94},{"Itemcode":"64103978","Description":"Cath Guiding-Destination 6x45","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":564.06},{"Itemcode":"64104162","Description":"Shears Harmonic Endo GR 1","CDM Revenue Code":"272","Standard Price":2118.54,"Note":"**"},{"Itemcode":"64104163","Description":"Shears Harmonic CRVD Blade","CDM Revenue Code":"272","Standard Price":1269.9,"Note":"**"},{"Itemcode":"64104164","Description":"Shears Harmonic ACE 36cm","CDM Revenue Code":"272","Standard Price":555.9},{"Itemcode":"64104423","Description":"Pleurx Drain Cath Kit 500ml","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":367.2,"Note":"**"},{"Itemcode":"64104914","Description":"Kit: Post Crani 110-4G","CDM Revenue Code":"272","Standard Price":3460.86},{"Itemcode":"64105034","Description":"Kit Jejunostomy Ndl 5Fr 071284","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64105533","Description":"Kit Venous 19Fr B10 96600-019","CDM Revenue Code":"272","Standard Price":1272.96},{"Itemcode":"64105883","Description":"Endostitch Unit Autosut 173016","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"64105963","Description":"Tunneler: Large 9009-16","CDM Revenue Code":"272","Standard Price":309.06,"Note":"**"},{"Itemcode":"64105964","Description":"Tunneler: Small 9009-18","CDM Revenue Code":"272","Standard Price":309.06,"Note":"**"},{"Itemcode":"64106784","Description":"Esu: Argun Handle","CDM Revenue Code":"272","Standard Price":310.08},{"Itemcode":"64107787","Description":"Anchor Kit Lead - Neurostim","CDM Revenue Code":"278","Standard Price":807.84},{"Itemcode":"64107788","Description":"Cap Bone Locking - Spine","CDM Revenue Code":"278","Standard Price":1422.9,"Note":"**"},{"Itemcode":"64107789","Description":"SUTURE SPEEDSTITCH OM-8085","CDM Revenue Code":"278","Standard Price":930.24},{"Itemcode":"64107790","Description":"Cath Ureteral Open End 5Fr","CDM Revenue Code":"272","CDM HCPCS":"C1758","Standard Price":90.78,"Note":"**"},{"Itemcode":"64107791","Description":"Prosthesis Penile Reservoir IZ","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":8718.96,"Note":"**"},{"Itemcode":"64108266","Description":"Kit: Access 72401850","CDM Revenue Code":"272","Standard Price":2269.5},{"Itemcode":"64108552","Description":"Prosthesis Ams 800 Pump","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":16789.2,"Note":"**"},{"Itemcode":"64108944","Description":"Sponge: Biocollagen 80-1460","CDM Revenue Code":"272","Standard Price":609.96,"Note":"**"},{"Itemcode":"64108951","Description":"Kit Accessory Lum Cat 910-121","CDM Revenue Code":"272","Standard Price":1038.36,"Note":"**"},{"Itemcode":"64109050","Description":"Wire: Comp Spring Sys 961499","CDM Revenue Code":"272","Standard Price":1940.04},{"Itemcode":"64109165","Description":"Membrane Sepra Film","CDM Revenue Code":"272","Standard Price":2617.32,"Note":"**"},{"Itemcode":"64109373","Description":"Transfusion Suretrans 8590000","CDM Revenue Code":"272","Standard Price":681.36,"Note":"**"},{"Itemcode":"64110238","Description":"Kit: Cranioplastic 43-1050","CDM Revenue Code":"272","Standard Price":2738.7,"Note":"**"},{"Itemcode":"64110379","Description":"Drain: Davol Sump 0080450","CDM Revenue Code":"272","Standard Price":191.76},{"Itemcode":"64110582","Description":"Depuy: Fem Prep 5461-01-000","CDM Revenue Code":"272","Standard Price":1671.78,"Note":"**"},{"Itemcode":"64111169","Description":"Reload Suture Assist Sw120","CDM Revenue Code":"272","Standard Price":541.62},{"Itemcode":"64111170","Description":"Reload Suture Assist Sw110","CDM Revenue Code":"272","Standard Price":182.58},{"Itemcode":"64111171","Description":"Unit Suture Assist Sw100","CDM Revenue Code":"272","Standard Price":2652.0},{"Itemcode":"64111405","Description":"Needle: Periuretheral 890-204","CDM Revenue Code":"272","Standard Price":168.3},{"Itemcode":"64111723","Description":"Scraper: Membrane 20.04","CDM Revenue Code":"272","Standard Price":716.04,"Note":"**"},{"Itemcode":"64111828","Description":"Implant: Medpore 6322","CDM Revenue Code":"278","Standard Price":2488.8},{"Itemcode":"64111848","Description":"Set: Prostate Stab 500118200","CDM Revenue Code":"270","Standard Price":249.9,"Note":"**"},{"Itemcode":"64111882","Description":"Interceed Barrier 3X4 4350","CDM Revenue Code":"278","Standard Price":1526.94,"Note":"**"},{"Itemcode":"64111891","Description":"Manipulator: Uterine Tmi1151","CDM Revenue Code":"272","Standard Price":184.62,"Note":"**"},{"Itemcode":"64112031","Description":"Device: Syr Cook Jlsad060000","CDM Revenue Code":"272","Standard Price":2086.92},{"Itemcode":"64112195","Description":"Medpor Implant Sheet","CDM Revenue Code":"278","Standard Price":2069.58},{"Itemcode":"64112776","Description":"Kit: Cardio Terumo 62432","CDM Revenue Code":"272","Standard Price":752.76,"Note":"**"},{"Itemcode":"64113111","Description":"Suprafoil: Sjackson Fss04","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":52.02},{"Itemcode":"64113228","Description":"Neurostim Lead Acc Kit 3550-09","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":907.8},{"Itemcode":"64113335","Description":"Danek: Biopsy Needle 960-225","CDM Revenue Code":"272","Standard Price":2751.96,"Note":"**"},{"Itemcode":"64113345","Description":"Set: Micro-Puncture 217243","CDM Revenue Code":"272","Standard Price":245.82},{"Itemcode":"64114075","Description":"Cath Thermachoice Iii Tc003","CDM Revenue Code":"272","Standard Price":5838.48},{"Itemcode":"64114161","Description":"Suture: Lasso Arthre Ar406590S","CDM Revenue Code":"272","Standard Price":616.08},{"Itemcode":"64114334","Description":"Avitene: Collagen 1010020","CDM Revenue Code":"272","Standard Price":1034.28,"Note":"**"},{"Itemcode":"64114560","Description":"Tubing Selector Ultra 1517079","CDM Revenue Code":"272","Standard Price":1816.62},{"Itemcode":"64114812","Description":"Splint Nasal 15-24060","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64114964","Description":"Drain: Sump Davol 0080420","CDM Revenue Code":"272","Standard Price":206.04},{"Itemcode":"64115008","Description":"Insert: Octobase Medtron 28707","CDM Revenue Code":"272","Standard Price":322.32,"Note":"**"},{"Itemcode":"64115165","Description":"Tray: Foley Bard Temp 909116","CDM Revenue Code":"272","CDM HCPCS":"A4314","Standard Price":215.22},{"Itemcode":"64115243","Description":"Gen NeuroStim Non-Rechrg 7426","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":31889.28},{"Itemcode":"64115703","Description":"Cannula: Terumo 24Fr 13030","CDM Revenue Code":"272","Standard Price":155.04},{"Itemcode":"64115841","Description":"Stay: Surgical 3311-1G","CDM Revenue Code":"272","Standard Price":48.96},{"Itemcode":"64115842","Description":"Stay Surgical 3350-8G","CDM Revenue Code":"272","Standard Price":323.34},{"Itemcode":"64115850","Description":"Delivery Set: Mps Qm 5001102","CDM Revenue Code":"272","Standard Price":719.1,"Note":"**"},{"Itemcode":"64115884","Description":"Kit Transtibial Ar1897S","CDM Revenue Code":"272","Standard Price":1194.42,"Note":"**"},{"Itemcode":"64116207","Description":"Microtip: Turbos 8065-740837","CDM Revenue Code":"272","Standard Price":483.48},{"Itemcode":"64116421","Description":"Tip: Smoke Aspiration Se-100","CDM Revenue Code":"272","Standard Price":81.6},{"Itemcode":"64116424","Description":"Perfusion: Beating Hearts Lv 1","CDM Revenue Code":"272","Standard Price":6874.8,"Note":"**"},{"Itemcode":"64117019","Description":"Kyphon: Syringe Inflation A08A","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"64117030","Description":"Smith Nephew: Needle 7207877","CDM Revenue Code":"272","Standard Price":1597.32},{"Itemcode":"64117159","Description":"Edwards: Open Heart Disp Pack","CDM Revenue Code":"272","Standard Price":8762.82},{"Itemcode":"64117162","Description":"Edwards: Non Open Heart Pack","CDM Revenue Code":"272","Standard Price":2840.7},{"Itemcode":"64117269","Description":"Sleeve: Limb Protec 9-7920-003","CDM Revenue Code":"272","Standard Price":53.04},{"Itemcode":"64117363","Description":"Kit: Groshong Repair 7742000","CDM Revenue Code":"272","Standard Price":782.34},{"Itemcode":"64117801","Description":"Mender: Meniscus Rich 7209485","CDM Revenue Code":"272","Standard Price":780.3,"Note":"**"},{"Itemcode":"64117803","Description":"Sholuder Kit: 3583","CDM Revenue Code":"272","Standard Price":473.28},{"Itemcode":"64117938","Description":"Irrigation: Pert Dial 5B9766","CDM Revenue Code":"272","Standard Price":52.02},{"Itemcode":"64118089","Description":"Kit Ventricular Drainage","CDM Revenue Code":"272","Standard Price":1076.1,"Note":"**"},{"Itemcode":"64118291","Description":"Pencil Bayonet Elect 9560575","CDM Revenue Code":"272","Standard Price":443.7,"Note":"**"},{"Itemcode":"64118447","Description":"Tip: Round 30 Degree Alcon","CDM Revenue Code":"272","Standard Price":525.3},{"Itemcode":"64118575","Description":"Kit: Endo Radial Rad02","CDM Revenue Code":"272","Standard Price":3678.12},{"Itemcode":"64118867","Description":"Stay Elastic Lonestar 3311-8G","CDM Revenue Code":"272","Standard Price":380.46},{"Itemcode":"64118871","Description":"Pack: Procedural Acucise Bk004","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":7345.02},{"Itemcode":"64119023","Description":"Pack: Valve Deroyal 94-0243","CDM Revenue Code":"272","Standard Price":411.06,"Note":"**"},{"Itemcode":"64119222","Description":"Dressing Acticoat 4X8 20201","CDM Revenue Code":"272","Standard Price":98.94,"Note":"**"},{"Itemcode":"64119298","Description":"Tip: Forcep Codman 8035070S","CDM Revenue Code":"272","Standard Price":2258.28,"Note":"**"},{"Itemcode":"64119301","Description":"Sphere: Eye 14mm Bausch L1414","CDM Revenue Code":"272","Standard Price":348.84},{"Itemcode":"64119302","Description":"Sphere: Eye 16mm Bausch L1416","CDM Revenue Code":"278","Standard Price":348.84},{"Itemcode":"64119303","Description":"Sphere: Eye 18mm Bausch L1418","CDM Revenue Code":"278","Standard Price":348.84},{"Itemcode":"64119304","Description":"Sphere: Eye 20mm Bausch L1420","CDM Revenue Code":"272","Standard Price":348.84},{"Itemcode":"64119305","Description":"Sphere: Eye 22mm Sphere L1422","CDM Revenue Code":"272","Standard Price":251.94},{"Itemcode":"64119308","Description":"Prosthesis Stapes 70145928","CDM Revenue Code":"278","Standard Price":1276.02},{"Itemcode":"64119482","Description":"Kit Ultra Infast 72403885 Ams","CDM Revenue Code":"278","CDM HCPCS":"C2631","Standard Price":5626.32},{"Itemcode":"64119483","Description":"System Tvt Opturator 810081","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":5585.52,"Note":"**"},{"Itemcode":"64119490","Description":"Kyphon: Mixer Bone Cmt 0033700","CDM Revenue Code":"272","Standard Price":929.22,"Note":"**"},{"Itemcode":"64119536","Description":"Insert Traction 66Mm N-10122","CDM Revenue Code":"272","CDM HCPCS":"C1713","Standard Price":157.08},{"Itemcode":"64130148","Description":"Implant: Radiesse 1Cc 8044M","CDM Revenue Code":"278","CDM HCPCS":"C1878","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64130229","Description":"Electro:Cath Pacin 5Fr 007154P","CDM Revenue Code":"272","Standard Price":934.32,"Note":"**"},{"Itemcode":"64130246","Description":"Pack Suture Pars AR-8862DS","CDM Revenue Code":"278","Standard Price":6252.6,"Note":"**"},{"Itemcode":"64130418","Description":"Needle: Deflux 3X23 159042","CDM Revenue Code":"272","Standard Price":345.78},{"Itemcode":"64130419","Description":"Cath Loop Nephrostomy Drainage","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":897.6,"Note":"**"},{"Itemcode":"64130462","Description":"Frontalis Suspension 585192","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"64130564","Description":"Drill Guide Kt Disp Ar-1322Ds","CDM Revenue Code":"272","Standard Price":929.22,"Note":"**"},{"Itemcode":"64130579","Description":"Tubing Pump Arthrex Ar-6410","CDM Revenue Code":"272","Standard Price":393.72,"Note":"**"},{"Itemcode":"64130627","Description":"Tape Glow N Tell Vas 1100-20","CDM Revenue Code":"272","Standard Price":347.82,"Note":"**"},{"Itemcode":"64130679","Description":"Suture:Grasper 30 Degr 251721","CDM Revenue Code":"272","Standard Price":1094.46},{"Itemcode":"64130927","Description":"Suture Smartstitch Om-8075","CDM Revenue Code":"272","Standard Price":556.92},{"Itemcode":"64131108","Description":"Cell Saver Fast Pack 206","CDM Revenue Code":"272","Standard Price":1398.42,"Note":"**"},{"Itemcode":"64131215","Description":"Currette 8.5Mm A11E","CDM Revenue Code":"272","Standard Price":1035.3},{"Itemcode":"64131252","Description":"Smart Stapes Piston 70145926","CDM Revenue Code":"272","Standard Price":1250.52},{"Itemcode":"64131253","Description":"Smart Thermal Tip 7013-1013","CDM Revenue Code":"272","Standard Price":168.3},{"Itemcode":"64131281","Description":"Micropuncture 4Fr Kit-002-36","CDM Revenue Code":"272","Standard Price":164.22,"Note":"**"},{"Itemcode":"64131328","Description":"Mixer Cement 606-563","CDM Revenue Code":"272","Standard Price":877.2},{"Itemcode":"64131330","Description":"Currette 6.5 A11D","CDM Revenue Code":"272","Standard Price":929.22},{"Itemcode":"64131458","Description":"Greenlt Laser Fiber Next Med","CDM Revenue Code":"272","Standard Price":4012.68},{"Itemcode":"64131555","Description":"Tube Cuffless Trach Fen 8Cfn","CDM Revenue Code":"272","CDM HCPCS":"A7520","Standard Price":278.46},{"Itemcode":"64131620","Description":"STENT TEMP NON-COR W/O DEL SYS","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":346.8},{"Itemcode":"64131621","Description":"Cath Angio non laser DCB Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C2623","Standard Price":8323.2},{"Itemcode":"64131847","Description":"Suture Grasper 45 Degre 251722","CDM Revenue Code":"272","Standard Price":930.24},{"Itemcode":"64131873","Description":"Spray Tip Fan 0210-018-000","CDM Revenue Code":"272","Standard Price":105.06,"Note":"**"},{"Itemcode":"64131977","Description":"Prosthesis Ams 800 Cuff","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":12255.3,"Note":"**"},{"Itemcode":"64131980","Description":"Prosthesis Ams 800 Balloon","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":7650.0},{"Itemcode":"64131985","Description":"Kit Essentials 04494-10","CDM Revenue Code":"272","Standard Price":219.3},{"Itemcode":"64132013","Description":"Apogee With Intepro 72404012","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":6024.12},{"Itemcode":"64132026","Description":"Bone Spike Short 71512449","CDM Revenue Code":"272","Standard Price":279.48},{"Itemcode":"64132041","Description":"Ams Accessory Kit","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64132061","Description":"Occluder Colpo-Pneumo Cpo-6","CDM Revenue Code":"272","Standard Price":424.32},{"Itemcode":"64132075","Description":"Ams Invance Sling 72403525","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":10076.58},{"Itemcode":"64132113","Description":"Needle Percutaneous 700-122","CDM Revenue Code":"272","Standard Price":206.04},{"Itemcode":"64132152","Description":"Valve Strata Ii Regular 42866","CDM Revenue Code":"278","Standard Price":14345.28,"Note":"**"},{"Itemcode":"64132162","Description":"Manifold Neptune 700-40","CDM Revenue Code":"272","Standard Price":180.54},{"Itemcode":"64132177","Description":"Essure Birth Control Ess205","CDM Revenue Code":"278","Standard Price":7891.74},{"Itemcode":"64132202","Description":"Needle 12Gx7.5 Dls-7122-01S","CDM Revenue Code":"272","Standard Price":344.76},{"Itemcode":"64132397","Description":"Tube Tear Duct Grp","CDM Revenue Code":"278","Standard Price":425.34},{"Itemcode":"64132450","Description":"Connector Crosslink Grp 4","CDM Revenue Code":"278","Standard Price":3199.74,"Note":"**"},{"Itemcode":"64132452","Description":"Connector Crosslink Grp 5","CDM Revenue Code":"278","Standard Price":7714.26},{"Itemcode":"64132495","Description":"Drain Hemovac 1/4 542108000","CDM Revenue Code":"272","Standard Price":335.58},{"Itemcode":"64132527","Description":"Pack Closure Cpp","CDM Revenue Code":"272","Standard Price":577.32},{"Itemcode":"64132564","Description":"Cath Gde Sos Omni 5Fr 10712005","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":153.0,"Note":"**"},{"Itemcode":"64132688","Description":"Illuminator W Angle 8065750425","CDM Revenue Code":"272","Standard Price":596.7},{"Itemcode":"64132711","Description":"Tissue Removal Device-Myosure","CDM Revenue Code":"272","Standard Price":4824.6,"Note":"**"},{"Itemcode":"64132755","Description":"MATRIX COLLAGEN 12X25CM","CDM Revenue Code":"278","CDM HCPCS":"C9354","Standard Price":32318.7},{"Itemcode":"64132787","Description":"Needle Gripper 20X1 21-276224","CDM Revenue Code":"272","Standard Price":28.56,"Note":"**"},{"Itemcode":"64132804","Description":"K-Wire 1.0 Wright 4411-2000","CDM Revenue Code":"272","Standard Price":157.08},{"Itemcode":"64132858","Description":"Plug Anal Fistul C-Afp-0.6X9.5","CDM Revenue Code":"272","Standard Price":3439.44},{"Itemcode":"64132873","Description":"Kit Accessory","CDM Revenue Code":"272","Standard Price":742.56,"Note":"**"},{"Itemcode":"64132972","Description":"Valve Adjustable Supa","CDM Revenue Code":"278","Standard Price":11137.38},{"Itemcode":"64133002","Description":"GUIDE POST 8226-75","CDM Revenue Code":"278","Standard Price":347.82},{"Itemcode":"64133023","Description":"Arm Sling Shot Medium 08503","CDM Revenue Code":"272","Standard Price":442.68},{"Itemcode":"64133040","Description":"Prosthesis Penile Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C2622","Standard Price":10619.22},{"Itemcode":"64133043","Description":"Button Septal 1524110","CDM Revenue Code":"278","Standard Price":1251.54,"Note":"**"},{"Itemcode":"64133069","Description":"Reattachment Device 498.807S","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":10653.9},{"Itemcode":"64133089","Description":"Lead Epicardial 5071-35Cm","CDM Revenue Code":"278","CDM HCPCS":"C1896","Standard Price":2647.92},{"Itemcode":"64133135","Description":"CorkScrew, Bone","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1394.34},{"Itemcode":"64133136","Description":"Wire Ortho Supply Grp 3","CDM Revenue Code":"272","Standard Price":1373.94,"Note":"**"},{"Itemcode":"64133154","Description":"Cap End Lead","CDM Revenue Code":"272","Standard Price":164.22},{"Itemcode":"64133192","Description":"Handpiece Solo Grip 70537020","CDM Revenue Code":"272","Standard Price":20135.82},{"Itemcode":"64133227","Description":"Allograft Osteochond Foa20C","CDM Revenue Code":"278","Standard Price":33796.68},{"Itemcode":"64133241","Description":"Syringe Deflux 1Ml 159034","CDM Revenue Code":"278","CDM HCPCS":"L8606","Standard Price":8100.84},{"Itemcode":"64133348","Description":"Reservoir W/Filter Atr2900Df","CDM Revenue Code":"272","Standard Price":608.94},{"Itemcode":"64133428","Description":"Cord Stabilizing","CDM Revenue Code":"278","Standard Price":4231.98},{"Itemcode":"64134053","Description":"Radielle Voice Gel","CDM Revenue Code":"278","CDM HCPCS":"C1878","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64134062","Description":"Kit Jejunostomy Laparos 51442","CDM Revenue Code":"272","Standard Price":820.08},{"Itemcode":"64134067","Description":"Capio Open Access 831-125","CDM Revenue Code":"272","CDM HCPCS":"C2631","Standard Price":2395.98,"Note":"**"},{"Itemcode":"64134085","Description":"Maonka 4Mm Wide Fci S1-1630U","CDM Revenue Code":"272","Standard Price":451.86},{"Itemcode":"64134091","Description":"Needle Interstim 5 041829","CDM Revenue Code":"272","Standard Price":258.06},{"Itemcode":"64134102","Description":"Tip Uterine Manipulator Umw676","CDM Revenue Code":"272","Standard Price":282.54},{"Itemcode":"64134110","Description":"Alloderm Tissue 4X16 102082","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":9069.84},{"Itemcode":"64134126","Description":"Device Electrosurg 700-103027","CDM Revenue Code":"272","Standard Price":9897.06},{"Itemcode":"64134128","Description":"System Hta Hydroblation 55016","CDM Revenue Code":"272","Standard Price":4607.34,"Note":"**"},{"Itemcode":"64134141","Description":"Tray Urologists Bard 123400","CDM Revenue Code":"272","Standard Price":1174.02,"Note":"**"},{"Itemcode":"64134150","Description":"Graft Zenform 6X10 830-245","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":4680.78},{"Itemcode":"64134154","Description":"System Oats","CDM Revenue Code":"272","Standard Price":3316.02},{"Itemcode":"64134160","Description":"Tray Trach Blue Rhino 263567","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2487.78,"Note":"**"},{"Itemcode":"64134182","Description":"Electroce Vapor 4.0Mm 225370","CDM Revenue Code":"272","Standard Price":1308.66},{"Itemcode":"64134199","Description":"Implant Medpore Sst 22Mm 80006","CDM Revenue Code":"278","Standard Price":2965.14,"Note":"**"},{"Itemcode":"64134211","Description":"Pak Total Vitrecto 8065-750220","CDM Revenue Code":"272","Standard Price":2514.3},{"Itemcode":"64134219","Description":"Pencil 25Ga Diathermy 14-5011","CDM Revenue Code":"272","Standard Price":256.02,"Note":"**"},{"Itemcode":"64134256","Description":"Implant Medpor Sst 16Mm 80000","CDM Revenue Code":"278","Standard Price":2965.14,"Note":"**"},{"Itemcode":"64134257","Description":"Implant Medpor SST 18Mm 80002","CDM Revenue Code":"278","Standard Price":3002.88,"Note":"**"},{"Itemcode":"64134278","Description":"Stent Lacrimal Fci S1-1350U","CDM Revenue Code":"278","Standard Price":724.2},{"Itemcode":"64134294","Description":"Tube Laryngectomy Martin","CDM Revenue Code":"278","Standard Price":664.02},{"Itemcode":"64134299","Description":"Monoka 3Mm Medium 51-1710U","CDM Revenue Code":"278","Standard Price":451.86},{"Itemcode":"64134300","Description":"Prosthesis Classic 142104","CDM Revenue Code":"278","Standard Price":747.66},{"Itemcode":"64134301","Description":"Prosthesis Classic 142105","CDM Revenue Code":"278","Standard Price":737.46},{"Itemcode":"64134303","Description":"Prosthesis Classic 70142121","CDM Revenue Code":"278","Standard Price":717.06},{"Itemcode":"64134304","Description":"Prosthesis Classic 4Mm 142100","CDM Revenue Code":"278","Standard Price":864.96},{"Itemcode":"64134305","Description":"Prosthesis Classic 4Mm 142101","CDM Revenue Code":"278","Standard Price":1161.78},{"Itemcode":"64134308","Description":"Piston Smart Gyrus 70145929","CDM Revenue Code":"278","Standard Price":1276.02},{"Itemcode":"64134319","Description":"Sling Shot Large Breg 08504","CDM Revenue Code":"274","CDM HCPCS":"L3670","Standard Price":402.9,"Note":"**"},{"Itemcode":"64134327","Description":"Versajet 45 Degree/14Mm 50636","CDM Revenue Code":"272","Standard Price":2627.52,"Note":"**"},{"Itemcode":"64134330","Description":"Pericardium 6X8 Bov Pc-0608Sn","CDM Revenue Code":"278","Standard Price":2412.3},{"Itemcode":"64134340","Description":"Tubing Aerosol Spray Has01","CDM Revenue Code":"272","Standard Price":322.32},{"Itemcode":"64134341","Description":"Lapsac Cook 054800","CDM Revenue Code":"272","Standard Price":421.26,"Note":"**"},{"Itemcode":"64134348","Description":"Graft Xenform 8X12 830-247","CDM Revenue Code":"278","Standard Price":6422.94},{"Itemcode":"64134368","Description":"Filter Trap Ease 466-P306Au","CDM Revenue Code":"278","Standard Price":3412.92},{"Itemcode":"64134386","Description":"Coaptite 1ML SYR M0068903000","CDM Revenue Code":"278","CDM HCPCS":"L8606","Standard Price":1814.58,"Note":"**"},{"Itemcode":"64134389","Description":"Implant Subtalar MBA","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9700.2,"Note":"**"},{"Itemcode":"64134403","Description":"Prosthesis Urolume 72402015","CDM Revenue Code":"278","Standard Price":13102.92},{"Itemcode":"64134408","Description":"Forcep Bayonet Disp 20-1420Ki","CDM Revenue Code":"272","Standard Price":293.76},{"Itemcode":"64134414","Description":"Lead Test Kit Interstim 3057","CDM Revenue Code":"278","CDM HCPCS":"C1897","Standard Price":644.64},{"Itemcode":"64134415","Description":"Tube Baker Jujunst 16F 0042510","CDM Revenue Code":"278","Standard Price":1607.52},{"Itemcode":"64134417","Description":"Needle Soft Tip 25G 8065149525","CDM Revenue Code":"272","Standard Price":193.8},{"Itemcode":"64134445","Description":"Piston Smart .6X4.25 70145927","CDM Revenue Code":"278","Standard Price":1201.56},{"Itemcode":"64134446","Description":"Piston Smart .6X3.75 70145925","CDM Revenue Code":"278","Standard Price":1250.52},{"Itemcode":"64134447","Description":"Sheet No Channel Ultra 7210","CDM Revenue Code":"278","Standard Price":1925.76},{"Itemcode":"64134472","Description":"Baha Abutment 8.5Mm 90410","CDM Revenue Code":"278","Standard Price":6643.26},{"Itemcode":"64134477","Description":"Implant Medpor Sst 20Mm 80004","CDM Revenue Code":"278","Standard Price":3150.78},{"Itemcode":"64134478","Description":"Apogee/Intexem Lp 72404089","CDM Revenue Code":"278","Standard Price":8461.92},{"Itemcode":"64134518","Description":"Kit Procedure Scoop T10Sp9","CDM Revenue Code":"272","Standard Price":2723.4},{"Itemcode":"64134523","Description":"Surgisis 4-Layer Tissue Graft","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":2647.92},{"Itemcode":"64134532","Description":"Generator Ipg Interstim 3058","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":37956.24,"Note":"**"},{"Itemcode":"64134533","Description":"Patient Programmer Inter 3037","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":5076.54},{"Itemcode":"64134534","Description":"Peg Smooth 2.3X20 Cos-2320","CDM Revenue Code":"278","Standard Price":669.12,"Note":"**"},{"Itemcode":"64134535","Description":"Peg Smooth 2.3X18 Cos-2318","CDM Revenue Code":"278","Standard Price":669.12},{"Itemcode":"64134536","Description":"Peg Smooth 2.3X24 Cos-2324","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":669.12},{"Itemcode":"64134537","Description":"Peg Smooth 2.3X22 Cos-2322","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":669.12,"Note":"**"},{"Itemcode":"64134553","Description":"Cavity Evaluation Device 9030","CDM Revenue Code":"272","Standard Price":913.92},{"Itemcode":"64134555","Description":"Kit Maxcess Disposable 3200060","CDM Revenue Code":"272","Standard Price":7797.9},{"Itemcode":"64134557","Description":"Gelport 120Mm Applied C8Xx2","CDM Revenue Code":"272","Standard Price":2420.46,"Note":"**"},{"Itemcode":"64134559","Description":"Cable High Freq Mono 277Kb-D10","CDM Revenue Code":"272","Standard Price":184.62},{"Itemcode":"64134567","Description":"Ultradine Fh 3.5 23101","CDM Revenue Code":"278","Standard Price":1163.82},{"Itemcode":"64134572","Description":"Cuff Nerve Colgn 4.0MMX2.5CM","CDM Revenue Code":"278","CDM HCPCS":"C9355","Standard Price":6611.64},{"Itemcode":"64134574","Description":"Marker Tissue Mt-Nw-887-8Xx","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":440.64,"Note":"**"},{"Itemcode":"64134577","Description":"Peg Partial Thread Tp20000","CDM Revenue Code":"278","Standard Price":644.64},{"Itemcode":"64134578","Description":"Kit Tightrope Mini Ar-8911Ds","CDM Revenue Code":"278","Standard Price":3040.62},{"Itemcode":"64134579","Description":"Solution Adept 0600041","CDM Revenue Code":"272","Standard Price":1232.16,"Note":"**"},{"Itemcode":"64134580","Description":"Kit Tipless Irrig 8065741081","CDM Revenue Code":"278","Standard Price":419.22},{"Itemcode":"64134588","Description":"Dressing Nasal Meropck 1520000","CDM Revenue Code":"272","Standard Price":463.08,"Note":"**"},{"Itemcode":"64134600","Description":"Kit Flexiflo Gastro 10F 50190","CDM Revenue Code":"272","Standard Price":1069.98,"Note":"**"},{"Itemcode":"64134602","Description":"Needle Side Kick M0068903040","CDM Revenue Code":"272","Standard Price":275.4,"Note":"**"},{"Itemcode":"64134604","Description":"Alloderm 16X20 X-Thick 982320","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":36877.08},{"Itemcode":"64134609","Description":"Battery System 1.5Mm 50-1010","CDM Revenue Code":"272","Standard Price":645.66},{"Itemcode":"64134618","Description":"Pak Total+Vit 23Ga 8065750828","CDM Revenue Code":"272","Standard Price":2118.54},{"Itemcode":"64134620","Description":"Scraper Tano 23G 20.04.23","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64134623","Description":"Sling Advance Male","CDM Revenue Code":"278","CDM HCPCS":"C2631","Standard Price":15601.92},{"Itemcode":"64134625","Description":"System Lactosorb 1.5 915-2816","CDM Revenue Code":"278","Standard Price":3370.08},{"Itemcode":"64134636","Description":"Ultradine Fh 3.0 23201","CDM Revenue Code":"278","Standard Price":1162.8},{"Itemcode":"64134638","Description":"Graft Gamma 50X62.5 Gg625","CDM Revenue Code":"278","CDM HCPCS":"Q4111","Standard Price":1857.42},{"Itemcode":"64134641","Description":"Patch Soft Tissue 1405010010","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1209.72,"Note":"**"},{"Itemcode":"64134662","Description":"Device Relieva Inflation Bid30","CDM Revenue Code":"272","Standard Price":480.42,"Note":"**"},{"Itemcode":"64134678","Description":"Allograft L Hamicondyle 268011","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":35334.84},{"Itemcode":"64134679","Description":"Tissue Strattice 20X20 2020002","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":38763.06,"Note":"**"},{"Itemcode":"64134680","Description":"Strattice 16X20","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":31010.04,"Note":"**"},{"Itemcode":"64134683","Description":"Sizer Mammary Grp 2","CDM Revenue Code":"272","Standard Price":1439.22,"Note":"**"},{"Itemcode":"64134690","Description":"Paste Dbm 1Cc Trel-Xc Txcpa01","CDM Revenue Code":"278","Standard Price":1147.5},{"Itemcode":"64134692","Description":"Protector Nerve 7X4Cm Nw740","CDM Revenue Code":"278","CDM HCPCS":"C9353","Standard Price":6100.62},{"Itemcode":"64134693","Description":"Ring Malyugin Mal0001","CDM Revenue Code":"272","Standard Price":724.2},{"Itemcode":"64134695","Description":"Strattice 10 X 16 Cm 1016002","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":15056.22,"Note":"**"},{"Itemcode":"64134697","Description":"Elevate Posterior","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":7430.7},{"Itemcode":"64134703","Description":"System Pinnacle 831705","CDM Revenue Code":"278","CDM HCPCS":"C2631","Standard Price":7884.6},{"Itemcode":"64134709","Description":"Alloderm Tissue 8X16 102128","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":15972.18},{"Itemcode":"64134710","Description":"Integra BiWndMtrx 4x5cmBMW4051","CDM Revenue Code":"278","CDM HCPCS":"Q4104","Standard Price":16542.36,"Note":"**"},{"Itemcode":"64134711","Description":"Allograft Femoral 086130-003","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":35334.84},{"Itemcode":"64134716","Description":"Sys Prolift +M Pfrp02/Pfra02","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":8554.74},{"Itemcode":"64134717","Description":"System Prolift +M Total Pfrt02","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":10547.82},{"Itemcode":"64134719","Description":"Dressing Nasopore","CDM Revenue Code":"272","Standard Price":642.6,"Note":"**"},{"Itemcode":"64134723","Description":"Graft Pegasus 9 X 10Cm Ofx2000","CDM Revenue Code":"278","Standard Price":10643.7},{"Itemcode":"64134724","Description":"Tray Urologist Disposab 123400","CDM Revenue Code":"272","Standard Price":723.18},{"Itemcode":"64134725","Description":"Tenoglide 4X5 Tg451","CDM Revenue Code":"278","CDM HCPCS":"C9356","Standard Price":10701.84,"Note":"**"},{"Itemcode":"64134727","Description":"Permacol 20X30Cm 152030","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":31969.86,"Note":"**"},{"Itemcode":"64134728","Description":"Permacol 15X20Cmx1.5Mm P151520","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":16615.8},{"Itemcode":"64134730","Description":"Permacol 20X40Cmx1.5Mm 152040","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":48739.68},{"Itemcode":"64134734","Description":"Permacol 28X40Cmx1.5Mm 152840","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":86629.62},{"Itemcode":"64134736","Description":"Permacol 10X20Cmx1.5Mm 151020","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":14062.74,"Note":"**"},{"Itemcode":"64134737","Description":"Integra Wound Matrix 8x10cm","CDM Revenue Code":"278","CDM HCPCS":"Q4108","Standard Price":29116.92},{"Itemcode":"64134738","Description":"Tissue Flexhd 12Cmx24Cm 472224","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":29980.86},{"Itemcode":"64134739","Description":"Permacol 10X10Cmx1.0Mm 101010","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":5410.08},{"Itemcode":"64134740","Description":"Pacemaker Accent Rf Dr Pm2210","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":19279.02},{"Itemcode":"64134741","Description":"Lead Revision Kit 3550-10","CDM Revenue Code":"272","Standard Price":1539.18},{"Itemcode":"64134742","Description":"Permacol 20X50Cmx1.5Mm 152050","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":60924.6},{"Itemcode":"64134744","Description":"Plug Anal Fistula","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":4591.02,"Note":"**"},{"Itemcode":"64134746","Description":"Filler Void Otomimix 7014-3266","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":1704.42},{"Itemcode":"64134747","Description":"Lactosorb Template","CDM Revenue Code":"272","Standard Price":1103.64},{"Itemcode":"64134748","Description":"Sling Solyx System 850-700","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":5342.76},{"Itemcode":"64134749","Description":"System Uphold Vaginal 831-708","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":8711.82,"Note":"**"},{"Itemcode":"64134750","Description":"Alloderm Tissue 6X12 102071","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":8902.56},{"Itemcode":"64134751","Description":"Wound Matrix Integra 10x25CM","CDM Revenue Code":"278","CDM HCPCS":"Q4108","Standard Price":10643.7},{"Itemcode":"64134752","Description":"Tissue Flexhd 12Cmx12Cm 472122","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":15952.8},{"Itemcode":"64134754","Description":"Alloderm Tissue 4X4 Cm 402025","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":2533.68},{"Itemcode":"64134756","Description":"Catheter Irrigation","CDM Revenue Code":"272","Standard Price":823.14},{"Itemcode":"64134757","Description":"Enseal Cautery Device Disp","CDM Revenue Code":"272","Standard Price":2317.44,"Note":"**"},{"Itemcode":"64134759","Description":"Strattice 6X16Cm 0616002","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":10643.7},{"Itemcode":"64134761","Description":"Guidewire Relieva Gw35080V","CDM Revenue Code":"272","Standard Price":823.14},{"Itemcode":"64134762","Description":"Catheter M Sinus Guide Gc110","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":1890.06},{"Itemcode":"64134764","Description":"Pacemaker Zepher Xl Sr 5626","CDM Revenue Code":"275","Standard Price":14370.78},{"Itemcode":"64134765","Description":"Port Sils 12Mm Silspt12","CDM Revenue Code":"278","Standard Price":2318.46},{"Itemcode":"64134767","Description":"Relieva Luma 20Deg Tip Sis100A","CDM Revenue Code":"278","Standard Price":2783.58},{"Itemcode":"64134768","Description":"Putty Scaffold 2.5Cc Ios10125","CDM Revenue Code":"278","Standard Price":2131.8},{"Itemcode":"64134769","Description":"Tissue Pelvisoft 6X8Cm 481068","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":3678.12},{"Itemcode":"64134770","Description":"Kit Nasal Epistat Cath 1527030","CDM Revenue Code":"278","Standard Price":627.3},{"Itemcode":"64134771","Description":"Strattice 20 X 25Cm 2025002","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":45760.26,"Note":"**"},{"Itemcode":"64134772","Description":"Strattice 6 X 10Cm 0610008","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":7627.56,"Note":"**"},{"Itemcode":"64134773","Description":"Strattice 8 X 16 Cm 0816001","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":11776.92},{"Itemcode":"64134774","Description":"Shunt Denver Ascites 42-2050","CDM Revenue Code":"278","Standard Price":7379.7},{"Itemcode":"64134776","Description":"Expander Tissue Ankle 3614-04","CDM Revenue Code":"278","Standard Price":3798.48},{"Itemcode":"64134777","Description":"Strattice 10X10Cm 1010002","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":10519.26},{"Itemcode":"64134778","Description":"Prosima Mesh Pelvic Rpr Sys","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":7552.08},{"Itemcode":"64134779","Description":"Seamguard Biosorb Reinforcmnt","CDM Revenue Code":"278","Standard Price":1512.66,"Note":"**"},{"Itemcode":"64134780","Description":"Plasmax Concentrator 800-0516","CDM Revenue Code":"272","Standard Price":3839.28},{"Itemcode":"64134781","Description":"Sling Male Invance Iz 72403530","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":13863.84},{"Itemcode":"64134782","Description":"Sling Tvt Exact Tvtrl","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":5211.18,"Note":"**"},{"Itemcode":"64134783","Description":"Suture Shuttle Lasso","CDM Revenue Code":"272","Standard Price":1086.3,"Note":"**"},{"Itemcode":"64134784","Description":"Endograb Insert Eg000A","CDM Revenue Code":"272","Standard Price":795.6},{"Itemcode":"64134785","Description":"System Adiana Permanent A6000","CDM Revenue Code":"278","Standard Price":6114.9},{"Itemcode":"64134786","Description":"Marrowstim Mini Conc 800-0610A","CDM Revenue Code":"272","Standard Price":8062.08},{"Itemcode":"64134787","Description":"Clip Filshie Avm-851J","CDM Revenue Code":"272","Standard Price":598.74},{"Itemcode":"64134790","Description":"Sling Abbrevo Tvtoml","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":5811.96,"Note":"**"},{"Itemcode":"64134791","Description":"Gen Neurostim Non-Rechrg 102","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":52379.04},{"Itemcode":"64134793","Description":"Staple Calcaneal Barbed","CDM Revenue Code":"272","Standard Price":5058.18},{"Itemcode":"64134794","Description":"Cath Balloon Karlan Cholang","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":586.5},{"Itemcode":"64134795","Description":"Integra Mesh Mwm4051 10X12.5CM","CDM Revenue Code":"278","CDM HCPCS":"C9363","Standard Price":14382.0},{"Itemcode":"64134796","Description":"Ent Fusion Sys Disp Tracker","CDM Revenue Code":"272","Standard Price":867.0,"Note":"**"},{"Itemcode":"64134797","Description":"Implant Chest Wall Right","CDM Revenue Code":"278","Standard Price":6114.9},{"Itemcode":"64134804","Description":"Integra Wnd Mtrx Mwm2021 2X2","CDM Revenue Code":"278","CDM HCPCS":"Q4104","Standard Price":9817.5,"Note":"**"},{"Itemcode":"64134805","Description":"Reservoir Conceal Iz 720185-01","CDM Revenue Code":"272","Standard Price":7326.66},{"Itemcode":"64134806","Description":"PM DUAL RR Generator ADDR01","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":13525.2},{"Itemcode":"64134807","Description":"Bolt Removal Trigen 7163-1278","CDM Revenue Code":"272","Standard Price":3524.1},{"Itemcode":"64134811","Description":"Sheeting Silastic .020 501-3","CDM Revenue Code":"278","Standard Price":1645.26,"Note":"**"},{"Itemcode":"64134812","Description":"Osteotome 6Mm Flat Ohfo2060Su","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64134813","Description":"Implant Medpor Titan 81050","CDM Revenue Code":"278","Standard Price":4692.0},{"Itemcode":"64134816","Description":"Kit Anoscope Sterile Slideone","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64134817","Description":"Kit Onq Expansion","CDM Revenue Code":"272","Standard Price":354.96,"Note":"**"},{"Itemcode":"64134818","Description":"Testicular Saline Implant Colo","CDM Revenue Code":"278","Standard Price":7038.0},{"Itemcode":"64134819","Description":"Tutoplast Fascia 2X14Cm 68021","CDM Revenue Code":"278","Standard Price":6161.82},{"Itemcode":"64134820","Description":"Device Myosure Trd 10-401","CDM Revenue Code":"272","Standard Price":5737.5},{"Itemcode":"64134821","Description":"Lead Pacer Isoflex 1948-58","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2573.46},{"Itemcode":"64134822","Description":"Implant 3 Unilateral Sys Baha","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":32873.58},{"Itemcode":"64134823","Description":"Reamer Arrowhead 95-3000","CDM Revenue Code":"272","Standard Price":322.32},{"Itemcode":"64134824","Description":"Reamer 7.0Mm 71674040","CDM Revenue Code":"272","Standard Price":2922.3},{"Itemcode":"64134825","Description":"Implant Speed Forefoot","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3890.28},{"Itemcode":"64134827","Description":"RPR Sys Distal Biceps Ar-2260","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5183.64,"Note":"**"},{"Itemcode":"64134828","Description":"Sealant Progel 4Ml Pgps002","CDM Revenue Code":"278","CDM HCPCS":"C2615","Standard Price":3982.08},{"Itemcode":"64134829","Description":"System Endo Release 310138","CDM Revenue Code":"272","Standard Price":5038.8},{"Itemcode":"64134831","Description":"Pump Penile Ms 72404233","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":23955.72,"Note":"**"},{"Itemcode":"64134832","Description":"Kit Spy Elite Lc 3006","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64134833","Description":"Tightope Syndemosis Kit","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5366.22,"Note":"**"},{"Itemcode":"64134834","Description":"Plasmabutton Electrode","CDM Revenue Code":"272","Standard Price":2545.92,"Note":"**"},{"Itemcode":"64134835","Description":"Vitagel Hemostat","CDM Revenue Code":"278","Standard Price":1255.62},{"Itemcode":"64134836","Description":"Kit V Probe Cryo-206","CDM Revenue Code":"278","CDM HCPCS":"C2618","Standard Price":17639.88,"Note":"**"},{"Itemcode":"64134837","Description":"Frame Ilizaroth F&A 71070395","CDM Revenue Code":"270","Standard Price":24024.06},{"Itemcode":"64134838","Description":"Alloderm Tissue 6X16 992196","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":10538.64},{"Itemcode":"64134839","Description":"Alloderm Rtu 16X20 152032","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":35533.74},{"Itemcode":"64134840","Description":"Stent Opth Monoka 4MmW S1-1800","CDM Revenue Code":"278","Standard Price":602.82,"Note":"**"},{"Itemcode":"64134841","Description":"Alloderm 8 X 16Cm Thin 1516128","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":13890.36},{"Itemcode":"64134842","Description":"Alloderm Rtu 4X16Cm 152064","CDM Revenue Code":"278","Standard Price":8484.36},{"Itemcode":"64134843","Description":"Alloderm Rtu 8X16Cm 1520128","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":13401.78,"Note":"**"},{"Itemcode":"64134844","Description":"Synpor Titanium Mesh","CDM Revenue Code":"278","Standard Price":5634.48},{"Itemcode":"64134845","Description":"Device Fixation Strap25","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64134846","Description":"System Exair Ant/Posterior","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":6969.66},{"Itemcode":"64134847","Description":"Penile Prosthesis Titan Colopl","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":27726.66},{"Itemcode":"64134848","Description":"Strattice 9Cmx18.5Cm Con2006","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":10643.7},{"Itemcode":"64134849","Description":"Strattice 10Cmx22Cm Con3006","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":10653.9},{"Itemcode":"64134850","Description":"Screw/Kit Mini Scorpion Dx","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5792.58},{"Itemcode":"64134851","Description":"RELIEVA SPIN BALLOON SYS","CDM Revenue Code":"278","CDM HCPCS":"C1726","Standard Price":7145.1,"Note":"**"},{"Itemcode":"64134852","Description":"Lead NeurStim Kit Test 3065","CDM Revenue Code":"278","CDM HCPCS":"C1897","Standard Price":1618.74},{"Itemcode":"64134853","Description":"Kit Accessory Compon Her01003","CDM Revenue Code":"272","Standard Price":2568.36},{"Itemcode":"64134854","Description":"Nail Panta 10X150Mm 500050Nd","CDM Revenue Code":"278","Standard Price":13138.62},{"Itemcode":"64134855","Description":"Cath Ureteral Lighted G16747","CDM Revenue Code":"272","CDM HCPCS":"C1758","Standard Price":1027.14},{"Itemcode":"64134856","Description":"Kit Speedbridge Ar-8928Bc-Cp","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10604.94,"Note":"**"},{"Itemcode":"64134857","Description":"Extractor Stone Saliva","CDM Revenue Code":"272","Standard Price":1857.42,"Note":"**"},{"Itemcode":"64134858","Description":"Set Dilator Salivary G24131","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64134859","Description":"Linx Reflux Mgmt System","CDM Revenue Code":"278","Standard Price":17582.76,"Note":"**"},{"Itemcode":"64134860","Description":"Rod Tendon","CDM Revenue Code":"278","Standard Price":6347.46},{"Itemcode":"64134861","Description":"Rod Tendon Trial","CDM Revenue Code":"278","Standard Price":2648.94},{"Itemcode":"64134862","Description":"Strattice 25 X 40Cm 2540002","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":91947.9},{"Itemcode":"64134863","Description":"Elevate W/Intexen 720129-01","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":9084.12},{"Itemcode":"64134864","Description":"Nail Valor 11.5X200 415101120R","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":12537.84},{"Itemcode":"64134865","Description":"Permacol 15X20Cmx1.0Mm P101520","CDM Revenue Code":"278","CDM HCPCS":"C9364","Standard Price":16615.8},{"Itemcode":"64134866","Description":"Grafix Prime 7.5X15 Ps21075","CDM Revenue Code":"278","CDM HCPCS":"Q4133","Standard Price":8460.9},{"Itemcode":"64134867","Description":"Sling Altis","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":5694.66},{"Itemcode":"64134868","Description":"Abthera Dressing M8275026/5.S","CDM Revenue Code":"272","Standard Price":1953.3,"Note":"**"},{"Itemcode":"64134869","Description":"Allomax Tissue 8X16Cm 1180816","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":13789.38},{"Itemcode":"64134870","Description":"Strattice 10 X 20Cm 102000","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":18821.04,"Note":"**"},{"Itemcode":"64134871","Description":"IBV Valve Sys Impl Airleak Dev","CDM Revenue Code":"278","Standard Price":9517.62},{"Itemcode":"64134872","Description":"Balloon Tamponade Bronchii","CDM Revenue Code":"278","Standard Price":637.5},{"Itemcode":"64134873","Description":"System Implant Ar-2600Sbs-5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10808.94,"Note":"**"},{"Itemcode":"64134874","Description":"Kit Laterjet 285180","CDM Revenue Code":"278","Standard Price":2994.72},{"Itemcode":"64134875","Description":"Cellerate Powder Wci-01-Sacrxp","CDM Revenue Code":"272","Standard Price":1353.54},{"Itemcode":"64134876","Description":"Kit Protoe Inst Disp 45710500","CDM Revenue Code":"272","Standard Price":795.6,"Note":"**"},{"Itemcode":"64134877","Description":"Dermis Axis 93-9612","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":8612.88,"Note":"**"},{"Itemcode":"64134878","Description":"Epifix 2X3Cm Gs-5230","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":4881.72,"Note":"**"},{"Itemcode":"64134879","Description":"Bone Stimulator/Don Joy","CDM Revenue Code":"272","Standard Price":10653.9,"Note":"**"},{"Itemcode":"64134880","Description":"Primatrix 6X6Cm Bov 6495-9-116","CDM Revenue Code":"278","CDM HCPCS":"Q4110","Standard Price":7921.32},{"Itemcode":"64134881","Description":"Xenmatrix 20X25Cm Porc 1162025","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":42871.62},{"Itemcode":"64134882","Description":"Stent, Ureteral Flexima","CDM Revenue Code":"278","CDM HCPCS":"C2625","Standard Price":4387.02,"Note":"**"},{"Itemcode":"64134883","Description":"Flexioflo Gi Tube Kit","CDM Revenue Code":"272","Standard Price":2076.72},{"Itemcode":"64134884","Description":"Nail Panta 13X180Mm 500380Nd","CDM Revenue Code":"272","Standard Price":14217.78},{"Itemcode":"64134885","Description":"Kit Platelet Abs-10012","CDM Revenue Code":"272","Standard Price":1900.26},{"Itemcode":"64134886","Description":"Tissue Flexhd 16X20Cm Pliable","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":34755.48,"Note":"**"},{"Itemcode":"64134887","Description":"Amniofix 1.25 Inject Ai-5125","CDM Revenue Code":"278","Standard Price":5952.72},{"Itemcode":"64134888","Description":"Stent Esophageal","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":9883.8},{"Itemcode":"64134889","Description":"Allograft Reset Matri 4X4 Rm44","CDM Revenue Code":"278","Standard Price":10820.16},{"Itemcode":"64134890","Description":"Liquidgen Allograft Injectable","CDM Revenue Code":"278","Standard Price":10643.7},{"Itemcode":"64134891","Description":"PICO Wnd Np System","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64134892","Description":"Alloderm Tissue 4X7","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":3724.02},{"Itemcode":"64134893","Description":"Allograft Reset Matri 2X2 Rm22","CDM Revenue Code":"278","Standard Price":8510.88},{"Itemcode":"64134894","Description":"Hmatrix Dermis 5.0X4.0C","CDM Revenue Code":"278","CDM HCPCS":"Q4134","Standard Price":2652.0},{"Itemcode":"64134895","Description":"Strattice 10X16Cm Lap Porcine","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":15056.22},{"Itemcode":"64134896","Description":"Alloderm Contour Medium Cm1520","CDM Revenue Code":"278","Standard Price":14655.36},{"Itemcode":"64134897","Description":"ClarixAdhBar4.0X3.0 Cr10-4030","CDM Revenue Code":"278","CDM HCPCS":"C1765","Standard Price":10653.9},{"Itemcode":"64134898","Description":"Sub Talar Fusion Cup Fixation","CDM Revenue Code":"278","Standard Price":5097.96,"Note":"**"},{"Itemcode":"64134899","Description":"Pleuristik","CDM Revenue Code":"278","Standard Price":1592.22},{"Itemcode":"64134900","Description":"Alloderm Contour Small Cs1520","CDM Revenue Code":"278","Standard Price":10653.9},{"Itemcode":"64134901","Description":"Kit Endoscopic Release Ar-8850","CDM Revenue Code":"272","Standard Price":1517.76},{"Itemcode":"64134902","Description":"Axoguard Nerve Protector","CDM Revenue Code":"278","Standard Price":9203.46,"Note":"**"},{"Itemcode":"64134903","Description":"Avance Nerve Graft 5Cm","CDM Revenue Code":"272","Standard Price":10123.5,"Note":"**"},{"Itemcode":"64134904","Description":"Implant Midface 5444-0-510","CDM Revenue Code":"278","Standard Price":52923.72},{"Itemcode":"64134905","Description":"Clarix 6.0X3.0 Cm Cr-10-6030","CDM Revenue Code":"278","CDM HCPCS":"C1765","Standard Price":10820.16},{"Itemcode":"64134906","Description":"Mesh Xenmatrix 10Cmx15 1161015","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":12933.6},{"Itemcode":"64134907","Description":"Mesh Xenmatrix 15Cmx20 1161520","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":25870.26},{"Itemcode":"64134908","Description":"Epifix 4X4Cm Gs-5440","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":10257.12,"Note":"**"},{"Itemcode":"64134909","Description":"Amniofix 2X3Cm Aps-5230","CDM Revenue Code":"278","Standard Price":4789.92},{"Itemcode":"64134910","Description":"Amniofix 2.Oml Inject Ai-5200","CDM Revenue Code":"278","Standard Price":8512.92},{"Itemcode":"64134911","Description":"Clarix Cr-02-4040","CDM Revenue Code":"278","Standard Price":8894.4},{"Itemcode":"64134912","Description":"Clarix Cr-10-2525","CDM Revenue Code":"278","Standard Price":8104.92},{"Itemcode":"64134913","Description":"Neox 100 Graft 4.0X3.0","CDM Revenue Code":"278","CDM HCPCS":"Q4156","Standard Price":9345.24},{"Itemcode":"64134914","Description":"Amniofix .5Ml Inject Ai-5050","CDM Revenue Code":"278","Standard Price":3186.48},{"Itemcode":"64134915","Description":"Cath Hemodialysis Short Term","CDM Revenue Code":"278","CDM HCPCS":"C1752","Standard Price":586.5,"Note":"**"},{"Itemcode":"64134916","Description":"Absorba Tack Fixation","CDM Revenue Code":"278","Standard Price":2357.22,"Note":"**"},{"Itemcode":"64134917","Description":"Amniotic Membrane Wound Cover","CDM Revenue Code":"278","CDM HCPCS":"V2790","Standard Price":5332.56},{"Itemcode":"64134918","Description":"Clarix 25Mg","CDM Revenue Code":"278","Standard Price":3817.86},{"Itemcode":"64134919","Description":"KIT FAST TISSUE REMOVAL","CDM Revenue Code":"272","Standard Price":3264.0,"Note":"**"},{"Itemcode":"64134920","Description":"CLARIX FLO 50MG CR-FL-50","CDM Revenue Code":"278","CDM HCPCS":"Q4155","Standard Price":6378.06},{"Itemcode":"64134921","Description":"XPRESS MULTI SINUS LPLF-10","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":6398.46,"Note":"**"},{"Itemcode":"64134922","Description":"DERMACLOSE RC 204010","CDM Revenue Code":"272","Standard Price":4048.38},{"Itemcode":"64134923","Description":"CLARIX CR-10-8030","CDM Revenue Code":"278","Standard Price":17566.44},{"Itemcode":"64134924","Description":"CLARIX CR-02-2020","CDM Revenue Code":"278","Standard Price":5396.82},{"Itemcode":"64134925","Description":"TISSUE FLEXHD 16X16CM HP161","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":12175.74},{"Itemcode":"64134926","Description":"REVOLVE FAT GRAFT KIT RV0004","CDM Revenue Code":"272","Standard Price":2627.52,"Note":"**"},{"Itemcode":"64134927","Description":"GRAFT ENHANCE 3CMX4CM 322304","CDM Revenue Code":"278","Standard Price":5118.36},{"Itemcode":"64134928","Description":"OASIS ULTRA 5X7CM 306813000013","CDM Revenue Code":"278","CDM HCPCS":"Q4124","Standard Price":1769.7},{"Itemcode":"64134929","Description":"WND MTRX OASIS ULTRA 7X10","CDM Revenue Code":"278","CDM HCPCS":"Q4124","Standard Price":3645.48},{"Itemcode":"64134930","Description":"TISSUE FLEXHD 8X16CM HP1816","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":15426.48},{"Itemcode":"64134931","Description":"MATRIX WOUND MESD 8X10 MWM8101","CDM Revenue Code":"278","CDM HCPCS":"C9363","Standard Price":32907.24,"Note":"**"},{"Itemcode":"64134932","Description":"PROPEL SINUS IMPLANT","CDM Revenue Code":"278","CDM HCPCS":"C2625","Standard Price":3114.06,"Note":"**"},{"Itemcode":"64134933","Description":"GOLD MARKER QLRAD","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":664.02,"Note":"**"},{"Itemcode":"64134934","Description":"ALLODERM CONTOUR PERF 132SQCM","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":13825.08,"Note":"**"},{"Itemcode":"64134935","Description":"DERMIS ACELLULAR 8X12/1.50MM","CDM Revenue Code":"278","Standard Price":10653.9},{"Itemcode":"64134936","Description":"VITAGEL 2.0ML SYNTHE 2113-0202","CDM Revenue Code":"278","Standard Price":1323.96},{"Itemcode":"64134937","Description":"DERMIS ACELLULAR 16X20","CDM Revenue Code":"278","Standard Price":27050.4},{"Itemcode":"64134938","Description":"SYSTEM SHOULDER","CDM Revenue Code":"278","Standard Price":18039.72},{"Itemcode":"64134939","Description":"ALLODERM RTU 6X16CM 1518616","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":10653.9,"Note":"**"},{"Itemcode":"64134940","Description":"DERMIS HMATRIX 5.0X7.0C 208037","CDM Revenue Code":"278","CDM HCPCS":"Q4134","Standard Price":4255.44},{"Itemcode":"64134941","Description":"IMPLANT COCHLEAR C124RE Z60132","CDM Revenue Code":"278","CDM HCPCS":"L8614","Standard Price":41846.52},{"Itemcode":"64134942","Description":"KIT DUAL PROCESSOR DUALN6","CDM Revenue Code":"278","CDM HCPCS":"L8614","Standard Price":43449.96},{"Itemcode":"64134943","Description":"Matristem PSMX 7 x 10 cm","CDM Revenue Code":"278","Standard Price":8420.1},{"Itemcode":"64134944","Description":"Matristem MicroMatrix 1000mg","CDM Revenue Code":"278","CDM HCPCS":"Q4118","Standard Price":10164.3,"Note":"**"},{"Itemcode":"64134945","Description":"Matristem Psm 5X5CM PSM0505","CDM Revenue Code":"278","Standard Price":2281.74},{"Itemcode":"64134946","Description":"DRILL GUIDE 3MM & 4MM 92139","CDM Revenue Code":"272","Standard Price":1120.98},{"Itemcode":"64134947","Description":"Drill Widening 4MM 92141","CDM Revenue Code":"272","Standard Price":1194.42},{"Itemcode":"64134948","Description":"Processor Cochlear BAHA3 92843","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":11835.06},{"Itemcode":"64134949","Description":"Implant Baha Grp 2","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":9600.24,"Note":"**"},{"Itemcode":"64134952","Description":"Matristem PSMX 5x5cm PSMx0505","CDM Revenue Code":"278","Standard Price":2387.82},{"Itemcode":"64134953","Description":"SYSTEM PEAK PLASMA 278001","CDM Revenue Code":"272","Standard Price":1857.42,"Note":"**"},{"Itemcode":"64134954","Description":"Wand Serfas Energy 279-250-101","CDM Revenue Code":"278","Standard Price":936.36},{"Itemcode":"64134955","Description":"Implant X-fuse Xlarge AXF-XL","CDM Revenue Code":"278","Standard Price":7222.62},{"Itemcode":"64134956","Description":"Implant X-fuse Large AXF-LO","CDM Revenue Code":"278","Standard Price":7222.62},{"Itemcode":"64134957","Description":"System Suspension Encore","CDM Revenue Code":"278","Standard Price":9384.0},{"Itemcode":"64134958","Description":"Fixator Subtalor Frame","CDM Revenue Code":"272","Standard Price":16571.94},{"Itemcode":"64134959","Description":"Stent Micro Bypass MIGS","CDM Revenue Code":"278","CDM HCPCS":"C1783","Standard Price":7476.6,"Note":"**"},{"Itemcode":"64134960","Description":"Wnd Matrix Matristem 10x15","CDM Revenue Code":"278","Standard Price":14303.46},{"Itemcode":"64134961","Description":"Matristem Pelvic Floor PFM0912","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":7555.14,"Note":"**"},{"Itemcode":"64134962","Description":"Implant Alpha Sophono","CDM Revenue Code":"278","Standard Price":9811.38},{"Itemcode":"64134963","Description":"Kit Processor Alpha 2","CDM Revenue Code":"272","Standard Price":12156.36},{"Itemcode":"64134964","Description":"Speed Titan Implant 25x20x20","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6687.12},{"Itemcode":"64134965","Description":"STENT STOMA 11MM","CDM Revenue Code":"278","Standard Price":2236.86},{"Itemcode":"64134966","Description":"STENT NON-CO/COV PROTEGE","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4241.16,"Note":"**"},{"Itemcode":"64134967","Description":"ALLODERM CON LG CL15xxP","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":18745.56,"Note":"**"},{"Itemcode":"64134968","Description":"Sound Processor, BAHA BP110","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":10346.88},{"Itemcode":"64134969","Description":"ALLODERM 2X4CM XThick 982011","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":2485.74},{"Itemcode":"64134970","Description":"Allograft, Artery","CDM Revenue Code":"278","Standard Price":21504.66},{"Itemcode":"64134971","Description":"Plating System, Bunion","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":3408.84},{"Itemcode":"64134972","Description":"STRATTICE 6X8 0608005","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":5716.08},{"Itemcode":"64134973","Description":"MATRISTEM PELVIC FLR PFM10X15","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":13580.28},{"Itemcode":"64134974","Description":"Matristem Matrix Plus MSPL0710","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":7712.22},{"Itemcode":"64134975","Description":"Stimulator/Locator Nerve 9094","CDM Revenue Code":"272","Standard Price":2647.92,"Note":"**"},{"Itemcode":"64134976","Description":"IMPLNT SYS INT BRACE AR-1688CP","CDM Revenue Code":"278","Standard Price":6552.48,"Note":"**"},{"Itemcode":"64134977","Description":"IMPLANT SPEED 20X15 SE-2015TI","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7251.18},{"Itemcode":"64134978","Description":"Matrix Surg Plus 5x7 MSPL0507","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":3856.62},{"Itemcode":"64134979","Description":"Integra Derm Reg Te 8x10 38101","CDM Revenue Code":"278","CDM HCPCS":"Q4105","Standard Price":29755.44},{"Itemcode":"64134980","Description":"ALLODERM 3X7 102020","CDM Revenue Code":"278","Standard Price":3595.5},{"Itemcode":"64134981","Description":"IMPLANT TESTICULAR 450-1329","CDM Revenue Code":"278","Standard Price":7887.66},{"Itemcode":"64134982","Description":"BONE PUNCH Grp 1","CDM Revenue Code":"272","Standard Price":571.2},{"Itemcode":"64134983","Description":"BONE PUNCH Grp 2","CDM Revenue Code":"272","Standard Price":1579.98},{"Itemcode":"64134984","Description":"Humeral Fx Shoulder Stem","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":20926.32},{"Itemcode":"64134985","Description":"AMNIOFIX 2.0X12CM APS-5212","CDM Revenue Code":"278","Standard Price":4242.18,"Note":"**"},{"Itemcode":"64134986","Description":"Implant BME Speed Grp 1","CDM Revenue Code":"278","Standard Price":4260.54},{"Itemcode":"64134987","Description":"Implant BME Speed Grp 2","CDM Revenue Code":"278","Standard Price":6791.16},{"Itemcode":"64134988","Description":"Wedge System, Biofoam","CDM Revenue Code":"278","Standard Price":9627.78},{"Itemcode":"64134989","Description":"Avance Nerve Graft 30MM","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":9839.94,"Note":"**"},{"Itemcode":"64134991","Description":"Myosure Lite Tissue Rem 30-401","CDM Revenue Code":"272","Standard Price":2820.3,"Note":"**"},{"Itemcode":"64134992","Description":"Device Myosure XL 50-503XL","CDM Revenue Code":"272","Standard Price":4937.82,"Note":"**"},{"Itemcode":"64134993","Description":"Matrix Micro 500MG MM0500","CDM Revenue Code":"278","CDM HCPCS":"Q4118","Standard Price":5555.94,"Note":"**"},{"Itemcode":"64134994","Description":"Kit Interphalangeal","CDM Revenue Code":"272","Standard Price":1402.5},{"Itemcode":"64134995","Description":"Human Bone Mimetic, Etex","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6639.18},{"Itemcode":"64134996","Description":"Patch,Amniotic 4x4","CDM Revenue Code":"278","CDM HCPCS":"V2790","Standard Price":6123.06},{"Itemcode":"64134997","Description":"Patch,Amniotic 2x2 CYGNUS","CDM Revenue Code":"278","CDM HCPCS":"Q4170","Standard Price":4876.62},{"Itemcode":"64134998","Description":"KIT SM JOINT TAK AR-89434DSC","CDM Revenue Code":"272","Standard Price":1059.78,"Note":"**"},{"Itemcode":"64134999","Description":"Amniotic/Human Tissue Matrix","CDM Revenue Code":"278","Standard Price":6492.3},{"Itemcode":"64135083","Description":"Tray Lumbar Punc 20X31/2 4301C","CDM Revenue Code":"272","Standard Price":55.08,"Note":"**"},{"Itemcode":"64135500","Description":"Fibertak Kit","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1421.88,"Note":"**"},{"Itemcode":"64135501","Description":"Matristem Wnd MatrixPlus 10x10","CDM Revenue Code":"278","Standard Price":8734.26},{"Itemcode":"64135502","Description":"Kit Template /w K-Wires M225","CDM Revenue Code":"272","Standard Price":970.02},{"Itemcode":"64135503","Description":"Generator, VNS AspireSR","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":81186.9},{"Itemcode":"64135504","Description":"Lead, VNS PerennialFlex","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":19819.62},{"Itemcode":"64135505","Description":"Tunneler for VNS","CDM Revenue Code":"272","Standard Price":1981.86},{"Itemcode":"64135506","Description":"Kit for Tenfuse PIP Fusion","CDM Revenue Code":"272","Standard Price":2235.84,"Note":"**"},{"Itemcode":"64135507","Description":"Patch,Amniotic 2x3","CDM Revenue Code":"278","Standard Price":5611.02,"Note":"**"},{"Itemcode":"64135508","Description":"Epifix 7x7CM GS-5770","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":31429.26,"Note":"**"},{"Itemcode":"64135509","Description":"Protector Nerve 3x40MM AG0340","CDM Revenue Code":"278","Standard Price":9021.9,"Note":"**"},{"Itemcode":"64135510","Description":"Gen Neurostim Gastric Enterra","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":29417.82,"Note":"**"},{"Itemcode":"64135511","Description":"Lead Neurostim Enterra 4351","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":9384.0,"Note":"**"},{"Itemcode":"64135512","Description":"PaliGen Flow 1.00ML PF-010100","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":9341.16},{"Itemcode":"64135513","Description":"Matristem Wnd Matrix Pls 10x15","CDM Revenue Code":"278","Standard Price":13100.88},{"Itemcode":"64135514","Description":"Implant Humeral Stem Elbow","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":25451.04},{"Itemcode":"64135515","Description":"Cement, Otomimix 2gm","CDM Revenue Code":"278","Standard Price":1705.44,"Note":"**"},{"Itemcode":"64135516","Description":"Tacker, Hernia Fixtn Grp 1","CDM Revenue Code":"278","Standard Price":1664.64,"Note":"**"},{"Itemcode":"64135517","Description":"Tacker, Hernia Fixtn Grp 2","CDM Revenue Code":"278","Standard Price":2392.92,"Note":"**"},{"Itemcode":"64135518","Description":"Abutment BAHA, Aud Device Comp","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":7870.32,"Note":"**"},{"Itemcode":"64135519","Description":"Sizer Mammary Grp 3","CDM Revenue Code":"272","Standard Price":2080.8},{"Itemcode":"64135520","Description":"Cable, Interstim","CDM Revenue Code":"272","Standard Price":520.2,"Note":"**"},{"Itemcode":"64135521","Description":"Neurostim Extrnl, Sacrl","CDM Revenue Code":"272","Standard Price":2122.62,"Note":"**"},{"Itemcode":"64135522","Description":"Implant Cochlear CI522 Z382660","CDM Revenue Code":"278","CDM HCPCS":"L8614","Standard Price":42966.48},{"Itemcode":"64135523","Description":"Amniotic Inject Allogen .25ML","CDM Revenue Code":"278","Standard Price":6378.06},{"Itemcode":"64135524","Description":"AllogrftFlexHD Pliable 6x16cm","CDM Revenue Code":"278","Standard Price":12540.9},{"Itemcode":"64135526","Description":"Expander Tissue UHP","CDM Revenue Code":"278","Standard Price":8872.98},{"Itemcode":"64135527","Description":"SLIC Screw Prep Pack","CDM Revenue Code":"272","Standard Price":3894.36},{"Itemcode":"64135528","Description":"KIT Insert Suprapubic","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":572.22,"Note":"**"},{"Itemcode":"64135529","Description":"Cannula, Airway L-T","CDM Revenue Code":"272","Standard Price":615.06},{"Itemcode":"64135530","Description":"Mesh Hernia Phasix","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":22908.18},{"Itemcode":"64135531","Description":"ABUTMENT BAHA 8.5MM","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":6987.0},{"Itemcode":"64135532","Description":"BAHA DRILLS","CDM Revenue Code":"278","Standard Price":1014.9,"Note":"**"},{"Itemcode":"64135533","Description":"IMPLANT /C ABUTMENTBAHA","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":9722.64},{"Itemcode":"64135534","Description":"BAHA IMPLANT GRP 1","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":5950.68,"Note":"**"},{"Itemcode":"64135535","Description":"CATH BALLOON, DIL-SINUS Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":2048.16},{"Itemcode":"64135536","Description":"CATH BALLOON, DIL-SINUS Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":2601.0},{"Itemcode":"64135537","Description":"MATRISTEM WND MATRIX PSM 4X12","CDM Revenue Code":"278","Standard Price":3959.64},{"Itemcode":"64135538","Description":"MESH PHASIX 4X6 1190200","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":8851.56,"Note":"**"},{"Itemcode":"64135539","Description":"MESH PHASIX 10X12 1190500","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":34320.96,"Note":"**"},{"Itemcode":"64135540","Description":"ALLOGEN .50ML PO1-AMF-0050","CDM Revenue Code":"278","Standard Price":8744.46},{"Itemcode":"64135541","Description":"DermaSpan Meshed ACD 4X4","CDM Revenue Code":"278","Standard Price":6398.46},{"Itemcode":"64135542","Description":"KIT UCL SUTURE PASSER","CDM Revenue Code":"272","Standard Price":4235.04},{"Itemcode":"64135543","Description":"IMPLANT MAGNET BAHA BIM400","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":8830.14,"Note":"**"},{"Itemcode":"64135544","Description":"PROCESSOR SOUND BAHA 5","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":11656.56,"Note":"**"},{"Itemcode":"64135545","Description":"KIT MAGNET BAHA FUZ1078","CDM Revenue Code":"272","Standard Price":883.32},{"Itemcode":"64135546","Description":"Mesh,Ventralight w/Echo PS4X6","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":2392.92},{"Itemcode":"64135547","Description":"Device Lap Suture Ti Knot","CDM Revenue Code":"272","Standard Price":1194.42},{"Itemcode":"64135548","Description":"TUBE GI GRP 3","CDM Revenue Code":"272","Standard Price":676.26,"Note":"**"},{"Itemcode":"64135549","Description":"Mesh, Hernia Ventralight 10x13","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":9675.72,"Note":"**"},{"Itemcode":"64135550","Description":"Tissue Expander Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":8947.44,"Note":"**"},{"Itemcode":"64135551","Description":"Bio-Connekt Wnd Matrix 5x5cm","CDM Revenue Code":"278","CDM HCPCS":"Q4161","Standard Price":3839.28},{"Itemcode":"64135552","Description":"MESH PHASIX ST 6X8 1201520","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":17464.44},{"Itemcode":"64135553","Description":"HYALOMATRIX, WOUND 5X5CM","CDM Revenue Code":"278","CDM HCPCS":"Q4117","Standard Price":1421.88},{"Itemcode":"64135554","Description":"DermaSpan Meshed ACD 5X5","CDM Revenue Code":"278","Standard Price":6398.46},{"Itemcode":"64135555","Description":"MESH PHASIX 4X4 1201010","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":8275.26},{"Itemcode":"64135556","Description":"Reform Capsular Tension Ring","CDM Revenue Code":"278","Standard Price":1054.68,"Note":"**"},{"Itemcode":"64135557","Description":"Graft Nerve Avance","CDM Revenue Code":"278","Standard Price":17328.78,"Note":"**"},{"Itemcode":"64135558","Description":"Protector Nerve AG0540","CDM Revenue Code":"278","Standard Price":9276.9,"Note":"**"},{"Itemcode":"64135559","Description":"Pacemaker- Dual RR DR GRP A","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":13525.2},{"Itemcode":"64135560","Description":"Reamer , Crosstie 2.2-2.5","CDM Revenue Code":"272","Standard Price":530.4,"Note":"**"},{"Itemcode":"64135561","Description":"Alloderm Small Perf 77sqcm","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":10158.18},{"Itemcode":"64135562","Description":"COUNTERSINK X POST 118-02077","CDM Revenue Code":"272","Standard Price":1809.48},{"Itemcode":"64135563","Description":"INTERNAL FIXATN POST X MED","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9354.42},{"Itemcode":"64135564","Description":"Strattice 6X13cm 0613009","CDM Revenue Code":"278","CDM HCPCS":"Q4130","Standard Price":6650.4},{"Itemcode":"64135565","Description":"Reform Capsular Tension Ring","CDM Revenue Code":"278","Standard Price":1045.5},{"Itemcode":"64135566","Description":"BLADE DISPOSABLE GRP 4","CDM Revenue Code":"272","Standard Price":2080.8,"Note":"**"},{"Itemcode":"64135567","Description":"BLADE DISPOSABLE GRP 5","CDM Revenue Code":"272","Standard Price":2985.54,"Note":"**"},{"Itemcode":"64135568","Description":"BLADE SHAVER iO","CDM Revenue Code":"272","Standard Price":6628.98},{"Itemcode":"64135570","Description":"IMPLNT-ASSEMBLY TOTAL ELBOW","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":15216.36},{"Itemcode":"64135571","Description":"Trach System, Scoop Proc","CDM Revenue Code":"272","Standard Price":1267.86},{"Itemcode":"64135572","Description":"Implant Uro System-Urolift","CDM Revenue Code":"278","CDM HCPCS":"L8699","Standard Price":3728.1,"Note":"**"},{"Itemcode":"64135573","Description":"Bony Void Filler Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10924.2,"Note":"**"},{"Itemcode":"64135574","Description":"Bag, Lap Retrieval Grp1","CDM Revenue Code":"272","Standard Price":245.82,"Note":"**"},{"Itemcode":"64135575","Description":"Bag, Lap Retrieval Grp2","CDM Revenue Code":"272","Standard Price":530.4,"Note":"**"},{"Itemcode":"64135576","Description":"Resorb Mrkr Imp-Biozorb; ea","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":5332.56},{"Itemcode":"64135577","Description":"Rod Spacer, Tendon","CDM Revenue Code":"278","Standard Price":7643.88},{"Itemcode":"64135578","Description":"Central Venous Cath Group 1A","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":614.04},{"Itemcode":"64135579","Description":"External Fixator Cmpnts Grp 5","CDM Revenue Code":"272","Standard Price":6866.64,"Note":"**"},{"Itemcode":"64135580","Description":"External Fixator Cmpnts Grp 6","CDM Revenue Code":"272","Standard Price":7907.04},{"Itemcode":"64135581","Description":"Implant Joint Grp 15","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":21016.08,"Note":"**"},{"Itemcode":"64135582","Description":"SPACER, HYDROGEL-SPACEOAR","CDM Revenue Code":"278","Standard Price":9636.96,"Note":"**"},{"Itemcode":"64135583","Description":"Suture-Arrow Kissloc","CDM Revenue Code":"278","Standard Price":3199.74},{"Itemcode":"64135584","Description":"Fixatn Plate Package-Arrow","CDM Revenue Code":"278","Standard Price":1327.02},{"Itemcode":"64135585","Description":"ALGRFT MEMB AMNIOTC 200MU4X8CM","CDM Revenue Code":"278","Standard Price":13508.88},{"Itemcode":"64135586","Description":"Sleeve Guide for PLATE P51-950","CDM Revenue Code":"272","Standard Price":2363.34},{"Itemcode":"64135587","Description":"Chisel Bone Fenes P99-150-0035","CDM Revenue Code":"272","Standard Price":1408.62},{"Itemcode":"64135588","Description":"Prosthesis Testicular 450-1329","CDM Revenue Code":"278","Standard Price":7886.64},{"Itemcode":"64135590","Description":"Tube Biliary 27-260","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":532.44},{"Itemcode":"64135591","Description":"Cord, Amniotic 2x3 Thick","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":7326.66,"Note":"**"},{"Itemcode":"64135592","Description":"Kit-PEEK Tunnel Button Implant","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4765.44},{"Itemcode":"64135593","Description":"Kit Elbow, Humeral Screws","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1272.96,"Note":"**"},{"Itemcode":"64135594","Description":"Kit Elbow, Articulation Size4","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":3966.78},{"Itemcode":"64135595","Description":"T.Elbow, Comp Humeral PlasmaSp","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16906.5},{"Itemcode":"64135596","Description":"T.Elbow, Comp Ulnar PlasmaSp","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":15216.36},{"Itemcode":"64135597","Description":"Implant Cochlear CI512 Z209051","CDM Revenue Code":"278","Standard Price":42966.48},{"Itemcode":"64135598","Description":"STAPLER SEPTAL, ENT 601-00100","CDM Revenue Code":"272","Standard Price":901.68,"Note":"**"},{"Itemcode":"64135599","Description":"DiltnSys-EustachnTube EU061655","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":4265.64,"Note":"**"},{"Itemcode":"64135600","Description":"Patch,Amniotic 3x4","CDM Revenue Code":"278","Standard Price":9116.76},{"Itemcode":"64135601","Description":"Kit Pleurx Pat Starter 50-0071","CDM Revenue Code":"278","Standard Price":1517.76,"Note":"**"},{"Itemcode":"64135602","Description":"VPULSE W/COMPRESSION PD C00002","CDM Revenue Code":"272","Standard Price":1294.38,"Note":"**"},{"Itemcode":"64135603","Description":"ALGRFT BONE SCAFFOLD 2.5CC VIA","CDM Revenue Code":"278","Standard Price":7209.36},{"Itemcode":"64135605","Description":"Patch,Amniotic 2X3 CAM0203","CDM Revenue Code":"272","Standard Price":9086.16},{"Itemcode":"64135606","Description":"CrossTie Allograft","CDM Revenue Code":"278","Standard Price":6378.06},{"Itemcode":"64135607","Description":"GRAFT NERVE AVANCE 111250","CDM Revenue Code":"278","Standard Price":11665.74},{"Itemcode":"64135608","Description":"ALGRFT BONE SCAFFOLD 5CC VIAGR","CDM Revenue Code":"278","Standard Price":8791.38},{"Itemcode":"64135609","Description":"Allogen 0.5ml Inj Amnion","CDM Revenue Code":"278","Standard Price":4905.18},{"Itemcode":"64135610","Description":"Allogen 0.25 ml Inj Amnion","CDM Revenue Code":"278","Standard Price":3839.28},{"Itemcode":"64135611","Description":"Drill Bit/Sonianchor","CDM Revenue Code":"272","Standard Price":2346.0},{"Itemcode":"64135612","Description":"Kit Suture Anchor Sonianchor","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2465.34},{"Itemcode":"64135613","Description":"IMPL Mesh Phasix 3x4","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":6079.2,"Note":"**"},{"Itemcode":"64135614","Description":"Allograft PIP 2.8mm","CDM Revenue Code":"278","Standard Price":6808.5},{"Itemcode":"64135615","Description":"DBM Morsellized Matrix 1cc","CDM Revenue Code":"278","Standard Price":2423.52},{"Itemcode":"64135616","Description":"Reamer 12,15,16mm","CDM Revenue Code":"272","Standard Price":3710.76,"Note":"**"},{"Itemcode":"64135617","Description":"Plate Fusion Ankle 5920601L","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10543.74},{"Itemcode":"64135618","Description":"Rod Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6866.64,"Note":"**"},{"Itemcode":"64135619","Description":"Drill Bit 1.4x70mm","CDM Revenue Code":"272","Standard Price":742.56},{"Itemcode":"64135620","Description":"PLANER BONE 8MM","CDM Revenue Code":"278","Standard Price":1252.56,"Note":"**"},{"Itemcode":"64135621","Description":"Plt Rib Biobridge Resorb","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4701.18},{"Itemcode":"64135622","Description":"Barrier Avive 2x4CM CA0204","CDM Revenue Code":"278","Standard Price":8872.98,"Note":"**"},{"Itemcode":"64135623","Description":"Barrier Avive 3x4CM CA0304","CDM Revenue Code":"278","Standard Price":10143.9,"Note":"**"},{"Itemcode":"64135624","Description":"IMPLANT MTP TOE Polyvinyl","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12172.68,"Note":"**"},{"Itemcode":"64135625","Description":"ALGRFT AMNIO MEMB Revita 2x2cm","CDM Revenue Code":"278","Standard Price":4159.56},{"Itemcode":"64135627","Description":"Algrft Memb Amnio-Revita 2x2cm","CDM Revenue Code":"278","Standard Price":4159.56},{"Itemcode":"64135628","Description":"GAUGE DEPTH IOL CL1","CDM Revenue Code":"278","Standard Price":1857.42},{"Itemcode":"64135629","Description":"Matrix, Dermal-Dermaspan 4x8","CDM Revenue Code":"278","CDM HCPCS":"Q4126","Standard Price":11293.44},{"Itemcode":"64135630","Description":"Allograft Amniotic 1ml Rheo","CDM Revenue Code":"278","Standard Price":9598.2,"Note":"**"},{"Itemcode":"64135631","Description":"Pin Fixation/Temp GR2","CDM Revenue Code":"272","Standard Price":684.42,"Note":"**"},{"Itemcode":"64135632","Description":"Arthroflex Allograft 35x35mm","CDM Revenue Code":"278","CDM HCPCS":"Q4125","Standard Price":8032.5},{"Itemcode":"64135633","Description":"\"MESH PHASIX 6\"\" ROUND 1200015\"","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":12172.68,"Note":"**"},{"Itemcode":"64135634","Description":"LENS PRESBY-C FNCTN -SND","CDM Revenue Code":"276","CDM HCPCS":"V2788","Standard Price":1035.3},{"Itemcode":"64135635","Description":"Passer Suture REV FG0008","CDM Revenue Code":"272","Standard Price":1055.7},{"Itemcode":"64135636","Description":"Graft Porcine, Oto 0.4x0.6cm","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":717.06,"Note":"**"},{"Itemcode":"64135637","Description":"Graft ENT-TRG-2X3CM","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":1161.78,"Note":"**"},{"Itemcode":"64135638","Description":"Implant Staple Kit-NeoSpan","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7275.66},{"Itemcode":"64135639","Description":"Amniofill 500MG AF-0500","CDM Revenue Code":"278","Standard Price":4905.18,"Note":"**"},{"Itemcode":"64135640","Description":"Graft Porcine, Oto 0.6x0.9cm","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":982.26,"Note":"**"},{"Itemcode":"64135641","Description":"Algrf Amnio Wet-Palingen 2x6cm","CDM Revenue Code":"278","CDM HCPCS":"Q4173","Standard Price":7166.52},{"Itemcode":"64135642","Description":"Algraft Vendajae 200-008-0204","CDM Revenue Code":"278","Standard Price":7998.84},{"Itemcode":"64135644","Description":"Implant Tarsi Stent, Size 6,7","CDM Revenue Code":"278","Standard Price":6824.82,"Note":"**"},{"Itemcode":"64135645","Description":"Algrf Amnio Wet-Palingen 2x4cm","CDM Revenue Code":"278","CDM HCPCS":"Q4173","Standard Price":7998.84},{"Itemcode":"64135646","Description":"ALLOGEN 1.00ML PO1-AMF-0100","CDM Revenue Code":"278","Standard Price":9981.72,"Note":"**"},{"Itemcode":"64135647","Description":"Prosth Penile Pump Assy Titan","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":15351.0},{"Itemcode":"64135648","Description":"Kit Biocomposite AR-8928BCJ-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9636.96,"Note":"**"},{"Itemcode":"64135649","Description":"Amniotic Placenta Mem 4x4","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":6793.2},{"Itemcode":"64135650","Description":"Bone Staple P71-010-1010-S","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7490.88,"Note":"**"},{"Itemcode":"64135651","Description":"Cellerate Powder 5gram","CDM Revenue Code":"272","Standard Price":6378.06},{"Itemcode":"64135652","Description":"KIT COCHLR DUL PROCESSR DUALN7","CDM Revenue Code":"278","CDM HCPCS":"L8614","Standard Price":48934.5},{"Itemcode":"64135653","Description":"Allograft Cellentra 1cc","CDM Revenue Code":"278","Standard Price":2149.14},{"Itemcode":"64135654","Description":"Putty DBM Stagraft 2cc","CDM Revenue Code":"278","Standard Price":2334.78},{"Itemcode":"64135655","Description":"Kit EPFXPRESS ENDOTRAC 3100-D","CDM Revenue Code":"272","Standard Price":2815.2,"Note":"**"},{"Itemcode":"64135656","Description":"ALLODERM LG 164sqcm CL1518P","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":19734.96},{"Itemcode":"64135657","Description":"ALLODERM 199.5sqcm CXL1518P","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":19097.46,"Note":"**"},{"Itemcode":"64135658","Description":"IMPL Sophono ALPHA2 MPO E++","CDM Revenue Code":"278","Standard Price":13846.5},{"Itemcode":"64135659","Description":"Kit Implant Sterile, Sophono","CDM Revenue Code":"278","CDM HCPCS":"L8690","Standard Price":9811.38},{"Itemcode":"64135660","Description":"NS Generator, Inspire IV 3028","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":57820.74,"Note":"**"},{"Itemcode":"64135661","Description":"NS Lead Stimulation 4063","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":6594.3,"Note":"**"},{"Itemcode":"64135662","Description":"NS Lead Resp Pressr Sens 4323","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":10313.22,"Note":"**"},{"Itemcode":"64135663","Description":"Remote Sleep Inspire IPG 2500N","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":5972.1,"Note":"**"},{"Itemcode":"64135664","Description":"Impl Kit StapleInstaFix10x10mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5140.8},{"Itemcode":"64135665","Description":"InstaFix Accessory Kit 2.0mm","CDM Revenue Code":"272","Standard Price":2308.26},{"Itemcode":"64135666","Description":"Balloon Postpartum-Rapid Instl","CDM Revenue Code":"272","Standard Price":1204.62},{"Itemcode":"64135667","Description":"LEAD PM Tendril MRI","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2016.54,"Note":"**"},{"Itemcode":"64135668","Description":"PM DRR Gen Assurity MRI","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":12848.94,"Note":"**"},{"Itemcode":"64135669","Description":"IMPL Button, Biceps","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1565.7},{"Itemcode":"64135670","Description":"Shunt Glaucoma CYPASS System","CDM Revenue Code":"278","CDM HCPCS":"C1783","Standard Price":7038.0},{"Itemcode":"64135671","Description":"Expander, Tissue Aerofoam 60cc","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":10412.16},{"Itemcode":"64135672","Description":"Controller Dosage Aeroform","CDM Revenue Code":"272","Standard Price":1852.32},{"Itemcode":"64135673","Description":"AlgrfAmniWet-PalngnXPLUS 2x6cm","CDM Revenue Code":"278","CDM HCPCS":"Q4173","Standard Price":7998.84},{"Itemcode":"64135674","Description":"Epicord 3.0 x 5.0cm","CDM Revenue Code":"278","CDM HCPCS":"Q4187","Standard Price":10566.18,"Note":"**"},{"Itemcode":"64135675","Description":"EpiFix Particulate 100.0mg Inj","CDM Revenue Code":"278","CDM HCPCS":"Q4145","Standard Price":7808.1,"Note":"**"},{"Itemcode":"64135676","Description":"ALLODERM LG 164sqcm CL1519","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":16128.24},{"Itemcode":"64135677","Description":"Bit Drill Cannulated 2.7mm","CDM Revenue Code":"272","Standard Price":3288.48,"Note":"**"},{"Itemcode":"64135678","Description":"AmnioFix 4X4cm APS-5440","CDM Revenue Code":"278","Standard Price":5974.14},{"Itemcode":"64135679","Description":"AmnioFix 6X16cm APS-5616","CDM Revenue Code":"278","Standard Price":11602.5},{"Itemcode":"64135680","Description":"Hemostat Bone Resorbable HQ6","CDM Revenue Code":"278","Standard Price":1592.22},{"Itemcode":"64135681","Description":"Epifix 4x6 GS-5460","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":12848.94,"Note":"**"},{"Itemcode":"64135682","Description":"ALLOGEN 2.00ML P01-AMF-0200","CDM Revenue Code":"278","Standard Price":9918.48},{"Itemcode":"64135683","Description":"Allogen FZ Liquid XL 2.0ml","CDM Revenue Code":"278","Standard Price":12845.88},{"Itemcode":"64135684","Description":"Impl HammerTube Sys 3.50x16mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7326.66,"Note":"**"},{"Itemcode":"64135685","Description":"Syst Endoblade Gastroc Recess","CDM Revenue Code":"272","Standard Price":3743.4,"Note":"**"},{"Itemcode":"64135686","Description":"TYRX Neuro Absorb Antibac Env","CDM Revenue Code":"278","Standard Price":4161.6,"Note":"**"},{"Itemcode":"64135687","Description":"Allgrft Amnio Biovance 2x2CM","CDM Revenue Code":"278","CDM HCPCS":"Q4154","Standard Price":2509.2},{"Itemcode":"64135688","Description":"Putty Bone Montage 5cc","CDM Revenue Code":"278","Standard Price":8343.6,"Note":"**"},{"Itemcode":"64135689","Description":"Implant Mandible SD449.510B","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":23380.44},{"Itemcode":"64135690","Description":"Kit Mandible Reconst SD900.001","CDM Revenue Code":"278","Standard Price":15948.72},{"Itemcode":"64135691","Description":"Impl Staple DynaNite 13Wx10L","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7925.4},{"Itemcode":"64135692","Description":"SET DUAFIT DISP INSTR A0610401","CDM Revenue Code":"272","Standard Price":4579.8},{"Itemcode":"64135693","Description":"Prosthesis Voice","CDM Revenue Code":"272","Standard Price":1951.26},{"Itemcode":"64135694","Description":"Kit Fusion Motoband","CDM Revenue Code":"272","Standard Price":3328.26,"Note":"**"},{"Itemcode":"64135695","Description":"Graft Jacket 5X5 8600-5X05","CDM Revenue Code":"278","CDM HCPCS":"Q4107","Standard Price":9409.5},{"Itemcode":"64135697","Description":"HANDPIECE TENJET 76000","CDM Revenue Code":"272","Standard Price":2927.4},{"Itemcode":"64135698","Description":"ALLODERM 199.5sqcm CXL1518","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":30849.9,"Note":"**"},{"Itemcode":"64135699","Description":"Putty DBM Stagraft Plus","CDM Revenue Code":"278","Standard Price":4751.16},{"Itemcode":"64135700","Description":"NUCEL .5CC NC-1000","CDM Revenue Code":"278","Standard Price":2765.22,"Note":"**"},{"Itemcode":"64135701","Description":"NuShield 1.6sq cm NO-1160c","CDM Revenue Code":"278","Standard Price":1483.08,"Note":"**"},{"Itemcode":"64135702","Description":"NuShield 2x4sq cm NO-1240","CDM Revenue Code":"278","Standard Price":3701.58,"Note":"**"},{"Itemcode":"64135703","Description":"NUCEL MEDIUM NC-1001","CDM Revenue Code":"278","Standard Price":7527.6,"Note":"**"},{"Itemcode":"64135704","Description":"CT LUCIA 602 ++20.5D","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":910.86},{"Itemcode":"64135705","Description":"Amniofix 16.0mm Disc APS-5160","CDM Revenue Code":"278","Standard Price":1745.22},{"Itemcode":"64135706","Description":"Composite Layer Helx ABS-4050","CDM Revenue Code":"272","Standard Price":290.7,"Note":"**"},{"Itemcode":"64135707","Description":"SLED MEDIAL 42mm MMSLED-42","CDM Revenue Code":"278","Standard Price":3032.46},{"Itemcode":"64135708","Description":"KIT PRP GENIUS 30ML G20030","CDM Revenue Code":"272","Standard Price":8991.3,"Note":"**"},{"Itemcode":"64135709","Description":"Reamer Disp 10.5 AR-1410LP-50","CDM Revenue Code":"272","Standard Price":1014.9,"Note":"**"},{"Itemcode":"64135710","Description":"Shunt Pleural Peri 42-9000","CDM Revenue Code":"278","Standard Price":6117.96},{"Itemcode":"64135711","Description":"Shunt Pleural 42-2020","CDM Revenue Code":"278","Standard Price":8573.1},{"Itemcode":"64135712","Description":"Impl HammerTube Sys 2.75x14mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5152.02,"Note":"**"},{"Itemcode":"64135713","Description":"VersaWrap Protector Tendon 2x2","CDM Revenue Code":"272","Standard Price":9180.0,"Note":"**"},{"Itemcode":"64135714","Description":"Matrix, Dermal-Dermaspan 4x8","CDM Revenue Code":"278","CDM HCPCS":"Q4126","Standard Price":11636.16},{"Itemcode":"64135715","Description":"Scissor Hyp Disp HYP-ST-DS","CDM Revenue Code":"272","Standard Price":671.16},{"Itemcode":"64135716","Description":"AmnioFill 2000mg AF-2000","CDM Revenue Code":"272","Standard Price":13923.0,"Note":"**"},{"Itemcode":"64135717","Description":"NUCEL 2cc NC-1002","CDM Revenue Code":"278","Standard Price":10608.0,"Note":"**"},{"Itemcode":"64135718","Description":"Kit Interstim Smart TH90G01","CDM Revenue Code":"272","Standard Price":8154.9,"Note":"**"},{"Itemcode":"64135719","Description":"Device Colpassist 831821","CDM Revenue Code":"272","Standard Price":2188.92,"Note":"**"},{"Itemcode":"64135720","Description":"Imp Sys Lig Deltoid Reconstr","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8176.32},{"Itemcode":"64135721","Description":"Impl Staple DynaNite 11Wx10L","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6252.6},{"Itemcode":"64135722","Description":"Alloderm CM1516","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":12726.54,"Note":"**"},{"Itemcode":"64135723","Description":"Implant Medpor Titan 81032","CDM Revenue Code":"278","Standard Price":5375.4,"Note":"**"},{"Itemcode":"64135724","Description":"Tissue Patch Cornea GPC-W","CDM Revenue Code":"278","Standard Price":1404.54,"Note":"**"},{"Itemcode":"64135725","Description":"Implant Latera LATSYS","CDM Revenue Code":"278","Standard Price":4161.6,"Note":"**"},{"Itemcode":"64135726","Description":"Sys Hammertoe Fixation","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4998.0,"Note":"**"},{"Itemcode":"64135727","Description":"Alloderm Thick16x20cm 1519320","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":30866.22,"Note":"**"},{"Itemcode":"64135728","Description":"INnate Implant 3.6mmx50mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3032.46,"Note":"**"},{"Itemcode":"64135729","Description":"INnate Instrument Kit 4.5mm","CDM Revenue Code":"272","Standard Price":1300.5,"Note":"**"},{"Itemcode":"64135730","Description":"Alloderm Contour XL CXL1519P","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":19869.6,"Note":"**"},{"Itemcode":"64135731","Description":"Alloderm Contour Large CL1516","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":15813.06,"Note":"**"},{"Itemcode":"64135732","Description":"Matrix Wound PURAPLY 2x2","CDM Revenue Code":"278","CDM HCPCS":"Q4196","Standard Price":3136.5,"Note":"**"},{"Itemcode":"64135733","Description":"System Scout Multi Sinus","CDM Revenue Code":"272","Standard Price":8154.9,"Note":"**"},{"Itemcode":"64135734","Description":"Kit Instr AXI++LINE","CDM Revenue Code":"272","Standard Price":975.12,"Note":"**"},{"Itemcode":"64135735","Description":"BARRIER AVIVE 3X6CM CA0306","CDM Revenue Code":"278","Standard Price":12514.38,"Note":"**"},{"Itemcode":"64135736","Description":"GuideWire DigiFuse DW-2590","CDM Revenue Code":"272","Standard Price":5352.96,"Note":"**"},{"Itemcode":"64135737","Description":"CABLE NAVG TRUDI TDNC001","CDM Revenue Code":"272","Standard Price":1154.64,"Note":"**"},{"Itemcode":"64135738","Description":"TheraSkin XLR 104TSXLR","CDM Revenue Code":"278","CDM HCPCS":"Q4121","Standard Price":10266.3,"Note":"**"},{"Itemcode":"64135739","Description":"VIA Form Moldable, 2.5cc","CDM Revenue Code":"278","Standard Price":6900.3,"Note":"**"},{"Itemcode":"64135740","Description":"Tissue FlexHD 11x20 SF2002","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":11611.68,"Note":"**"},{"Itemcode":"64135742","Description":"Allgrft Amnio Biovance 2x4CM","CDM Revenue Code":"278","CDM HCPCS":"Q4154","Standard Price":9409.5,"Note":"**"},{"Itemcode":"64135743","Description":"Matrix Amnion Patch 4x6","CDM Revenue Code":"272","Standard Price":7423.56,"Note":"**"},{"Itemcode":"64135744","Description":"Instr Kit Cartiva 10mm MTK-10","CDM Revenue Code":"272","Standard Price":2340.9,"Note":"**"},{"Itemcode":"64135745","Description":"Prosthesis Penile Tactra 11x16","CDM Revenue Code":"278","CDM HCPCS":"C2622","Standard Price":38106.18,"Note":"**"},{"Itemcode":"64135746","Description":"H50 Ablator Aspiration AR-9835","CDM Revenue Code":"272","Standard Price":1035.3,"Note":"**"},{"Itemcode":"64135747","Description":"ALLODERM LG 164sqcm CL1518","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":15813.06,"Note":"**"},{"Itemcode":"64135748","Description":"ALLODERM 320sqcm 1518320","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":30866.22,"Note":"**"},{"Itemcode":"64135749","Description":"Endoblade System AR-8850DC","CDM Revenue Code":"272","Standard Price":2509.2,"Note":"**"},{"Itemcode":"64135750","Description":"Kit Instrument TH00001","CDM Revenue Code":"272","Standard Price":1300.5,"Note":"**"},{"Itemcode":"64135751","Description":"Zone Navigator AR-7900","CDM Revenue Code":"272","Standard Price":1300.5,"Note":"**"},{"Itemcode":"64135752","Description":"Anterior Cann Zone Nav AR-7905","CDM Revenue Code":"272","Standard Price":780.3,"Note":"**"},{"Itemcode":"64135753","Description":"Lt Can Mid ZN Navigtr AR-7910L","CDM Revenue Code":"272","Standard Price":780.3,"Note":"**"},{"Itemcode":"64135754","Description":"Allgrft Amnio Biovance 3x5CM","CDM Revenue Code":"278","CDM HCPCS":"Q4154","Standard Price":4867.44,"Note":"**"},{"Itemcode":"64135755","Description":"Kit Instr STRM-1MPJ-INST-KT","CDM Revenue Code":"272","Standard Price":2205.24,"Note":"**"},{"Itemcode":"64135756","Description":"Kit Tenodesis Graft Sizing","CDM Revenue Code":"272","Standard Price":1535.1,"Note":"**"},{"Itemcode":"64135757","Description":"INBONE Alignment Guide PROPINB","CDM Revenue Code":"272","Standard Price":5444.76,"Note":"**"},{"Itemcode":"64135758","Description":"Plate Strl Instr Kit 1500-4700","CDM Revenue Code":"272","Standard Price":2075.7,"Note":"**"},{"Itemcode":"64135759","Description":"INBONE Screw Bone Remover","CDM Revenue Code":"272","Standard Price":858.84,"Note":"**"},{"Itemcode":"64135760","Description":"PuraPlyAM-COM 5x5","CDM Revenue Code":"278","CDM HCPCS":"Q4196","Standard Price":9116.76,"Note":"**"},{"Itemcode":"64135761","Description":"PuraForce 6x3cm 550-004","CDM Revenue Code":"272","Standard Price":7527.6,"Note":"**"},{"Itemcode":"64135762","Description":"Instr Kit Cartiva 8mm MTK-08","CDM Revenue Code":"272","Standard Price":2340.9,"Note":"**"},{"Itemcode":"64135763","Description":"Alloderm Lg Perforated CL1519P","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":16283.28,"Note":"**"},{"Itemcode":"64135764","Description":"Mesh Ovine Poly Perm 10x20cm","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":14586.0,"Note":"**"},{"Itemcode":"64135765","Description":"PuraForce 6x2cm 550-002","CDM Revenue Code":"278","Standard Price":5406.0,"Note":"**"},{"Itemcode":"64135766","Description":"PuraForce 8x4cm 550-002","CDM Revenue Code":"278","Standard Price":9409.5,"Note":"**"},{"Itemcode":"64135767","Description":"TheraSkin 2x3 102TSL","CDM Revenue Code":"278","CDM HCPCS":"Q4121","Standard Price":5089.8,"Note":"**"},{"Itemcode":"64135768","Description":"Neurostimulator Axonics 1101","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":33816.06,"Note":"**"},{"Itemcode":"64135769","Description":"Remote Control Axonics 2301","CDM Revenue Code":"278","CDM HCPCS":"C1787","Standard Price":3349.68,"Note":"**"},{"Itemcode":"64135770","Description":"Lead Impl Kit Axonics 1801","CDM Revenue Code":"278","CDM HCPCS":"C1894","Standard Price":1706.46,"Note":"**"},{"Itemcode":"64135771","Description":"Charging Sys Axonics 1401","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":3576.12,"Note":"**"},{"Itemcode":"64136128","Description":"Vein Femoral Cryolife V060","CDM Revenue Code":"278","Standard Price":21978.96},{"Itemcode":"64136162","Description":"Navigus Kit External 9730848","CDM Revenue Code":"272","Standard Price":5012.28,"Note":"**"},{"Itemcode":"64136172","Description":"Charging System Stim 37752","CDM Revenue Code":"272","Standard Price":10194.9},{"Itemcode":"64136175","Description":"Antenna Dorsal Stimulat 37092","CDM Revenue Code":"272","Standard Price":516.12},{"Itemcode":"64136183","Description":"Lead Quattro Sprint 6944-65","CDM Revenue Code":"278","Standard Price":16234.32},{"Itemcode":"64136196","Description":"Plug Small Bone 6215-5-001","CDM Revenue Code":"278","Standard Price":449.82,"Note":"**"},{"Itemcode":"64136220","Description":"Tube Humerus T2 1806-0073S","CDM Revenue Code":"278","Standard Price":1099.56,"Note":"**"},{"Itemcode":"64136259","Description":"Stent Graft Endoprosthesis","CDM Revenue Code":"278","Standard Price":16181.28,"Note":"**"},{"Itemcode":"64136279","Description":"Valve Delta 42824","CDM Revenue Code":"278","Standard Price":5326.44},{"Itemcode":"64136280","Description":"Valve Delta 42822","CDM Revenue Code":"278","Standard Price":5302.98},{"Itemcode":"64136291","Description":"Remote Patient Sc-5500-02","CDM Revenue Code":"272","Standard Price":2791.74},{"Itemcode":"64136292","Description":"Generator Pulse Sc-1110","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":45722.52},{"Itemcode":"64136293","Description":"Charger Patient Sc-6400-02","CDM Revenue Code":"272","Standard Price":10378.5},{"Itemcode":"64136295","Description":"Kit Patient Trial Sc-6500-02","CDM Revenue Code":"272","Standard Price":622.2},{"Itemcode":"64136296","Description":"Stylet Enhance 70Cm Sc-4395-70","CDM Revenue Code":"272","Standard Price":770.1,"Note":"**"},{"Itemcode":"64136301","Description":"Accudrain Csf System Ins-8401","CDM Revenue Code":"272","Standard Price":1352.52,"Note":"**"},{"Itemcode":"64136302","Description":"Cath Ventricular 951-303","CDM Revenue Code":"272","Standard Price":944.52,"Note":"**"},{"Itemcode":"64136309","Description":"Implant Medpore Micro Plate","CDM Revenue Code":"278","Standard Price":2440.86},{"Itemcode":"64136312","Description":"Stylet Enhanced Sc-4395-50Cm","CDM Revenue Code":"272","Standard Price":770.1},{"Itemcode":"64136325","Description":"Loop 25Mm Gooseneck Gn2500","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1698.3,"Note":"**"},{"Itemcode":"64136338","Description":"Plug Port","CDM Revenue Code":"272","Standard Price":319.26},{"Itemcode":"64136339","Description":"Wrench -Pacer/Neurostim","CDM Revenue Code":"272","Standard Price":293.76,"Note":"**"},{"Itemcode":"64136346","Description":"Bone Spike 71512450","CDM Revenue Code":"272","Standard Price":279.48},{"Itemcode":"64136360","Description":"Set Blood Pump 36/42 05050036H","CDM Revenue Code":"272","Standard Price":60184.08},{"Itemcode":"64136368","Description":"Compressor Open 395.51","CDM Revenue Code":"278","Standard Price":1925.76},{"Itemcode":"64136377","Description":"Valve Holter Med 82-1601","CDM Revenue Code":"272","Standard Price":1459.62},{"Itemcode":"64136379","Description":"Reservoir Nl850-1211","CDM Revenue Code":"272","Standard Price":1845.18},{"Itemcode":"64136382","Description":"Allograft Osteochond Foa30C","CDM Revenue Code":"278","Standard Price":33478.44},{"Itemcode":"64136408","Description":"Reservoir Csf Nl850","CDM Revenue Code":"278","Standard Price":1708.5},{"Itemcode":"64136420","Description":"Synchro Med Ii Pt Mgr 8832","CDM Revenue Code":"278","CDM HCPCS":"C1772","Standard Price":9668.58},{"Itemcode":"64136441","Description":"Pyramesh 10Mm 905-902","CDM Revenue Code":"278","Standard Price":24962.46},{"Itemcode":"64136443","Description":"Kit Tool Rotation 6056","CDM Revenue Code":"272","Standard Price":176.46},{"Itemcode":"64136444","Description":"Mesh Panel Small Neuro 01-7182","CDM Revenue Code":"278","Standard Price":4380.9,"Note":"**"},{"Itemcode":"64136451","Description":"Module Neurovision Grp 1","CDM Revenue Code":"272","Standard Price":3839.28,"Note":"**"},{"Itemcode":"64136453","Description":"Fiberloop # 2 Ar-7234","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64136454","Description":"System Charging Sc-6412","CDM Revenue Code":"278","Standard Price":7137.96},{"Itemcode":"64136470","Description":"Defibrillator Dual V-268","CDM Revenue Code":"278","Standard Price":78862.32},{"Itemcode":"64136476","Description":"Crosslink Bar 6902530","CDM Revenue Code":"278","Standard Price":568.14},{"Itemcode":"64136485","Description":"Defib Dr-Virtuoso D154Awg","CDM Revenue Code":"278","CDM HCPCS":"C1721","Standard Price":74266.2},{"Itemcode":"64136490","Description":"Cath Suprapubic 12Fr Ac01A","CDM Revenue Code":"272","Standard Price":1030.2},{"Itemcode":"64136491","Description":"Tip Driver 2.5Mm Hpc-0025","CDM Revenue Code":"272","Standard Price":939.42},{"Itemcode":"64136503","Description":"Clip Stimulation","CDM Revenue Code":"272","Standard Price":1592.22,"Note":"**"},{"Itemcode":"64136504","Description":"Defib. Vr-Virtuoso D154Vwc-Sys","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"64136521","Description":"Charge System Ans 3701","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":3877.02},{"Itemcode":"64136522","Description":"Programmer Patient Ans 3851","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":2975.34},{"Itemcode":"64136539","Description":"Coil Embolization Gr 1","CDM Revenue Code":"278","Standard Price":324.36},{"Itemcode":"64136550","Description":"Angioseal","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1101.6,"Note":"**"},{"Itemcode":"64136554","Description":"Extension/Adapter Lead DBS/NS","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":3201.78,"Note":"**"},{"Itemcode":"64136558","Description":"Kit Pleural Cath 50-7000","CDM Revenue Code":"278","CDM HCPCS":"C1729","Standard Price":2511.24,"Note":"**"},{"Itemcode":"64136567","Description":"Pacemaker Sys Sensia Sedro1-D","CDM Revenue Code":"278","Standard Price":0.0},{"Itemcode":"64136579","Description":"Flexhd 8X16 Derm Tissue 472816","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":13481.34},{"Itemcode":"64136584","Description":"NeuroStim Kit Pnt Trial- Grp2","CDM Revenue Code":"272","Standard Price":626.28},{"Itemcode":"64136585","Description":"Alloderm Tissue 16X20 102320","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":34713.66},{"Itemcode":"64136588","Description":"Tenoglide 2X2 Tg221","CDM Revenue Code":"278","CDM HCPCS":"C9356","Standard Price":9050.46,"Note":"**"},{"Itemcode":"64136591","Description":"Allograft Meniscus M040","CDM Revenue Code":"278","Standard Price":21978.96},{"Itemcode":"64136601","Description":"Clip Aneurysm Group 3","CDM Revenue Code":"278","Standard Price":2016.54,"Note":"**"},{"Itemcode":"64136608","Description":"Lead NS Surgcl 70CM SC-8120-70","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":9200.4},{"Itemcode":"64136614","Description":"Lead NeurStim SurgKit 2x8-50Cm","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":9200.4},{"Itemcode":"64136619","Description":"Pacemaker Sr-Sensia Sesro1","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":14466.66},{"Itemcode":"64136622","Description":"Gen Vagal Nerve Stim 102R","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":44501.58},{"Itemcode":"64136631","Description":"Spacer Anterior Stt36130-8Lr","CDM Revenue Code":"278","Standard Price":22316.58},{"Itemcode":"64136640","Description":"Prosthesis Penile Inflatable","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":19273.92},{"Itemcode":"64136646","Description":"Allograft R Condyle 268012","CDM Revenue Code":"278","Standard Price":33644.7},{"Itemcode":"64136649","Description":"System Pedicle Access 2010024","CDM Revenue Code":"272","Standard Price":2202.18},{"Itemcode":"64136655","Description":"Kit Dilator Vascular","CDM Revenue Code":"272","Standard Price":1128.12},{"Itemcode":"64136661","Description":"Stent Airway Bifuc M00570680","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":12105.36},{"Itemcode":"64136665","Description":"Stem Hip L92528","CDM Revenue Code":"278","Standard Price":28632.42},{"Itemcode":"64136666","Description":"Pump Pain Ap-3000L","CDM Revenue Code":"278","CDM HCPCS":"C1772","Standard Price":23027.52},{"Itemcode":"64136667","Description":"Permacol Tissue 20X30 152030","CDM Revenue Code":"278","Standard Price":48472.44},{"Itemcode":"64136669","Description":"Dextrus Seal Cap Hap02","CDM Revenue Code":"272","Standard Price":2437.8},{"Itemcode":"64136671","Description":"Kit Maxcess Disp 3200061","CDM Revenue Code":"272","Standard Price":4602.24},{"Itemcode":"64136673","Description":"Kit Disp Xlif 2010050","CDM Revenue Code":"272","Standard Price":4235.04},{"Itemcode":"64136674","Description":"Lead Icd Sprint 6947-58Cm","CDM Revenue Code":"278","CDM HCPCS":"C1895","Standard Price":16156.8},{"Itemcode":"64136675","Description":"Generator Primeadvance37702Sys","CDM Revenue Code":"278","Standard Price":58497.0},{"Itemcode":"64136678","Description":"Stimulator Restor Sys 37711 -D","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":58497.0},{"Itemcode":"64136679","Description":"Stent Viabahn 7X 10-15 VBH","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":12183.9,"Note":"**"},{"Itemcode":"64136680","Description":"Kit Restore Tripole 37711Sy","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":63568.44},{"Itemcode":"64136681","Description":"Valve Aortic Homograft Avoo","CDM Revenue Code":"278","Standard Price":39036.42},{"Itemcode":"64136686","Description":"Guide Cutting Custom Knee Imp","CDM Revenue Code":"272","Standard Price":6398.46},{"Itemcode":"64136688","Description":"Tool Tunneling Sc-4254","CDM Revenue Code":"272","Standard Price":1194.42,"Note":"**"},{"Itemcode":"64136691","Description":"Stem Femoral Hip L92522","CDM Revenue Code":"278","Standard Price":24085.26},{"Itemcode":"64136699","Description":"Kit Electrode Needle 8010040","CDM Revenue Code":"272","Standard Price":5780.34},{"Itemcode":"64136708","Description":"Pad Pacing Fibrillator 305","CDM Revenue Code":"272","Standard Price":230.52},{"Itemcode":"64136711","Description":"Prosthesis Penile Pump Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":24614.64},{"Itemcode":"64136713","Description":"Connector Pump 8578","CDM Revenue Code":"278","Standard Price":795.6,"Note":"**"},{"Itemcode":"64136714","Description":"Handpiece, Bipolar","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64136715","Description":"Lead Size 20 302-20","CDM Revenue Code":"278","Standard Price":16912.62},{"Itemcode":"64136716","Description":"Charge System Mini Scs 3721","CDM Revenue Code":"272","Standard Price":2639.76},{"Itemcode":"64136725","Description":"Graftrope Ac Ar-2258","CDM Revenue Code":"278","Standard Price":4235.04},{"Itemcode":"64136731","Description":"Graft Surgisis C-Sah-8H-13X15","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":11768.76},{"Itemcode":"64136733","Description":"Integra Bilayer MWD 8x10cm","CDM Revenue Code":"278","CDM HCPCS":"Q4104","Standard Price":15745.74},{"Itemcode":"64136734","Description":"Integra Wnd Matrix 8x10cm","CDM Revenue Code":"278","CDM HCPCS":"Q4108","Standard Price":27050.4},{"Itemcode":"64136740","Description":"Remote Control Scs Sc-5210","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":2791.74},{"Itemcode":"64136750","Description":"Kit Disp Navigation Howmedica","CDM Revenue Code":"272","Standard Price":2647.92,"Note":"**"},{"Itemcode":"64136754","Description":"Dress Acticoat 4X10 66021772","CDM Revenue Code":"272","Standard Price":302.94,"Note":"**"},{"Itemcode":"64136756","Description":"Coseal 8Ml 934072","CDM Revenue Code":"272","Standard Price":3850.5,"Note":"**"},{"Itemcode":"64136759","Description":"Graft Acellular Flex 472620","CDM Revenue Code":"278","Standard Price":33243.84},{"Itemcode":"64136760","Description":"Oxygenator Quadrox Hmod2030","CDM Revenue Code":"272","Standard Price":4756.26},{"Itemcode":"64136761","Description":"Spool Transition 152.200","CDM Revenue Code":"278","Standard Price":2647.92},{"Itemcode":"64136762","Description":"Bumper 10Mm 452.150S","CDM Revenue Code":"278","Standard Price":2647.92},{"Itemcode":"64136764","Description":"Clip Stimulation 675.700","CDM Revenue Code":"272","Standard Price":2772.36},{"Itemcode":"64136765","Description":"Component Prox Hip 21-108293","CDM Revenue Code":"278","Standard Price":27266.64},{"Itemcode":"64136766","Description":"Light Source Quadrant 9560658","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64136767","Description":"Defibrillator Dual 2207-36","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":59770.98},{"Itemcode":"64136768","Description":"Lead Durata Icd Dual Coil","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":13119.24},{"Itemcode":"64136770","Description":"Suction Reservior 910500","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"64136771","Description":"Lead Attain 88Cm 4195-88Cm","CDM Revenue Code":"278","Standard Price":10237.74},{"Itemcode":"64136772","Description":"Sheath Safe Coronary Sinus","CDM Revenue Code":"278","CDM HCPCS":"C1894","Standard Price":8212.02},{"Itemcode":"64136775","Description":"Allograft Talus Human 32647001","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64136777","Description":"Kit Electrode 8050015","CDM Revenue Code":"272","Standard Price":4478.82,"Note":"**"},{"Itemcode":"64136778","Description":"Kit Dilator 2029950","CDM Revenue Code":"272","Standard Price":4058.58,"Note":"**"},{"Itemcode":"64136780","Description":"System Harvesting Vh-3000","CDM Revenue Code":"272","Standard Price":4052.46,"Note":"**"},{"Itemcode":"64136784","Description":"Stent Life Flexstar","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":8957.64},{"Itemcode":"64136785","Description":"Permacol Collagen P151828","CDM Revenue Code":"278","Standard Price":23774.16},{"Itemcode":"64136790","Description":"Pak Accessory 502","CDM Revenue Code":"272","Standard Price":2816.22},{"Itemcode":"64136791","Description":"Stem Femoral Grip 1012-04-070","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":13270.2},{"Itemcode":"64136792","Description":"Lead Extension Neuro 3341/3382","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":3817.86},{"Itemcode":"64136793","Description":"Filter Fem/Jug Grp 1","CDM Revenue Code":"278","Standard Price":6320.94},{"Itemcode":"64136794","Description":"Lead Reliance","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":15216.36},{"Itemcode":"64136796","Description":"Pacer/Defib Cognis N119","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":76925.34},{"Itemcode":"64136799","Description":"Block Custom System Fem/Tib","CDM Revenue Code":"272","Standard Price":6398.46},{"Itemcode":"64136800","Description":"Tip Inserter Disp 03.617.902","CDM Revenue Code":"272","Standard Price":711.96,"Note":"**"},{"Itemcode":"64136802","Description":"Allograft Trinity 10Cc 410110","CDM Revenue Code":"278","Standard Price":14499.3},{"Itemcode":"64136806","Description":"Stent Trach/Airway","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8533.32},{"Itemcode":"64136808","Description":"Adaptor Pocket 1X4 74001","CDM Revenue Code":"278","Standard Price":2627.52},{"Itemcode":"64136809","Description":"Generator Restore 37712-D","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":60187.14},{"Itemcode":"64136812","Description":"Allograft Osteochond 32147002","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":36180.42},{"Itemcode":"64136813","Description":"Battery Deep Brain Stim 37601","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":59392.56,"Note":"**"},{"Itemcode":"64136814","Description":"Defibrillator Concerto D274Trk","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":82622.04},{"Itemcode":"64136815","Description":"Catheter Guide Attain 6250-Mpr","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":1364.76},{"Itemcode":"64136816","Description":"Kit Accessory Scs 3550-P4","CDM Revenue Code":"272","Standard Price":1327.02,"Note":"**"},{"Itemcode":"64136817","Description":"Plate Spire 45Mm 9240100","CDM Revenue Code":"278","Standard Price":13525.2,"Note":"**"},{"Itemcode":"64136818","Description":"Dilator Sextant 8675424","CDM Revenue Code":"272","Standard Price":1448.4},{"Itemcode":"64136819","Description":"Scalpel Disp 1001-90112","CDM Revenue Code":"272","Standard Price":1422.9},{"Itemcode":"64136823","Description":"KIT ACCESS PEDICLE 624.027S","CDM Revenue Code":"272","Standard Price":4925.58},{"Itemcode":"64136826","Description":"Device Synfix Plate","CDM Revenue Code":"278","Standard Price":21302.7},{"Itemcode":"64136829","Description":"Lead Durata","CDM Revenue Code":"278","CDM HCPCS":"C1895","Standard Price":15300.0},{"Itemcode":"64136830","Description":"Defib Pro Rf 3207-36","CDM Revenue Code":"275","Standard Price":78202.38},{"Itemcode":"64136834","Description":"NS Adaptor Pocket Scs 74002","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":4222.8},{"Itemcode":"64136835","Description":"Pack Custom Ccs Perf Cb6F98R2","CDM Revenue Code":"272","Standard Price":2975.34},{"Itemcode":"64136836","Description":"Tube Delivery Graft 2090-0227","CDM Revenue Code":"272","Standard Price":2387.82},{"Itemcode":"64136838","Description":"Tube Delivery 2090-0216","CDM Revenue Code":"272","Standard Price":1910.46},{"Itemcode":"64136841","Description":"Consulta Crt Bi-V D224Trk","CDM Revenue Code":"278","CDM HCPCS":"C1882","Standard Price":79052.04},{"Itemcode":"64136842","Description":"Occluder Vascular Abd Ocl24Us","CDM Revenue Code":"278","Standard Price":10643.7},{"Itemcode":"64137115","Description":"Cath: Iabp -Cl","CDM Revenue Code":"272","Standard Price":3826.02,"Note":"**"},{"Itemcode":"64137500","Description":"Filter Vena Cava","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":3732.18},{"Itemcode":"64137563","Description":"Guidewire Journey 300cm Strt","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1040.4,"Note":"**"},{"Itemcode":"64137790","Description":"Tray: Pericardiocentesis","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":970.02},{"Itemcode":"64138013","Description":"Nail Valor 415101120R","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":12833.64,"Note":"**"},{"Itemcode":"64138294","Description":"Cath Guid 6FR MultiD, Envoy","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2288.88},{"Itemcode":"64138295","Description":"Plate Spinal 12X34X24MM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":16906.5},{"Itemcode":"64138296","Description":"Graft Vasc, Gortex 8x40","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":1882.92,"Note":"**"},{"Itemcode":"64138297","Description":"Impl Insert Tibia Stab XLK 8MM","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":2772.36},{"Itemcode":"64138298","Description":"GenNeurostim NonHF RchrgBatSys","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":47527.92},{"Itemcode":"64138300","Description":"Stent, Endopros:7X10MMX120CM","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":11818.74,"Note":"**"},{"Itemcode":"64138301","Description":"Syst Endoblade Plantr Fasc Rel","CDM Revenue Code":"272","Standard Price":5455.98,"Note":"**"},{"Itemcode":"64138302","Description":"Arrowlock Fixation System","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5439.66},{"Itemcode":"64138403","Description":"Kit Bone Marrow","CDM Revenue Code":"272","Standard Price":9363.6},{"Itemcode":"64138407","Description":"Sheath Introducer 24Fr Sdv2228","CDM Revenue Code":"272","Standard Price":1712.58},{"Itemcode":"64138408","Description":"Sheath Introducer 12Fr Sdv2228","CDM Revenue Code":"272","Standard Price":1712.58},{"Itemcode":"64138409","Description":"Kit Hip Disposable Ar-6509Dc","CDM Revenue Code":"272","Standard Price":2742.78},{"Itemcode":"64138410","Description":"Light Source Disp 48250210","CDM Revenue Code":"272","Standard Price":1771.74},{"Itemcode":"64138411","Description":"Disposable Extractor 90-5140","CDM Revenue Code":"272","Standard Price":2202.18},{"Itemcode":"64138412","Description":"Kit Platelet 60Ml Apc-60","CDM Revenue Code":"272","Standard Price":1845.18},{"Itemcode":"64138413","Description":"Kit Applicator Spray","CDM Revenue Code":"272","Standard Price":258.06},{"Itemcode":"64138414","Description":"Filter Co2 Laser Omniguide","CDM Revenue Code":"272","Standard Price":386.58},{"Itemcode":"64138415","Description":"Kit Navigated Pedicle 9733498","CDM Revenue Code":"272","Standard Price":2445.96},{"Itemcode":"64138416","Description":"Lead Defibrilator Sprint","CDM Revenue Code":"278","CDM HCPCS":"C1895","Standard Price":21766.8},{"Itemcode":"64138417","Description":"Cath Silverhawk","CDM Revenue Code":"272","CDM HCPCS":"C1714","Standard Price":10643.7},{"Itemcode":"64138418","Description":"Tray Tibial 1294-35-415","CDM Revenue Code":"278","Standard Price":22109.52},{"Itemcode":"64138420","Description":"Fiber Laser Neuro-L","CDM Revenue Code":"272","Standard Price":8867.88},{"Itemcode":"64138421","Description":"Remote Access 7438","CDM Revenue Code":"272","Standard Price":2645.88},{"Itemcode":"64138422","Description":"Handpiece Solo Grip 705-37020","CDM Revenue Code":"272","Standard Price":16028.28},{"Itemcode":"64138423","Description":"Kit Dis Mars 3V 698.600S","CDM Revenue Code":"272","Standard Price":10365.24},{"Itemcode":"64138424","Description":"Remote Access 7438","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":2645.88},{"Itemcode":"64138425","Description":"Rope Tight Acl Ar-1588T","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1857.42},{"Itemcode":"64138426","Description":"Lead Icd 65Cm 7120-65","CDM Revenue Code":"278","CDM HCPCS":"C1895","Standard Price":16602.54},{"Itemcode":"64138427","Description":"Osteotome Flexible 9986-21-27","CDM Revenue Code":"272","Standard Price":689.52,"Note":"**"},{"Itemcode":"64138428","Description":"System Disp Joint 904837","CDM Revenue Code":"272","Standard Price":2985.54},{"Itemcode":"64138429","Description":"Wire Ensnare Retrieval","CDM Revenue Code":"272","Standard Price":1857.42,"Note":"**"},{"Itemcode":"64138430","Description":"Kit Platelet Abs-10012","CDM Revenue Code":"272","Standard Price":1418.82},{"Itemcode":"64138431","Description":"Applicator Spray Abs-10051","CDM Revenue Code":"272","Standard Price":373.32},{"Itemcode":"64138432","Description":"Kit Platelet 20Ml Apc-20","CDM Revenue Code":"272","Standard Price":1250.52},{"Itemcode":"64138433","Description":"Femur Distal L FDF","CDM Revenue Code":"278","Standard Price":13508.88},{"Itemcode":"64138434","Description":"Stem Hip L92526","CDM Revenue Code":"272","Standard Price":26509.8},{"Itemcode":"64138435","Description":"Kit Procedure Scoop T10Sp11","CDM Revenue Code":"272","Standard Price":3735.24},{"Itemcode":"64138436","Description":"Kit Refill Synchrome Pump 8551","CDM Revenue Code":"272","Standard Price":180.54,"Note":"**"},{"Itemcode":"64138437","Description":"Proxiderm Expander Tissue D460","CDM Revenue Code":"272","Standard Price":625.26},{"Itemcode":"64138438","Description":"Condyl Hemi Partial 43747002","CDM Revenue Code":"278","Standard Price":23838.42},{"Itemcode":"64138440","Description":"Applier Atriclip 260066R","CDM Revenue Code":"272","Standard Price":6378.06},{"Itemcode":"64138442","Description":"Atriclip Occlusion Device","CDM Revenue Code":"278","Standard Price":6378.06},{"Itemcode":"64138443","Description":"Graft Homograft Aort Av0021","CDM Revenue Code":"278","Standard Price":33796.68},{"Itemcode":"64138444","Description":"Graft Homograft Aortic Av0025","CDM Revenue Code":"278","Standard Price":35120.64},{"Itemcode":"64138445","Description":"Knife Metrix Sheath 1571-00","CDM Revenue Code":"272","Standard Price":2074.68},{"Itemcode":"64138446","Description":"Graft Homograft Av10025","CDM Revenue Code":"278","Standard Price":33796.68},{"Itemcode":"64138447","Description":"MatrixMesh Integra 2X2 Bmw2021","CDM Revenue Code":"278","CDM HCPCS":"Q4104","Standard Price":6147.54,"Note":"**"},{"Itemcode":"64138448","Description":"Graft Iliac Aortic 9X7.3 R010","CDM Revenue Code":"278","Standard Price":59173.26},{"Itemcode":"64138449","Description":"NuroStm Rechrg Systm SC-6412-3","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":6492.3,"Note":"**"},{"Itemcode":"64138450","Description":"ICD Singl FortifyVr Cd1231-40Q","CDM Revenue Code":"278","CDM HCPCS":"C1722","Standard Price":52705.44},{"Itemcode":"64138451","Description":"Tube Exchange Monitor 315-0001","CDM Revenue Code":"272","Standard Price":625.26},{"Itemcode":"64138452","Description":"Filter Laser L-1608R1","CDM Revenue Code":"272","Standard Price":386.58},{"Itemcode":"64138453","Description":"Gen Deep Brain Activa Sc 37602","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":30719.34,"Note":"**"},{"Itemcode":"64138454","Description":"Kit Platelet 60Ml Apc-60","CDM Revenue Code":"272","Standard Price":1756.44},{"Itemcode":"64138455","Description":"Battery System 70-1010","CDM Revenue Code":"272","Standard Price":613.02,"Note":"**"},{"Itemcode":"64138456","Description":"Implant Toe Small 4571-0100","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2647.92},{"Itemcode":"64138457","Description":"Kit Disp Pro Toe 4571-0300","CDM Revenue Code":"272","Standard Price":811.92},{"Itemcode":"64138458","Description":"Implant Titan Medpor 81040","CDM Revenue Code":"278","Standard Price":10643.7},{"Itemcode":"64138459","Description":"Suture Shuttle 45 Right 251004","CDM Revenue Code":"272","Standard Price":864.96},{"Itemcode":"64138460","Description":"Passer Connector Om-8010","CDM Revenue Code":"272","Standard Price":689.52,"Note":"**"},{"Itemcode":"64138461","Description":"Needle Ava Flex Afh0011","CDM Revenue Code":"272","Standard Price":2647.92},{"Itemcode":"64138462","Description":"Cath 3Lu 7F 16C Ask-42703-Pcsj","CDM Revenue Code":"272","Standard Price":750.72,"Note":"**"},{"Itemcode":"64138463","Description":"Device Turbo Hawk Lx-M Th-Lx-M","CDM Revenue Code":"272","CDM HCPCS":"C1714","Standard Price":10653.9},{"Itemcode":"64138464","Description":"Filter Trapease 466-P306Au","CDM Revenue Code":"278","Standard Price":5937.42},{"Itemcode":"64138465","Description":"Component Art Graft Hero1002","CDM Revenue Code":"278","Standard Price":3903.54},{"Itemcode":"64138466","Description":"Component Venous Hero1001","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":10044.96},{"Itemcode":"64138468","Description":"Screw Pedicel Access 3400021","CDM Revenue Code":"272","Standard Price":4478.82},{"Itemcode":"64138469","Description":"Generator Primeadvanced 37702","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":50858.22},{"Itemcode":"64138470","Description":"Tool Flexor Tendon T0-Ftrt","CDM Revenue Code":"272","Standard Price":2652.0},{"Itemcode":"64138471","Description":"ICD Sj4 Fort Dua Ch Cd2231-40Q","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":63155.34},{"Itemcode":"64138473","Description":"Brigade Implant 6941238","CDM Revenue Code":"278","Standard Price":16906.5},{"Itemcode":"64138474","Description":"Extender Lateral 7756067","CDM Revenue Code":"278","Standard Price":2652.0},{"Itemcode":"64138475","Description":"Guide Cutting Tr7100-L","CDM Revenue Code":"272","Standard Price":3839.28},{"Itemcode":"64138476","Description":"Wire Spider SM Spd2Us-050","CDM Revenue Code":"272","CDM HCPCS":"C1884","Standard Price":6824.82},{"Itemcode":"64138477","Description":"NS Lead Kit Ext 40Cm 37081-40","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":2965.14},{"Itemcode":"64138478","Description":"Generator Pulse Spine 37713","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":58497.0},{"Itemcode":"64138479","Description":"Generator Rf Sr Pm1210","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":16240.44},{"Itemcode":"64138481","Description":"Implant Distal Biceps Ar-2260","CDM Revenue Code":"278","Standard Price":5692.62},{"Itemcode":"64138483","Description":"Device Reattachment 498.806S","CDM Revenue Code":"278","Standard Price":8030.46},{"Itemcode":"64138484","Description":"Pack Hip Arthroscopy Ar-6509Ds","CDM Revenue Code":"272","Standard Price":2742.78},{"Itemcode":"64138485","Description":"Shunt Lumbar Strata 44420","CDM Revenue Code":"278","Standard Price":13128.42},{"Itemcode":"64138486","Description":"Osseoflex Delivery System","CDM Revenue Code":"278","Standard Price":6718.74},{"Itemcode":"64138487","Description":"Button Patella 7.0 P306-0070-W","CDM Revenue Code":"278","Standard Price":2934.54},{"Itemcode":"64138488","Description":"Botton Ziploop Joint 904834","CDM Revenue Code":"278","Standard Price":2858.04},{"Itemcode":"64138489","Description":"Implant Zero P 9Mm 04.617.139S","CDM Revenue Code":"278","Standard Price":9703.26,"Note":"**"},{"Itemcode":"64138490","Description":"Kit Cranial Access Ins-Hith","CDM Revenue Code":"272","Standard Price":1991.04,"Note":"**"},{"Itemcode":"64138491","Description":"Set Temp Monitor 1104Hmt","CDM Revenue Code":"272","Standard Price":4206.48},{"Itemcode":"64138492","Description":"ICP Ventricular 110-4Hmt","CDM Revenue Code":"272","Standard Price":3487.38},{"Itemcode":"64138493","Description":"Device Synfix 30Mm 08.802.012S","CDM Revenue Code":"278","Standard Price":21978.96},{"Itemcode":"64138494","Description":"Tissue Ovation 1Cc Ps31001","CDM Revenue Code":"278","Standard Price":10653.9},{"Itemcode":"64138495","Description":"Cath Crosser 5Fr Cru014S","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":10643.7},{"Itemcode":"64138496","Description":"Kit Maxcess Disp 324xxxx","CDM Revenue Code":"272","Standard Price":6824.82,"Note":"**"},{"Itemcode":"64138497","Description":"System Cement Delivery Cds2A","CDM Revenue Code":"272","Standard Price":2627.52,"Note":"**"},{"Itemcode":"64138498","Description":"Cement Mixer Cx01B","CDM Revenue Code":"272","Standard Price":1899.24,"Note":"**"},{"Itemcode":"64138500","Description":"Kit Sheath Laser 14Fr 500-012","CDM Revenue Code":"272","Standard Price":9426.84},{"Itemcode":"64138501","Description":"Device Lead Lock #2 518-019","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2578.56},{"Itemcode":"64138502","Description":"Kit Lld Accessory 518-027","CDM Revenue Code":"272","Standard Price":596.7},{"Itemcode":"64138503","Description":"Kit Maxcess Shim 3240061","CDM Revenue Code":"272","Standard Price":4602.24},{"Itemcode":"64138504","Description":"Screw Driver Disp 450-0600","CDM Revenue Code":"272","Standard Price":587.52},{"Itemcode":"64138506","Description":"Cement Gun And Bone Sz3 Cc02A","CDM Revenue Code":"272","Standard Price":539.58},{"Itemcode":"64138507","Description":"Device Corknot 030800","CDM Revenue Code":"272","Standard Price":2122.62,"Note":"**"},{"Itemcode":"64138508","Description":"Reload Corknot 030850","CDM Revenue Code":"272","Standard Price":259.08},{"Itemcode":"64138509","Description":"Kit Mixing 417200","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64138510","Description":"Slitter Ds2A003","CDM Revenue Code":"272","Standard Price":322.32},{"Itemcode":"64138511","Description":"Gun Meniscal 228143","CDM Revenue Code":"272","Standard Price":1098.54},{"Itemcode":"64138512","Description":"EP Cath Guid Fxd Crv Intercard","CDM Revenue Code":"272","CDM HCPCS":"C1893","Standard Price":3228.3},{"Itemcode":"64138513","Description":"Needle Omnispan","CDM Revenue Code":"272","Standard Price":1751.34},{"Itemcode":"64138514","Description":"ICD Sj4 Unify Crt C Cd3231-40Q","CDM Revenue Code":"278","Standard Price":74388.6},{"Itemcode":"64138515","Description":"Kit Mdfl Ar-1360B-Cp","CDM Revenue Code":"278","Standard Price":8403.78},{"Itemcode":"64138516","Description":"Mesh Panel 01-7340","CDM Revenue Code":"278","Standard Price":2652.0},{"Itemcode":"64138517","Description":"Tubing Str Shot To Xps 1895522","CDM Revenue Code":"272","Standard Price":172.38,"Note":"**"},{"Itemcode":"64138518","Description":"Device Endovascular 300-30159","CDM Revenue Code":"272","Standard Price":23652.78},{"Itemcode":"64138519","Description":"Stent Tracheal Covrd 9X38","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10915.02,"Note":"**"},{"Itemcode":"64138520","Description":"Driver Disp","CDM Revenue Code":"272","Standard Price":1134.24,"Note":"**"},{"Itemcode":"64138521","Description":"Pack Pin 99-35039-00002St10","CDM Revenue Code":"272","Standard Price":2223.6,"Note":"**"},{"Itemcode":"64138522","Description":"Generator Pulse Dbs 37603","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":30719.34,"Note":"**"},{"Itemcode":"64138523","Description":"Implant Impacted Lg 6713926","CDM Revenue Code":"278","Standard Price":13525.2},{"Itemcode":"64138524","Description":"Graft Stent Thor Tf4040C159Cp","CDM Revenue Code":"278","Standard Price":54523.08},{"Itemcode":"64138525","Description":"Graft Stent Tf4242C15Cp","CDM Revenue Code":"278","Standard Price":56890.5},{"Itemcode":"64138526","Description":"Tack Holding 321-0004","CDM Revenue Code":"272","Standard Price":161.16},{"Itemcode":"64138527","Description":"Mangifuse 1Cmx10Cm 7509211","CDM Revenue Code":"278","Standard Price":9861.36},{"Itemcode":"64138528","Description":"Cath Support Crosser Crus6A","CDM Revenue Code":"272","Standard Price":10643.7},{"Itemcode":"64138529","Description":"Drill Cannulated 338.332","CDM Revenue Code":"272","Standard Price":6868.68},{"Itemcode":"64138530","Description":"Tubing Selector 5450-850-003","CDM Revenue Code":"272","Standard Price":2098.14,"Note":"**"},{"Itemcode":"64138531","Description":"Lead Tool Epicardial 10626","CDM Revenue Code":"272","Standard Price":4052.46},{"Itemcode":"64138532","Description":"Vitagel Hemostat 2113-0000","CDM Revenue Code":"278","Standard Price":2364.36},{"Itemcode":"64138533","Description":"Patch Perica 7X15 Cmcv-003-402","CDM Revenue Code":"278","Standard Price":5524.32},{"Itemcode":"64138534","Description":"Button Retro Ar-1592","CDM Revenue Code":"272","Standard Price":2011.44},{"Itemcode":"64138535","Description":"Tightrope Rt Ar-1588Rt","CDM Revenue Code":"278","Standard Price":1570.8,"Note":"**"},{"Itemcode":"64138536","Description":"Cutter Flip","CDM Revenue Code":"272","Standard Price":2467.38,"Note":"**"},{"Itemcode":"64138537","Description":"Patch Cormatrix Cmcv-006-609","CDM Revenue Code":"278","Standard Price":2161.38,"Note":"**"},{"Itemcode":"64138538","Description":"Tool Tunneling 3655","CDM Revenue Code":"272","Standard Price":742.56},{"Itemcode":"64138539","Description":"Set Impella Pump 005062","CDM Revenue Code":"278","Standard Price":94676.4},{"Itemcode":"64138540","Description":"Set Impella Pump Ld A/C 005082","CDM Revenue Code":"278","Standard Price":94676.4},{"Itemcode":"64138541","Description":"Kit Disp Suture Tak Ar-1322Dsc","CDM Revenue Code":"278","Standard Price":1042.44,"Note":"**"},{"Itemcode":"64138542","Description":"Button Retro 12Mm Ar-1588-60","CDM Revenue Code":"278","Standard Price":1247.46},{"Itemcode":"64138543","Description":"Aigis Pm Abx Env Cmrm3133","CDM Revenue Code":"278","Standard Price":3993.3},{"Itemcode":"64138544","Description":"System Mobile Charging 3711","CDM Revenue Code":"272","Standard Price":2639.76},{"Itemcode":"64138545","Description":"Wire Reduction 4.3 03.120.023","CDM Revenue Code":"272","Standard Price":2756.04},{"Itemcode":"64138546","Description":"Cutter 2.9 72202403","CDM Revenue Code":"272","Standard Price":2127.72},{"Itemcode":"64138547","Description":"Catheter Scoop 9Cm C-9-2","CDM Revenue Code":"272","Standard Price":717.06},{"Itemcode":"64138548","Description":"Catheter Balloon Cmd15","CDM Revenue Code":"272","Standard Price":10653.9},{"Itemcode":"64138549","Description":"Pack Disposable Mcp-Dis-Str","CDM Revenue Code":"272","Standard Price":1970.64},{"Itemcode":"64138550","Description":"Gen AICD Energen VR HE E141","CDM Revenue Code":"278","CDM HCPCS":"C1722","Standard Price":48721.32},{"Itemcode":"64138551","Description":"Powder Absorbable 2114-0003","CDM Revenue Code":"272","Standard Price":226.44},{"Itemcode":"64138552","Description":"Pack Mpfl Ar-1360-B-Lp","CDM Revenue Code":"272","Standard Price":8403.78},{"Itemcode":"64138553","Description":"Passer Suture","CDM Revenue Code":"272","Standard Price":674.22,"Note":"**"},{"Itemcode":"64138555","Description":"Sleeve Inserter 7168-7031","CDM Revenue Code":"278","Standard Price":881.28},{"Itemcode":"64138556","Description":"Recorder Reveal Xt 9529","CDM Revenue Code":"278","Standard Price":15047.04},{"Itemcode":"64138557","Description":"Dilator Stimular 945Nsd2750","CDM Revenue Code":"272","Standard Price":2188.92},{"Itemcode":"64138558","Description":"Bipolar Long 1590-00","CDM Revenue Code":"272","Standard Price":2404.14},{"Itemcode":"64138559","Description":"Tip Inserter 03.820.134S","CDM Revenue Code":"272","Standard Price":661.98,"Note":"**"},{"Itemcode":"64138560","Description":"Cage Plate 26X32 08.802.004S","CDM Revenue Code":"278","Standard Price":19950.18},{"Itemcode":"64138562","Description":"Drill Step 6.4 7163-1160","CDM Revenue Code":"272","Standard Price":3861.72},{"Itemcode":"64138563","Description":"Lead Reliance Df4","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":16535.22},{"Itemcode":"64138564","Description":"Matrix Collagen 5Cm Cnw6050","CDM Revenue Code":"278","CDM HCPCS":"C9361","Standard Price":7123.68},{"Itemcode":"64138565","Description":"Defib Protecta Xt D314Trg","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":88188.18},{"Itemcode":"64138566","Description":"Lead Pacemaker 4296-88Cm","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":11339.34},{"Itemcode":"64138567","Description":"Cage T-Lif 12Mm 08.812.212","CDM Revenue Code":"278","Standard Price":19526.88,"Note":"**"},{"Itemcode":"64138568","Description":"Device Synfic 08.802.019S","CDM Revenue Code":"278","Standard Price":21302.7},{"Itemcode":"64138569","Description":"Monopolar Hook Ar-6528-02","CDM Revenue Code":"272","Standard Price":3020.22},{"Itemcode":"64138570","Description":"Ovation Small .3Cc Ps31030","CDM Revenue Code":"278","Standard Price":6804.42},{"Itemcode":"64138571","Description":"Kit Magellan Mar01","CDM Revenue Code":"272","Standard Price":7891.74},{"Itemcode":"64138572","Description":"Graft Grafix Core 5X5 Ps22055","CDM Revenue Code":"278","CDM HCPCS":"Q4132","Standard Price":7365.42},{"Itemcode":"64138573","Description":"Graft L Medial Menisca 2822502","CDM Revenue Code":"278","Standard Price":16061.94},{"Itemcode":"64138574","Description":"Grafix Prime 5X5 Ps21055","CDM Revenue Code":"278","CDM HCPCS":"Q4133","Standard Price":10313.22},{"Itemcode":"64138575","Description":"System Charging 3722","CDM Revenue Code":"272","Standard Price":2639.76},{"Itemcode":"64138576","Description":"Set Disp Juggerknot 912041","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1941.06},{"Itemcode":"64138577","Description":"Cage Peek Xlif 6210160","CDM Revenue Code":"278","Standard Price":18597.66},{"Itemcode":"64138578","Description":"Disc Artifcl 5-6MM 09.820.0XXS","CDM Revenue Code":"278","Standard Price":16311.84,"Note":"**"},{"Itemcode":"64138579","Description":"Kit W Syringe 03.702.215S","CDM Revenue Code":"272","Standard Price":790.5},{"Itemcode":"64138580","Description":"Kit Access 03.804.512S","CDM Revenue Code":"272","Standard Price":2053.26},{"Itemcode":"64138581","Description":"Spacer Peek 10X22Mm 193.101","CDM Revenue Code":"278","Standard Price":19560.54,"Note":"**"},{"Itemcode":"64138582","Description":"Anchor Peek Xc-201-01","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6808.5},{"Itemcode":"64138583","Description":"Gen NS Pulse Sc-1132","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":55115.7},{"Itemcode":"64138584","Description":"NSKit Remote Control SC-5532-1","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":4497.18,"Note":"**"},{"Itemcode":"64138585","Description":"Pack Hip Scope Ar-6526S","CDM Revenue Code":"272","Standard Price":2742.78},{"Itemcode":"64138586","Description":"Cage Peek 10X26Mm 193.102","CDM Revenue Code":"278","Standard Price":19560.54,"Note":"**"},{"Itemcode":"64138587","Description":"Screw Driver Lag 71674068","CDM Revenue Code":"272","Standard Price":2647.92},{"Itemcode":"64138588","Description":"Spacer 10X30Cm 193.113","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138589","Description":"Implant Brigade 6941234","CDM Revenue Code":"278","Standard Price":16906.5},{"Itemcode":"64138590","Description":"Anchor System Implt","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9603.3,"Note":"**"},{"Itemcode":"64138591","Description":"Kit 3-Arm Disp Davinci 420290","CDM Revenue Code":"272","Standard Price":1060.8},{"Itemcode":"64138592","Description":"Permacol 10X15Cmx1.5Mm P151015","CDM Revenue Code":"278","Standard Price":10480.5},{"Itemcode":"64138594","Description":"Cage Peek 7-14Mmx30Mm 193.103","CDM Revenue Code":"278","Standard Price":21640.32,"Note":"**"},{"Itemcode":"64138595","Description":"System Delivery Ar-2268","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7192.02},{"Itemcode":"64138596","Description":"Kit Protoe Inst Disp 45710500","CDM Revenue Code":"272","Standard Price":1398.42},{"Itemcode":"64138597","Description":"Sheath Laser","CDM Revenue Code":"272","CDM HCPCS":"C2629","Standard Price":10405.02},{"Itemcode":"64138598","Description":"Countersink","CDM Revenue Code":"272","Standard Price":1327.02,"Note":"**"},{"Itemcode":"64138599","Description":"Spacer 10X26Mm 193.112","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138600","Description":"Scalpel Plasma Aw-422552/3.Om","CDM Revenue Code":"272","Standard Price":2276.64,"Note":"**"},{"Itemcode":"64138602","Description":"Filter Meridian Femoral Md800F","CDM Revenue Code":"278","Standard Price":4672.62},{"Itemcode":"64138603","Description":"Cone Body 11-301302","CDM Revenue Code":"278","Standard Price":20723.34},{"Itemcode":"64138604","Description":"Graft Stent Thoracic Vamf","CDM Revenue Code":"278","Standard Price":65918.52,"Note":"**"},{"Itemcode":"64138605","Description":"Anchor Sys Implant Ar-1360C-Cp","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6218.94,"Note":"**"},{"Itemcode":"64138606","Description":"Perclose Proglide 12673","CDM Revenue Code":"272","Standard Price":1183.2},{"Itemcode":"64138607","Description":"Chargng Sys Int/Ext-Repl 37754","CDM Revenue Code":"274","CDM HCPCS":"L8689","Standard Price":10194.9},{"Itemcode":"64138608","Description":"Remote Patient Sc-15532-1","CDM Revenue Code":"272","Standard Price":4497.18},{"Itemcode":"64138609","Description":"Plate Sup/Inf End Pdl-M-Sp06S","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":15216.36},{"Itemcode":"64138610","Description":"Marker Meduim 10Mm Pdl-M-T10S","CDM Revenue Code":"278","Standard Price":4435.98},{"Itemcode":"64138611","Description":"Custom Cutting Block","CDM Revenue Code":"272","Standard Price":3839.28,"Note":"**"},{"Itemcode":"64138612","Description":"Alloderm Rtu 16X20Cm 1520320","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":35237.94,"Note":"**"},{"Itemcode":"64138614","Description":"Graft Stent Vam3232C150Tu","CDM Revenue Code":"278","Standard Price":62537.22,"Note":"**"},{"Itemcode":"64138615","Description":"Alloderm Tissue Contour CL1520","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":18204.96},{"Itemcode":"64138616","Description":"Graft 32147001","CDM Revenue Code":"278","Standard Price":37026.0},{"Itemcode":"64138617","Description":"NS Kit Lead Trial SC-2316-50E","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":8983.14,"Note":"**"},{"Itemcode":"64138618","Description":"Lead Targeting 66-It-Ar4P","CDM Revenue Code":"272","Standard Price":689.52,"Note":"**"},{"Itemcode":"64138619","Description":"Splint Nasal Posisep X 9210584","CDM Revenue Code":"272","Standard Price":678.3,"Note":"**"},{"Itemcode":"64138620","Description":"Kit Access 8700-9112","CDM Revenue Code":"272","Standard Price":5972.1},{"Itemcode":"64138621","Description":"Kit Monitor 8700-9122","CDM Revenue Code":"272","Standard Price":3839.28},{"Itemcode":"64138622","Description":"Cage Latis 10X32Mm 181.210","CDM Revenue Code":"278","Standard Price":16906.5},{"Itemcode":"64138623","Description":"Screw Cap Head Tulip 1119-0100","CDM Revenue Code":"278","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64138624","Description":"Patch Tissue 4X7 Cmcv-004-404","CDM Revenue Code":"278","Standard Price":3391.5},{"Itemcode":"64138625","Description":"Illuminator 38-Light-1","CDM Revenue Code":"272","Standard Price":1612.62},{"Itemcode":"64138627","Description":"Cage Latis 10X32Mm 181.209","CDM Revenue Code":"278","Standard Price":19933.86},{"Itemcode":"64138628","Description":"Device Anchor Band Fb-201-01","CDM Revenue Code":"278","Standard Price":3412.92,"Note":"**"},{"Itemcode":"64138629","Description":"TAVR VALVE","CDM Revenue Code":"278","Standard Price":109892.76,"Note":"**"},{"Itemcode":"64138630","Description":"CLAMP BAND 1754-55-055","CDM Revenue Code":"272","Standard Price":3993.3},{"Itemcode":"64138631","Description":"IMPLANTABLE DOPPLER PROBE","CDM Revenue Code":"278","Standard Price":3984.12},{"Itemcode":"64138632","Description":"DIALATOR ENDOVAS","CDM Revenue Code":"272","Standard Price":929.22,"Note":"**"},{"Itemcode":"64138633","Description":"Heart-Lung Dispo Kit - ECMO","CDM Revenue Code":"272","Standard Price":44379.18,"Note":"**"},{"Itemcode":"64138635","Description":"STARFIX PLATFORM UNILATERAL","CDM Revenue Code":"272","Standard Price":10560.06},{"Itemcode":"64138636","Description":"STARFIX PLATFORM BILATERAL","CDM Revenue Code":"272","Standard Price":15216.36},{"Itemcode":"64138639","Description":"TRAY PLATFORM SZ 3 1294-35-315","CDM Revenue Code":"278","Standard Price":23898.6},{"Itemcode":"64138640","Description":"Iovera System Disp Tip","CDM Revenue Code":"272","Standard Price":2340.9,"Note":"**"},{"Itemcode":"64138641","Description":"KIT DISP TOGGLEL WASHER 909846","CDM Revenue Code":"272","Standard Price":3528.18},{"Itemcode":"64138642","Description":"KIT T3AMZ DISPOSABLE AR-13217","CDM Revenue Code":"272","Standard Price":2999.82,"Note":"**"},{"Itemcode":"64138644","Description":"BOLT EXTRACTION 71631320","CDM Revenue Code":"272","Standard Price":1650.36,"Note":"**"},{"Itemcode":"64138645","Description":"TRAY CHEST TUBE 16FR G05462","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":905.76},{"Itemcode":"64138646","Description":"SPACER RISE 10X30MM 193.123","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138647","Description":"OSTEOTOME FLEXIBLE","CDM Revenue Code":"272","Standard Price":3097.74},{"Itemcode":"64138648","Description":"SYRINGE VASOSHIELD VH5001","CDM Revenue Code":"272","Standard Price":1029.18,"Note":"**"},{"Itemcode":"64138649","Description":"DEVICE SYNFIX 32MM 08.802.001S","CDM Revenue Code":"278","Standard Price":21302.7},{"Itemcode":"64138650","Description":"ADAPTER ENDO III 139249","CDM Revenue Code":"278","Standard Price":939.42},{"Itemcode":"64138651","Description":"AWL DISPOSABLE 3608-90035","CDM Revenue Code":"272","Standard Price":1113.84},{"Itemcode":"64138652","Description":"KIT CATH INSERTION VP-211","CDM Revenue Code":"272","Standard Price":1029.18},{"Itemcode":"64138653","Description":"SYSTEM SHOULDER 10MX83M 113630","CDM Revenue Code":"278","Standard Price":20139.9},{"Itemcode":"64138654","Description":"HANDLE DISTAL iO-DH","CDM Revenue Code":"272","Standard Price":1327.02},{"Itemcode":"64138656","Description":"SPLITTER FASCIAL 8801279","CDM Revenue Code":"278","Standard Price":2652.0},{"Itemcode":"64138657","Description":"TUBE SET COMBO 905103","CDM Revenue Code":"272","Standard Price":3199.74},{"Itemcode":"64138658","Description":"CATHETER CORONARY SINUS PR9","CDM Revenue Code":"272","Standard Price":8487.42},{"Itemcode":"64138659","Description":"CAGE BRIGADE 7502075","CDM Revenue Code":"278","Standard Price":18597.66},{"Itemcode":"64138666","Description":"TIP YANK WAVEGUIDE","CDM Revenue Code":"272","Standard Price":1368.84},{"Itemcode":"64138667","Description":"STIMULATOR 39286-65CM","CDM Revenue Code":"278","Standard Price":20964.06},{"Itemcode":"64138668","Description":"NAIL VALOR 11.5X200 415101120L","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13038.66},{"Itemcode":"64138669","Description":"SPACER 8-15MM (26MM) 193.122","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138670","Description":"AVS ARIA NEURO PROBE DILATOR","CDM Revenue Code":"272","Standard Price":3839.28},{"Itemcode":"64138671","Description":"CORENT CAGE","CDM Revenue Code":"278","Standard Price":18597.66,"Note":"**"},{"Itemcode":"64138672","Description":"OSTEOTOME 6MM SERRA OHSO2060SU","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64138673","Description":"KIT PLATELET ABS-10011","CDM Revenue Code":"272","Standard Price":872.1},{"Itemcode":"64138674","Description":"KIT SHOULDER SPS0121K","CDM Revenue Code":"278","Standard Price":13527.24},{"Itemcode":"64138675","Description":"TRAIL SPS971","CDM Revenue Code":"278","Standard Price":2013.48},{"Itemcode":"64138676","Description":"Kit Platelet","CDM Revenue Code":"272","Standard Price":872.1},{"Itemcode":"64138677","Description":"Device Fusion","CDM Revenue Code":"278","Standard Price":22576.68},{"Itemcode":"64138678","Description":"Nail Valor 415101125R","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13038.66,"Note":"**"},{"Itemcode":"64138679","Description":"WAND APOLLO LG AP9","CDM Revenue Code":"272","Standard Price":18918.96},{"Itemcode":"64138680","Description":"Cath Pulmonary Endovent EV","CDM Revenue Code":"272","Standard Price":6056.76,"Note":"**"},{"Itemcode":"64138681","Description":"Kit EMG Module 8050315","CDM Revenue Code":"272","Standard Price":3839.28,"Note":"**"},{"Itemcode":"64138682","Description":"KIT PROC XLIF PRECEPT 8027088","CDM Revenue Code":"278","Standard Price":36850.56},{"Itemcode":"64138683","Description":"Davinci Forcep 428080","CDM Revenue Code":"272","Standard Price":5998.62},{"Itemcode":"64138684","Description":"COUPLER GEM VAS W/PROBE","CDM Revenue Code":"278","Standard Price":3688.32},{"Itemcode":"64138685","Description":"CAGE CORVENT 10MM 1663012","CDM Revenue Code":"278","Standard Price":22824.54},{"Itemcode":"64138686","Description":"Mesh Panel Lactosorb 915-2412","CDM Revenue Code":"278","Standard Price":3612.84},{"Itemcode":"64138687","Description":"WIRE MOD J TIP 260CM WWIJ35260","CDM Revenue Code":"272","Standard Price":1612.62},{"Itemcode":"64138688","Description":"Integra DRT 8x10 38101","CDM Revenue Code":"278","CDM HCPCS":"Q4105","Standard Price":23994.48},{"Itemcode":"64138689","Description":"Stem Shoulder 12x83mm 113632","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":13017.24},{"Itemcode":"64138690","Description":"Imp Spine Dev Interlam 14-16MM","CDM Revenue Code":"278","CDM HCPCS":"C1821","Standard Price":19670.7,"Note":"**"},{"Itemcode":"64138691","Description":"ANCHOR BUMPY 97791","CDM Revenue Code":"272","Standard Price":1060.8,"Note":"**"},{"Itemcode":"64138692","Description":"Plate Spinal Process 121316","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":19443.24},{"Itemcode":"64138693","Description":"Pusher Kit 2.9 AR-2923DS","CDM Revenue Code":"272","Standard Price":1327.02},{"Itemcode":"64138694","Description":"COMPONENT FEMORAL 71461016","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":26340.48},{"Itemcode":"64138695","Description":"KIT PREP FEMORAL SZ6 5555-2256","CDM Revenue Code":"272","Standard Price":1022.04,"Note":"**"},{"Itemcode":"64138696","Description":"KIT PREP TIBIAL SZ6 5555-2326","CDM Revenue Code":"272","Standard Price":729.3},{"Itemcode":"64138697","Description":"Cable Trial","CDM Revenue Code":"272","Standard Price":1060.8},{"Itemcode":"64138698","Description":"BUTTON RIGIDLOOP 25MM 232014","CDM Revenue Code":"272","Standard Price":2344.98,"Note":"**"},{"Itemcode":"64138699","Description":"KIT RIDGIDLOOP","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64138700","Description":"MESH MALLEABLE LG 53-00486","CDM Revenue Code":"278","Standard Price":3769.92},{"Itemcode":"64138701","Description":"Genratr Neuro Rechg SC-1032A/B","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":58497.0},{"Itemcode":"64138702","Description":"Blade Shaver Micro iO-MBS5.5","CDM Revenue Code":"272","Standard Price":6557.58},{"Itemcode":"64138704","Description":"Femoral Component 150351","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":21263.94},{"Itemcode":"64138705","Description":"DISK ARTIFICIAL CORE ASSEMBLY","CDM Revenue Code":"278","Standard Price":7811.16},{"Itemcode":"64138706","Description":"DISK ARTIFICIAL END PLATE","CDM Revenue Code":"278","Standard Price":16852.44},{"Itemcode":"64138707","Description":"GRAFT MITROFLOW CONDUIT MVC030","CDM Revenue Code":"278","Standard Price":9372.78},{"Itemcode":"64138708","Description":"HANDLE DISTAL","CDM Revenue Code":"272","Standard Price":1501.44},{"Itemcode":"64138709","Description":"CAGE FUSION 10X26MM 1124.1011","CDM Revenue Code":"278","Standard Price":21640.32,"Note":"**"},{"Itemcode":"64138710","Description":"GRAFT GRAFIX XC 7.5X15 PS24075","CDM Revenue Code":"278","CDM HCPCS":"Q4133","Standard Price":20795.76},{"Itemcode":"64138711","Description":"KIT PORTAL ENTRY","CDM Revenue Code":"272","Standard Price":1745.22},{"Itemcode":"64138712","Description":"LEVEL BUBBLE DISP","CDM Revenue Code":"272","Standard Price":1077.12},{"Itemcode":"64138713","Description":"DISC CERVICAL","CDM Revenue Code":"278","Standard Price":15216.36},{"Itemcode":"64138714","Description":"CAGE LUMBAR 8-12MM 1124.1111","CDM Revenue Code":"278","Standard Price":21640.32,"Note":"**"},{"Itemcode":"64138715","Description":"CAGE 10MMX50MMX6 2968050","CDM Revenue Code":"278","Standard Price":20964.06},{"Itemcode":"64138716","Description":"CAGE 10X31MM 1124.1013","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138717","Description":"ANCHOR SUTURE","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1910.46,"Note":"**"},{"Itemcode":"64138718","Description":"DILATOR 4.75MM 72203951","CDM Revenue Code":"278","Standard Price":1035.3},{"Itemcode":"64138719","Description":"KIT PORTAL ENTRY","CDM Revenue Code":"272","Standard Price":1746.24,"Note":"**"},{"Itemcode":"64138720","Description":"PASSER SUTURE 02590","CDM Revenue Code":"272","Standard Price":1852.32,"Note":"**"},{"Itemcode":"64138721","Description":"PORTAL ENTRY KIT 00241","CDM Revenue Code":"272","Standard Price":1746.24},{"Itemcode":"64138722","Description":"LEAD RA 1944-52","CDM Revenue Code":"278","Standard Price":2720.34},{"Itemcode":"64138724","Description":"WRAPSURGI BIORESORB 27204","CDM Revenue Code":"278","Standard Price":1309.68},{"Itemcode":"64138725","Description":"KIT LEAD NEUROSTIMULATOR","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":15300.0,"Note":"**"},{"Itemcode":"64138726","Description":"KIT ACCESS PEDICLE","CDM Revenue Code":"272","Standard Price":3915.78,"Note":"**"},{"Itemcode":"64138728","Description":"CAGE LORDOTIC 194.945","CDM Revenue Code":"278","Standard Price":20287.8},{"Itemcode":"64138729","Description":"BULLET ENDO 698.135S","CDM Revenue Code":"272","Standard Price":3808.68},{"Itemcode":"64138730","Description":"DISC PCM MEDIUM 6.5MM 7680365","CDM Revenue Code":"278","Standard Price":15216.36},{"Itemcode":"64138732","Description":"CAGE FUSION 2926250","CDM Revenue Code":"278","Standard Price":23060.16},{"Itemcode":"64138733","Description":"REDUCTION DEVICE","CDM Revenue Code":"272","Standard Price":1501.44},{"Itemcode":"64138734","Description":"EPIPHYSIS MODULAR 130720101","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":20189.88},{"Itemcode":"64138735","Description":"SYSTEM OATS 10MM AR-1981-10S","CDM Revenue Code":"272","Standard Price":3169.14,"Note":"**"},{"Itemcode":"64138736","Description":"BAR 10.5X250MM 71062250","CDM Revenue Code":"272","Standard Price":1263.78},{"Itemcode":"64138737","Description":"CLAMP 6 H MULTIPIN 71067376","CDM Revenue Code":"272","Standard Price":4435.98,"Note":"**"},{"Itemcode":"64138738","Description":"GUIDEWIRE GROUP 3","CDM Revenue Code":"272","Standard Price":1298.46,"Note":"**"},{"Itemcode":"64138739","Description":"KIT PROC XLIF PRECEPT 8200265","CDM Revenue Code":"278","Standard Price":45648.06},{"Itemcode":"64138740","Description":"CAGE TLIF 9-13MM 1124.1112","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138741","Description":"STENT VIABAHN","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10643.7,"Note":"**"},{"Itemcode":"64138748","Description":"GRAFT STENT","CDM Revenue Code":"278","Standard Price":53678.52},{"Itemcode":"64138749","Description":"PUSHER KNOT AR-4515","CDM Revenue Code":"272","Standard Price":949.62,"Note":"**"},{"Itemcode":"64138750","Description":"DEVICE INTERLLAMINER UQ100010","CDM Revenue Code":"278","CDM HCPCS":"C1821","Standard Price":19668.66},{"Itemcode":"64138751","Description":"CAGE LUMBAR 1124.1113","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138752","Description":"KIT ACCESSORY KYPHO","CDM Revenue Code":"272","Standard Price":8901.54},{"Itemcode":"64138753","Description":"MIXER INJECTION SYS TO60415","CDM Revenue Code":"272","Standard Price":1910.46},{"Itemcode":"64138754","Description":"BIPOLAR ELLMAN 4793.692","CDM Revenue Code":"272","Standard Price":2469.42},{"Itemcode":"64138755","Description":"STEM FEMORAL 1572-02-195","CDM Revenue Code":"278","Standard Price":20839.62},{"Itemcode":"64138756","Description":"BIPOLAR TRIGGER 40990.0031","CDM Revenue Code":"272","Standard Price":2647.92},{"Itemcode":"64138757","Description":"SYSTEM ENDO RELEASE 310040","CDM Revenue Code":"272","Standard Price":5038.8},{"Itemcode":"64138758","Description":"ROD LENGHTEN 5.5 MS1-5590S","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":59173.26},{"Itemcode":"64138759","Description":"CATH VISION 88901","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":4260.54},{"Itemcode":"64138760","Description":"DISSECTOR","CDM Revenue Code":"272","Standard Price":8685.3},{"Itemcode":"64138761","Description":"KIT ACCESS 210CM 701063540","CDM Revenue Code":"272","Standard Price":770.1,"Note":"**"},{"Itemcode":"64138762","Description":"HIPGRID 1015-012-121","CDM Revenue Code":"272","Standard Price":1194.42},{"Itemcode":"64138763","Description":"IRRIGATOR ENDOWRIST 410299","CDM Revenue Code":"272","Standard Price":1166.88},{"Itemcode":"64138764","Description":"TIP YANK ES3Y","CDM Revenue Code":"272","Standard Price":1459.62,"Note":"**"},{"Itemcode":"64138765","Description":"DEVICE RETRIEVAL 4200-20","CDM Revenue Code":"272","Standard Price":8937.24},{"Itemcode":"64138766","Description":"AWL STARTER DISP","CDM Revenue Code":"272","Standard Price":3412.92},{"Itemcode":"64138767","Description":"DISC CERVICAL MB3355","CDM Revenue Code":"278","Standard Price":15216.36},{"Itemcode":"64138768","Description":"KIT ACL DISP 232300","CDM Revenue Code":"272","Standard Price":2647.92,"Note":"**"},{"Itemcode":"64138769","Description":"PLUG 14-524038","CDM Revenue Code":"278","Standard Price":322.32},{"Itemcode":"64138770","Description":"KIT PUSHLOCK 3.5 AR-1926DS","CDM Revenue Code":"272","Standard Price":929.22},{"Itemcode":"64138771","Description":"BATTERY RESTORE SENSOR 97714","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":63400.14,"Note":"**"},{"Itemcode":"64138772","Description":"PIP ASCENSION PACK PIP-DIS-STR","CDM Revenue Code":"272","Standard Price":2043.06},{"Itemcode":"64138773","Description":"DEVICE COR KNOT MINI 031350","CDM Revenue Code":"272","Standard Price":2985.54,"Note":"**"},{"Itemcode":"64138774","Description":"CAGE PLATE 13MM 376.413","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":16906.5},{"Itemcode":"64138775","Description":"COMPONENT FEMORAL PX02-0855-W","CDM Revenue Code":"278","Standard Price":24504.48},{"Itemcode":"64138776","Description":"SCREW MARKER FIDUCIAL 019006","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":429.42},{"Itemcode":"64138777","Description":"LEAD ICD LDA220Q-58","CDM Revenue Code":"278","CDM HCPCS":"C1895","Standard Price":13119.24},{"Itemcode":"64138778","Description":"LEAD RA TENDRIL ICD 2088TC-46","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2647.92},{"Itemcode":"64138779","Description":"ELLIPSE DR ICD DUEL CD2411-36Q","CDM Revenue Code":"278","CDM HCPCS":"C1721","Standard Price":42266.76},{"Itemcode":"64138780","Description":"MESH XENMATRIX 10X15CM 1151015","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":13338.54},{"Itemcode":"64138781","Description":"KIT CENTRIFUGE GSBMA-60","CDM Revenue Code":"272","Standard Price":7891.74,"Note":"**"},{"Itemcode":"64138782","Description":"CAGE VBR","CDM Revenue Code":"278","Standard Price":21302.7},{"Itemcode":"64138783","Description":"BOLT ILIAC 8.5X70MM 8438570","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4692.0},{"Itemcode":"64138784","Description":"SPACER CERVICAL RISE 193.121","CDM Revenue Code":"278","Standard Price":21640.32,"Note":"**"},{"Itemcode":"64138785","Description":"TAPE FIBER COLLAGEN COATED","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"64138786","Description":"PUNCH 5.5 AR-1927PBS","CDM Revenue Code":"272","Standard Price":585.48,"Note":"**"},{"Itemcode":"64138787","Description":"CAGE LUMBAR 10X36 1124.1211","CDM Revenue Code":"278","Standard Price":21640.32},{"Itemcode":"64138788","Description":"KIT DILATOR AR-1923PK","CDM Revenue Code":"272","Standard Price":1166.88},{"Itemcode":"64138790","Description":"PLATFORM BIL MP-KIT-02D","CDM Revenue Code":"272","Standard Price":11328.12},{"Itemcode":"64138792","Description":"ENDOWRIST VESSEL SEALER 410322","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64138793","Description":"GUIDE/SHEATH HELI-FX","CDM Revenue Code":"272","Standard Price":7511.28,"Note":"**"},{"Itemcode":"64138794","Description":"ENDOANCHOR HELI FX SA-85","CDM Revenue Code":"278","Standard Price":16061.94,"Note":"**"},{"Itemcode":"64138795","Description":"Endoprosthesis VBJR061502A","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":13213.08,"Note":"**"},{"Itemcode":"64138796","Description":"REAMER DHS TRIPLE 338.13","CDM Revenue Code":"272","Standard Price":6353.58},{"Itemcode":"64138797","Description":"XLIF 2-LEVEL W/PLATE 8027025","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":33865.02},{"Itemcode":"64138798","Description":"CERVICAL FUSION KIT 8027189","CDM Revenue Code":"278","Standard Price":15448.92},{"Itemcode":"64138799","Description":"LUMBAR FUSION KIT","CDM Revenue Code":"278","Standard Price":36445.62},{"Itemcode":"64138800","Description":"ANTERIOR/POSTERIOR FUSION KIT","CDM Revenue Code":"278","Standard Price":57211.8},{"Itemcode":"64138801","Description":"GUIDE SUTURE 3.7 AR-1906","CDM Revenue Code":"272","Standard Price":2608.14},{"Itemcode":"64138802","Description":"FILLER BONE 90-300-251008","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13981.14},{"Itemcode":"64138803","Description":"WITTMAN PATCH EWP2040","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":9811.38},{"Itemcode":"64138804","Description":"SPINAL CORD STIMULATOR KIT","CDM Revenue Code":"278","Standard Price":68020.74,"Note":"**"},{"Itemcode":"64138805","Description":"CAGE RISE 10X22MM 193.141","CDM Revenue Code":"278","Standard Price":20641.74},{"Itemcode":"64138806","Description":"Access Platform Gelpoint Advan","CDM Revenue Code":"272","Standard Price":2739.72,"Note":"**"},{"Itemcode":"64138807","Description":"Access Platform Gelpoint Mini","CDM Revenue Code":"272","Standard Price":2422.5,"Note":"**"},{"Itemcode":"64138808","Description":"Access Platform Gelpnt Transan","CDM Revenue Code":"272","Standard Price":3023.28,"Note":"**"},{"Itemcode":"64138809","Description":"EXPANDER TISSUE TEXP120RH","CDM Revenue Code":"278","Standard Price":8439.48},{"Itemcode":"64138810","Description":"KIT QUICKSET 16CC ABS-3016","CDM Revenue Code":"278","Standard Price":13787.34},{"Itemcode":"64138811","Description":"CAGE PEEK 1124.1232","CDM Revenue Code":"278","Standard Price":20641.74},{"Itemcode":"64138812","Description":"CAGE PEEK 10X36MM 1124.1212","CDM Revenue Code":"278","Standard Price":20641.74},{"Itemcode":"64138813","Description":"BUTTON TIGHTROPE AR-1588TB","CDM Revenue Code":"278","Standard Price":1044.48},{"Itemcode":"64138814","Description":"VALVE HEART SOLO 21MM ICV1247","CDM Revenue Code":"278","Standard Price":18706.8},{"Itemcode":"64138815","Description":"CABLE MONITORING 38-STIM","CDM Revenue Code":"272","Standard Price":1383.12},{"Itemcode":"64138816","Description":"LIGHTSOURCE DISPO 38-LIGHT-1","CDM Revenue Code":"272","Standard Price":1528.98},{"Itemcode":"64138817","Description":"TIGHTROPE KNOTLESS AR-8926SS","CDM Revenue Code":"278","Standard Price":5104.08},{"Itemcode":"64138818","Description":"KIT SUTURE APEX AR-7298","CDM Revenue Code":"278","Standard Price":2320.5,"Note":"**"},{"Itemcode":"64138819","Description":"STEM HUMERAL AR-9100-07S","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":19238.22},{"Itemcode":"64138820","Description":"CAGE PEEK 10X26MM 1124.1033","CDM Revenue Code":"278","Standard Price":20641.74},{"Itemcode":"64138821","Description":"EPIFIX 6.0X16.0CM XL-5616","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":25236.84},{"Itemcode":"64138822","Description":"TSH MOLD,CEMENT SPACER","CDM Revenue Code":"272","Standard Price":4666.5},{"Itemcode":"64138823","Description":"CAGE EXPANDABLE","CDM Revenue Code":"278","Standard Price":18706.8},{"Itemcode":"64138824","Description":"CAGE CERVICAL 1124.1032","CDM Revenue Code":"278","Standard Price":20641.74},{"Itemcode":"64138825","Description":"PROBE CRYO-ABLATION CRY03","CDM Revenue Code":"272","Standard Price":9384.0,"Note":"**"},{"Itemcode":"64138826","Description":"CAGE 10X31MM 9-13MM 1124.1132","CDM Revenue Code":"278","Standard Price":21640.32,"Note":"**"},{"Itemcode":"64138827","Description":"GRAFT NERVE AVANCE 411270","CDM Revenue Code":"278","Standard Price":15216.36,"Note":"**"},{"Itemcode":"64138828","Description":"CABLE 1X16 OR SC-4116","CDM Revenue Code":"272","Standard Price":1592.22,"Note":"**"},{"Itemcode":"64138829","Description":"ALLODERM 9.6X19.3CM CM1516","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":14654.34,"Note":"**"},{"Itemcode":"64138830","Description":"Generator,NeurostimMRI Implan","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":45648.06},{"Itemcode":"64138832","Description":"DEVICE SUTURING FB-101-01","CDM Revenue Code":"272","Standard Price":2122.62},{"Itemcode":"64138833","Description":"PROGRAMMER PNT NEUROSTIM 3853","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":2972.28},{"Itemcode":"64138836","Description":"VALVE, SAPIEN TAVR","CDM Revenue Code":"278","Standard Price":109892.76,"Note":"**"},{"Itemcode":"64138837","Description":"GUIDEWIRE, WIRE Y","CDM Revenue Code":"272","Standard Price":1592.22},{"Itemcode":"64138838","Description":"GRAFT ENDOVASCULAR AAA GRP2","CDM Revenue Code":"278","Standard Price":36414.0,"Note":"**"},{"Itemcode":"64138839","Description":"GEN NEUROST RECHRG DBS ACTIVA","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":74388.6,"Note":"**"},{"Itemcode":"64138840","Description":"BIPOLAR TRIGGER 130401019A","CDM Revenue Code":"272","Standard Price":3412.92},{"Itemcode":"64138841","Description":"COMPONENT HUMERAL 130720103","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":19257.6},{"Itemcode":"64138842","Description":"CAGE CERVICAL 10X22MM 193.111","CDM Revenue Code":"278","Standard Price":20641.74},{"Itemcode":"64138843","Description":"CATH GUIDE 8F 54CM ACUITY 7069","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":1889.04},{"Itemcode":"64138844","Description":"COVER, LOCK SPINE","CDM Revenue Code":"278","Standard Price":938.4},{"Itemcode":"64138845","Description":"CAP,PIN","CDM Revenue Code":"272","Standard Price":261.12},{"Itemcode":"64138846","Description":"KIT REVISION, INTRATHECAL CATH","CDM Revenue Code":"272","Standard Price":2132.82},{"Itemcode":"64138847","Description":"PUMP BALLOON, FIBER OPTIC","CDM Revenue Code":"272","Standard Price":4416.6,"Note":"**"},{"Itemcode":"64138848","Description":"LOOP RETRO BUTTON FIXATN DEV","CDM Revenue Code":"278","Standard Price":1781.94},{"Itemcode":"64138849","Description":"REAMER, CANNULATED GRP 1","CDM Revenue Code":"272","Standard Price":1040.4,"Note":"**"},{"Itemcode":"64138850","Description":"ENDO PROSTHESIS COVRD W/ DEL V","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":11480.1,"Note":"**"},{"Itemcode":"64138851","Description":"CATHETER ANGIOGRAPHIC MUSTANG","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1300.5,"Note":"**"},{"Itemcode":"64138852","Description":"AAA Endoprosthesis Excluder","CDM Revenue Code":"278","Standard Price":36349.74,"Note":"**"},{"Itemcode":"64138853","Description":"CLIP,RAVINE LAT ACCESS SYS","CDM Revenue Code":"272","Standard Price":2414.34,"Note":"**"},{"Itemcode":"64138854","Description":"Screw Spine,Pedicle 6.0","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9000.48},{"Itemcode":"64138855","Description":"Blade, Helical TFN","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3726.06,"Note":"**"},{"Itemcode":"64138856","Description":"REAMER, CANNULATED GRP 2","CDM Revenue Code":"272","Standard Price":2467.38,"Note":"**"},{"Itemcode":"64138857","Description":"Sealant, Progel","CDM Revenue Code":"272","Standard Price":3626.1,"Note":"**"},{"Itemcode":"64138858","Description":"Screw Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6970.68,"Note":"**"},{"Itemcode":"64138859","Description":"Screw Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7803.0,"Note":"**"},{"Itemcode":"64138860","Description":"Screw Grp 11","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9051.48,"Note":"**"},{"Itemcode":"64138861","Description":"Screw Grp 12","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9883.8},{"Itemcode":"64138862","Description":"Screw Grp 13","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10924.2},{"Itemcode":"64138863","Description":"CONNECTOR,NERVE PORCINE ECM","CDM Revenue Code":"278","Standard Price":5439.66,"Note":"**"},{"Itemcode":"64138864","Description":"PIN,STEINMAN","CDM Revenue Code":"272","Standard Price":47.94,"Note":"**"},{"Itemcode":"64138865","Description":"GUIDE,NERVE INTEGRA","CDM Revenue Code":"278","CDM HCPCS":"C9352","Standard Price":5750.76},{"Itemcode":"64138866","Description":"STEM,HUMERAL ARTHREX","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":20183.76},{"Itemcode":"64138867","Description":"KIT ACCESS. RP BOOTS DBS","CDM Revenue Code":"272","Standard Price":582.42},{"Itemcode":"64138868","Description":"KIT COMPLEX FUSION,SPINE","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8642.46},{"Itemcode":"64138869","Description":"GUIDE PIN","CDM Revenue Code":"272","Standard Price":416.16,"Note":"**"},{"Itemcode":"64138870","Description":"NAIL, VALOR 10X150","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13836.3},{"Itemcode":"64138871","Description":"WAND,TURBO,REDUCTION ENT","CDM Revenue Code":"272","Standard Price":1078.14,"Note":"**"},{"Itemcode":"64138872","Description":"STEM HUMERAL ARTHREX UNIVERSE","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":20183.76},{"Itemcode":"64138873","Description":"CATH -OFF-ROAD REENTRY","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":9130.02},{"Itemcode":"64138874","Description":"NEEDLE CURVED,SPEED CINCH","CDM Revenue Code":"272","Standard Price":2410.26},{"Itemcode":"64138875","Description":"ABS,IMPLANT,TIGHTRPE AR-1588TN","CDM Revenue Code":"278","Standard Price":1395.36},{"Itemcode":"64138876","Description":"GUIDE PIN W/REAMERS","CDM Revenue Code":"272","Standard Price":2466.36,"Note":"**"},{"Itemcode":"64138877","Description":"INTERLLAMINER IMPLANT","CDM Revenue Code":"278","CDM HCPCS":"C1821","Standard Price":19670.7},{"Itemcode":"64138878","Description":"KIT OCTAPOLAR, DBS","CDM Revenue Code":"272","Standard Price":795.6},{"Itemcode":"64138879","Description":"IMPLANT SHOULDER REVERSE","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":23669.1,"Note":"**"},{"Itemcode":"64138880","Description":"ELECTRODE DISP GRP 3","CDM Revenue Code":"272","Standard Price":2601.0},{"Itemcode":"64138881","Description":"LEAD,EXTNSN, NEUROSTIM","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":3615.9},{"Itemcode":"64138882","Description":"WAND, MULTIVAC ENT","CDM Revenue Code":"272","Standard Price":1373.94},{"Itemcode":"64138883","Description":"NEEDLE GRP 3","CDM Revenue Code":"272","Standard Price":2496.96,"Note":"**"},{"Itemcode":"64138884","Description":"STENT BILIARY GRP 2","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6242.4},{"Itemcode":"64138885","Description":"STENT BILIARY GRP 4","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":10404.0},{"Itemcode":"64138886","Description":"STENT BILIARY GRP 3","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":7803.0},{"Itemcode":"64138887","Description":"FUSION,CERVICAL CONSTRUCT","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":15553.98},{"Itemcode":"64138888","Description":"Non-Charge Surg Supply","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"64138889","Description":"REAMER ORTHO GRP 2","CDM Revenue Code":"272","Standard Price":2601.0,"Note":"**"},{"Itemcode":"64138890","Description":"IMPNT-BLADE,HELICAL TFN","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3726.06},{"Itemcode":"64138891","Description":"KIT,ACL ALL INSIDE ARTHREX","CDM Revenue Code":"272","Standard Price":2913.12},{"Itemcode":"64138893","Description":"Cath Angio non laser DCB Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C2623","Standard Price":6355.62,"Note":"**"},{"Itemcode":"64138894","Description":"Cath Angio non laser DCB Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C2623","Standard Price":7282.8},{"Itemcode":"64138895","Description":"Epifix 6.5x16","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":26858.64},{"Itemcode":"64138896","Description":"KIT,KYPHON,BILAT DIR","CDM Revenue Code":"278","Standard Price":9363.6},{"Itemcode":"64138897","Description":"Stem, Femoral Depuy","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":26426.16},{"Itemcode":"64138898","Description":"Graft Bone Substitute 16cc","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":17938.74},{"Itemcode":"64138900","Description":"Pack,Cath/Sheath ClosureFast","CDM Revenue Code":"272","Standard Price":3092.64,"Note":"**"},{"Itemcode":"64138901","Description":"Stent nonCoa/Cov w/del GRP I","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4459.44,"Note":"**"},{"Itemcode":"64138902","Description":"Kit Vertebroplasty","CDM Revenue Code":"272","Standard Price":5545.74},{"Itemcode":"64138903","Description":"Nail, Ortho Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9363.6,"Note":"**"},{"Itemcode":"64138905","Description":"Inserter Tip Articular Surface","CDM Revenue Code":"272","Standard Price":828.24},{"Itemcode":"64138906","Description":"System Illumination, Spine","CDM Revenue Code":"272","Standard Price":7056.36,"Note":"**"},{"Itemcode":"64138907","Description":"Bit Drill Grp","CDM Revenue Code":"272","Standard Price":130.56,"Note":"**"},{"Itemcode":"64138908","Description":"PUNCH DISP","CDM Revenue Code":"272","Standard Price":1443.3},{"Itemcode":"64138909","Description":"Bone Graft Sub Bead Kit 25cc","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4415.58},{"Itemcode":"64138910","Description":"Valve Heart Perceval LRG","CDM Revenue Code":"278","Standard Price":33136.74},{"Itemcode":"64138911","Description":"Stent Trachea Coated w/Del Sys","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10435.62},{"Itemcode":"64138912","Description":"Endopros AAA, Excluder","CDM Revenue Code":"278","Standard Price":37142.28,"Note":"**"},{"Itemcode":"64138913","Description":"Fixation Device grp 2","CDM Revenue Code":"278","Standard Price":2462.28,"Note":"**"},{"Itemcode":"64138914","Description":"Introducer/Sheath Grp 5","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":3641.4},{"Itemcode":"64138915","Description":"Guidewire, Vascular","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":85.68,"Note":"**"},{"Itemcode":"64138916","Description":"VAD Catheter, Impella CP","CDM Revenue Code":"278","Standard Price":84532.5,"Note":"**"},{"Itemcode":"64138917","Description":"Arthroflex Allograft 4x7cm","CDM Revenue Code":"278","CDM HCPCS":"Q4125","Standard Price":13150.86,"Note":"**"},{"Itemcode":"64138918","Description":"Cage Spinal Interbody Synfix","CDM Revenue Code":"278","Standard Price":19580.94,"Note":"**"},{"Itemcode":"64138919","Description":"Kit Maxcess4 XLIFT","CDM Revenue Code":"272","Standard Price":9765.48},{"Itemcode":"64138920","Description":"Cage Spine Expandable","CDM Revenue Code":"278","Standard Price":16738.2,"Note":"**"},{"Itemcode":"64138921","Description":"Injector Graft/ Luna 360 Cage","CDM Revenue Code":"272","Standard Price":1910.46,"Note":"**"},{"Itemcode":"64138922","Description":"Kit Accessory Benvenue Spine","CDM Revenue Code":"272","Standard Price":6654.48},{"Itemcode":"64138923","Description":"Paste DBM Orthoblast","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":963.9,"Note":"**"},{"Itemcode":"64138925","Description":"Surgicel Snow Dressing","CDM Revenue Code":"272","Standard Price":673.2,"Note":"**"},{"Itemcode":"64138926","Description":"Cage Cervical Amendia","CDM Revenue Code":"278","Standard Price":18597.66},{"Itemcode":"64138927","Description":"Fiberloop w/Fiber Tag&Needle","CDM Revenue Code":"272","Standard Price":948.6},{"Itemcode":"64138928","Description":"Intralaminar Fusion Device sz8","CDM Revenue Code":"278","Standard Price":20287.8},{"Itemcode":"64138929","Description":"Stent Innova Nonct/cv w/del","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":9178.98},{"Itemcode":"64138930","Description":"Cage FlxFit 9mm AT0909","CDM Revenue Code":"278","Standard Price":19611.54},{"Itemcode":"64138931","Description":"Adherus Dural Sealant","CDM Revenue Code":"272","Standard Price":3199.74,"Note":"**"},{"Itemcode":"64138932","Description":"Drill Bit 2.4mm NAV2075","CDM Revenue Code":"272","Standard Price":5545.74,"Note":"**"},{"Itemcode":"64138933","Description":"Kit Dilators - Spine","CDM Revenue Code":"272","Standard Price":2319.48,"Note":"**"},{"Itemcode":"64138934","Description":"Stent Coated W/Deliv Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":7656.12},{"Itemcode":"64138935","Description":"Stent Coated w/Del Sys Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8509.86},{"Itemcode":"64138936","Description":"NAIL VALOR 150 to 200MM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13837.32,"Note":"**"},{"Itemcode":"64138937","Description":"Spacer,Global Shou Monoblock","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":5494.74},{"Itemcode":"64138938","Description":"Putty Human Tissue - Propel","CDM Revenue Code":"278","Standard Price":5310.12},{"Itemcode":"64138939","Description":"Dialysis Access Sys Implant","CDM Revenue Code":"278","CDM HCPCS":"C1881","Standard Price":1592.22},{"Itemcode":"64138940","Description":"THR-Taper Adapt Fem","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":258.06},{"Itemcode":"64138941","Description":"Endoprosthesis AAA,Thorac Prox","CDM Revenue Code":"278","Standard Price":62537.22},{"Itemcode":"64138942","Description":"Stent Ncoa/Ncov w/Del Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":5651.82},{"Itemcode":"64138943","Description":"Segment Fibula Allograft","CDM Revenue Code":"278","Standard Price":2878.44},{"Itemcode":"64138945","Description":"Spinal Cage Expandable","CDM Revenue Code":"278","Standard Price":19611.54,"Note":"**"},{"Itemcode":"64138946","Description":"Spinal Cage/Spacer Grp 9","CDM Revenue Code":"278","Standard Price":17062.56,"Note":"**"},{"Itemcode":"64138947","Description":"GRAFT MITROFLOW CONDUIT 28MM","CDM Revenue Code":"278","Standard Price":8957.64},{"Itemcode":"64138948","Description":"Cannula, Spine Precis","CDM Revenue Code":"272","Standard Price":2122.62},{"Itemcode":"64138949","Description":"BLADE DISPOSABLE GRP 3","CDM Revenue Code":"272","Standard Price":1560.6,"Note":"**"},{"Itemcode":"64138950","Description":"NAIL, ORTHO GRP 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10924.2,"Note":"**"},{"Itemcode":"64138951","Description":"Manual Distractor MMD-003","CDM Revenue Code":"272","Standard Price":2132.82},{"Itemcode":"64138952","Description":"Guide Cath Omni Flush","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":82.62,"Note":"**"},{"Itemcode":"64138953","Description":"Fiberloop #4 Ar-7229","CDM Revenue Code":"272","Standard Price":322.32},{"Itemcode":"64138954","Description":"Lead Extension Neurostim 55cm","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":3710.76},{"Itemcode":"64138955","Description":"Plate 10mm 2 hole","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":17921.4,"Note":"**"},{"Itemcode":"64138956","Description":"Low Cost Screw Grp - 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":57.12},{"Itemcode":"64138957","Description":"Low Cost Screw Grp - 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":98.94},{"Itemcode":"64138958","Description":"Low Cost Screw Grp - 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":119.34,"Note":"**"},{"Itemcode":"64138959","Description":"Low Cost Screw Grp - 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":145.86,"Note":"**"},{"Itemcode":"64138960","Description":"Low Cost Screw Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":176.46,"Note":"**"},{"Itemcode":"64138961","Description":"Low Cost Screw Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":208.08,"Note":"**"},{"Itemcode":"64138962","Description":"Low Cost Screw Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":249.9,"Note":"**"},{"Itemcode":"64138963","Description":"Low Cost Screw Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":280.5,"Note":"**"},{"Itemcode":"64138964","Description":"Low Cost Screw Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":322.32,"Note":"**"},{"Itemcode":"64138965","Description":"Low Cost Screw Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":364.14,"Note":"**"},{"Itemcode":"64138966","Description":"Device Interllaminer Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1821","Standard Price":10593.72},{"Itemcode":"64138967","Description":"Component Femoral 71421165","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":23388.6},{"Itemcode":"64138968","Description":"Pin Guide 98-8500-000-01","CDM Revenue Code":"272","Standard Price":4052.46,"Note":"**"},{"Itemcode":"64138969","Description":"Button insert AR-2262","CDM Revenue Code":"272","Standard Price":742.56},{"Itemcode":"64138970","Description":"Stratafix Knotless Device","CDM Revenue Code":"272","Standard Price":179.52,"Note":"**"},{"Itemcode":"64138971","Description":"Dermabond/Prineo","CDM Revenue Code":"272","Standard Price":489.6},{"Itemcode":"64138972","Description":"Plug Rod 5.5 2000-1005","CDM Revenue Code":"278","Standard Price":322.32},{"Itemcode":"64138973","Description":"Algrft Amniotic Fluid 1.0ml","CDM Revenue Code":"278","Standard Price":8791.38},{"Itemcode":"64138975","Description":"Neurostim Lead Kit CoveredgeX","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":15301.02,"Note":"**"},{"Itemcode":"64138976","Description":"Shunt Valve Adjust","CDM Revenue Code":"278","Standard Price":17039.1},{"Itemcode":"64138977","Description":"Router Str 1.1mm","CDM Revenue Code":"272","Standard Price":614.04},{"Itemcode":"64138978","Description":"Wand Lapro 90 Right","CDM Revenue Code":"272","Standard Price":875.16},{"Itemcode":"64138979","Description":"Wound Retractor Grp 1","CDM Revenue Code":"272","Standard Price":364.14,"Note":"**"},{"Itemcode":"64138980","Description":"Wound Retractor Grp 2","CDM Revenue Code":"272","Standard Price":572.22,"Note":"**"},{"Itemcode":"64138981","Description":"Device Secure Safeguard 82000","CDM Revenue Code":"278","Standard Price":451.86},{"Itemcode":"64138982","Description":"Tip Yankauer Vue","CDM Revenue Code":"272","Standard Price":1029.18,"Note":"**"},{"Itemcode":"64138983","Description":"Knot Pusher MI-KP-001","CDM Revenue Code":"272","Standard Price":1327.02},{"Itemcode":"64138984","Description":"Prosthesis Breast Implnt Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":6554.52},{"Itemcode":"64138985","Description":"Prosthesis Breast Implnt Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":8531.28},{"Itemcode":"64138986","Description":"Suture Belt MI-ISBA-001","CDM Revenue Code":"272","Standard Price":530.4,"Note":"**"},{"Itemcode":"64138987","Description":"Cage Peek 10MM AT0910","CDM Revenue Code":"278","Standard Price":19611.54},{"Itemcode":"64138988","Description":"Tot Shoulder Cap Price Depuy","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":19273.92},{"Itemcode":"64138989","Description":"Spine-Cage Lock","CDM Revenue Code":"278","Standard Price":5332.56},{"Itemcode":"64138990","Description":"Cage ALIF","CDM Revenue Code":"278","Standard Price":21268.02},{"Itemcode":"64138991","Description":"Kit Endo Pushlok","CDM Revenue Code":"272","Standard Price":1503.48,"Note":"**"},{"Itemcode":"64138992","Description":"Cannula Split","CDM Revenue Code":"272","Standard Price":1380.06},{"Itemcode":"64138993","Description":"Pusher Knot Curved","CDM Revenue Code":"272","Standard Price":824.16},{"Itemcode":"64138994","Description":"Tube GI Grp 3","CDM Revenue Code":"278","Standard Price":894.54,"Note":"**"},{"Itemcode":"64138995","Description":"Tube GI Grp 4","CDM Revenue Code":"278","Standard Price":998.58,"Note":"**"},{"Itemcode":"64138996","Description":"Tube Esophageal,Blakemore","CDM Revenue Code":"278","Standard Price":1976.76},{"Itemcode":"64138997","Description":"Kit Disp Instru PFF0001","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":8453.76},{"Itemcode":"64138998","Description":"Skin Sub - Amniotic Cord 3x6","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":10531.5,"Note":"**"},{"Itemcode":"64138999","Description":"Adapter Hip Mold 431188","CDM Revenue Code":"272","Standard Price":2254.2},{"Itemcode":"64139000","Description":"Bowl Mixing w/ del sys","CDM Revenue Code":"272","Standard Price":1246.44,"Note":"**"},{"Itemcode":"64139001","Description":"Spacer Mold 431181","CDM Revenue Code":"272","Standard Price":7195.08,"Note":"**"},{"Itemcode":"64139002","Description":"STENT PROMUS PREMIER","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":5332.56},{"Itemcode":"64139004","Description":"Gen NeurostimNoRechrg Proclaim","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":48200.1,"Note":"**"},{"Itemcode":"64139005","Description":"GRAFT ENDOVASCULAR AAA GRP1","CDM Revenue Code":"278","Standard Price":33727.32,"Note":"**"},{"Itemcode":"64139006","Description":"IMPL JT:HeadRadial ALN-RHI-220","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":10024.56,"Note":"**"},{"Itemcode":"64139007","Description":"PATCH TUTO 8x14cm","CDM Revenue Code":"278","Standard Price":1300.5,"Note":"**"},{"Itemcode":"64139008","Description":"KIT SCP KNEE","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":12763.26,"Note":"**"},{"Itemcode":"64139009","Description":"IMPLANTABLE RECHARGE NEUROSTIM","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":63399.12},{"Itemcode":"64139010","Description":"STERNALOCK SYSTEM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":14315.7},{"Itemcode":"64139011","Description":"Kit Accessory Luna 3D Spine","CDM Revenue Code":"272","Standard Price":6654.48,"Note":"**"},{"Itemcode":"64139012","Description":"CATHETER IVUS Eagle Eye","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":3626.1},{"Itemcode":"64139013","Description":"Graft Vascular Grp 6 B","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":5722.2},{"Itemcode":"64139014","Description":"Graft Vascular Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":9363.6},{"Itemcode":"64139015","Description":"Graft Vascular Grp 11","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":10404.0},{"Itemcode":"64139016","Description":"Graft Vascular Grp 12","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":11444.4},{"Itemcode":"64139017","Description":"Wire Ortho Low Cost Grp 1","CDM Revenue Code":"272","Standard Price":185.64,"Note":"**"},{"Itemcode":"64139018","Description":"Bolt Iliac","CDM Revenue Code":"278","Standard Price":5972.1},{"Itemcode":"64139019","Description":"Wrap Amniofix TN-5220","CDM Revenue Code":"278","Standard Price":2908.02},{"Itemcode":"64139020","Description":"Spine Pedicle Access Kit","CDM Revenue Code":"272","Standard Price":1246.44,"Note":"**"},{"Itemcode":"64139021","Description":"Pin Guide; Femoral","CDM Revenue Code":"272","Standard Price":2122.62,"Note":"**"},{"Itemcode":"64139022","Description":"Generator CRT-D Dynagen G151","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":65935.86},{"Itemcode":"64139023","Description":"Suture Anchor Speedbridge","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4067.76,"Note":"**"},{"Itemcode":"64139024","Description":"Button Tightrope; Anchor","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1698.3,"Note":"**"},{"Itemcode":"64139025","Description":"KIT PNT TRIAL,NEUROSTIM GRP 1","CDM Revenue Code":"272","Standard Price":451.86},{"Itemcode":"64139026","Description":"Pack ACL Autogrft,Graftlink","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5157.12,"Note":"**"},{"Itemcode":"64139027","Description":"Sys Spine Fusion/Fixxatn","CDM Revenue Code":"278","Standard Price":8509.86},{"Itemcode":"64139028","Description":"AICD, Single Emblem","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":67626.0},{"Itemcode":"64139029","Description":"Lead S-ICD Emblem","CDM Revenue Code":"275","CDM HCPCS":"C1896","Standard Price":13525.2},{"Itemcode":"64139030","Description":"Cap for Screw","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1592.22},{"Itemcode":"64139031","Description":"Spine Cage Lateral","CDM Revenue Code":"278","Standard Price":25360.26},{"Itemcode":"64139032","Description":"Spine Shim Lateral","CDM Revenue Code":"278","Standard Price":795.6},{"Itemcode":"64139033","Description":"Drill Bit Lag Screw","CDM Revenue Code":"272","Standard Price":3412.92,"Note":"**"},{"Itemcode":"64139034","Description":"Pin Guide","CDM Revenue Code":"272","Standard Price":1256.64,"Note":"**"},{"Itemcode":"64139035","Description":"Gen NeuroStim NonRechr Prime","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":43957.92},{"Itemcode":"64139036","Description":"PLATE OCCIPITAL ADJ","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":18224.34},{"Itemcode":"64139037","Description":"Valve Aortic Supra Annular","CDM Revenue Code":"278","Standard Price":12848.94},{"Itemcode":"64139038","Description":"Tap, Spine Vertex","CDM Revenue Code":"272","Standard Price":6398.46},{"Itemcode":"64139039","Description":"Kit Spinal Fusion Dtrax","CDM Revenue Code":"272","Standard Price":3626.1},{"Itemcode":"64139040","Description":"Videoscpe, Disposable","CDM Revenue Code":"272","Standard Price":1502.46,"Note":"**"},{"Itemcode":"64139041","Description":"External Fixator Cmpnts Grp 7","CDM Revenue Code":"272","Standard Price":6866.64},{"Itemcode":"64139042","Description":"External Fixator Cmpnts Grp 8","CDM Revenue Code":"272","Standard Price":7907.04},{"Itemcode":"64139043","Description":"Fixator External","CDM Revenue Code":"272","Standard Price":11379.12},{"Itemcode":"64139044","Description":"Ext Fixn Implants Grp1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":208.08},{"Itemcode":"64139045","Description":"Ext Fixn Implants Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":582.42,"Note":"**"},{"Itemcode":"64139046","Description":"Ext Fixn Implants Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":728.28},{"Itemcode":"64139047","Description":"Ext Fixn Implants Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":936.36},{"Itemcode":"64139048","Description":"Ext Fixn Implants Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1248.48,"Note":"**"},{"Itemcode":"64139049","Description":"Ext Fixn Implants Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1560.6},{"Itemcode":"64139050","Description":"Ext Fixn Implants Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2080.8},{"Itemcode":"64139051","Description":"Ext Fixn Implants Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3121.2},{"Itemcode":"64139052","Description":"Ext Fixn Implants Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4161.6},{"Itemcode":"64139053","Description":"Ext Fixn Implants Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5202.0,"Note":"**"},{"Itemcode":"64139054","Description":"Ext Fixn Implants Grp 11","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6242.4},{"Itemcode":"64139055","Description":"Gen Neuro nonHF Recharge","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":58497.0,"Note":"**"},{"Itemcode":"64139056","Description":"Anchor Spine Coalition","CDM Revenue Code":"278","Standard Price":2122.62},{"Itemcode":"64139057","Description":"SUTURE SPEEDSTITCH","CDM Revenue Code":"272","Standard Price":516.12,"Note":"**"},{"Itemcode":"64139058","Description":"KIT CHARGE","CDM Revenue Code":"272","Standard Price":5387.64,"Note":"**"},{"Itemcode":"64139059","Description":"KIT IPG","CDM Revenue Code":"278","CDM HCPCS":"C1822","Standard Price":56389.68,"Note":"**"},{"Itemcode":"64139060","Description":"VALVE HEART AORTIC MED PVS23","CDM Revenue Code":"278","Standard Price":33136.74},{"Itemcode":"64139061","Description":"STENT INNOVA","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":10450.92},{"Itemcode":"64139062","Description":"PIN REDUCTION","CDM Revenue Code":"272","Standard Price":2239.92},{"Itemcode":"64139063","Description":"Algrft Memb Amniotic 4x8cm","CDM Revenue Code":"278","Standard Price":13507.86},{"Itemcode":"64139064","Description":"Algrft Memb Amniotic 2x4cm","CDM Revenue Code":"278","Standard Price":10642.68},{"Itemcode":"64139065","Description":"Tiss Transfer Sys Lipogem","CDM Revenue Code":"272","Standard Price":8509.86},{"Itemcode":"64139066","Description":"Primatrix Meshed Implant","CDM Revenue Code":"278","CDM HCPCS":"Q4110","Standard Price":39545.4},{"Itemcode":"64139067","Description":"Balloon Solopath Access","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":3284.4},{"Itemcode":"64139068","Description":"VASC CLSR-Perclose A-T","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1211.76,"Note":"**"},{"Itemcode":"64139069","Description":"Valve Heart Grp 4","CDM Revenue Code":"278","Standard Price":23331.48,"Note":"**"},{"Itemcode":"64139070","Description":"Plug Vascular","CDM Revenue Code":"278","Standard Price":3548.58},{"Itemcode":"64139071","Description":"Graft Nerve Avanc 70MM","CDM Revenue Code":"278","Standard Price":16314.9,"Note":"**"},{"Itemcode":"64139072","Description":"Clamp Trauma Fixation","CDM Revenue Code":"272","Standard Price":3084.48},{"Itemcode":"64139073","Description":"Clip Aneurysm Grp 4","CDM Revenue Code":"278","Standard Price":2546.94},{"Itemcode":"64139074","Description":"Pin External Fixatn 150,250MM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":581.4,"Note":"**"},{"Itemcode":"64139075","Description":"Fixation Device Post 30Deg","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":584.46},{"Itemcode":"64139076","Description":"Graft Nerve Repair","CDM Revenue Code":"278","Standard Price":8199.78},{"Itemcode":"64139077","Description":"Pin External Fixation 300MM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":610.98,"Note":"**"},{"Itemcode":"64139078","Description":"Strut Cortical 1.5x10.0cm","CDM Revenue Code":"278","Standard Price":2665.26},{"Itemcode":"64139079","Description":"Plasma Scalpel 85MM","CDM Revenue Code":"272","Standard Price":2328.66},{"Itemcode":"64139080","Description":"System Oscar Cement Removal","CDM Revenue Code":"272","Standard Price":6398.46,"Note":"**"},{"Itemcode":"64139081","Description":"Kit Prevena Incision Mgmt Sys","CDM Revenue Code":"278","Standard Price":2625.48,"Note":"**"},{"Itemcode":"64139082","Description":"Ablator Aspiration AR-9811","CDM Revenue Code":"272","Standard Price":1242.36,"Note":"**"},{"Itemcode":"64139083","Description":"Pin Exchange 3.2MM 500375","CDM Revenue Code":"272","Standard Price":546.72,"Note":"**"},{"Itemcode":"64139084","Description":"Implant Ifuse SI JOINT FUSN","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10265.28,"Note":"**"},{"Itemcode":"64139086","Description":"IMPLANT MXL 8083424","CDM Revenue Code":"278","Standard Price":22823.52},{"Itemcode":"64139087","Description":"STEM FEMORAL","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":21671.94},{"Itemcode":"64139088","Description":"Algrft Valv Pulm Conduit6-32mm","CDM Revenue Code":"278","Standard Price":65208.6},{"Itemcode":"64139089","Description":"Filter, Vena Cava-Cook","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":5545.74},{"Itemcode":"64139090","Description":"Graft Endo TGU282810","CDM Revenue Code":"278","Standard Price":54945.36},{"Itemcode":"64139091","Description":"Retriever Vascular Vrs-6.0-90","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2516.34,"Note":"**"},{"Itemcode":"64139092","Description":"Implant Crani Custom","CDM Revenue Code":"278","Standard Price":52995.12},{"Itemcode":"64139093","Description":"Drill Bit Cannulated","CDM Revenue Code":"272","Standard Price":4205.46,"Note":"**"},{"Itemcode":"64139094","Description":"Cath Angio VTEK","CDM Revenue Code":"272","Standard Price":134.64,"Note":"**"},{"Itemcode":"64139095","Description":"Snare En 18-30","CDM Revenue Code":"278","CDM HCPCS":"C1773","Standard Price":1989.0,"Note":"**"},{"Itemcode":"64139096","Description":"Stent Self Expand 1012529-80","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3091.62},{"Itemcode":"64139097","Description":"Ring Annuloplasty Tricuspidl","CDM Revenue Code":"278","Standard Price":9298.32,"Note":"**"},{"Itemcode":"64139098","Description":"End Cap,VBR Spacer","CDM Revenue Code":"278","Standard Price":10315.26},{"Itemcode":"64139099","Description":"Cap Certex Spinal Screw","CDM Revenue Code":"278","Standard Price":2346.0},{"Itemcode":"64139100","Description":"Kit Swivelock Disp","CDM Revenue Code":"272","Standard Price":2084.88,"Note":"**"},{"Itemcode":"64139101","Description":"CAGE EXPANDABLE","CDM Revenue Code":"278","Standard Price":35695.92,"Note":"**"},{"Itemcode":"64139102","Description":"Cage 3D expandalbe 14mm8degree","CDM Revenue Code":"278","Standard Price":16737.18},{"Itemcode":"64139103","Description":"Valve Aortic PTFE ONXAAP-2_","CDM Revenue Code":"278","Standard Price":25360.26},{"Itemcode":"64139104","Description":"Probe Neuro","CDM Revenue Code":"272","Standard Price":1592.22},{"Itemcode":"64139105","Description":"IMPL NS Kit Lead Adaptor 25cm","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":2143.02},{"Itemcode":"64139106","Description":"Sealant Dural w/Appl","CDM Revenue Code":"272","Standard Price":3390.48,"Note":"**"},{"Itemcode":"64139107","Description":"Implant NS Lead Attain","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":22011.6,"Note":"**"},{"Itemcode":"64139108","Description":"Wand Hipvac 50","CDM Revenue Code":"272","Standard Price":3407.82,"Note":"**"},{"Itemcode":"64139109","Description":"Flowport CAT01549","CDM Revenue Code":"272","Standard Price":2095.08},{"Itemcode":"64139110","Description":"Stent Endopros Tracheobronch","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4052.46},{"Itemcode":"64139111","Description":"Stent Endopros Wall","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4051.44},{"Itemcode":"64139112","Description":"IMPLANT HIP HELICAL GRP 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3945.36},{"Itemcode":"64139113","Description":"NS Lead Penta 3mm 60cm","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":22823.52},{"Itemcode":"64139114","Description":"Probe, Cautery Spine","CDM Revenue Code":"272","Standard Price":1989.0},{"Itemcode":"64139117","Description":"Cage Corpectomy","CDM Revenue Code":"278","Standard Price":21167.04},{"Itemcode":"64139118","Description":"Cinch Meniscal","CDM Revenue Code":"272","Standard Price":2164.44,"Note":"**"},{"Itemcode":"64139119","Description":"Clamp External Fixator","CDM Revenue Code":"272","Standard Price":2486.76,"Note":"**"},{"Itemcode":"64139120","Description":"Stent Periph wDel 6x40x125","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":5011.26},{"Itemcode":"64139121","Description":"Microcath Supercross 5303","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2360.28},{"Itemcode":"64139122","Description":"Kit Cranial Access INS-HITH","CDM Revenue Code":"272","Standard Price":1991.04},{"Itemcode":"64139123","Description":"GudeWire Viper VPR-GW-FT14","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1007.76,"Note":"**"},{"Itemcode":"64139124","Description":"Wireguide Micro G50793","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":859.86},{"Itemcode":"64139125","Description":"Guidewire Hydro HMW14300ST","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":997.56},{"Itemcode":"64139126","Description":"Cath Vision IVUS 88901","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":4905.18,"Note":"**"},{"Itemcode":"64139127","Description":"Insert Lock 370002","CDM Revenue Code":"278","Standard Price":262.14},{"Itemcode":"64139128","Description":"GuideWire Viper VPR-GW-200","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1007.76},{"Itemcode":"64139129","Description":"Cement Spacer, Knee SPK0122","CDM Revenue Code":"278","Standard Price":11623.92},{"Itemcode":"64139130","Description":"Wrap Amniofix TN-5460","CDM Revenue Code":"278","Standard Price":9378.9},{"Itemcode":"64139131","Description":"Stent Endo AAA INT Iliac","CDM Revenue Code":"278","Standard Price":10396.86},{"Itemcode":"64139132","Description":"VASC CLOSURE DEV-MYNX MX6721","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1072.02,"Note":"**"},{"Itemcode":"64139133","Description":"Shaft Driver Disp 7480741t","CDM Revenue Code":"272","Standard Price":769.08,"Note":"**"},{"Itemcode":"64139134","Description":"Stent Covered I-Cast","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10190.82},{"Itemcode":"64139135","Description":"STENT COVERED 85455","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10190.82},{"Itemcode":"64139136","Description":"Kit Access, Nuvasive","CDM Revenue Code":"272","Standard Price":11835.06},{"Itemcode":"64139137","Description":"Kit Needle Spine 5001-90009-G1","CDM Revenue Code":"272","Standard Price":1592.22},{"Itemcode":"64139138","Description":"GRAFT LINK ACL FGL","CDM Revenue Code":"278","Standard Price":9268.74,"Note":"**"},{"Itemcode":"64139140","Description":"Drill Guide/Sleeve","CDM Revenue Code":"272","Standard Price":594.66,"Note":"**"},{"Itemcode":"64139141","Description":"Pack Graft Link AR-1588AL-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5728.32,"Note":"**"},{"Itemcode":"64139142","Description":"Interspace, Shoulder w/cement","CDM Revenue Code":"278","Standard Price":13526.22},{"Itemcode":"64139143","Description":"PLUG CABLE 370004","CDM Revenue Code":"278","Standard Price":276.42},{"Itemcode":"64139144","Description":"IMPL PIN DRILL 4.0 5023-6-150","CDM Revenue Code":"272","Standard Price":527.34},{"Itemcode":"64139145","Description":"IMPL PIN DRILL 5.0 5018-5-250","CDM Revenue Code":"272","Standard Price":596.7},{"Itemcode":"64139146","Description":"Endobutton 72202799","CDM Revenue Code":"278","Standard Price":1888.02,"Note":"**"},{"Itemcode":"64139147","Description":"Tendon Gracilis 1976-39","CDM Revenue Code":"278","Standard Price":8318.1,"Note":"**"},{"Itemcode":"64139148","Description":"ScrewCann 12.5mm 10-P-12550-01","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":21978.96},{"Itemcode":"64139149","Description":"ScrewCann 8.5mm 10-S08545-01","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":13525.2},{"Itemcode":"64139150","Description":"Pin Fixatn Provisionl 71173585","CDM Revenue Code":"272","Standard Price":2691.78},{"Itemcode":"64139151","Description":"Cath Endovascular","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":10126.56},{"Itemcode":"64139152","Description":"NS Tool Tunneling","CDM Revenue Code":"272","Standard Price":535.5,"Note":"**"},{"Itemcode":"64139153","Description":"Mesh Hernia, Parietex","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":1224.0},{"Itemcode":"64139154","Description":"Cath Dialys Chronc Sport Pack","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":1617.72,"Note":"**"},{"Itemcode":"64139155","Description":"Implant Joint Grp 8A","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":7386.84,"Note":"**"},{"Itemcode":"64139156","Description":"Implant Joint Grp 8B","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":8125.32,"Note":"**"},{"Itemcode":"64139157","Description":"Implant Joint Grp 8C","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":8947.44,"Note":"**"},{"Itemcode":"64139158","Description":"JOINT STABILIZN SYS-PLATE BASE","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":24818.64,"Note":"**"},{"Itemcode":"64139159","Description":"PIN AXIS IJS-EAP-25452","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1564.68,"Note":"**"},{"Itemcode":"64139160","Description":"Cage Peek 9x26x11 5891255","CDM Revenue Code":"278","Standard Price":20287.8,"Note":"**"},{"Itemcode":"64139161","Description":"Dvice Occlsn Intraortic ICF100","CDM Revenue Code":"278","Standard Price":10704.9,"Note":"**"},{"Itemcode":"64139162","Description":"Intro Sheath 9FR IS19A","CDM Revenue Code":"272","Standard Price":1857.42,"Note":"**"},{"Itemcode":"64139163","Description":"TKR-H Comp Fem Assem","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":33599.82},{"Itemcode":"64139164","Description":"CHRGE SYSTM DBS Activa RC37651","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":8957.64,"Note":"**"},{"Itemcode":"64139165","Description":"CAGE VBR CS2250-12-16","CDM Revenue Code":"278","Standard Price":31796.46},{"Itemcode":"64139166","Description":"Spine Clamp Lock","CDM Revenue Code":"278","Standard Price":8453.76},{"Itemcode":"64139167","Description":"Spine Device Stable","CDM Revenue Code":"278","Standard Price":11496.42},{"Itemcode":"64139168","Description":"Kypho Balln Cath INTVM","CDM Revenue Code":"272","Standard Price":9331.98,"Note":"**"},{"Itemcode":"64139169","Description":"ACID_GEN Dynagen VR Singl","CDM Revenue Code":"278","CDM HCPCS":"C1722","Standard Price":44633.16},{"Itemcode":"64139170","Description":"TSR Glenosphere ECC 42MM","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":7562.28,"Note":"**"},{"Itemcode":"64139171","Description":"PACK EPI-SENSE CDP-4330-5","CDM Revenue Code":"272","Standard Price":42266.76,"Note":"**"},{"Itemcode":"64139172","Description":"HANDPIECE EVS MICRO 23-121-1","CDM Revenue Code":"272","Standard Price":2836.62,"Note":"**"},{"Itemcode":"64139173","Description":"CATH PORT GRP 3","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":2016.54,"Note":"**"},{"Itemcode":"64139174","Description":"TUBE DRAINAGE CHEST PLEURA","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":2095.08,"Note":"**"},{"Itemcode":"64139175","Description":"PLATELET PLASMA KIT AMS310","CDM Revenue Code":"272","Standard Price":2042.04,"Note":"**"},{"Itemcode":"64139176","Description":"Trephine Extractor","CDM Revenue Code":"272","Standard Price":4588.98},{"Itemcode":"64139177","Description":"SCS-Kit Trial 977DS26SYS","CDM Revenue Code":"278","Standard Price":4692.0},{"Itemcode":"64139178","Description":"Latitude NXT Adapter Cellular","CDM Revenue Code":"272","Standard Price":1857.42},{"Itemcode":"64139179","Description":"VIVA CRT-P C6TR01","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":26712.78},{"Itemcode":"64139180","Description":"CUSTOM IMP-iTotal Knee TPS","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16902.42},{"Itemcode":"64139181","Description":"VAD-Head Pump Blood","CDM Revenue Code":"272","Standard Price":991.44},{"Itemcode":"64139182","Description":"Alloderm Tiss 2x4 Thick 102012","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":2334.78},{"Itemcode":"64139183","Description":"Stent Polaris M00619214202","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":935.34},{"Itemcode":"64139184","Description":"Cannula Ang H965251920","CDM Revenue Code":"272","Standard Price":43956.9},{"Itemcode":"64139185","Description":"Thoracic Stent Graft","CDM Revenue Code":"278","Standard Price":62536.2,"Note":"**"},{"Itemcode":"64139186","Description":"Pacemaker DR Advisa A2DR01SYS","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":19998.12},{"Itemcode":"64139189","Description":"BALLOON VIABAHN VBX 6X19MM","CDM Revenue Code":"278","Standard Price":8648.58,"Note":"**"},{"Itemcode":"64139190","Description":"SPACER ALIF SYNFIX EVOLUTION","CDM Revenue Code":"278","Standard Price":18597.66,"Note":"**"},{"Itemcode":"64139191","Description":"STENT BILIARY GPS MINI","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3626.1},{"Itemcode":"64139192","Description":"GUIDEWIRE VASC, TRANSEND","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2625.48},{"Itemcode":"64139193","Description":"WAND COBLATION","CDM Revenue Code":"272","Standard Price":2563.26},{"Itemcode":"64139194","Description":"LEAD NEUROSTIM LINEAR","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":7745.88},{"Itemcode":"64139195","Description":"BALLOON EXP VIABAHN VBX","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":12070.68,"Note":"**"},{"Itemcode":"64139196","Description":"Graft Stent Valiant Thoracic","CDM Revenue Code":"278","Standard Price":62536.2},{"Itemcode":"64139209","Description":"Blade Disposable Grp 2","CDM Revenue Code":"272","Standard Price":1298.46,"Note":"**"},{"Itemcode":"64139210","Description":"Stapler-Reloads Disp. Grp 1","CDM Revenue Code":"272","Standard Price":429.42,"Note":"**"},{"Itemcode":"64139211","Description":"Stapler-Reloads Disp. Grp 2","CDM Revenue Code":"272","Standard Price":770.1,"Note":"**"},{"Itemcode":"64139212","Description":"Stapler-Reloads Disp. Grp 3","CDM Revenue Code":"272","Standard Price":1191.36,"Note":"**"},{"Itemcode":"64139213","Description":"Stapler-Reloads Disp. Grp 4","CDM Revenue Code":"272","Standard Price":3420.06,"Note":"**"},{"Itemcode":"64139214","Description":"Blade Disposable Grp 1","CDM Revenue Code":"272","Standard Price":491.64,"Note":"**"},{"Itemcode":"64139215","Description":"Plate Grp 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5710.98,"Note":"**"},{"Itemcode":"64139216","Description":"Plate Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5336.64,"Note":"**"},{"Itemcode":"64139217","Description":"Probe Grp 1","CDM Revenue Code":"272","Standard Price":1106.7,"Note":"**"},{"Itemcode":"64139218","Description":"Probe Grp 2","CDM Revenue Code":"272","Standard Price":1078.14,"Note":"**"},{"Itemcode":"64139219","Description":"Probe Grp 3","CDM Revenue Code":"272","Standard Price":2538.78,"Note":"**"},{"Itemcode":"64139220","Description":"Probe Grp 4","CDM Revenue Code":"272","Standard Price":2784.6,"Note":"**"},{"Itemcode":"64139238","Description":"Cap Bone/Neuro Grp 1","CDM Revenue Code":"278","Standard Price":538.56,"Note":"**"},{"Itemcode":"64139239","Description":"Cap Bone/Neuro Grp 2","CDM Revenue Code":"278","Standard Price":923.1,"Note":"**"},{"Itemcode":"64139240","Description":"Cap Bone/Neuro Grp 3","CDM Revenue Code":"278","Standard Price":953.7,"Note":"**"},{"Itemcode":"64139248","Description":"Tissue Expander Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":2697.9,"Note":"**"},{"Itemcode":"64139250","Description":"Burr Hole Cover Grp 2","CDM Revenue Code":"278","Standard Price":1252.56,"Note":"**"},{"Itemcode":"64139251","Description":"Aortic/Cardio Punch Grp 1","CDM Revenue Code":"272","Standard Price":198.9},{"Itemcode":"64139252","Description":"Stent Endoprosthes Fluency Grp","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":9980.7,"Note":"**"},{"Itemcode":"64139255","Description":"Nail, Ortho Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":488.58},{"Itemcode":"64139256","Description":"Nail, Ortho Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1730.94,"Note":"**"},{"Itemcode":"64139257","Description":"Nail, Ortho Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3743.4,"Note":"**"},{"Itemcode":"64139258","Description":"Nail, Ortho Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4800.12,"Note":"**"},{"Itemcode":"64139259","Description":"Nail, Ortho Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6146.52,"Note":"**"},{"Itemcode":"64139260","Description":"Tube Gi Grp 2","CDM Revenue Code":"278","Standard Price":615.06,"Note":"**"},{"Itemcode":"64139265","Description":"Ablator Grp","CDM Revenue Code":"272","Standard Price":2247.06},{"Itemcode":"64139274","Description":"Adapter","CDM Revenue Code":"272","Standard Price":786.42,"Note":"**"},{"Itemcode":"64139275","Description":"Adapter Grp 1","CDM Revenue Code":"272","Standard Price":376.38},{"Itemcode":"64139279","Description":"Allograft Eye C1762 Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":2978.4},{"Itemcode":"64139280","Description":"Tutoplast Pericardium 68250","CDM Revenue Code":"278","Standard Price":1459.62,"Note":"**"},{"Itemcode":"64139281","Description":"Tissue Amniotic-per procedure","CDM Revenue Code":"278","CDM HCPCS":"V2790","Standard Price":3166.08,"Note":"**"},{"Itemcode":"64139284","Description":"Cath Central Venous Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":1680.96,"Note":"**"},{"Itemcode":"64139286","Description":"Allograft Orth/Neuro Grp 6","CDM Revenue Code":"278","Standard Price":6683.04,"Note":"**"},{"Itemcode":"64139287","Description":"Allograft Orth/Neuro Grp 5","CDM Revenue Code":"278","Standard Price":5232.6,"Note":"**"},{"Itemcode":"64139288","Description":"Allograft Orth/Neuro Grp 4","CDM Revenue Code":"278","Standard Price":4092.24,"Note":"**"},{"Itemcode":"64139289","Description":"Allograft Orth/Neuro Grp 3","CDM Revenue Code":"278","Standard Price":2711.16,"Note":"**"},{"Itemcode":"64139290","Description":"Allograft Orth/Neuro Grp 2","CDM Revenue Code":"278","Standard Price":1952.28,"Note":"**"},{"Itemcode":"64139291","Description":"Allograft Orth/Neuro Grp 1","CDM Revenue Code":"278","Standard Price":973.08,"Note":"**"},{"Itemcode":"64139301","Description":"Anchor Bone Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2041.02,"Note":"**"},{"Itemcode":"64139302","Description":"Anchor Bone Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1938.0,"Note":"**"},{"Itemcode":"64139303","Description":"Anchor Bone Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1190.34,"Note":"**"},{"Itemcode":"64139305","Description":"Arthowand Group 1","CDM Revenue Code":"272","Standard Price":1135.26,"Note":"**"},{"Itemcode":"64139309","Description":"Balloon Kyphoplasty","CDM Revenue Code":"272","Standard Price":4905.18,"Note":"**"},{"Itemcode":"64139311","Description":"Barrier Sheet Grp 1","CDM Revenue Code":"278","Standard Price":2069.58,"Note":"**"},{"Itemcode":"64139313","Description":"Bit Drill Grp 4","CDM Revenue Code":"272","Standard Price":2248.08,"Note":"**"},{"Itemcode":"64139314","Description":"Bit Drill Grp 3","CDM Revenue Code":"272","Standard Price":1410.66,"Note":"**"},{"Itemcode":"64139315","Description":"Bit Drill Grp 2","CDM Revenue Code":"272","Standard Price":867.0,"Note":"**"},{"Itemcode":"64139316","Description":"Bit Drill Grp 1","CDM Revenue Code":"272","Standard Price":539.58,"Note":"**"},{"Itemcode":"64139322","Description":"Implant Hip Helical Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2786.64},{"Itemcode":"64139327","Description":"Blower Mister Off Pump","CDM Revenue Code":"272","Standard Price":322.32},{"Itemcode":"64139328","Description":"Bolt Locking Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1667.7},{"Itemcode":"64139329","Description":"Bolt Locking Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":378.42},{"Itemcode":"64139330","Description":"Bolt Spinal Pedicle Grp 2","CDM Revenue Code":"278","Standard Price":3414.96},{"Itemcode":"64139331","Description":"Bolt Spinal Pedicle Grp 1","CDM Revenue Code":"278","Standard Price":2613.24,"Note":"**"},{"Itemcode":"64139334","Description":"Burr Grp 3","CDM Revenue Code":"272","Standard Price":1603.44,"Note":"**"},{"Itemcode":"64139335","Description":"Burr Grp 2","CDM Revenue Code":"272","Standard Price":725.22,"Note":"**"},{"Itemcode":"64139336","Description":"Burr Grp 1","CDM Revenue Code":"272","Standard Price":479.4,"Note":"**"},{"Itemcode":"64139337","Description":"Cable Ortho Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":916.98},{"Itemcode":"64139338","Description":"Cable Ortho Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":325.38},{"Itemcode":"64139339","Description":"Cable Ortho Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3809.7,"Note":"**"},{"Itemcode":"64139340","Description":"Cable Ortho Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2538.78,"Note":"**"},{"Itemcode":"64139341","Description":"Cable Ortho Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1570.8,"Note":"**"},{"Itemcode":"64139345","Description":"Cage High Cost","CDM Revenue Code":"278","Standard Price":17138.04,"Note":"**"},{"Itemcode":"64139346","Description":"Cannula Coronary Grp 2","CDM Revenue Code":"272","Standard Price":2649.96,"Note":"**"},{"Itemcode":"64139347","Description":"Cannula Coronary Grp 1","CDM Revenue Code":"272","Standard Price":278.46,"Note":"**"},{"Itemcode":"64139349","Description":"Cannula Ortho/Neuro","CDM Revenue Code":"272","Standard Price":225.42,"Note":"**"},{"Itemcode":"64139360","Description":"Catch Endo","CDM Revenue Code":"272","Standard Price":627.3,"Note":"**"},{"Itemcode":"64139364","Description":"Cath Angiographic","CDM Revenue Code":"272","Standard Price":663.0},{"Itemcode":"64139369","Description":"Cath Balloon Dil Non-Vasc Grp2","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":1314.78,"Note":"**"},{"Itemcode":"64139370","Description":"Cath Balloon Dil Non-Vasc Grp1","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":954.72},{"Itemcode":"64139371","Description":"Cath Balloon Angioplasty Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":3005.94,"Note":"**"},{"Itemcode":"64139372","Description":"Cath Balloon Angioplasty Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":2131.8,"Note":"**"},{"Itemcode":"64139373","Description":"Cath Spinal Neuro Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1755","Standard Price":4095.3,"Note":"**"},{"Itemcode":"64139374","Description":"Cath Balloon Angioplasty Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":860.88,"Note":"**"},{"Itemcode":"64139377","Description":"Cath Biliary Cholangiogram","CDM Revenue Code":"272","Standard Price":485.52,"Note":"**"},{"Itemcode":"64139379","Description":"Cath Central Venous Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":219.3,"Note":"**"},{"Itemcode":"64139382","Description":"Cath Csf Grp 2","CDM Revenue Code":"272","Standard Price":757.86,"Note":"**"},{"Itemcode":"64139383","Description":"Cath Csf Grp 1","CDM Revenue Code":"272","Standard Price":639.54,"Note":"**"},{"Itemcode":"64139386","Description":"Cath Embolectomy C1757 Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":1363.74},{"Itemcode":"64139387","Description":"Cath Embolectomy C1757 Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":394.74,"Note":"**"},{"Itemcode":"64139388","Description":"Cath Indwelling, 3way-Foley","CDM Revenue Code":"272","CDM HCPCS":"A4346","Standard Price":335.58,"Note":"**"},{"Itemcode":"64139389","Description":"Cath Guiding Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":388.62,"Note":"**"},{"Itemcode":"64139390","Description":"Cath Hemodialysis C1750 Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":2428.62,"Note":"**"},{"Itemcode":"64139391","Description":"Cath Hemodialysis C1750 Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":1206.66,"Note":"**"},{"Itemcode":"64139395","Description":"Sling Urology C1771 Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":4314.6,"Note":"**"},{"Itemcode":"64139400","Description":"Cath Port C1788 Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":1589.16,"Note":"**"},{"Itemcode":"64139401","Description":"Cath Port C1788 Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":1493.28,"Note":"**"},{"Itemcode":"64139403","Description":"Cath Spinal Neuro Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1755","Standard Price":2122.62},{"Itemcode":"64139404","Description":"Cath Suprapubic","CDM Revenue Code":"272","CDM HCPCS":"A4335","Standard Price":506.94},{"Itemcode":"64139405","Description":"Cath Ureteral","CDM Revenue Code":"272","CDM HCPCS":"C1758","Standard Price":431.46,"Note":"**"},{"Itemcode":"64139408","Description":"LowCost-Cath Baln Angio Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":282.54},{"Itemcode":"64139410","Description":"Cath Vascular Bern","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":116.28,"Note":"**"},{"Itemcode":"64139411","Description":"Cath Closure Vnus","CDM Revenue Code":"272","CDM HCPCS":"C1888","Standard Price":3785.22},{"Itemcode":"64139412","Description":"Cautery Endo","CDM Revenue Code":"272","Standard Price":345.78,"Note":"**"},{"Itemcode":"64139413","Description":"Cement Bone Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9439.08,"Note":"**"},{"Itemcode":"64139414","Description":"Cement Bone Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5910.9},{"Itemcode":"64139415","Description":"Cement Bone Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":371.28,"Note":"**"},{"Itemcode":"64139422","Description":"Cement Spinal Kit 283910000","CDM Revenue Code":"278","Standard Price":9776.7,"Note":"**"},{"Itemcode":"64139424","Description":"Cement Bone Restrictor Grp 1","CDM Revenue Code":"278","Standard Price":1025.1,"Note":"**"},{"Itemcode":"64139427","Description":"Clamp External Fixator Grp 3","CDM Revenue Code":"272","Standard Price":3714.84},{"Itemcode":"64139430","Description":"Clip Aneurysm Grp 2","CDM Revenue Code":"278","Standard Price":1355.58},{"Itemcode":"64139431","Description":"Clip Aneurysm Grp 1","CDM Revenue Code":"278","Standard Price":309.06},{"Itemcode":"64139434","Description":"Clip Applier Grp 3","CDM Revenue Code":"272","Standard Price":2640.78,"Note":"**"},{"Itemcode":"64139435","Description":"Clip Applier Grp 2","CDM Revenue Code":"272","Standard Price":820.08,"Note":"**"},{"Itemcode":"64139436","Description":"Clip Applier Grp 1","CDM Revenue Code":"272","Standard Price":505.92,"Note":"**"},{"Itemcode":"64139437","Description":"Clip Craniofix","CDM Revenue Code":"278","Standard Price":600.78,"Note":"**"},{"Itemcode":"64139438","Description":"Clip Raney Gun","CDM Revenue Code":"272","Standard Price":390.66,"Note":"**"},{"Itemcode":"64139453","Description":"Connector Crosslink Grp 3","CDM Revenue Code":"278","Standard Price":3093.66,"Note":"**"},{"Itemcode":"64139454","Description":"Connector Crosslink Grp 2","CDM Revenue Code":"278","Standard Price":3096.72,"Note":"**"},{"Itemcode":"64139455","Description":"Connector Crosslink Grp 1","CDM Revenue Code":"278","Standard Price":2099.16,"Note":"**"},{"Itemcode":"64139456","Description":"Connector Csf","CDM Revenue Code":"278","Standard Price":413.1},{"Itemcode":"64139457","Description":"Connector Orth/Neuro Grp 5","CDM Revenue Code":"278","Standard Price":19213.74},{"Itemcode":"64139458","Description":"Connector Orth/Neuro Grp 4","CDM Revenue Code":"278","Standard Price":4481.88,"Note":"**"},{"Itemcode":"64139459","Description":"Connector Orth/Neuro Grp 3","CDM Revenue Code":"278","Standard Price":3067.14,"Note":"**"},{"Itemcode":"64139460","Description":"Connector Orth/Neuro Grp 2","CDM Revenue Code":"278","Standard Price":2224.62,"Note":"**"},{"Itemcode":"64139461","Description":"Connector Orth/Neuro Grp 1","CDM Revenue Code":"278","Standard Price":803.76},{"Itemcode":"64139466","Description":"Cutter Suture / Knot 72201537","CDM Revenue Code":"272","Standard Price":495.72,"Note":"**"},{"Itemcode":"64139471","Description":"Derma Skin Carrier","CDM Revenue Code":"270","Standard Price":217.26,"Note":"**"},{"Itemcode":"64139475","Description":"Dura Subtitute Grp 4","CDM Revenue Code":"278","Standard Price":6749.34,"Note":"**"},{"Itemcode":"64139476","Description":"Dura Subtitute Grp 3","CDM Revenue Code":"278","Standard Price":3488.4,"Note":"**"},{"Itemcode":"64139477","Description":"Dura Subtitute Grp 2","CDM Revenue Code":"278","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64139478","Description":"Dura Subtitute Grp 1","CDM Revenue Code":"278","Standard Price":895.56},{"Itemcode":"64139481","Description":"Electrode Disposable Grp 1","CDM Revenue Code":"272","Standard Price":750.72,"Note":"**"},{"Itemcode":"64139483","Description":"Electrode Disposable Grp 2","CDM Revenue Code":"272","Standard Price":1138.32,"Note":"**"},{"Itemcode":"64139487","Description":"External Fixator Cmpnts Grp 4","CDM Revenue Code":"272","Standard Price":5828.28,"Note":"**"},{"Itemcode":"64139488","Description":"External Fixator Cmpnts Grp 3","CDM Revenue Code":"272","Standard Price":3193.62,"Note":"**"},{"Itemcode":"64139489","Description":"External Fixator Cmpnts Grp 2","CDM Revenue Code":"272","Standard Price":1063.86,"Note":"**"},{"Itemcode":"64139490","Description":"External Fixator Cmpnts Grp1","CDM Revenue Code":"272","Standard Price":345.78,"Note":"**"},{"Itemcode":"64139491","Description":"Graft Felt Teflon Vascular","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":605.88,"Note":"**"},{"Itemcode":"64139502","Description":"Fixation Device grp 1","CDM Revenue Code":"278","Standard Price":1824.78,"Note":"**"},{"Itemcode":"64139505","Description":"Forcep Grp 2","CDM Revenue Code":"272","Standard Price":2398.02,"Note":"**"},{"Itemcode":"64139506","Description":"Forcep Grp 1","CDM Revenue Code":"272","Standard Price":859.86,"Note":"**"},{"Itemcode":"64139509","Description":"Generator Icd","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":46493.64},{"Itemcode":"64139510","Description":"Pacemaker, Gen, Dual Grp1","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":15093.96},{"Itemcode":"64139524","Description":"Graft Patch Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":658.92},{"Itemcode":"64139547","Description":"Grasper Endo","CDM Revenue Code":"272","Standard Price":1264.8,"Note":"**"},{"Itemcode":"64139548","Description":"Guidewire Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":216.24,"Note":"**"},{"Itemcode":"64139549","Description":"Guidewire Ortho Grp 1","CDM Revenue Code":"272","Standard Price":394.74,"Note":"**"},{"Itemcode":"64139550","Description":"Guidewire Ortho Grp 2","CDM Revenue Code":"272","Standard Price":953.7,"Note":"**"},{"Itemcode":"64139559","Description":"Hook Spinal/Pedicle Disp Grp 5","CDM Revenue Code":"278","Standard Price":4714.44},{"Itemcode":"64139560","Description":"Hook Spinal/Pedicle Disp Grp 4","CDM Revenue Code":"278","Standard Price":3072.24},{"Itemcode":"64139561","Description":"Hook Spinal/Pedicle Disp Grp 3","CDM Revenue Code":"278","Standard Price":2306.22,"Note":"**"},{"Itemcode":"64139562","Description":"Hook Spinal/Pedicle Disp Grp 2","CDM Revenue Code":"278","Standard Price":1239.3},{"Itemcode":"64139563","Description":"Hook Spinal/Pedicle Disp Grp 1","CDM Revenue Code":"278","Standard Price":651.78},{"Itemcode":"64139571","Description":"Implant Cornea","CDM Revenue Code":"278","CDM HCPCS":"V2785","Standard Price":10643.7},{"Itemcode":"64139573","Description":"Implant Eyelid","CDM Revenue Code":"278","Standard Price":1442.28,"Note":"**"},{"Itemcode":"64139576","Description":"Implant Forehead","CDM Revenue Code":"278","Standard Price":1406.58},{"Itemcode":"64139578","Description":"Implant Glaucoma Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1783","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64139589","Description":"Implant Orbital","CDM Revenue Code":"278","Standard Price":3655.68},{"Itemcode":"64139590","Description":"Implant Sclera Labtician","CDM Revenue Code":"278","Standard Price":85.68,"Note":"**"},{"Itemcode":"64139591","Description":"Implant Sclera Tutoplast Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":2872.32},{"Itemcode":"64139592","Description":"Implant Sclera Tutoplast Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":1459.62,"Note":"**"},{"Itemcode":"64139593","Description":"Implant Thyroplasty","CDM Revenue Code":"278","CDM HCPCS":"C1878","Standard Price":1922.7},{"Itemcode":"64139600","Description":"Implant Jnt Toe Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":6720.78},{"Itemcode":"64139605","Description":"Inflation Device Vascular","CDM Revenue Code":"272","Standard Price":219.3,"Note":"**"},{"Itemcode":"64139606","Description":"Introducer/Sheath Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":1459.62,"Note":"**"},{"Itemcode":"64139609","Description":"Introducer/Sheath Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":2379.66,"Note":"**"},{"Itemcode":"64139610","Description":"IOL Grp 2","CDM Revenue Code":"276","Standard Price":801.72},{"Itemcode":"64139611","Description":"IOL Grp 1","CDM Revenue Code":"276","Standard Price":774.18,"Note":"**"},{"Itemcode":"64139613","Description":"Kit / System Harvesting","CDM Revenue Code":"272","Standard Price":706.86,"Note":"**"},{"Itemcode":"64139614","Description":"Kit Arterial","CDM Revenue Code":"272","Standard Price":1278.06},{"Itemcode":"64139615","Description":"Kit Aspirator Ortho","CDM Revenue Code":"272","Standard Price":1134.24},{"Itemcode":"64139616","Description":"Prosthesis Kit Penile/Uri GR1","CDM Revenue Code":"278","CDM HCPCS":"C1815","Standard Price":2421.48,"Note":"**"},{"Itemcode":"64139617","Description":"Kit Bead Grp 2","CDM Revenue Code":"278","Standard Price":6591.24},{"Itemcode":"64139618","Description":"Kit Bead Grp 1","CDM Revenue Code":"278","Standard Price":2794.8},{"Itemcode":"64139619","Description":"Kit Thyroplasty","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"64139621","Description":"Knife","CDM Revenue Code":"272","Standard Price":1506.54,"Note":"**"},{"Itemcode":"64139623","Description":"Knife Eye","CDM Revenue Code":"272","Standard Price":245.82},{"Itemcode":"64139624","Description":"Kypho Add'L Fracture Tray","CDM Revenue Code":"272","Standard Price":9934.8,"Note":"**"},{"Itemcode":"64139625","Description":"Kypho Bx Device Not Implant","CDM Revenue Code":"272","Standard Price":642.6,"Note":"**"},{"Itemcode":"64139626","Description":"Kypho First Fracture Kit/Tray","CDM Revenue Code":"278","Standard Price":10917.06,"Note":"**"},{"Itemcode":"64139628","Description":"Kypho Introducer Kit","CDM Revenue Code":"272","Standard Price":6353.58},{"Itemcode":"64139630","Description":"Lacrimal Intubation","CDM Revenue Code":"272","Standard Price":541.62,"Note":"**"},{"Itemcode":"64139637","Description":"Laser Fiber Trimedyne","CDM Revenue Code":"272","Standard Price":742.56,"Note":"**"},{"Itemcode":"64139638","Description":"Laser Fiber Grp 2","CDM Revenue Code":"272","Standard Price":6098.58,"Note":"**"},{"Itemcode":"64139639","Description":"Laser Fiber Grp 1","CDM Revenue Code":"272","Standard Price":2017.56,"Note":"**"},{"Itemcode":"64139640","Description":"Lead Pacemaker","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2122.62,"Note":"**"},{"Itemcode":"64139641","Description":"Lead Neuro C1778 Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":10770.18,"Note":"**"},{"Itemcode":"64139642","Description":"Lead Neuro C1778 Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":8790.36,"Note":"**"},{"Itemcode":"64139643","Description":"Lead Neuro C1778 Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":3482.28},{"Itemcode":"64139644","Description":"Lead Neuro C1778 Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":2648.94},{"Itemcode":"64139645","Description":"Ligasure Handpiece Grp 1","CDM Revenue Code":"272","Standard Price":2570.4,"Note":"**"},{"Itemcode":"64139646","Description":"Ligasure Handpiece Grp 2","CDM Revenue Code":"272","Standard Price":3014.1,"Note":"**"},{"Itemcode":"64139649","Description":"Mesh Genl Surg C1781 Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":6957.42,"Note":"**"},{"Itemcode":"64139650","Description":"Mesh Genl Surg C1781 Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":4143.24,"Note":"**"},{"Itemcode":"64139651","Description":"Mesh Genl Surg C1781 Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":2695.86,"Note":"**"},{"Itemcode":"64139652","Description":"Mesh Genl Surg C1781 Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1547.34,"Note":"**"},{"Itemcode":"64139653","Description":"Mesh Genl Surg C1781 Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":888.42,"Note":"**"},{"Itemcode":"64139654","Description":"Mesh Genl Surg C1781 Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":316.2,"Note":"**"},{"Itemcode":"64139655","Description":"Optimesh","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":14996.04},{"Itemcode":"64139656","Description":"Microtip Neuro","CDM Revenue Code":"272","Standard Price":2951.88,"Note":"**"},{"Itemcode":"64139669","Description":"Needle Grp 2","CDM Revenue Code":"272","Standard Price":911.88,"Note":"**"},{"Itemcode":"64139670","Description":"Needle Grp 1","CDM Revenue Code":"272","Standard Price":453.9,"Note":"**"},{"Itemcode":"64139671","Description":"Nut","CDM Revenue Code":"278","Standard Price":624.24,"Note":"**"},{"Itemcode":"64139673","Description":"On-Q Soaker Pain Pump Grp 2","CDM Revenue Code":"272","Standard Price":1726.86,"Note":"**"},{"Itemcode":"64139674","Description":"On-Q Soaker Pain Pump Grp 1","CDM Revenue Code":"272","Standard Price":954.72},{"Itemcode":"64139680","Description":"Perforator Cranial","CDM Revenue Code":"272","Standard Price":920.04,"Note":"**"},{"Itemcode":"64139682","Description":"Peristrip Grp 1","CDM Revenue Code":"278","Standard Price":1039.38,"Note":"**"},{"Itemcode":"64139683","Description":"Pin Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1359.66,"Note":"**"},{"Itemcode":"64139684","Description":"Pin Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":846.6,"Note":"**"},{"Itemcode":"64139685","Description":"Pin Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":314.16,"Note":"**"},{"Itemcode":"64139694","Description":"Plate Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4073.88,"Note":"**"},{"Itemcode":"64139695","Description":"Plate Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3143.64,"Note":"**"},{"Itemcode":"64139696","Description":"Plate Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1092.42,"Note":"**"},{"Itemcode":"64139697","Description":"Plate Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":906.78,"Note":"**"},{"Itemcode":"64139698","Description":"Plate Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":360.06,"Note":"**"},{"Itemcode":"64139699","Description":"Plate End - Artificial Disk","CDM Revenue Code":"278","Standard Price":19950.18},{"Itemcode":"64139700","Description":"Polar Care","CDM Revenue Code":"272","Standard Price":759.9,"Note":"**"},{"Itemcode":"64139708","Description":"Programmer Neuro","CDM Revenue Code":"272","CDM HCPCS":"C1787","Standard Price":4689.96,"Note":"**"},{"Itemcode":"64139709","Description":"Prosthesis Breast Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":4600.2,"Note":"**"},{"Itemcode":"64139710","Description":"Prosthesis Breast Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":3545.52,"Note":"**"},{"Itemcode":"64139711","Description":"Prosthesis Breast Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":2566.32,"Note":"**"},{"Itemcode":"64139712","Description":"Prosthesis Ear GR1","CDM Revenue Code":"278","CDM HCPCS":"L8613","Standard Price":1438.2,"Note":"**"},{"Itemcode":"64139716","Description":"Prosthesis Penile C1813 Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":20052.18,"Note":"**"},{"Itemcode":"64139718","Description":"Prosthesis Penile Pump Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":17438.94},{"Itemcode":"64139719","Description":"Prosthesis Penile Reservoir","CDM Revenue Code":"278","CDM HCPCS":"C1813","Standard Price":6229.14},{"Itemcode":"64139726","Description":"Pump Neuro","CDM Revenue Code":"278","CDM HCPCS":"C1772","Standard Price":37454.4,"Note":"**"},{"Itemcode":"64139729","Description":"Reamer Ortho Grp 1","CDM Revenue Code":"272","Standard Price":1640.16,"Note":"**"},{"Itemcode":"64139730","Description":"Retractor Grp 1","CDM Revenue Code":"272","Standard Price":1466.76,"Note":"**"},{"Itemcode":"64139734","Description":"Retractor Grp 2","CDM Revenue Code":"272","Standard Price":2974.32,"Note":"**"},{"Itemcode":"64139740","Description":"Ring Mitral","CDM Revenue Code":"278","Standard Price":9898.08,"Note":"**"},{"Itemcode":"64139745","Description":"Rod Grp 4","CDM Revenue Code":"278","Standard Price":2032.86,"Note":"**"},{"Itemcode":"64139746","Description":"Rod Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1662.6,"Note":"**"},{"Itemcode":"64139747","Description":"Rod Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1126.08,"Note":"**"},{"Itemcode":"64139748","Description":"Rod Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":705.84,"Note":"**"},{"Itemcode":"64139750","Description":"Scissor Endo","CDM Revenue Code":"272","Standard Price":1028.16,"Note":"**"},{"Itemcode":"64139753","Description":"Screw Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3733.2,"Note":"**"},{"Itemcode":"64139754","Description":"Screw Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2057.34,"Note":"**"},{"Itemcode":"64139755","Description":"Screw Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1343.34,"Note":"**"},{"Itemcode":"64139756","Description":"Screw Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":825.18,"Note":"**"},{"Itemcode":"64139757","Description":"Screw Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":466.14,"Note":"**"},{"Itemcode":"64139767","Description":"Screw Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4302.36,"Note":"**"},{"Itemcode":"64139773","Description":"Shears Harmonic Endo GR 2","CDM Revenue Code":"272","Standard Price":2454.12,"Note":"**"},{"Itemcode":"64139774","Description":"Introducer/Sheath Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":559.98,"Note":"**"},{"Itemcode":"64139775","Description":"Introducer/Sheath Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":116.28,"Note":"**"},{"Itemcode":"64139776","Description":"Sheeting Silastic Neuro","CDM Revenue Code":"278","Standard Price":579.36,"Note":"**"},{"Itemcode":"64139779","Description":"Shunt Carotid","CDM Revenue Code":"272","Standard Price":2133.84,"Note":"**"},{"Itemcode":"64139781","Description":"Shunt Coronary","CDM Revenue Code":"278","Standard Price":283.56,"Note":"**"},{"Itemcode":"64139784","Description":"Skin Adhesive Grp 2","CDM Revenue Code":"272","Standard Price":1740.12},{"Itemcode":"64139785","Description":"Skin Adhesive Grp 1","CDM Revenue Code":"272","Standard Price":137.7,"Note":"**"},{"Itemcode":"64139791","Description":"Sling Urology C1771 Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1771","Standard Price":5026.56,"Note":"**"},{"Itemcode":"64139795","Description":"Spacer Tapered Grp 2","CDM Revenue Code":"278","Standard Price":936.36},{"Itemcode":"64139796","Description":"Spacer Tapered Grp 1","CDM Revenue Code":"278","Standard Price":624.24,"Note":"**"},{"Itemcode":"64139798","Description":"Stabilizer Cv Sternal Grp 2","CDM Revenue Code":"278","Standard Price":4692.0,"Note":"**"},{"Itemcode":"64139799","Description":"Stabilizer Cv Grp 1","CDM Revenue Code":"278","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64139800","Description":"Staple Bone Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5962.92,"Note":"**"},{"Itemcode":"64139801","Description":"Staple Bone Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2748.9},{"Itemcode":"64139802","Description":"Staple Bone Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":747.66,"Note":"**"},{"Itemcode":"64139803","Description":"Staple Bone Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":504.9},{"Itemcode":"64139804","Description":"Staple Bone Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6889.08,"Note":"**"},{"Itemcode":"64139820","Description":"Stent Biliary C1876","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":5110.2,"Note":"**"},{"Itemcode":"64139821","Description":"StentUretal Temp WODel Sys Gr1","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":733.38,"Note":"**"},{"Itemcode":"64139823","Description":"Stent Vascular Grp 2","CDM Revenue Code":"278","Standard Price":6720.78},{"Itemcode":"64139825","Description":"Stimulator Bone","CDM Revenue Code":"278","Standard Price":16738.2,"Note":"**"},{"Itemcode":"64139829","Description":"Stone Basket Grp 2","CDM Revenue Code":"272","Standard Price":1032.24,"Note":"**"},{"Itemcode":"64139830","Description":"Stone Basket Grp 1","CDM Revenue Code":"272","Standard Price":502.86,"Note":"**"},{"Itemcode":"64139831","Description":"Stylet","CDM Revenue Code":"272","Standard Price":317.22},{"Itemcode":"64139832","Description":"Surgicel","CDM Revenue Code":"272","Standard Price":495.72,"Note":"**"},{"Itemcode":"64139834","Description":"Suture Retriever 71111579","CDM Revenue Code":"272","Standard Price":799.68,"Note":"**"},{"Itemcode":"64139835","Description":"Syringe Bio Glue","CDM Revenue Code":"272","Standard Price":3552.66,"Note":"**"},{"Itemcode":"64139837","Description":"Tap Grp 2","CDM Revenue Code":"272","Standard Price":1194.42,"Note":"**"},{"Itemcode":"64139838","Description":"Tap Grp 1","CDM Revenue Code":"272","Standard Price":642.6,"Note":"**"},{"Itemcode":"64139840","Description":"Template","CDM Revenue Code":"272","Standard Price":374.34,"Note":"**"},{"Itemcode":"64139842","Description":"Tissue Expander Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":6394.38,"Note":"**"},{"Itemcode":"64139843","Description":"Tray Applicator Mammosite","CDM Revenue Code":"272","Standard Price":10865.04},{"Itemcode":"64139844","Description":"Trocar Grp 1","CDM Revenue Code":"272","Standard Price":262.14,"Note":"**"},{"Itemcode":"64139845","Description":"Trocar Grp 2","CDM Revenue Code":"272","Standard Price":945.54,"Note":"**"},{"Itemcode":"64139846","Description":"Trocar Grp 3","CDM Revenue Code":"272","Standard Price":2122.62,"Note":"**"},{"Itemcode":"64139848","Description":"Tube Gi Grp 1","CDM Revenue Code":"272","Standard Price":199.92,"Note":"**"},{"Itemcode":"64139850","Description":"Tube Myringotomy","CDM Revenue Code":"278","Standard Price":245.82,"Note":"**"},{"Itemcode":"64139852","Description":"Tube Trach Grp 2","CDM Revenue Code":"272","Standard Price":1566.72,"Note":"**"},{"Itemcode":"64139853","Description":"Tube Trach Cuffed Grp1","CDM Revenue Code":"272","CDM HCPCS":"A7521","Standard Price":259.08,"Note":"**"},{"Itemcode":"64139855","Description":"Tunneling Tool","CDM Revenue Code":"272","Standard Price":3179.34},{"Itemcode":"64139856","Description":"Uterine Manipulator","CDM Revenue Code":"272","Standard Price":495.72,"Note":"**"},{"Itemcode":"64139858","Description":"Valve Heart Aortic W/Graft","CDM Revenue Code":"278","Standard Price":18260.04},{"Itemcode":"64139859","Description":"Valve Csf Grp 2","CDM Revenue Code":"278","Standard Price":4246.26,"Note":"**"},{"Itemcode":"64139860","Description":"Valve Csf Grp 1","CDM Revenue Code":"278","Standard Price":1537.14},{"Itemcode":"64139861","Description":"Valve Lumbar","CDM Revenue Code":"278","Standard Price":5622.24,"Note":"**"},{"Itemcode":"64139864","Description":"Valve Heart Grp 1","CDM Revenue Code":"278","Standard Price":16549.5},{"Itemcode":"64139865","Description":"Valve Heart Grp 2","CDM Revenue Code":"278","Standard Price":18275.34,"Note":"**"},{"Itemcode":"64139866","Description":"Valve Heart Grp 3","CDM Revenue Code":"278","Standard Price":19631.94},{"Itemcode":"64139867","Description":"Valvulotome","CDM Revenue Code":"272","Standard Price":8015.16},{"Itemcode":"64139873","Description":"Washer Grp 2","CDM Revenue Code":"278","Standard Price":2414.34},{"Itemcode":"64139874","Description":"Washer Grp 1","CDM Revenue Code":"278","Standard Price":205.02,"Note":"**"},{"Itemcode":"64139876","Description":"Wire Ortho Supply Grp 2","CDM Revenue Code":"272","Standard Price":844.56,"Note":"**"},{"Itemcode":"64139878","Description":"Wire Ortho Supply Grp 1","CDM Revenue Code":"272","Standard Price":377.4,"Note":"**"},{"Itemcode":"64139912","Description":"URO Open Major Supply Charge","CDM Revenue Code":"272","Standard Price":2521.44},{"Itemcode":"64139913","Description":"URO Intermediate Supply Charg","CDM Revenue Code":"272","Standard Price":1118.94},{"Itemcode":"64139914","Description":"URO Open Minor Supply Charge","CDM Revenue Code":"272","Standard Price":874.14},{"Itemcode":"64139996","Description":"Lens Presby Correcting Functn","CDM Revenue Code":"276","CDM HCPCS":"V2788","Standard Price":995.0,"Note":"**"},{"Itemcode":"64139997","Description":"Restor Conventional Iol","CDM Revenue Code":"276","Standard Price":872.1},{"Itemcode":"64139998","Description":"Restor Lens -D","CDM Revenue Code":"276","Standard Price":0.0},{"Itemcode":"64140000","Description":"Neurostim Kit Anchor","CDM Revenue Code":"272","Standard Price":806.82,"Note":"**"},{"Itemcode":"64140001","Description":"Insert Trial Lgn POLY PS SZ5-6","CDM Revenue Code":"278","Standard Price":1284.18},{"Itemcode":"64140002","Description":"NS Gen Precsn HF Rechg SC-1200","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":55115.7,"Note":"**"},{"Itemcode":"64140003","Description":"External Fixator Cmpnts Grp 2A","CDM Revenue Code":"272","Standard Price":1300.5,"Note":"**"},{"Itemcode":"64140004","Description":"External Fixator Cmpnts Grp 2B","CDM Revenue Code":"272","Standard Price":1592.22,"Note":"**"},{"Itemcode":"64140005","Description":"Kit Accessory ACL/PCL 014725","CDM Revenue Code":"272","Standard Price":1469.82,"Note":"**"},{"Itemcode":"64140006","Description":"Shaft Drive Seal 351.718S","CDM Revenue Code":"272","Standard Price":211.14,"Note":"**"},{"Itemcode":"64140007","Description":"Clip Lock 352.260S","CDM Revenue Code":"272","Standard Price":567.12,"Note":"**"},{"Itemcode":"64140008","Description":"Tube Assembly 314.746S","CDM Revenue Code":"272","Standard Price":2734.62,"Note":"**"},{"Itemcode":"64140009","Description":"Filter Graft RTA 352.229S","CDM Revenue Code":"272","Standard Price":2546.94,"Note":"**"},{"Itemcode":"64140011","Description":"CAGE PEEK XL 6200445","CDM Revenue Code":"278","Standard Price":19442.22},{"Itemcode":"64140012","Description":"OH VALV SUTERE CHORD-X 1/2CIR","CDM Revenue Code":"278","Standard Price":8453.76,"Note":"**"},{"Itemcode":"64140013","Description":"OH VALV-SIZER CHORD-X CXCS","CDM Revenue Code":"278","Standard Price":1327.02},{"Itemcode":"64140014","Description":"Probe Ablation XL90 Ar-9821","CDM Revenue Code":"272","Standard Price":906.78,"Note":"**"},{"Itemcode":"64140015","Description":"Stent Biliary Visi Pro","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3626.1},{"Itemcode":"64140016","Description":"KIT SNARE RETRIEVAL SRK30","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1564.68},{"Itemcode":"64140017","Description":"Collagen Scaffold LG 2169-3","CDM Revenue Code":"278","Standard Price":8571.06},{"Itemcode":"64140018","Description":"Lead AICD SGL Reliance 0293","CDM Revenue Code":"275","CDM HCPCS":"C1777","Standard Price":12679.62},{"Itemcode":"64140019","Description":"CAP DEPUY CEMENTED KNEE","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12172.68,"Note":"**"},{"Itemcode":"64140020","Description":"CAP DEPUY HIP UNI-BIPOLAR","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":10482.54,"Note":"**"},{"Itemcode":"64140021","Description":"CAP TORNIER SHOULDER TOTAL","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16906.5,"Note":"**"},{"Itemcode":"64140022","Description":"CAP DEPUY T SHOULDER REVERSE","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":28741.56,"Note":"**"},{"Itemcode":"64140023","Description":"CAP HIP UNI-BIPOLAR S/N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":10482.54,"Note":"**"},{"Itemcode":"64140024","Description":"Graft Stent Thor 30MM","CDM Revenue Code":"278","Standard Price":57464.76},{"Itemcode":"64140025","Description":"Graft Stent Thor 38MM","CDM Revenue Code":"278","Standard Price":54928.02},{"Itemcode":"64140026","Description":"Cath Distal Shunt Progav","CDM Revenue Code":"278","Standard Price":10293.84},{"Itemcode":"64140027","Description":"Valve,Shunt Adj Prosa","CDM Revenue Code":"278","Standard Price":12162.48},{"Itemcode":"64140028","Description":"CAP UPCHRG-HIP TOTAL DEPUY","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16398.54,"Note":"**"},{"Itemcode":"64140029","Description":"CAP-KNEE TOTAL JOURNEY S/N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16111.92,"Note":"**"},{"Itemcode":"64140030","Description":"CAP- HIP TOTAL OXI S/N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16906.5,"Note":"**"},{"Itemcode":"64140031","Description":"NS Genr Precision SC-1140sys","CDM Revenue Code":"278","CDM HCPCS":"C1767","Standard Price":58497.0},{"Itemcode":"64140032","Description":"EPIFIX 18 MM DISK GS-5180","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":1781.94,"Note":"**"},{"Itemcode":"64140033","Description":"CAP DEPUY T SHOULDER","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":16906.5},{"Itemcode":"64140034","Description":"CAP T KNEE HI DEMND-INSERT S/N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":14420.76,"Note":"**"},{"Itemcode":"64140035","Description":"STENT INNOVA 39293-07103","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4052.46,"Note":"**"},{"Itemcode":"64140036","Description":"TOE FUSN SYSTEM PIP; 1PP-ON","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3839.28},{"Itemcode":"64140037","Description":"CAP, END X CORE","CDM Revenue Code":"278","Standard Price":4265.64},{"Itemcode":"64140038","Description":"IM HIP-SLEEVE/DRILL GUIDE","CDM Revenue Code":"272","Standard Price":1195.44},{"Itemcode":"64140039","Description":"SPINAL SET SCREW BLOCKER GR1","CDM Revenue Code":"278","Standard Price":322.32},{"Itemcode":"64140040","Description":"SPINAL SET SCREW BLOCKER GR2","CDM Revenue Code":"278","Standard Price":664.02},{"Itemcode":"64140041","Description":"CAP MIS FOR SET SCREW 16A034","CDM Revenue Code":"278","Standard Price":1592.22},{"Itemcode":"64140042","Description":"GENERATOR MONTAGE SC-1210A","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":58497.0},{"Itemcode":"64140043","Description":"CAP-TORNIER SHOULDER REVERSE","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":28741.56,"Note":"**"},{"Itemcode":"64140044","Description":"SHEATH SAFE 10.5 FR 667466-001","CDM Revenue Code":"272","CDM HCPCS":"C1892","Standard Price":322.32},{"Itemcode":"64140045","Description":"CAP KNEE T CEMENTED NK-ZIMMER","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12172.68,"Note":"**"},{"Itemcode":"64140046","Description":"STYLET MRI 9735566","CDM Revenue Code":"272","Standard Price":2878.44},{"Itemcode":"64140047","Description":"TIP LASER DIFF MRI 400-T10","CDM Revenue Code":"272","Standard Price":47320.86,"Note":"**"},{"Itemcode":"64140048","Description":"CUTTER FLIP AR-1204AF-80","CDM Revenue Code":"272","Standard Price":1723.8},{"Itemcode":"64140049","Description":"NEEDLE SCORPION AR-13991N","CDM Revenue Code":"272","Standard Price":742.56},{"Itemcode":"64140050","Description":"SUTURE LASSO 90 AR-6069-90","CDM Revenue Code":"272","Standard Price":848.64},{"Itemcode":"64140051","Description":"SOLN WOUND LAVAGE-BACTISURE","CDM Revenue Code":"272","Standard Price":2559.18,"Note":"**"},{"Itemcode":"64140052","Description":"Sys LAA-ATRICLIP PROV 35-50MM","CDM Revenue Code":"278","Standard Price":18597.66,"Note":"**"},{"Itemcode":"64140053","Description":"FEMO STOP COMPRES++SYS C11165","CDM Revenue Code":"272","Standard Price":556.92,"Note":"**"},{"Itemcode":"64140054","Description":"FORCEP BIPOLAR BAYONET TIP","CDM Revenue Code":"272","Standard Price":5127.54,"Note":"**"},{"Itemcode":"64140055","Description":"DRILL GUIDE PROBE","CDM Revenue Code":"272","Standard Price":8477.22},{"Itemcode":"64140058","Description":"Cap K3 Knee Uni Partl-Zuk S/N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":10820.16,"Note":"**"},{"Itemcode":"64140059","Description":"Cath CFS Ventricular INS-4500","CDM Revenue Code":"278","Standard Price":674.22,"Note":"**"},{"Itemcode":"64140060","Description":"Allograft Spacer BALM0007 7mm","CDM Revenue Code":"278","Standard Price":4265.64},{"Itemcode":"64140061","Description":"CAP-T KNEE CEMNTLES HYBRID ZIM","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":15976.26,"Note":"**"},{"Itemcode":"64140062","Description":"Syst Delivery Osseoflx OF-0348","CDM Revenue Code":"272","Standard Price":2772.36},{"Itemcode":"64140063","Description":"Balln Steer Osseoflx OF-0224","CDM Revenue Code":"272","Standard Price":3347.64},{"Itemcode":"64140064","Description":"Drill Hand Osseoflx OF-0217","CDM Revenue Code":"272","Standard Price":1034.28},{"Itemcode":"64140065","Description":"Kit Acc Vclas Neur-Anchr/sty","CDM Revenue Code":"272","Standard Price":10143.9,"Note":"**"},{"Itemcode":"64140066","Description":"CAP-T. Knee Cemented-Consensus","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12172.68},{"Itemcode":"64140067","Description":"Trephine Extractor 18- 18.5m","CDM Revenue Code":"272","Standard Price":1303.56},{"Itemcode":"64140068","Description":"T KNEE CEMENTLESS DEPUY PATELA","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":15216.36,"Note":"**"},{"Itemcode":"64140069","Description":"ANCHOR-KNEE LIGAMNT AUGMNT RPR","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5097.96,"Note":"**"},{"Itemcode":"64140070","Description":"REAMER 9.5MM, AR-1409LP-50","CDM Revenue Code":"272","Standard Price":1034.28,"Note":"**"},{"Itemcode":"64140071","Description":"SHIMM 10,14MM; SP INTERBDY CG","CDM Revenue Code":"278","Standard Price":9598.2},{"Itemcode":"64140072","Description":"SHELL SHORT 2PART CAGE","CDM Revenue Code":"278","Standard Price":9598.2,"Note":"**"},{"Itemcode":"64140073","Description":"SHELL ASSY 27MM-SP INTERBDY CG","CDM Revenue Code":"278","Standard Price":9598.2},{"Itemcode":"64140074","Description":"CAP-HIP TOTAL RESURFC S/N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":27050.4},{"Itemcode":"64140075","Description":"STENT PERIPH OTW - SUPERA","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6804.42,"Note":"**"},{"Itemcode":"64140076","Description":"CATH,BALLN EVERCROSS","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":636.48},{"Itemcode":"64140077","Description":"CATH ATHERECTOMY,HAWKONE","CDM Revenue Code":"272","CDM HCPCS":"C1714","Standard Price":10482.54,"Note":"**"},{"Itemcode":"64140078","Description":"CATH THROMB SET ANGIOJET 6FR","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":7273.62},{"Itemcode":"64140079","Description":"PM GEN 1 CHMBR SR-MRI ACCOLADE","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":12172.68},{"Itemcode":"64140080","Description":"Kit Baloon Strt 10GA Vertebrex","CDM Revenue Code":"272","Standard Price":4820.52,"Note":"**"},{"Itemcode":"64140081","Description":"Allograft Spacer 018406 6MM","CDM Revenue Code":"278","Standard Price":7114.5},{"Itemcode":"64140082","Description":"Cerv Disc Pros MB3575","CDM Revenue Code":"278","Standard Price":20287.8},{"Itemcode":"64140083","Description":"NS Cable Ext Trial Intellis","CDM Revenue Code":"272","Standard Price":5545.74,"Note":"**"},{"Itemcode":"64140084","Description":"Stent Innova 7mmx60mmx130cm","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3091.62,"Note":"**"},{"Itemcode":"64140085","Description":"Guide Sheath Steerable","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2452.08},{"Itemcode":"64140087","Description":"Needle Disp Reline","CDM Revenue Code":"272","Standard Price":8705.7},{"Itemcode":"64140088","Description":"Device Inflation, Osseon","CDM Revenue Code":"272","Standard Price":530.4},{"Itemcode":"64140089","Description":"Blade Helical-80,100MM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4014.72,"Note":"**"},{"Itemcode":"64140090","Description":"Catheter Passer Tunneler 38cm","CDM Revenue Code":"272","Standard Price":632.4,"Note":"**"},{"Itemcode":"64140091","Description":"Filter Vena Cava","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":4427.82},{"Itemcode":"64140092","Description":"T Knee Cemented Stnd Insrt SN","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12172.68,"Note":"**"},{"Itemcode":"64140093","Description":"Imp Del Biocomp AR-2260BC","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4692.0,"Note":"**"},{"Itemcode":"64140094","Description":"AMNIOFILL 100MG","CDM Revenue Code":"278","Standard Price":9598.2,"Note":"**"},{"Itemcode":"64140095","Description":"EPIFIX XL 9.0CMX15CM","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":33290.76},{"Itemcode":"64140096","Description":"ANCHOR SUTURE GR1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1194.42,"Note":"**"},{"Itemcode":"64140097","Description":"DEVICE SPINE DISCECTOMY","CDM Revenue Code":"278","Standard Price":4171.8},{"Itemcode":"64140098","Description":"KIT HIP DISP W/DRILL GUID","CDM Revenue Code":"278","Standard Price":2879.46,"Note":"**"},{"Itemcode":"64140099","Description":"CAP T KNEE JOURNEY OXINIUM S&N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12511.32,"Note":"**"},{"Itemcode":"64140100","Description":"CAP TKNEE LEGION OXINUM GII SN","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":13863.84,"Note":"**"},{"Itemcode":"64140102","Description":"SUTURE MITRAL 2-0 CHORD-X","CDM Revenue Code":"272","Standard Price":2132.82},{"Itemcode":"64140103","Description":"NS KIT ++ LEADS 9771 ISYS","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":83869.5},{"Itemcode":"64140104","Description":"AICD Unify Assura CRT-D","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":58304.22},{"Itemcode":"64140105","Description":"SIZER TLIF LUNA LUN3501-08","CDM Revenue Code":"272","Standard Price":2509.2},{"Itemcode":"64140106","Description":"Cap TKnee W/Vit E Ploy","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":15249.0,"Note":"**"},{"Itemcode":"64140109","Description":"EPIFIX Fenestrated 9x9cm","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":19682.94,"Note":"**"},{"Itemcode":"64140110","Description":"SYSTEM DELIVERY CEMENT","CDM Revenue Code":"272","Standard Price":1560.6,"Note":"**"},{"Itemcode":"64140111","Description":"End Plate Assy","CDM Revenue Code":"278","Standard Price":15745.74,"Note":"**"},{"Itemcode":"64140112","Description":"BOLT PEDICAL","CDM Revenue Code":"278","Standard Price":1122.0},{"Itemcode":"64140113","Description":"REAMER PASSING PIN 4.5MM","CDM Revenue Code":"278","Standard Price":385.56},{"Itemcode":"64140114","Description":"CAP SHOULDER HEMI FLEX TORNIER","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":13923.0,"Note":"**"},{"Itemcode":"64140115","Description":"CAP T SHOULDER TORNIER SIMPL","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":18232.5,"Note":"**"},{"Itemcode":"64140116","Description":"Sys Flex LAA Excl Vclip 45mm","CDM Revenue Code":"272","Standard Price":8364.0},{"Itemcode":"64140117","Description":"Custom TMJ Bilateral Bundle","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":54697.5},{"Itemcode":"64140118","Description":"ATRICLIP FLEX","CDM Revenue Code":"272","Standard Price":8364.0,"Note":"**"},{"Itemcode":"64140119","Description":"DRILL BIT CANN 16MM 03.037.104","CDM Revenue Code":"272","Standard Price":5229.54},{"Itemcode":"64140120","Description":"IMPLANT COCHLEAR CI532 Z285654","CDM Revenue Code":"278","CDM HCPCS":"L8614","Standard Price":47829.84},{"Itemcode":"64140121","Description":"ROD CIRCULAR 4922-7-220","CDM Revenue Code":"278","Standard Price":2042.04},{"Itemcode":"64140122","Description":"ROD GUIDE 2.0 71751146","CDM Revenue Code":"272","Standard Price":1166.88,"Note":"**"},{"Itemcode":"64140123","Description":"TEMPLATE SIZING 15MM 329.932","CDM Revenue Code":"272","Standard Price":5741.58},{"Itemcode":"64140124","Description":"TISSUE DERMA MATRIX PDMW-4X8","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":9143.28},{"Itemcode":"64140125","Description":"CAP T. Hip Porous Fem S&N","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":14917.5},{"Itemcode":"64140126","Description":"Cable Stern TIw/ndl 3TPR 1 cut","CDM Revenue Code":"278","Standard Price":2378.64,"Note":"**"},{"Itemcode":"64140127","Description":"AICD DYNAGEN MINI DF4 VR","CDM Revenue Code":"278","CDM HCPCS":"C1722","Standard Price":35802.0},{"Itemcode":"64140128","Description":"IPG W/CHARGE SYST","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":60664.5,"Note":"**"},{"Itemcode":"64140129","Description":"LEAD SPRINT QUATTRO","CDM Revenue Code":"278","CDM HCPCS":"C1895","Standard Price":14586.0},{"Itemcode":"64140130","Description":"PATCH BOVINE PERICARDIAL","CDM Revenue Code":"278","Standard Price":884.34,"Note":"**"},{"Itemcode":"64140131","Description":"ACL BACKUP FIXATION SYS","CDM Revenue Code":"278","Standard Price":2509.2,"Note":"**"},{"Itemcode":"64140132","Description":"ZIMMER TOTAL KNEE VITAMIN","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":14586.0},{"Itemcode":"64140133","Description":"TMJ FOSSA & MANDI COMP","CDM Revenue Code":"272","Standard Price":31492.5},{"Itemcode":"64140134","Description":"STENT GRAFT","CDM Revenue Code":"278","Standard Price":56337.66},{"Itemcode":"64140135","Description":"HEAD REDUCTION","CDM Revenue Code":"272","Standard Price":2340.9,"Note":"**"},{"Itemcode":"64140136","Description":"CAP SET","CDM Revenue Code":"272","Standard Price":316.2},{"Itemcode":"64140137","Description":"HIP HEMI S&N","CDM Revenue Code":"278","Standard Price":11934.0,"Note":"**"},{"Itemcode":"64140138","Description":"NEEDLE DELIVERY DLS-7126-05S","CDM Revenue Code":"272","Standard Price":1697.28,"Note":"**"},{"Itemcode":"64140139","Description":"Algrft Amniotic Mem Fen 9x20cm","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":39168.0,"Note":"**"},{"Itemcode":"64140140","Description":"LEAD TRIAL INFINION 1X16 70CM","CDM Revenue Code":"278","CDM HCPCS":"C1897","Standard Price":3136.5},{"Itemcode":"64140141","Description":"TORQUE WRENCH KIT","CDM Revenue Code":"272","Standard Price":525.3},{"Itemcode":"64140142","Description":"PASSER SUT LASSO CRVD","CDM Revenue Code":"272","Standard Price":676.26},{"Itemcode":"64140143","Description":"Syndesmosis Repair Implant Sys","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6251.58,"Note":"**"},{"Itemcode":"64140144","Description":"BONE GRAFT SUBSTITUTE PUTTY","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2159.34},{"Itemcode":"64140145","Description":"KNEE TOTAL PERSONA HYBRID CAP","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":14586.0,"Note":"**"},{"Itemcode":"64140146","Description":"KNEE TOTAL AESCULAP CAP","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":19723.74,"Note":"**"},{"Itemcode":"64140147","Description":"CAP END","CDM Revenue Code":"278","Standard Price":4182.0},{"Itemcode":"64140148","Description":"Omni Robot Knee Cap","CDM Revenue Code":"278","Standard Price":11934.0},{"Itemcode":"64140149","Description":"Kit Cement","CDM Revenue Code":"278","Standard Price":2823.36},{"Itemcode":"64140150","Description":"Balloon Kyho","CDM Revenue Code":"272","Standard Price":6273.0},{"Itemcode":"64140151","Description":"drill hand","CDM Revenue Code":"272","Standard Price":556.92},{"Itemcode":"64140152","Description":"Needle Biopsy 13G","CDM Revenue Code":"272","Standard Price":556.92},{"Itemcode":"64140153","Description":"BALLOON EXPAND BXAL083902A","CDM Revenue Code":"278","Standard Price":10259.16,"Note":"**"},{"Itemcode":"64140154","Description":"Lactosorb system","CDM Revenue Code":"278","Standard Price":4624.68,"Note":"**"},{"Itemcode":"64140155","Description":"Powder Surg Collagen","CDM Revenue Code":"272","CDM HCPCS":"A6010","Standard Price":6251.58,"Note":"**"},{"Itemcode":"64140156","Description":"SYS HERO HERO1000","CDM Revenue Code":"272","Standard Price":13260.0,"Note":"**"},{"Itemcode":"64140157","Description":"KIT COMP AR-7297","CDM Revenue Code":"272","Standard Price":2509.2},{"Itemcode":"64140158","Description":"KIT TORQUE","CDM Revenue Code":"272","Standard Price":2092.02},{"Itemcode":"64140159","Description":"Implant Crani PK621318","CDM Revenue Code":"278","Standard Price":32487.0},{"Itemcode":"64140160","Description":"Implant Crani 4350","CDM Revenue Code":"278","Standard Price":24531.0},{"Itemcode":"64140161","Description":"Plate Cerv Dual 1174.1001","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":18232.5},{"Itemcode":"64140162","Description":"Stimulator Neuro 37703","CDM Revenue Code":"278","CDM HCPCS":"C1820","Standard Price":28177.5},{"Itemcode":"64140163","Description":"Header 2 Port 3032","CDM Revenue Code":"272","Standard Price":2300.1},{"Itemcode":"64140164","Description":"GRAFT ENDOVASCULAR AAA GRP4","CDM Revenue Code":"278","Standard Price":46405.92,"Note":"**"},{"Itemcode":"64140165","Description":"KIT CARTILAGE BIOPSY 80006","CDM Revenue Code":"272","Standard Price":2374.56},{"Itemcode":"64140166","Description":"CUFF INFRARENAL A28-28/C75V","CDM Revenue Code":"272","Standard Price":17565.42},{"Itemcode":"64140167","Description":"Spinal Cage Expandable Grp 1A","CDM Revenue Code":"278","Standard Price":21547.5},{"Itemcode":"64140168","Description":"Plug Graft Cont 1676817","CDM Revenue Code":"278","Standard Price":466.14},{"Itemcode":"64140169","Description":"SHIM DISC","CDM Revenue Code":"272","Standard Price":2211.36,"Note":"**"},{"Itemcode":"64140170","Description":"MODEL BONE 3D FF-PSG-0003","CDM Revenue Code":"272","Standard Price":7109.4},{"Itemcode":"64140171","Description":"KIT TRACKER RM-1000","CDM Revenue Code":"272","Standard Price":2091.0},{"Itemcode":"64140172","Description":"Extractor Nail","CDM Revenue Code":"272","Standard Price":1169.94,"Note":"**"},{"Itemcode":"64140173","Description":"Spacer Nail GA04041","CDM Revenue Code":"272","Standard Price":36918.9,"Note":"**"},{"Itemcode":"64140174","Description":"Anchor Ligament Fiber Tak","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2054.28,"Note":"**"},{"Itemcode":"64140175","Description":"KIT ACCESS TDAK0021","CDM Revenue Code":"272","Standard Price":3115.08,"Note":"**"},{"Itemcode":"64140176","Description":"Bolt Locking Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6427.02},{"Itemcode":"64140177","Description":"SPINAL CORD STIMULATOR KIT","CDM Revenue Code":"278","Standard Price":83869.5},{"Itemcode":"64140178","Description":"CAP-KNEE LGN GII PS OXI","CDM Revenue Code":"278","Standard Price":13591.5},{"Itemcode":"64140179","Description":"INLAY 8.5mm","CDM Revenue Code":"278","Standard Price":4600.2,"Note":"**"},{"Itemcode":"64140180","Description":"PACEMAKER PRODIGY MRI","CDM Revenue Code":"278","Standard Price":53583.66,"Note":"**"},{"Itemcode":"64140181","Description":"Cannula Ortho/Neuro Grp 4","CDM Revenue Code":"272","Standard Price":2574.48,"Note":"**"},{"Itemcode":"64140182","Description":"Cap knee Modular Vega","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":19723.74,"Note":"**"},{"Itemcode":"64140183","Description":"DISC CERVICAL MB3597","CDM Revenue Code":"278","Standard Price":19890.0,"Note":"**"},{"Itemcode":"64140184","Description":"Controller Patient","CDM Revenue Code":"272","Standard Price":4996.98,"Note":"**"},{"Itemcode":"64140185","Description":"Spine Cage Lateral GRP 1","CDM Revenue Code":"278","Standard Price":19890.0,"Note":"**"},{"Itemcode":"64140186","Description":"Thoracic Stent Graft GRP 2","CDM Revenue Code":"278","Standard Price":71255.16,"Note":"**"},{"Itemcode":"64140187","Description":"Stent Graft Endopros-Endurant","CDM Revenue Code":"278","Standard Price":33066.36,"Note":"**"},{"Itemcode":"64140188","Description":"KIT INTELIS TRIAL","CDM Revenue Code":"278","CDM HCPCS":"C1897","Standard Price":7522.5,"Note":"**"},{"Itemcode":"64140189","Description":"BALLOON CATH INTV-15-DDK","CDM Revenue Code":"278","CDM HCPCS":"C1726","Standard Price":9248.34,"Note":"**"},{"Itemcode":"64140190","Description":"Aortic Annuloplasty","CDM Revenue Code":"278","Standard Price":19890.0,"Note":"**"},{"Itemcode":"64140191","Description":"SHOULDER TOTAL DJ","CDM Revenue Code":"278","Standard Price":18232.5,"Note":"**"},{"Itemcode":"64140192","Description":"STAPLES TENDON","CDM Revenue Code":"272","Standard Price":1300.5,"Note":"**"},{"Itemcode":"64140193","Description":"NAIL FUSION 71931590","CDM Revenue Code":"272","Standard Price":21613.8,"Note":"**"},{"Itemcode":"64140194","Description":"REBEL H7493927432350","CDM Revenue Code":"272","Standard Price":2340.9,"Note":"**"},{"Itemcode":"64140195","Description":"STENT H7493926038400","CDM Revenue Code":"272","Standard Price":3730.14,"Note":"**"},{"Itemcode":"64140196","Description":"KYPHO BONE ACCESS KIT","CDM Revenue Code":"272","Standard Price":1820.7,"Note":"**"},{"Itemcode":"64140197","Description":"RF DUAL PROBE KIT","CDM Revenue Code":"272","Standard Price":13923.0,"Note":"**"},{"Itemcode":"64140198","Description":"IMPLANT FUSION SI","CDM Revenue Code":"278","Standard Price":28177.5,"Note":"**"},{"Itemcode":"64140200","Description":"IMPLANT SEROSAFUSE","CDM Revenue Code":"278","Standard Price":16501.56},{"Itemcode":"64140201","Description":"PLATE DISTAL RAD KIT","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":16575.0,"Note":"**"},{"Itemcode":"64140202","Description":"KIT GRAFT SIZING AR-1676ST","CDM Revenue Code":"272","Standard Price":1534.08,"Note":"**"},{"Itemcode":"64140203","Description":"SPINE ROD GRP","CDM Revenue Code":"272","Standard Price":14684.94,"Note":"**"},{"Itemcode":"64140205","Description":"KIT INSTRU DISP","CDM Revenue Code":"272","Standard Price":2080.8,"Note":"**"},{"Itemcode":"64141948","Description":"Mesh Genl Surg C1781 Grp 3B","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":2315.4,"Note":"**"},{"Itemcode":"64142021","Description":"Implant Joint Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":6764.64,"Note":"**"},{"Itemcode":"64142746","Description":"Stapler-Reloads Disp. Grp 3F","CDM Revenue Code":"272","Standard Price":2601.0,"Note":"**"},{"Itemcode":"64144433","Description":"Endotine Implant","CDM Revenue Code":"278","Standard Price":1362.72,"Note":"**"},{"Itemcode":"64145640","Description":"Graft Porcine, Oto 0.6x0.9cm","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":982.26,"Note":"**"},{"Itemcode":"64148863","Description":"CONNECTOR,NERVE PORCINE ECM","CDM Revenue Code":"278","Standard Price":5439.66},{"Itemcode":"64149211","Description":"Stapler-Reloads Disp. Grp 2","CDM Revenue Code":"272","Standard Price":770.1,"Note":"**"},{"Itemcode":"64149216","Description":"Plate Grp 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5336.64,"Note":"**"},{"Itemcode":"64149301","Description":"Anchor Bone Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2041.02,"Note":"**"},{"Itemcode":"64149313","Description":"Bit Drill Grp 4","CDM Revenue Code":"272","Standard Price":2248.08,"Note":"**"},{"Itemcode":"64149315","Description":"Bit Drill Grp 2","CDM Revenue Code":"272","Standard Price":867.0,"Note":"**"},{"Itemcode":"64149754","Description":"Screw Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2057.34,"Note":"**"},{"Itemcode":"64149756","Description":"Screw Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":825.18,"Note":"**"},{"Itemcode":"64149757","Description":"Screw Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":466.14,"Note":"**"},{"Itemcode":"64149878","Description":"Wire Ortho Supply Grp 1","CDM Revenue Code":"272","Standard Price":377.4,"Note":"**"},{"Itemcode":"64407030","Description":"Sys Fix Ultrafast Crv 72201491","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1711.56},{"Itemcode":"64408888","Description":"Non-Charge Anes Supply","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"64500002","Description":"Clip OTSC System 220 cm","CDM Revenue Code":"272","Standard Price":2203.812,"Note":"**"},{"Itemcode":"64500014","Description":"Anchor TT 220 cm Colon","CDM Revenue Code":"272","Standard Price":2204.118},{"Itemcode":"64500015","Description":"OTSC Anchor 165 CM","CDM Revenue Code":"272","Standard Price":2204.118},{"Itemcode":"64500020","Description":"Twin Grasper 220 CM","CDM Revenue Code":"272","Standard Price":2462.382,"Note":"**"},{"Itemcode":"64500021","Description":"Implantable Fastener Kit","CDM Revenue Code":"272","Standard Price":15740.436,"Note":"**"},{"Itemcode":"64500070","Description":"Grasper/Retriever","CDM Revenue Code":"272","Standard Price":613.02},{"Itemcode":"64500071","Description":"RETRIEVER ENDO HRD WIR","CDM Revenue Code":"272","Standard Price":2233.8,"Note":"**"},{"Itemcode":"64500218","Description":"Ebus Fna/Biopsy Needle","CDM Revenue Code":"272","Standard Price":583.44},{"Itemcode":"64501022","Description":"CATH BALLOON EXTRACTION PRORX","CDM Revenue Code":"272","Standard Price":770.1,"Note":"**"},{"Itemcode":"64501170","Description":"Blood Trans: 1 Unit-D","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"64501175","Description":"Blood Trans: Add'L Units-D","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"64502012","Description":"Bravo Capsule","CDM Revenue Code":"278","Standard Price":1151.58,"Note":"**"},{"Itemcode":"64502030","Description":"Cath Spyscope","CDM Revenue Code":"272","Standard Price":3370.08},{"Itemcode":"64502031","Description":"Forceps Disp Spybite Bx","CDM Revenue Code":"272","Standard Price":2652.0,"Note":"**"},{"Itemcode":"64502032","Description":"Set Colonic Decompression","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":907.8,"Note":"**"},{"Itemcode":"64502033","Description":"Fiapc Probe Disp","CDM Revenue Code":"272","Standard Price":1143.42,"Note":"**"},{"Itemcode":"64502035","Description":"Stent Advanix","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":724.2,"Note":"**"},{"Itemcode":"64502036","Description":"Stent Advanix Pigtail","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":351.9,"Note":"**"},{"Itemcode":"64502037","Description":"Rx Needleknife","CDM Revenue Code":"272","Standard Price":1029.18,"Note":"**"},{"Itemcode":"64502038","Description":"Naviflex Stent Delivery Sys","CDM Revenue Code":"272","Standard Price":543.66},{"Itemcode":"64502039","Description":"Guidewire Dreamwire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":994.5,"Note":"**"},{"Itemcode":"64502040","Description":"Jagwire Hydra","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":994.5,"Note":"**"},{"Itemcode":"64502041","Description":"Guidewire Pathfinder","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1300.5},{"Itemcode":"64502042","Description":"CATH BALLOON EXTRACTION HURCN","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":1323.96,"Note":"**"},{"Itemcode":"64502043","Description":"Gastric Lavage Sys","CDM Revenue Code":"272","Standard Price":1225.02},{"Itemcode":"64502044","Description":"Cath Balloon Quantum Billiary","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":1040.4},{"Itemcode":"64502045","Description":"Cath Dilation Graduated Cook","CDM Revenue Code":"272","Standard Price":413.1},{"Itemcode":"64502046","Description":"Cath Balloon Dil Non-Vascular","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":2445.96,"Note":"**"},{"Itemcode":"64502051","Description":"3-LUMEN EXTRACTION BALLOON V","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":638.52},{"Itemcode":"64502052","Description":"GUIDEWIRE VISIGLIDE","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":770.1},{"Itemcode":"64502053","Description":"DUETTE MUCOSECTOMY","CDM Revenue Code":"272","Standard Price":1539.18},{"Itemcode":"64502056","Description":"CATH ACCESS/DEL SPY SCOPE","CDM Revenue Code":"272","Standard Price":10450.92,"Note":"**"},{"Itemcode":"64502057","Description":"PROBE EHL, AUTOLITH","CDM Revenue Code":"272","Standard Price":2275.62,"Note":"**"},{"Itemcode":"64502058","Description":"Cath Balloon Non-Vasc-MaxFrce","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":1174.02},{"Itemcode":"64502091","Description":"StentFlex/PlasticW/ODelSys GR2","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":478.38},{"Itemcode":"64502092","Description":"StentFlex/PlasticW/ODelSys GR3","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":587.52,"Note":"**"},{"Itemcode":"64505006","Description":"SphinctertomeHydrotomw/Guidewi","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2255.22,"Note":"**"},{"Itemcode":"64505007","Description":"Sphincterotome Autotome","CDM Revenue Code":"272","Standard Price":1163.82,"Note":"**"},{"Itemcode":"64505008","Description":"Sphincterotome","CDM Revenue Code":"272","Standard Price":896.58,"Note":"**"},{"Itemcode":"64505009","Description":"Cath Gold Probe","CDM Revenue Code":"272","Standard Price":982.26,"Note":"**"},{"Itemcode":"64505010","Description":"Cath Esophogeal Dilatation","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":1211.76,"Note":"**"},{"Itemcode":"64505011","Description":"Cath Ercp Balloon","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":798.66,"Note":"**"},{"Itemcode":"64505012","Description":"Cath Esophogeal Ph Monitoring","CDM Revenue Code":"272","Standard Price":485.52},{"Itemcode":"64505014","Description":"G / J Tube","CDM Revenue Code":"272","Standard Price":355.98},{"Itemcode":"64505015","Description":"Needle Eus Biopsy","CDM Revenue Code":"272","Standard Price":1359.66,"Note":"**"},{"Itemcode":"64505016","Description":"Basket Stone Retreival","CDM Revenue Code":"272","Standard Price":1494.3,"Note":"**"},{"Itemcode":"64505017","Description":"Guidewire / Jagwire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1203.6,"Note":"**"},{"Itemcode":"64505018","Description":"Clip Resolution","CDM Revenue Code":"272","Standard Price":912.9,"Note":"**"},{"Itemcode":"64505019","Description":"Gdewre-Sphincterotome Jagtome","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1628.94,"Note":"**"},{"Itemcode":"64505020","Description":"Stent Non-Cov W/Delivery Sys","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":10653.9,"Note":"**"},{"Itemcode":"64505021","Description":"Stent Covered W/Delivery Sys","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":9965.4,"Note":"**"},{"Itemcode":"64505022","Description":"Stent Flexi/Plas W/Del Gr2","CDM Revenue Code":"278","CDM HCPCS":"C2625","Standard Price":739.5},{"Itemcode":"64505023","Description":"Feeding Tube Grp 2","CDM Revenue Code":"272","Standard Price":586.5,"Note":"**"},{"Itemcode":"64505024","Description":"Stent Flex/Plastic W/O Del Sys","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":447.78},{"Itemcode":"64505025","Description":"G Tube Grp 1","CDM Revenue Code":"272","Standard Price":279.48,"Note":"**"},{"Itemcode":"64505026","Description":"Stent,Non-cor, temp w/del sys","CDM Revenue Code":"278","CDM HCPCS":"C2625","Standard Price":714.0,"Note":"**"},{"Itemcode":"64505027","Description":"Alliance Ii Cre Syringe Disp","CDM Revenue Code":"272","Standard Price":204.0},{"Itemcode":"64505028","Description":"Cytology Brush","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"64505029","Description":"Cath Ercp/Biliary","CDM Revenue Code":"272","Standard Price":401.88,"Note":"**"},{"Itemcode":"64505031","Description":"Needle Sclerotherapy","CDM Revenue Code":"272","Standard Price":191.76,"Note":"**"},{"Itemcode":"64505032","Description":"Breeze Rx Inflation Device","CDM Revenue Code":"272","Standard Price":473.28,"Note":"**"},{"Itemcode":"64505034","Description":"Cannula","CDM Revenue Code":"272","Standard Price":330.48,"Note":"**"},{"Itemcode":"64505035","Description":"Cath Ano-Rectal Manometry","CDM Revenue Code":"272","Standard Price":307.02,"Note":"**"},{"Itemcode":"64505041","Description":"Cath Ablation Halo 360","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":5667.12},{"Itemcode":"64505042","Description":"Cath Ablation Halo 90","CDM Revenue Code":"272","Standard Price":5045.94,"Note":"**"},{"Itemcode":"64505043","Description":"Balloon Sizing Halo","CDM Revenue Code":"272","Standard Price":1983.9},{"Itemcode":"64505044","Description":"Cath Ablation Halo-Express","CDM Revenue Code":"272","Standard Price":10536.6},{"Itemcode":"64505048","Description":"Gastric Lavage System Easi-Lav","CDM Revenue Code":"272","Standard Price":1428.0,"Note":"**"},{"Itemcode":"64505049","Description":"Stent Cov W/Deliv Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10593.72,"Note":"**"},{"Itemcode":"64505056","Description":"Feeding Set Jejunal Pegj-12-24","CDM Revenue Code":"272","Standard Price":1237.26},{"Itemcode":"64505083","Description":"Probe Ph","CDM Revenue Code":"272","Standard Price":419.22,"Note":"**"},{"Itemcode":"64505084","Description":"Overtube Endoscopic; Esoph","CDM Revenue Code":"272","Standard Price":1035.3},{"Itemcode":"64505085","Description":"Ligator Polyloop","CDM Revenue Code":"272","Standard Price":546.72},{"Itemcode":"64505087","Description":"Nasobiliary Drainage Set","CDM Revenue Code":"272","Standard Price":742.56},{"Itemcode":"64505088","Description":"Ligator Speedband","CDM Revenue Code":"272","Standard Price":184.62,"Note":"**"},{"Itemcode":"64505133","Description":"Stent Flexi/Plas W/Del Gr1","CDM Revenue Code":"278","CDM HCPCS":"C2625","Standard Price":603.84},{"Itemcode":"64505134","Description":"Stent Flexi/Plas W/Del Gr2","CDM Revenue Code":"278","CDM HCPCS":"C2625","Standard Price":904.74},{"Itemcode":"64505231","Description":"Device Retrieval Spec Endo","CDM Revenue Code":"272","Standard Price":636.48,"Note":"**"},{"Itemcode":"64505500","Description":"Ligator: Multiband","CDM Revenue Code":"272","Standard Price":1418.82,"Note":"**"},{"Itemcode":"64505788","Description":"Retrieval Net","CDM Revenue Code":"272","Standard Price":606.9,"Note":"**"},{"Itemcode":"64505888","Description":"Tube: Blakemore","CDM Revenue Code":"272","Standard Price":1339.26,"Note":"**"},{"Itemcode":"64508888","Description":"Cdd Non-Chargeable Supplies","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"64509548","Description":"Guidewire Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":316.2,"Note":"**"},{"Itemcode":"64600006","Description":"Stent: Fluency Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":9788.94},{"Itemcode":"64600014","Description":"Probe Ablation XL90 Ar-9821","CDM Revenue Code":"272","Standard Price":906.78},{"Itemcode":"64600068","Description":"IOL-Posterior Chamber SOFTECHD","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":530.4},{"Itemcode":"64600069","Description":"IOL- POSTERIOR CHAMBER","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":931.26},{"Itemcode":"64600070","Description":"Rezoom Conventional Lens","CDM Revenue Code":"276","Standard Price":872.1},{"Itemcode":"64600071","Description":"Rezoom Lens -D","CDM Revenue Code":"276","Standard Price":0.0},{"Itemcode":"64600076","Description":"Tecnis Conventional Lens","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":872.1,"Note":"**"},{"Itemcode":"64600077","Description":"Toric A-C Lens ZCT, SN6AT","CDM Revenue Code":"276","CDM HCPCS":"V2787","Standard Price":591.0,"Note":"**"},{"Itemcode":"64600078","Description":"Crystalens -D","CDM Revenue Code":"276","Standard Price":0.0},{"Itemcode":"64600079","Description":"Crystalens Conventional Lens","CDM Revenue Code":"276","Standard Price":830.28},{"Itemcode":"64600080","Description":"Crystalens A-C Functionality","CDM Revenue Code":"276","CDM HCPCS":"V2787","Standard Price":1301.52},{"Itemcode":"64600081","Description":"Peg P-K Socket System","CDM Revenue Code":"278","Standard Price":1410.66},{"Itemcode":"64600100","Description":"Cuff Nerve Colgn 2.0MMX2.5CM","CDM Revenue Code":"278","CDM HCPCS":"C9355","Standard Price":6297.48},{"Itemcode":"64600101","Description":"Enduragen","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":3520.02},{"Itemcode":"64600102","Description":"Inforce Matrix-CnTiss Nonhuman","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":1251.54},{"Itemcode":"64600103","Description":"Tightrope Knotless Ar-8926Ss","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5407.02},{"Itemcode":"64600104","Description":"Epifix 4X4Cm Gs-5440","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":10663.08},{"Itemcode":"64600105","Description":"Epifix 2X3Cm Gs-5230","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":5656.92,"Note":"**"},{"Itemcode":"64600106","Description":"Amniofix 1.25Cc Inject Ai-5125","CDM Revenue Code":"278","Standard Price":7097.16},{"Itemcode":"64600107","Description":"Implant X-Fuse Large Axf-Xlo","CDM Revenue Code":"278","Standard Price":6902.34},{"Itemcode":"64600108","Description":"Allograft Epi 14Mmx2Cm Gs-5140","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":1589.16},{"Itemcode":"64600109","Description":"Kit Acl Disposable Ar-1898S","CDM Revenue Code":"272","Standard Price":770.1},{"Itemcode":"64600110","Description":"Guide Nerve Png630","CDM Revenue Code":"278","CDM HCPCS":"C9352","Standard Price":4372.74},{"Itemcode":"64600111","Description":"Amniofix .5Ml Inject Ai-5050","CDM Revenue Code":"278","Standard Price":3324.18},{"Itemcode":"64600112","Description":"Bone Stimulator 01-203-0001","CDM Revenue Code":"278","Standard Price":8572.08},{"Itemcode":"64600113","Description":"Impl I-Stent Micro AquesDrnag","CDM Revenue Code":"278","CDM HCPCS":"C1783","Standard Price":7145.1,"Note":"**"},{"Itemcode":"64600116","Description":"Kit Mini Osteoset 5Cc 84000611","CDM Revenue Code":"278","Standard Price":2915.16},{"Itemcode":"64600117","Description":"Kit Fast Rem Tx-1 554-1003-001","CDM Revenue Code":"272","Standard Price":3218.1},{"Itemcode":"64600118","Description":"Implant Cornea","CDM Revenue Code":"278","Standard Price":11665.74,"Note":"**"},{"Itemcode":"64600120","Description":"COUNTERSINK FINE DISP","CDM Revenue Code":"272","Standard Price":1280.1},{"Itemcode":"64600121","Description":"CUSTOM BONE WEDGE PMTP-21008","CDM Revenue Code":"278","Standard Price":8014.14},{"Itemcode":"64600122","Description":"KIT CARPAL TUNNEL 4116","CDM Revenue Code":"272","Standard Price":1279.08},{"Itemcode":"64600124","Description":"GUIDE NERVE INTEGRA 2mmX3CM","CDM Revenue Code":"278","CDM HCPCS":"C9352","Standard Price":7449.06},{"Itemcode":"64600125","Description":"COUNTERSINK DISP","CDM Revenue Code":"272","Standard Price":1488.18,"Note":"**"},{"Itemcode":"64600128","Description":"Alloderm 6x16CM 1520616","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":9876.66},{"Itemcode":"64600129","Description":"SYSTEM ENDO RELEASE 310138","CDM Revenue Code":"272","Standard Price":4601.22},{"Itemcode":"64600130","Description":"PACK PROC HAT-TRICK","CDM Revenue Code":"272","Standard Price":7465.38},{"Itemcode":"64600131","Description":"PROTECTOR NERVE 7MMX4CM","CDM Revenue Code":"278","CDM HCPCS":"C9353","Standard Price":5796.66},{"Itemcode":"64600132","Description":"Stylet Vasc Closure 6FR","CDM Revenue Code":"272","Standard Price":2836.62},{"Itemcode":"64600139","Description":"Algrft Amniotic Mem Fen 9x20cm","CDM Revenue Code":"278","CDM HCPCS":"Q4100","Standard Price":39168.0},{"Itemcode":"64600150","Description":"PIP ASCENSION PACK PIP-DIS-STR","CDM Revenue Code":"272","Standard Price":2043.06},{"Itemcode":"64600151","Description":"PROTECTOR NERVE 40MM AG0XXX","CDM Revenue Code":"278","Standard Price":8945.4,"Note":"**"},{"Itemcode":"64600152","Description":"ORTHOPAK 2 EXTERNAL 1067718","CDM Revenue Code":"272","Standard Price":16738.2},{"Itemcode":"64600153","Description":"EPIFIX 9.0 X 9.0 CM","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":20076.66},{"Itemcode":"64600155","Description":"EPIFIX 5X6CM GS-5560","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":18367.14},{"Itemcode":"64600156","Description":"CONNECTOR, NERVE, PORCINE ECM","CDM Revenue Code":"278","Standard Price":5439.66,"Note":"**"},{"Itemcode":"64600161","Description":"Set Disp Jugger Knot","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2465.34},{"Itemcode":"64600162","Description":"Pack, Finger Implant","CDM Revenue Code":"272","Standard Price":1867.62},{"Itemcode":"64600163","Description":"Countersink","CDM Revenue Code":"272","Standard Price":1193.4},{"Itemcode":"64600164","Description":"Tissue Patch Cornea GPC-W","CDM Revenue Code":"278","Standard Price":1433.1,"Note":"**"},{"Itemcode":"64600166","Description":"Epifix Powder/Inj 160mg","CDM Revenue Code":"278","CDM HCPCS":"Q4145","Standard Price":9807.3},{"Itemcode":"64600167","Description":"Lens Sensar","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":928.2},{"Itemcode":"64600168","Description":"ALLOGEN .1.0ML PO1-AMF-0100","CDM Revenue Code":"278","Standard Price":9981.72},{"Itemcode":"64600169","Description":"Epifix 100MG EI-5125","CDM Revenue Code":"278","CDM HCPCS":"Q4145","Standard Price":7808.1,"Note":"**"},{"Itemcode":"64600170","Description":"ARROWLOK FIXATION SYSTEM","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5438.64},{"Itemcode":"64600171","Description":"Suture Anchor Speedbridge","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5941.5},{"Itemcode":"64600172","Description":"Button Tightrope; Anchor","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1698.3},{"Itemcode":"64600174","Description":"Integra MatrxWnd BilyrMesh 2x2","CDM Revenue Code":"278","Standard Price":9482.94,"Note":"**"},{"Itemcode":"64600175","Description":"Kit Suturetak Disp","CDM Revenue Code":"272","Standard Price":1327.02},{"Itemcode":"64600176","Description":"Kit Swivelock Disp","CDM Revenue Code":"272","Standard Price":2084.88,"Note":"**"},{"Itemcode":"64600177","Description":"Kit Fusion Motoband","CDM Revenue Code":"272","Standard Price":3394.56},{"Itemcode":"64600178","Description":"Staple Fsn Motoclip","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7831.56},{"Itemcode":"64600179","Description":"PEG SMOOTH","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":572.22},{"Itemcode":"64600180","Description":"Pars Achilles JIG Suture Kit","CDM Revenue Code":"278","Standard Price":2571.42},{"Itemcode":"64600181","Description":"Peg Partial Threaded-Wrist","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":689.52},{"Itemcode":"64600183","Description":"Axogard Nerve Protector AG0340","CDM Revenue Code":"278","Standard Price":8509.86},{"Itemcode":"64600184","Description":"Screw Tenodesis","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1480.02},{"Itemcode":"64600185","Description":"Stent Visi Pro","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3626.1},{"Itemcode":"64600186","Description":"Cath Guide Omni Flush","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":82.62},{"Itemcode":"64600187","Description":"Coil Helical","CDM Revenue Code":"278","Standard Price":480.42},{"Itemcode":"64600188","Description":"Cinch Meniscal","CDM Revenue Code":"272","Standard Price":2164.44},{"Itemcode":"64600189","Description":"ORTHOCORD","CDM Revenue Code":"272","Standard Price":176.46},{"Itemcode":"64600190","Description":"STENT 8X80X80 VIUS08080","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":2559.18},{"Itemcode":"64600191","Description":"WIRE GD J 0.035X180 49-167","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":134.64},{"Itemcode":"64600192","Description":"WIRE BENTSON .035X180 49-177","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":147.9},{"Itemcode":"64600193","Description":"WIRE TIP V-14 39216-91821","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1038.36},{"Itemcode":"64600194","Description":"WIRE GUIDE","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":256.02,"Note":"**"},{"Itemcode":"64600195","Description":"TRAY TRACH BLU RHINO G13166","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2305.2},{"Itemcode":"64600196","Description":"KIT SNARE RETRIEVAL SRK30","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1564.68},{"Itemcode":"64600198","Description":"CATH SEEKER 5FR 150CM SK15035M","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2137.92},{"Itemcode":"64600199","Description":"CATH 4FR 65 STRT SEL 10731402","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":221.34},{"Itemcode":"64600200","Description":"CATH GUIDE STR 5F 65CM CG505","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":343.74},{"Itemcode":"64600201","Description":"CATH 4FR 150C STRT SEL11731507","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":646.68},{"Itemcode":"64600202","Description":"QUICK CLOT 183","CDM Revenue Code":"272","Standard Price":234.6,"Note":"**"},{"Itemcode":"64600203","Description":"SURGICLIP PREM TITANIUM","CDM Revenue Code":"272","Standard Price":414.12,"Note":"**"},{"Itemcode":"64600204","Description":"CUTTER SUTURE/PUSHER 72202674","CDM Revenue Code":"272","Standard Price":774.18},{"Itemcode":"64600205","Description":"ADHESIVE CLOSURE SKIN CLR222US","CDM Revenue Code":"272","Standard Price":492.66},{"Itemcode":"64600206","Description":"WAND ARTHRO SERFA 0279-351-400","CDM Revenue Code":"272","Standard Price":951.66},{"Itemcode":"64600207","Description":"SYS FIX ULTRAFAST CRV 72201491","CDM Revenue Code":"278","Standard Price":1676.88},{"Itemcode":"64600208","Description":"RETRACTOR CAPSULE MCR-0001","CDM Revenue Code":"272","Standard Price":176.46},{"Itemcode":"64600209","Description":"DERMACARRIER II 00-2195-012-00","CDM Revenue Code":"272","Standard Price":221.34,"Note":"**"},{"Itemcode":"64600210","Description":"EXPANDER PUPIL I RING 58700","CDM Revenue Code":"272","Standard Price":693.6,"Note":"**"},{"Itemcode":"64600211","Description":"PASSER SUTURE CHIA PERC 214101","CDM Revenue Code":"272","Standard Price":843.54,"Note":"**"},{"Itemcode":"64600212","Description":"PROBE ANTERIOR VIT 8065752134","CDM Revenue Code":"272","Standard Price":1007.76,"Note":"**"},{"Itemcode":"64600213","Description":"IOL Restor Alcon Multi SV25TO","CDM Revenue Code":"276","CDM HCPCS":"V2788","Standard Price":1035.3,"Note":"**"},{"Itemcode":"64600215","Description":"Stent Bil GPS Mini Paramount","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3626.1},{"Itemcode":"64600216","Description":"KIT PUSHLOK AR-1926DS","CDM Revenue Code":"272","Standard Price":928.2},{"Itemcode":"64600217","Description":"GRAFT Vascular Hemoshield","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":3002.88},{"Itemcode":"64600218","Description":"Graft Gamma 8x9 GG625","CDM Revenue Code":"278","CDM HCPCS":"Q4111","Standard Price":1857.42},{"Itemcode":"64600219","Description":"Support BK++TLSO UPT2633-15","CDM Revenue Code":"274","CDM HCPCS":"L0456","Standard Price":1589.16},{"Itemcode":"64600220","Description":"Endotine Mini CFD-22202","CDM Revenue Code":"278","Standard Price":2234.82,"Note":"**"},{"Itemcode":"64600221","Description":"Stylet Endovenos RFS2-6-12","CDM Revenue Code":"272","Standard Price":2836.62},{"Itemcode":"64600222","Description":"Kit Prevena PRE1001US","CDM Revenue Code":"272","Standard Price":2625.48},{"Itemcode":"64600223","Description":"CathAngioNon-LsrTranslum Grp A","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":556.92},{"Itemcode":"64600224","Description":"Kit BoneFiller Synth-Foot/Ankl","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":12763.26},{"Itemcode":"64600225","Description":"Wrap Amniofix 2.0x2.0cmTN-5220","CDM Revenue Code":"278","Standard Price":3095.7},{"Itemcode":"64600226","Description":"Kit Biocomposite AR-8928BC-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10603.92},{"Itemcode":"64600227","Description":"Implt Sys MPFL Bio AR-1360C-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6218.94},{"Itemcode":"64600228","Description":"Implt Sys ACL AR-1360CST-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10280.58},{"Itemcode":"64600229","Description":"Implt Sys ANKL AR-1675BC-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7465.38},{"Itemcode":"64600230","Description":"Imp Del Biocomp AR-2260BC","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6705.48,"Note":"**"},{"Itemcode":"64600231","Description":"Sys Imp Bioc Swivlck AR2600SBS","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10603.92},{"Itemcode":"64600232","Description":"Fibrtape Collgn Coat AR-7237-7","CDM Revenue Code":"272","Standard Price":483.48},{"Itemcode":"64600233","Description":"Guidewire 1.3MM AR-5050-01","CDM Revenue Code":"272","Standard Price":870.06},{"Itemcode":"64600234","Description":"Epifix 40mg Inject EI-5050","CDM Revenue Code":"278","CDM HCPCS":"Q4145","Standard Price":3093.66},{"Itemcode":"64600235","Description":"Amniofill 500MG AF-0500","CDM Revenue Code":"278","Standard Price":4905.18},{"Itemcode":"64600236","Description":"DRILL KIT RETROFSN AR-4157DS","CDM Revenue Code":"272","Standard Price":2742.78},{"Itemcode":"64600237","Description":"PACK GRAFT LINK AR-1588AL-CP","CDM Revenue Code":"278","Standard Price":5728.32},{"Itemcode":"64600238","Description":"Kit Drill BME 3.0MM DK-300","CDM Revenue Code":"272","Standard Price":2625.48},{"Itemcode":"64600239","Description":"Template Drilling BME EL-DTS","CDM Revenue Code":"272","Standard Price":583.44},{"Itemcode":"64600240","Description":"Imp Strght Bridge 4Leg","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9044.34},{"Itemcode":"64600241","Description":"Imp Strght Bridge 2Leg","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10237.74},{"Itemcode":"64600242","Description":"ALLOGRAFT BIOFIX FLOW 1CC BFA","CDM Revenue Code":"278","CDM HCPCS":"Q4162","Standard Price":11766.72,"Note":"**"},{"Itemcode":"64600243","Description":"Kit Biocomposite AR-8928BCJ-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8284.44},{"Itemcode":"64600244","Description":"Epifix 2x3cm ES-2300","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":4881.72},{"Itemcode":"64600245","Description":"BARRIER AVIVE 3X6CM CA0306","CDM Revenue Code":"278","Standard Price":12476.64,"Note":"**"},{"Itemcode":"64600246","Description":"Pack Suture Pars AR-8862DS","CDM Revenue Code":"278","Standard Price":4158.54},{"Itemcode":"64600247","Description":"CUTTER FLIP 8.5MM AR-1204AF-85","CDM Revenue Code":"272","Standard Price":1723.8},{"Itemcode":"64600248","Description":"BUTTON TIGHTROPE AR-1588TB-4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1188.3},{"Itemcode":"64600249","Description":"COUNTERSINK 4.0 P20-915-4000","CDM Revenue Code":"272","Standard Price":1016.94},{"Itemcode":"64600250","Description":"IMPNT TOE JNT MTP, CARTIVA","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":12172.68},{"Itemcode":"64600251","Description":"STNT OCULR-XEN SFT GEL 0449T","CDM Revenue Code":"278","CDM HCPCS":"C1783","Standard Price":5246.88,"Note":"**"},{"Itemcode":"64600252","Description":"Fixator Kit, Hand-Digit Widget","CDM Revenue Code":"272","Standard Price":6611.64},{"Itemcode":"64600253","Description":"Epicord 3.0 x 5.0CM","CDM Revenue Code":"278","CDM HCPCS":"Q4187","Standard Price":10566.18},{"Itemcode":"64600254","Description":"Graft Vascular GRP 6","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":4048.38},{"Itemcode":"64600255","Description":"Cath Atherectomy, 1.25","CDM Revenue Code":"272","CDM HCPCS":"C1724","Standard Price":11479.08},{"Itemcode":"64600256","Description":"Ring, Capsular TNSN EyeJet","CDM Revenue Code":"272","Standard Price":929.22},{"Itemcode":"64600257","Description":"Graft,Nerve Avance 3-4mm","CDM Revenue Code":"278","Standard Price":16906.5},{"Itemcode":"64600258","Description":"GRAFT VASCULAR GRP 8","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":9981.72},{"Itemcode":"64600259","Description":"Syndesmosis Repair Implant Sys","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6251.58},{"Itemcode":"64600260","Description":"NUCEL 2cc NC-1002","CDM Revenue Code":"278","Standard Price":10608.0,"Note":"**"},{"Itemcode":"64600261","Description":"STAPLES TENDON","CDM Revenue Code":"272","Standard Price":1300.5},{"Itemcode":"64600262","Description":"Reamer , Crosstie","CDM Revenue Code":"272","Standard Price":530.4},{"Itemcode":"64600263","Description":"PriMatrix 8X8 Sq Cm AG meshed","CDM Revenue Code":"278","CDM HCPCS":"Q4110","Standard Price":15947.7,"Note":"**"},{"Itemcode":"64600264","Description":"Closure Device Mynx","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1072.02},{"Itemcode":"64600265","Description":"Staple Bone Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6889.08,"Note":"**"},{"Itemcode":"64600266","Description":"DEVICE CATH MICRO","CDM Revenue Code":"272","Standard Price":6691.2,"Note":"**"},{"Itemcode":"64600273","Description":"Implant Eyelid","CDM Revenue Code":"278","Standard Price":1442.28},{"Itemcode":"64600279","Description":"Rod Grp 6","CDM Revenue Code":"278","Standard Price":6168.96},{"Itemcode":"64600280","Description":"SIZER MAMMARY GRP 1","CDM Revenue Code":"272","Standard Price":278.46},{"Itemcode":"64600281","Description":"Cath,Translum Angioplast Grp1A","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":728.28},{"Itemcode":"64600282","Description":"Cath,Translum Angioplast Grp1B","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":884.34},{"Itemcode":"64600389","Description":"CEMENT BONE GRP 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1549.38},{"Itemcode":"64600579","Description":"Plate Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":15022.56,"Note":"**"},{"Itemcode":"64600595","Description":"Plate Grp 8","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8322.18,"Note":"**"},{"Itemcode":"64600596","Description":"Plate Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8674.08},{"Itemcode":"64600798","Description":"BLADE DISPOSABLE GRP 6","CDM Revenue Code":"272","Standard Price":3641.4},{"Itemcode":"64600839","Description":"Epicord 2X3Cm","CDM Revenue Code":"278","CDM HCPCS":"Q4186","Standard Price":5348.88,"Note":"**"},{"Itemcode":"64600876","Description":"Anchor Bone Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2567.34,"Note":"**"},{"Itemcode":"64601249","Description":"Guidewire Grp 2","CDM Revenue Code":"272","Standard Price":643.62},{"Itemcode":"64601251","Description":"SCREW GRP 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4877.64},{"Itemcode":"64601270","Description":"Allograft Ort/Neu Human Grp7","CDM Revenue Code":"278","Standard Price":8851.56,"Note":"**"},{"Itemcode":"64601271","Description":"ALLOGRAFT ORTH/NEUR HUMAN GRP8","CDM Revenue Code":"278","Standard Price":20076.66},{"Itemcode":"64601356","Description":"Cath Guiding Low Cost Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":149.94},{"Itemcode":"64601531","Description":"TranslumAther Dir Cath-Hawkone","CDM Revenue Code":"272","Standard Price":10482.54},{"Itemcode":"64601549","Description":"FLEXHD 6X12 CM","CDM Revenue Code":"278","CDM HCPCS":"Q4128","Standard Price":6762.6},{"Itemcode":"64601687","Description":"GUIDE PIN, NON IMPLNT GR 3","CDM Revenue Code":"272","Standard Price":2985.54},{"Itemcode":"64601689","Description":"Allograft BiofixFlow 0.5CC","CDM Revenue Code":"278","CDM HCPCS":"Q4162","Standard Price":10237.74},{"Itemcode":"64601691","Description":"ALLGRFT AMNIO MEM BIOFIX 4X4CM","CDM Revenue Code":"278","CDM HCPCS":"Q4163","Standard Price":10549.86},{"Itemcode":"64601703","Description":"Plate Grp 9A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":10986.42},{"Itemcode":"64601746","Description":"Neurawrap Nrv Protectr 5mmx2cm","CDM Revenue Code":"278","CDM HCPCS":"C9353","Standard Price":6938.04},{"Itemcode":"64601747","Description":"Neuragen Nerve Guide 2 Cm","CDM Revenue Code":"278","CDM HCPCS":"C9352","Standard Price":6094.5},{"Itemcode":"64601748","Description":"Neuragen Nerve Guide 3 Cm","CDM Revenue Code":"278","CDM HCPCS":"C9352","Standard Price":8032.5},{"Itemcode":"64601750","Description":"Tap 5.5mm","CDM Revenue Code":"272","Standard Price":2625.48},{"Itemcode":"64601836","Description":"Screw Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":956.76,"Note":"**"},{"Itemcode":"64601838","Description":"Screw Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1639.14},{"Itemcode":"64601865","Description":"Bit Drill Grp 2A","CDM Revenue Code":"272","Standard Price":931.26},{"Itemcode":"64601866","Description":"Bit Drill Grp 2B","CDM Revenue Code":"272","Standard Price":1139.34,"Note":"**"},{"Itemcode":"64601868","Description":"Implant Hammerlock 20mm","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4798.08},{"Itemcode":"64601879","Description":"KIT JUGGER KNOT SZ1 OR 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2729.52},{"Itemcode":"64601883","Description":"Plate Grp 3 B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1633.02},{"Itemcode":"64601885","Description":"Plate Grp 3 C","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1992.06},{"Itemcode":"64601887","Description":"Plate Grp 3 D","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2434.74,"Note":"**"},{"Itemcode":"64601913","Description":"SCREW GRP 6 A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4077.96},{"Itemcode":"64601929","Description":"Bit Drill Grp 4 A","CDM Revenue Code":"272","Standard Price":2746.86,"Note":"**"},{"Itemcode":"64601947","Description":"Mesh Genl Surg C1781 Grp 3A","CDM Revenue Code":"278","CDM HCPCS":"C1781","Standard Price":1893.12},{"Itemcode":"64601967","Description":"Bony Void Filler Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1055.7,"Note":"**"},{"Itemcode":"64601972","Description":"Bony Void Filler Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2104.26,"Note":"**"},{"Itemcode":"64601973","Description":"BONY VOID FILLER GRP3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2761.14,"Note":"**"},{"Itemcode":"64601974","Description":"Bony Void Filler Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4486.98},{"Itemcode":"64601975","Description":"Bony Void Filler Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5416.2},{"Itemcode":"64601977","Description":"BONY VOID FILLER GRP 7","CDM Revenue Code":"278","Standard Price":9513.54},{"Itemcode":"64601997","Description":"KIT MENISCAL REPAIR AR-4550","CDM Revenue Code":"278","Standard Price":4245.24},{"Itemcode":"64602008","Description":"Screw Grp 1A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":572.22,"Note":"**"},{"Itemcode":"64602016","Description":"Implant Joint Grp 3","CDM Revenue Code":"278","Standard Price":1820.7},{"Itemcode":"64602017","Description":"IMPLANT JOINT GRP 4","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":2067.54,"Note":"**"},{"Itemcode":"64602018","Description":"Implant Joint Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":3037.56},{"Itemcode":"64602019","Description":"Implant Joint Group 6","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":4791.96,"Note":"**"},{"Itemcode":"64602020","Description":"Implant Joint Grp 7","CDM Revenue Code":"278","Standard Price":5941.5},{"Itemcode":"64602021","Description":"IMPLANT JOINT GRP 8","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":6703.44,"Note":"**"},{"Itemcode":"64602022","Description":"IMPLANT JOINT GRP 9","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":8323.2},{"Itemcode":"64602023","Description":"IMPLANT JOINT GRP 10","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":8843.4},{"Itemcode":"64602024","Description":"IMPLANT JOINT GRP 11","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":9675.72},{"Itemcode":"64602025","Description":"Implant Joint Grp 12","CDM Revenue Code":"278","CDM HCPCS":"C1776","Standard Price":13260.0},{"Itemcode":"64602036","Description":"Pin Fixation Hammertoe","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4529.82},{"Itemcode":"64602039","Description":"Screw Grp 1B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":698.7,"Note":"**"},{"Itemcode":"64602056","Description":"Screw Grp 2B","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1233.18},{"Itemcode":"64602085","Description":"Nail, Ortho Grp 2A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2075.7},{"Itemcode":"64602397","Description":"Tube Tear Duct","CDM Revenue Code":"278","Standard Price":425.34},{"Itemcode":"64602509","Description":"Stent,Peripheral SE","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3199.74},{"Itemcode":"64602527","Description":"Pack Closure Cpp","CDM Revenue Code":"272","Standard Price":577.32},{"Itemcode":"64602612","Description":"Cath Thrombec/Embolec","CDM Revenue Code":"272","Standard Price":581.4},{"Itemcode":"64602619","Description":"Dermabond, per vial","CDM Revenue Code":"272","Standard Price":136.68},{"Itemcode":"64602713","Description":"Washer Spiked,Ortho 14mm","CDM Revenue Code":"278","Standard Price":758.88},{"Itemcode":"64602731","Description":"Cath Angio 5FR, Soft-Vu","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":100.98},{"Itemcode":"64602735","Description":"GUIDE PIN Ti 2mm","CDM Revenue Code":"272","Standard Price":270.3},{"Itemcode":"64602745","Description":"Screw Grp 4A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2496.96,"Note":"**"},{"Itemcode":"64602788","Description":"Stent Biliary - Express","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4052.46},{"Itemcode":"64602790","Description":"Bony Void Filler Grp 6A","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8104.92,"Note":"**"},{"Itemcode":"64603171","Description":"AnchorSys Implt-AC ReprAR-2271","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6859.5},{"Itemcode":"64603172","Description":"ALLGRFT AMNIO MEM BIOFIX 2X4CM","CDM Revenue Code":"278","CDM HCPCS":"Q4163","Standard Price":5972.1},{"Itemcode":"64603189","Description":"KIT BIOSUTURE TAK","CDM Revenue Code":"272","Standard Price":848.64,"Note":"**"},{"Itemcode":"64603328","Description":"Tutoplast Pericardium 68250","CDM Revenue Code":"278","Standard Price":1563.66,"Note":"**"},{"Itemcode":"64603336","Description":"Set Frontalis Suspension Bd","CDM Revenue Code":"278","Standard Price":289.68},{"Itemcode":"64604008","Description":"Eye Sphere Implantable","CDM Revenue Code":"278","Standard Price":134.64},{"Itemcode":"64604085","Description":"Stent Opth Monoka 4MmW S1-1630","CDM Revenue Code":"278","Standard Price":451.86},{"Itemcode":"64604160","Description":"Tray Trach Blue Rhino 263567","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2556.12},{"Itemcode":"64604202","Description":"Stent Lacriminal","CDM Revenue Code":"278","Standard Price":520.2},{"Itemcode":"64604319","Description":"Sling Shot Large Breg 08504","CDM Revenue Code":"274","CDM HCPCS":"L3670","Standard Price":294.78,"Note":"**"},{"Itemcode":"64604327","Description":"Versajet II 45/14MM","CDM Revenue Code":"272","Standard Price":2627.52},{"Itemcode":"64604365","Description":"Closure Device Angioseal","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1113.84},{"Itemcode":"64604389","Description":"Implant Subtalar MBA","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":8954.58},{"Itemcode":"64604407","Description":"Eye Sphere Implant Gulden","CDM Revenue Code":"278","Standard Price":348.84},{"Itemcode":"64604408","Description":"Screw Cannulated Synthes","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":790.5},{"Itemcode":"64604409","Description":"Alloderm 2X4 cm","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":2334.78},{"Itemcode":"64604410","Description":"Corneal Tissue Mt#0015042","CDM Revenue Code":"278","CDM HCPCS":"V2785","Standard Price":13373.22,"Note":"**"},{"Itemcode":"64604411","Description":"Corneal Tissue Mt#0019054","CDM Revenue Code":"278","CDM HCPCS":"V2785","Standard Price":13508.88},{"Itemcode":"64604419","Description":"Eyelid Implant","CDM Revenue Code":"278","Standard Price":3964.74},{"Itemcode":"64604420","Description":"Fibrin Sealant","CDM Revenue Code":"272","Standard Price":1491.24},{"Itemcode":"64604421","Description":"Enduragen Collagen","CDM Revenue Code":"278","CDM HCPCS":"C1763","Standard Price":3520.02},{"Itemcode":"64604422","Description":"Graft Ambio-Dry Ad-5230","CDM Revenue Code":"278","CDM HCPCS":"V2790","Standard Price":2851.92,"Note":"**"},{"Itemcode":"64604424","Description":"Symblepharon Ring","CDM Revenue Code":"272","Standard Price":406.98},{"Itemcode":"64604425","Description":"Ring Malyugin Mal0001","CDM Revenue Code":"272","Standard Price":664.02,"Note":"**"},{"Itemcode":"64604426","Description":"Impl Screw","CDM Revenue Code":"278","Standard Price":397.8},{"Itemcode":"64604428","Description":"Implant Eyelid Gold","CDM Revenue Code":"278","Standard Price":1684.02},{"Itemcode":"64604429","Description":"Tutoplast Sclera Whole","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":2965.14},{"Itemcode":"64604430","Description":"Tutoplast Sclera 5X8","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":1563.66,"Note":"**"},{"Itemcode":"64604431","Description":"Tutoplast Fascia Lata","CDM Revenue Code":"278","CDM HCPCS":"C1762","Standard Price":5610.0},{"Itemcode":"64604433","Description":"Endotine Implant","CDM Revenue Code":"278","Standard Price":1055.7},{"Itemcode":"64604435","Description":"Cath Balloon Lacriminal Duct","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":1771.74},{"Itemcode":"64604437","Description":"PTOSE Up Implant","CDM Revenue Code":"278","Standard Price":385.56},{"Itemcode":"64604438","Description":"Set Lacriminal Intubation","CDM Revenue Code":"272","Standard Price":580.38},{"Itemcode":"64604439","Description":"Shunt Ex-Press Mini Glaucoma","CDM Revenue Code":"278","CDM HCPCS":"C1783","Standard Price":4245.24},{"Itemcode":"64604440","Description":"Baervelt Glaucoma Implant","CDM Revenue Code":"278","Standard Price":2947.8,"Note":"**"},{"Itemcode":"64604442","Description":"Malar Implant Medpor","CDM Revenue Code":"278","Standard Price":1132.2},{"Itemcode":"64604444","Description":"Nasal Arch","CDM Revenue Code":"278","Standard Price":1193.4},{"Itemcode":"64604445","Description":"Surgicel","CDM Revenue Code":"272","Standard Price":220.32},{"Itemcode":"64604446","Description":"Dermabond","CDM Revenue Code":"272","Standard Price":189.72},{"Itemcode":"64604447","Description":"Sheet Barrier","CDM Revenue Code":"278","Standard Price":2647.92},{"Itemcode":"64604448","Description":"Implant Flexblock","CDM Revenue Code":"278","Standard Price":2414.34},{"Itemcode":"64604449","Description":"Reform Capsular Tension Ring","CDM Revenue Code":"278","Standard Price":1144.44,"Note":"**"},{"Itemcode":"64604451","Description":"Amniograft","CDM Revenue Code":"278","CDM HCPCS":"V2790","Standard Price":3391.5},{"Itemcode":"64604453","Description":"Graft Ambio Dry Af1230","CDM Revenue Code":"278","CDM HCPCS":"V2790","Standard Price":3061.02},{"Itemcode":"64604454","Description":"Lens Tecnis Ntiol","CDM Revenue Code":"276","CDM HCPCS":"C1780","Standard Price":901.68},{"Itemcode":"64604455","Description":"Screw; Implant","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":331.5},{"Itemcode":"64604456","Description":"Plate Eyectr Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":694.62},{"Itemcode":"64604457","Description":"Plate Eyectr Grp 2","CDM Revenue Code":"278","Standard Price":891.48},{"Itemcode":"64604468","Description":"Pac Ant Vitrectomy","CDM Revenue Code":"272","Standard Price":962.88},{"Itemcode":"64604469","Description":"Drain Tube Extender Glcma Vlv","CDM Revenue Code":"272","Standard Price":664.02,"Note":"**"},{"Itemcode":"64604470","Description":"Bladeless Cataract Sur Imaging","CDM Revenue Code":"279","Standard Price":765.0,"Note":"**"},{"Itemcode":"64604477","Description":"Medpor SST Implant","CDM Revenue Code":"278","Standard Price":2201.16},{"Itemcode":"64604478","Description":"Implant Chaineyelid Platinum","CDM Revenue Code":"278","Standard Price":3838.26},{"Itemcode":"64604479","Description":"Zmaoo Tecnis P-C Iol -D","CDM Revenue Code":"276","Standard Price":3817.86},{"Itemcode":"64604481","Description":"Lens Presby-C Fnctn Multifocal","CDM Revenue Code":"276","CDM HCPCS":"V2788","Standard Price":995.0,"Note":"**"},{"Itemcode":"64604482","Description":"Corneal Tissue Impl Mm#0080844","CDM Revenue Code":"278","CDM HCPCS":"V2785","Standard Price":13802.64},{"Itemcode":"64604483","Description":"Corneal Tissue Imp Mt#0080853","CDM Revenue Code":"278","CDM HCPCS":"V2785","Standard Price":15216.36,"Note":"**"},{"Itemcode":"64604572","Description":"Cuff Nerve Collagen","CDM Revenue Code":"278","CDM HCPCS":"C9355","Standard Price":6038.4},{"Itemcode":"64604710","Description":"Integra BiWndMtrx 4x5cmBMW4051","CDM Revenue Code":"278","CDM HCPCS":"Q4104","Standard Price":16542.36},{"Itemcode":"64604737","Description":"Wound Matrix Restrata","CDM Revenue Code":"623","CDM HCPCS":"A6460","Standard Price":14917.5,"Note":"**"},{"Itemcode":"64604750","Description":"Alloderm 6x12","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":8454.78},{"Itemcode":"64604783","Description":"Suture Shuttle","CDM Revenue Code":"272","Standard Price":956.76},{"Itemcode":"64604833","Description":"Tightrope Syndemosis Kit","CDM Revenue Code":"278","Standard Price":3680.16},{"Itemcode":"64604835","Description":"Vitagel Hemostat","CDM Revenue Code":"278","Standard Price":1323.96},{"Itemcode":"64604840","Description":"Stent Opth Monoka 4MmW S1-1800","CDM Revenue Code":"278","Standard Price":624.24},{"Itemcode":"64604850","Description":"Screw/Kit Mini Scorpion","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4052.46},{"Itemcode":"64604903","Description":"AVANCE NERVE GRAFT 5CM","CDM Revenue Code":"272","Standard Price":10123.5},{"Itemcode":"64604922","Description":"Dermaclose RC 204010-K","CDM Revenue Code":"272","Standard Price":4047.36},{"Itemcode":"64604953","Description":"SYSTEM PEAK PLASMA 278001","CDM Revenue Code":"272","Standard Price":1783.98},{"Itemcode":"64604976","Description":"Imp Lig AugmRpr Sys AR-1688-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6551.46},{"Itemcode":"64604977","Description":"IMPLANT SPEED 20X15 SE-2015TI","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6898.26},{"Itemcode":"64604989","Description":"Avance Nerve Graft 30MM","CDM Revenue Code":"278","Standard Price":9647.16,"Note":"**"},{"Itemcode":"64605548","Description":"TUBE GI GRP 3","CDM Revenue Code":"278","Standard Price":708.9},{"Itemcode":"64605557","Description":"Graft Nerve Avance","CDM Revenue Code":"278","Standard Price":21049.74,"Note":"**"},{"Itemcode":"64605566","Description":"BLADE DISPOSABLE GRP 4","CDM Revenue Code":"272","Standard Price":2080.8,"Note":"**"},{"Itemcode":"64605569","Description":"ALLOGRFT BIOFIX FLOW 2CC BFA2","CDM Revenue Code":"278","CDM HCPCS":"Q4162","Standard Price":20964.06},{"Itemcode":"64605577","Description":"Rod Spacer, Tendon","CDM Revenue Code":"278","Standard Price":7643.88},{"Itemcode":"64605622","Description":"Barrier Avive 2x4CM CAO204","CDM Revenue Code":"278","Standard Price":8872.98,"Note":"**"},{"Itemcode":"64605623","Description":"Barrier Avive 3x4cm CA0304","CDM Revenue Code":"278","Standard Price":10143.9},{"Itemcode":"64605758","Description":"Plate Strl Instr Kit 1500-4700","CDM Revenue Code":"272","Standard Price":2075.7,"Note":"**"},{"Itemcode":"64605884","Description":"Kit Transtibial Acl Ar-1897S","CDM Revenue Code":"272","Standard Price":1209.72},{"Itemcode":"64606539","Description":"Coil Embolization","CDM Revenue Code":"278","Standard Price":363.12},{"Itemcode":"64606588","Description":"Tenoglide 2X2 Tg221","CDM Revenue Code":"278","CDM HCPCS":"C9356","Standard Price":7956.0,"Note":"**"},{"Itemcode":"64606679","Description":"Stent Viabahn 7X 10-15 VBH","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":11934.0},{"Itemcode":"64606793","Description":"Filter Fem/Jug Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":6320.94},{"Itemcode":"64607220","Description":"Balloon Inflation Device","CDM Revenue Code":"272","Standard Price":219.3},{"Itemcode":"64607500","Description":"Filter Vena Cava","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":3732.18},{"Itemcode":"64607501","Description":"GD Cath/Sheath - Pinnacle","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":564.06},{"Itemcode":"64607502","Description":"GD Cath/Sheath - Pinnacle Gr2","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":640.56},{"Itemcode":"64607503","Description":"Guide Cath Support - Rubicon","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":832.32},{"Itemcode":"64607504","Description":"Cath Endovenous RF","CDM Revenue Code":"272","CDM HCPCS":"C1888","Standard Price":3784.2},{"Itemcode":"64607505","Description":"Sheath/Introducr - Destination","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":508.98},{"Itemcode":"64607506","Description":"Glidesheath, Slendor","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":663.0},{"Itemcode":"64607507","Description":"Vascular Coil, Vortx","CDM Revenue Code":"278","Standard Price":481.44},{"Itemcode":"64607563","Description":"Guidewire Journey","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1038.36},{"Itemcode":"64607564","Description":"Stent Fluency Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8936.22},{"Itemcode":"64608301","Description":"Syst Endoblade Plantr Fasc Rel","CDM Revenue Code":"272","Standard Price":5348.88},{"Itemcode":"64608481","Description":"Implant Distal Biceps Ar-2260","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5362.14},{"Itemcode":"64608520","Description":"Driver Disp","CDM Revenue Code":"272","Standard Price":1111.8},{"Itemcode":"64608532","Description":"Vitagel Hemostat 2113-0000","CDM Revenue Code":"278","Standard Price":2159.34},{"Itemcode":"64608536","Description":"Cutter Flip","CDM Revenue Code":"272","Standard Price":2467.38},{"Itemcode":"64608749","Description":"PUSHER KNOT AR-4515","CDM Revenue Code":"272","Standard Price":949.62},{"Itemcode":"64608765","Description":"Ahmed Valve","CDM Revenue Code":"272","Standard Price":2628.54},{"Itemcode":"64608786","Description":"PUNCH 5.5 AR-1927PBS","CDM Revenue Code":"272","Standard Price":573.24,"Note":"**"},{"Itemcode":"64608859","Description":"Screw Grp 10","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":7803.0},{"Itemcode":"64608863","Description":"CONNECTOR,NERVE PORCINE ECM","CDM Revenue Code":"278","Standard Price":5225.46},{"Itemcode":"64608888","Description":"Eye/Surg Center Non Chargeable","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"64608889","Description":"REAMER ORTHO GRP 2","CDM Revenue Code":"272","Standard Price":2601.0,"Note":"**"},{"Itemcode":"64608892","Description":"Alloderm LG 164SQCM CL1516","CDM Revenue Code":"278","CDM HCPCS":"Q4116","Standard Price":18207.0},{"Itemcode":"64608900","Description":"Pack,Cath/Sheath ClosureFast","CDM Revenue Code":"272","Standard Price":3092.64},{"Itemcode":"64608949","Description":"BLADE DISPOSABLE GRP 3","CDM Revenue Code":"272","Standard Price":1144.44,"Note":"**"},{"Itemcode":"64608961","Description":"SCREW LOW COST GRP 6","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":202.98,"Note":"**"},{"Itemcode":"64608963","Description":"Low Cost Screw Grp 8","CDM Revenue Code":"278","Standard Price":280.5,"Note":"**"},{"Itemcode":"64608964","Description":"Low Cost Screw Grp 9","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":322.32},{"Itemcode":"64609026","Description":"PACK GRAFT LINK AR-1588AU-CP","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2900.88},{"Itemcode":"64609028","Description":"DRILL BIT, TWIST","CDM Revenue Code":"272","Standard Price":2607.12},{"Itemcode":"64609082","Description":"Ablator Aspiration AR-9811","CDM Revenue Code":"272","Standard Price":906.78,"Note":"**"},{"Itemcode":"64609128","Description":"GuideWire Viper VPR-GW-200","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1007.76},{"Itemcode":"64609147","Description":"Tendon Gracilis 1976-39","CDM Revenue Code":"278","Standard Price":8318.1},{"Itemcode":"64609159","Description":"PIN AXIS IJS-EAP-25452","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1534.08},{"Itemcode":"64609209","Description":"BLADE DISPOSABLE GRP2","CDM Revenue Code":"272","Standard Price":945.54,"Note":"**"},{"Itemcode":"64609214","Description":"BLADE DISPOSABLE GRP 1","CDM Revenue Code":"272","Standard Price":605.88,"Note":"**"},{"Itemcode":"64609215","Description":"PLATE GRP 7","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":6147.54,"Note":"**"},{"Itemcode":"64609216","Description":"Plate Grp 6 Surg Ctr","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":5306.04,"Note":"**"},{"Itemcode":"64609256","Description":"System Fixation Bone SBFS062","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2260.32},{"Itemcode":"64609279","Description":"ALLOGRAFT EYE HUMAN GRP 2","CDM Revenue Code":"278","Standard Price":2360.28},{"Itemcode":"64609281","Description":"Graft Amnio Wet AG-2015","CDM Revenue Code":"278","CDM HCPCS":"V2790","Standard Price":2622.42,"Note":"**"},{"Itemcode":"64609286","Description":"Allograft Ort/Neu Human Grp6","CDM Revenue Code":"278","Standard Price":7136.94,"Note":"**"},{"Itemcode":"64609287","Description":"Allograft Ort/Neu Human Grp5","CDM Revenue Code":"278","Standard Price":5682.42,"Note":"**"},{"Itemcode":"64609288","Description":"Allograft Orth/Neur Grp4","CDM Revenue Code":"278","Standard Price":4302.36,"Note":"**"},{"Itemcode":"64609289","Description":"Allograft Orth/Neur Human Grp3","CDM Revenue Code":"278","Standard Price":3330.3,"Note":"**"},{"Itemcode":"64609290","Description":"ALLOGRAFT ORTH/NEUR HUMAN GRP2","CDM Revenue Code":"278","Standard Price":1612.62,"Note":"**"},{"Itemcode":"64609291","Description":"Allograft Orth/Neur Human GRP1","CDM Revenue Code":"278","Standard Price":932.28},{"Itemcode":"64609301","Description":"Anchor Bone Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2152.2,"Note":"**"},{"Itemcode":"64609302","Description":"Anchor Bone Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1782.96,"Note":"**"},{"Itemcode":"64609305","Description":"Arthrowand GRP","CDM Revenue Code":"272","Standard Price":798.66},{"Itemcode":"64609313","Description":"DRILL BIT GRP 4","CDM Revenue Code":"272","Standard Price":1751.34,"Note":"**"},{"Itemcode":"64609314","Description":"Bit Drill Grp 3","CDM Revenue Code":"272","Standard Price":1390.26,"Note":"**"},{"Itemcode":"64609315","Description":"Bit Drill Grp 2","CDM Revenue Code":"272","Standard Price":765.0,"Note":"**"},{"Itemcode":"64609316","Description":"Bit Drill Grp 1","CDM Revenue Code":"272","Standard Price":694.62,"Note":"**"},{"Itemcode":"64609317","Description":"IOL- ANTERIOR CHAMBER","CDM Revenue Code":"276","CDM HCPCS":"V2630","Standard Price":527.0,"Note":"**"},{"Itemcode":"64609318","Description":"IOL A-C Symfony ZXT","CDM Revenue Code":"276","CDM HCPCS":"V2787","Standard Price":1085.0,"Note":"**"},{"Itemcode":"64609336","Description":"Burr Grp 1","CDM Revenue Code":"272","Standard Price":487.56,"Note":"**"},{"Itemcode":"64609349","Description":"Cannula Ortho/Neuro","CDM Revenue Code":"272","Standard Price":161.16,"Note":"**"},{"Itemcode":"64609374","Description":"Cath Balloon Angioplasty Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1166.88,"Note":"**"},{"Itemcode":"64609398","Description":"Wedge Enophthalmos Implant","CDM Revenue Code":"278","Standard Price":1800.3},{"Itemcode":"64609413","Description":"Cement Bone GRP 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":9394.2},{"Itemcode":"64609434","Description":"Clip Applier Grp 3","CDM Revenue Code":"272","Standard Price":2640.78},{"Itemcode":"64609435","Description":"Clip Applier Grp 2","CDM Revenue Code":"272","Standard Price":884.34},{"Itemcode":"64609436","Description":"Clip Applier Grp 1","CDM Revenue Code":"272","Standard Price":505.92},{"Itemcode":"64609483","Description":"Electrode Disp Grp 2","CDM Revenue Code":"272","Standard Price":951.66},{"Itemcode":"64609490","Description":"External Fixator Cmpnts Grp1","CDM Revenue Code":"272","Standard Price":583.44},{"Itemcode":"64609502","Description":"FIXATION DEVICE","CDM Revenue Code":"278","Standard Price":3817.86},{"Itemcode":"64609548","Description":"Guide Wire Ortho C1769 Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":208.08,"Note":"**"},{"Itemcode":"64609549","Description":"GUIDEWIRE ORTHO GRP 2","CDM Revenue Code":"272","Standard Price":394.74,"Note":"**"},{"Itemcode":"64609550","Description":"Guide Wire Endo Dbl End C1769","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":104.04},{"Itemcode":"64609551","Description":"GUIDEWIRE ORTHO 0.62 AR-8941KT","CDM Revenue Code":"272","Standard Price":202.98},{"Itemcode":"64609578","Description":"Implant Glaucoma Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1783","Standard Price":2595.9,"Note":"**"},{"Itemcode":"64609589","Description":"Orbital Sphere Medpor Implant","CDM Revenue Code":"278","Standard Price":2817.24},{"Itemcode":"64609611","Description":"IOL - Posterior Chamber","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":759.0,"Note":"**"},{"Itemcode":"64609621","Description":"Knife","CDM Revenue Code":"272","Standard Price":616.08},{"Itemcode":"64609630","Description":"Lacrimal Intubation","CDM Revenue Code":"272","Standard Price":541.62},{"Itemcode":"64609651","Description":"MESH GENL SURG C1781 GRP 4","CDM Revenue Code":"278","Standard Price":2180.76},{"Itemcode":"64609669","Description":"Needle Grp 2","CDM Revenue Code":"272","Standard Price":1225.02,"Note":"**"},{"Itemcode":"64609670","Description":"Needle Grp 1","CDM Revenue Code":"272","Standard Price":453.9},{"Itemcode":"64609683","Description":"PIN, BONE AXIS 2.5 X 5.5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1565.7},{"Itemcode":"64609685","Description":"PIN GRP1 IMPLANTABLE","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":314.16},{"Itemcode":"64609694","Description":"Plate Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":4221.78,"Note":"**"},{"Itemcode":"64609695","Description":"Plate Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3002.88,"Note":"**"},{"Itemcode":"64609696","Description":"Plate GRP 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2001.24},{"Itemcode":"64609697","Description":"Plate Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1002.66},{"Itemcode":"64609698","Description":"Plate Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":477.36},{"Itemcode":"64609700","Description":"Polar Care","CDM Revenue Code":"272","Standard Price":759.9},{"Itemcode":"64609709","Description":"PROSTHESIS BREAST GRP 3","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":3655.68},{"Itemcode":"64609710","Description":"Prosthesis Breast Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":3476.16},{"Itemcode":"64609711","Description":"PROSTHESIS BREAST GRP 1","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":2566.32,"Note":"**"},{"Itemcode":"64609729","Description":"Reamer Ortho","CDM Revenue Code":"272","Standard Price":1244.4,"Note":"**"},{"Itemcode":"64609730","Description":"Cath, Translum Angioplast Grp1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":666.06},{"Itemcode":"64609731","Description":"Cath, Translum Angioplast Grp2","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1035.3},{"Itemcode":"64609732","Description":"Cath, Translum Angioplast Grp3","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1170.96},{"Itemcode":"64609733","Description":"Cath Translum Angioplast Gr4","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1300.5},{"Itemcode":"64609734","Description":"Cath, Translum Angioplast Grp5","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1436.16},{"Itemcode":"64609735","Description":"Cath, Translum Angioplast Grp6","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1540.2},{"Itemcode":"64609736","Description":"Cath, Translum Angioplast Grp7","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1565.7},{"Itemcode":"64609737","Description":"Cath, Translum Antioplast Gr8","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1674.84},{"Itemcode":"64609740","Description":"Cath,Translum Angioplast Grp10","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":2429.64},{"Itemcode":"64609746","Description":"ROD GRP 3","CDM Revenue Code":"278","Standard Price":1353.54},{"Itemcode":"64609748","Description":"Rod Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":705.84},{"Itemcode":"64609753","Description":"Screw Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2579.58,"Note":"**"},{"Itemcode":"64609754","Description":"Screw Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1929.84,"Note":"**"},{"Itemcode":"64609755","Description":"Screw Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":1372.92,"Note":"**"},{"Itemcode":"64609756","Description":"Screw Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":777.24,"Note":"**"},{"Itemcode":"64609757","Description":"Screw Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":466.14,"Note":"**"},{"Itemcode":"64609767","Description":"SCREW GRP 6","CDM Revenue Code":"278","Standard Price":3346.62},{"Itemcode":"64609770","Description":"Stent Non-Coa/Non-Cov WDel Gr1","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3631.2},{"Itemcode":"64609771","Description":"Stent Non-Coa/Non-Cov WDel Gr2","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4057.56},{"Itemcode":"64609772","Description":"Stent Non-Coa/Non-Cov WDel Gr3","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4374.78},{"Itemcode":"64609773","Description":"Stent Non-Coa/Non-Cov WDel Gr4","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4692.0},{"Itemcode":"64609775","Description":"Introducer/Sheath Non-Lsr Grp1","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":116.28},{"Itemcode":"64609776","Description":"Stent Non-Coa/Non-Cov WDel Gr7","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6242.4},{"Itemcode":"64609790","Description":"Stent Coa/Cov WDel Sys Gr1","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8947.44},{"Itemcode":"64609792","Description":"Stent Coa/Cov WDel Sys Gr2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":9789.96},{"Itemcode":"64609800","Description":"Staple Bone Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":2947.8,"Note":"**"},{"Itemcode":"64609802","Description":"Staple Bone Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":878.22},{"Itemcode":"64609820","Description":"Stent Biliary","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":5110.2},{"Itemcode":"64609834","Description":"SUTURE RETRIEVER","CDM Revenue Code":"272","Standard Price":413.1,"Note":"**"},{"Itemcode":"64609838","Description":"TAP GRP 1","CDM Revenue Code":"272","Standard Price":554.88,"Note":"**"},{"Itemcode":"64609842","Description":"Tissue Expander Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1789","Standard Price":6394.38,"Note":"**"},{"Itemcode":"64609874","Description":"Washer Grp 1","CDM Revenue Code":"278","Standard Price":200.94},{"Itemcode":"64609876","Description":"Wire Ortho Supply Grp 2","CDM Revenue Code":"272","Standard Price":681.36,"Note":"**"},{"Itemcode":"64609878","Description":"WIRE ORTHO SUPPLY GRP 1","CDM Revenue Code":"272","Standard Price":126.48,"Note":"**"},{"Itemcode":"64609996","Description":"Lens Presby-C Fnctn ZXR SV25T0","CDM Revenue Code":"276","CDM HCPCS":"V2788","Standard Price":989.0,"Note":"**"},{"Itemcode":"64609997","Description":"Restor Conventional Lens","CDM Revenue Code":"276","CDM HCPCS":"V2632","Standard Price":931.26},{"Itemcode":"65102403","Description":"Kit: Gastrostomy Tube Replace","CDM Revenue Code":"272","Standard Price":340.68,"Note":"**"},{"Itemcode":"65102874","Description":"Tray: Paracentesis","CDM Revenue Code":"272","Standard Price":196.86,"Note":"**"},{"Itemcode":"65102876","Description":"Tray: Vaginal Delivery","CDM Revenue Code":"272","Standard Price":277.44},{"Itemcode":"65106360","Description":"Tray: Er Chest Tube Insertion","CDM Revenue Code":"272","Standard Price":287.64,"Note":"**"},{"Itemcode":"68252507","Description":"Sponsor supplied Study Drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259000","Description":"Carfilzomib 60mg-study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259001","Description":"IMMU-114-Study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259002","Description":"Ipilimumab 200mg/40ml Study dr","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259003","Description":"Ipilimumab 50mg/10ml Study drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259004","Description":"Nivolumab 100mg/10ml Study drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259005","Description":"Nivolumab 40mg/4ml Study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259006","Description":"Nivlumb/Plcbo100mg/10mlStdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259007","Description":"Panitumumab 100mg/5ml Stdy Drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259008","Description":"Panitumumab 400mg/20ml Stdy Dr","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259009","Description":"Pembrolizumab100mg/4ml StdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68259010","Description":"Pembrolizumab 50mg/2ml StdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68260120","Description":"Onc Central Line Dressing","CDM Revenue Code":"272","Standard Price":70.38},{"Itemcode":"68262507","Description":"Sponsor supplied Study Drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269000","Description":"Carfilzomib 60mg-study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269001","Description":"IMMU-114-Study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269002","Description":"Ipilimumab 200mg/40ml Study dr","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269003","Description":"Ipilimumab 50mg/10ml Study drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269004","Description":"Nivolumab 100mg/10ml Study drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269005","Description":"Nivolumab 40mg/4ml Study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269006","Description":"Nivlumb/Plcbo100mg/10mlStdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269007","Description":"Panitumumab 100mg/5ml Stdy Drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269008","Description":"Panitumumab 400mg/20ml Stdy Dr","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269009","Description":"Pembrolizumab100mg/4ml StdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68269010","Description":"Pembrolizumab 50mg/2ml StdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"68300250","Description":"Brachymesh 6720-Mesh/Per Seed","CDM Revenue Code":"278","CDM HCPCS":"C2642","Standard Price":431.46},{"Itemcode":"68300252","Description":"Cesium 131 Per Seed","CDM Revenue Code":"278","CDM HCPCS":"C2643","Standard Price":472.26,"Note":"**"},{"Itemcode":"68300253","Description":"Brachy Cesium-131Chlor per mCi","CDM Revenue Code":"278","CDM HCPCS":"C2644","Standard Price":478.38},{"Itemcode":"68300256","Description":"I-125 Each Seed","CDM Revenue Code":"278","CDM HCPCS":"C2639","Standard Price":205.02},{"Itemcode":"68300258","Description":"Fiducial Marker","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":1184.22,"Note":"**"},{"Itemcode":"68300264","Description":"CATH, BRACHYTHER SEED ADMIN","CDM Revenue Code":"272","CDM HCPCS":"C1728","Standard Price":297.84},{"Itemcode":"68300265","Description":"BRACHYTX, NON STR, HDR IR-192","CDM Revenue Code":"278","CDM HCPCS":"C1717","Standard Price":1444.32,"Note":"**"},{"Itemcode":"71101440","Description":"Pack: Hystosalpingogram","CDM Revenue Code":"272","Standard Price":366.18},{"Itemcode":"71101760","Description":"Pack: Sialogram","CDM Revenue Code":"272","Standard Price":279.48},{"Itemcode":"71127064","Description":"Clip: Stereotactic","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":507.96},{"Itemcode":"71180063","Description":"Needle Marker Supply","CDM Revenue Code":"272","Standard Price":166.26},{"Itemcode":"71300159","Description":"Cath Drainage","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":627.3},{"Itemcode":"71300160","Description":"Needle Biopsy","CDM Revenue Code":"272","Standard Price":265.2},{"Itemcode":"71301100","Description":"Needle: Yvecentesis","CDM Revenue Code":"272","Standard Price":184.62},{"Itemcode":"71301105","Description":"Needle: Co-Axial Intro","CDM Revenue Code":"272","Standard Price":100.98},{"Itemcode":"71301110","Description":"Probe Cover: Ultrasound","CDM Revenue Code":"272","Standard Price":93.84},{"Itemcode":"71301120","Description":"Needle: Tru Core 18G","CDM Revenue Code":"272","Standard Price":225.42},{"Itemcode":"71301490","Description":"Pack: Localization","CDM Revenue Code":"272","Standard Price":268.26},{"Itemcode":"71302145","Description":"Biopsy: Liver-D","CDM Revenue Code":"272","Standard Price":0.0},{"Itemcode":"71302566","Description":"Probe Needle Guide Kit","CDM Revenue Code":"270","Standard Price":106.08},{"Itemcode":"71304050","Description":"Pack: Amniocentesis - Us","CDM Revenue Code":"272","Standard Price":159.12},{"Itemcode":"71304075","Description":"Pack: Aspiration","CDM Revenue Code":"272","Standard Price":276.42,"Note":"**"},{"Itemcode":"71304150","Description":"Pack: Biopsy","CDM Revenue Code":"272","Standard Price":381.48,"Note":"**"},{"Itemcode":"71304155","Description":"Pack: Biopsy Renal","CDM Revenue Code":"272","Standard Price":339.66},{"Itemcode":"71304660","Description":"Pack: Psac Pseudo Aneurysm","CDM Revenue Code":"272","Standard Price":34.68},{"Itemcode":"71304750","Description":"Pack: Sonohystogram","CDM Revenue Code":"272","Standard Price":486.54},{"Itemcode":"71304885","Description":"Pack: Thoracentesis","CDM Revenue Code":"272","Standard Price":320.28},{"Itemcode":"71304930","Description":"Pack: Vaginal","CDM Revenue Code":"272","Standard Price":88.74},{"Itemcode":"71307018","Description":"Needle: Homer Mammalok","CDM Revenue Code":"272","Standard Price":214.2},{"Itemcode":"71307019","Description":"Needle: Biopsy Temno","CDM Revenue Code":"272","Standard Price":268.26},{"Itemcode":"71307026","Description":"Needle: Biopsy Bard","CDM Revenue Code":"272","Standard Price":187.68},{"Itemcode":"71307027","Description":"Cath: Drain Set Flexima 8Fr","CDM Revenue Code":"272","Standard Price":589.56},{"Itemcode":"71307028","Description":"Cath: Drain Set Flexima 6F","CDM Revenue Code":"272","Standard Price":629.34},{"Itemcode":"71307038","Description":"Needle: Biopsy Coax Temno","CDM Revenue Code":"272","Standard Price":425.34},{"Itemcode":"71307044","Description":"Needle: Spinal","CDM Revenue Code":"272","Standard Price":53.04},{"Itemcode":"71307064","Description":"Clip: Stereotactic","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":587.52},{"Itemcode":"71307074","Description":"Tray: Hsg","CDM Revenue Code":"272","Standard Price":340.68},{"Itemcode":"71307085","Description":"Set: Navarre Perc Access","CDM Revenue Code":"272","Standard Price":479.4},{"Itemcode":"71307090","Description":"Cath: Abcession Drainage","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":590.58},{"Itemcode":"71308888","Description":"Biopsy Results Letter","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"71400082","Description":"Brachymesh 6720-Mesh/Per Seed","CDM Revenue Code":"278","CDM HCPCS":"C2642","Standard Price":431.46},{"Itemcode":"71402105","Description":"90-Yttrium Spheres Per Vial","CDM Revenue Code":"278","CDM HCPCS":"C2616","Standard Price":80389.26,"Note":"**"},{"Itemcode":"71404962","Description":"I 125 Seed","CDM Revenue Code":"278","CDM HCPCS":"C2639","Standard Price":343.74},{"Itemcode":"71404963","Description":"Cesium 131 Stranded/ Per Seed","CDM Revenue Code":"278","CDM HCPCS":"C2642","Standard Price":431.46},{"Itemcode":"71405308","Description":"Xenon Kit/Xe 133 (20Mci)-D","CDM Revenue Code":"272","Standard Price":0.0},{"Itemcode":"71500150","Description":"Fast Find Grid","CDM Revenue Code":"270","Standard Price":40.8},{"Itemcode":"71502500","Description":"Tru-Core Ii Biopsy Needle","CDM Revenue Code":"272","Standard Price":216.24},{"Itemcode":"71502800","Description":"Stereotaxis-D","CDM Revenue Code":"272","Standard Price":0.0},{"Itemcode":"71504600","Description":"Pack: Aspiration","CDM Revenue Code":"272","Standard Price":265.2},{"Itemcode":"71504620","Description":"Pack: Biopsy","CDM Revenue Code":"272","Standard Price":366.18},{"Itemcode":"71504680","Description":"Pack: Sterotaxis","CDM Revenue Code":"272","Standard Price":40.8},{"Itemcode":"71506009","Description":"Electrode: 4.0 Cm-Leveen Needl","CDM Revenue Code":"272","Standard Price":4039.2},{"Itemcode":"71506100","Description":"Cath: Drainage All Purpose","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":544.68,"Note":"**"},{"Itemcode":"71506120","Description":"Cath: Locking Pigtail Drain","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":499.8},{"Itemcode":"71506450","Description":"Co-Axial Intro Needle","CDM Revenue Code":"272","Standard Price":96.9},{"Itemcode":"71506600","Description":"Needle: Biopsy Adj Throw Temno","CDM Revenue Code":"272","Standard Price":300.9},{"Itemcode":"71506610","Description":"Needle: Chiba","CDM Revenue Code":"272","Standard Price":74.46},{"Itemcode":"71506620","Description":"Needle: Biopsy Coaxial Temno","CDM Revenue Code":"272","Standard Price":351.9},{"Itemcode":"71506700","Description":"Set: Coaxial Aspiration","CDM Revenue Code":"272","Standard Price":200.94},{"Itemcode":"71506731","Description":"ApplicatrThermo Ablatn-ACCULIS","CDM Revenue Code":"272","Standard Price":8503.74},{"Itemcode":"71507730","Description":"Drain Set: Biliary/Nephro","CDM Revenue Code":"272","Standard Price":852.72},{"Itemcode":"71608102","Description":"Suros Handpiece 20 Mr (Access)","CDM Revenue Code":"272","Standard Price":2030.82},{"Itemcode":"71608103","Description":"Suros Localization Set 12 (Acc","CDM Revenue Code":"272","Standard Price":1130.16},{"Itemcode":"71608104","Description":"Suros Localization Set 20 (Acc","CDM Revenue Code":"272","Standard Price":1130.16},{"Itemcode":"71700003","Description":"Trufill Liquid Embolization Sy","CDM Revenue Code":"278","Standard Price":22245.18,"Note":"**"},{"Itemcode":"71700006","Description":"Stent: Fluency","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":9377.88,"Note":"**"},{"Itemcode":"71700007","Description":"Coil Emb Xtrasoft Orbit Glxy","CDM Revenue Code":"278","Standard Price":7805.04,"Note":"**"},{"Itemcode":"71700008","Description":"Power PICC","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":644.64,"Note":"**"},{"Itemcode":"71700009","Description":"Power PICC - Triple Lumen","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":747.66},{"Itemcode":"71700032","Description":"Stent Cov W/Deliv No Cost","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":1.02},{"Itemcode":"71700033","Description":"Osteocool Bone Access Kit","CDM Revenue Code":"272","Standard Price":1749.3,"Note":"**"},{"Itemcode":"71700034","Description":"Osteocool RF Single Probe Kit","CDM Revenue Code":"278","CDM HCPCS":"C1886","Standard Price":10308.12},{"Itemcode":"71700037","Description":"Osteocool RF Dual Probe Kit","CDM Revenue Code":"278","CDM HCPCS":"C1886","Standard Price":13280.4,"Note":"**"},{"Itemcode":"71700038","Description":"STENT WINGSPAN NEUROVASCULAR","CDM Revenue Code":"278","Standard Price":20172.54},{"Itemcode":"71700039","Description":"BALLOON GATEWAY","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":4306.44},{"Itemcode":"71700040","Description":"POWER PICC LEVEL 1","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":1153.62,"Note":"**"},{"Itemcode":"71700041","Description":"CATH, PICC 1LUM BIOFLO","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":795.6},{"Itemcode":"71700042","Description":"Osteocool Introduce Bevel Kit","CDM Revenue Code":"272","Standard Price":3182.4},{"Itemcode":"71700050","Description":"Penumbra Microcoil Cath","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":3966.78},{"Itemcode":"71700052","Description":"Kit Kyphon First Fracture","CDM Revenue Code":"272","Standard Price":11917.68},{"Itemcode":"71700060","Description":"Penumbra Sheath","CDM Revenue Code":"272","Standard Price":2096.1},{"Itemcode":"71700061","Description":"SHEATH, STEERABLE 7FR","CDM Revenue Code":"272","Standard Price":2453.1},{"Itemcode":"71700062","Description":"Stent: Fluency 9 X 80","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":7891.74,"Note":"**"},{"Itemcode":"71700067","Description":"Introducer Sheath Grp 3 E","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":520.2,"Note":"**"},{"Itemcode":"71700068","Description":"Introducer Sheath Grp 3 F","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":572.22,"Note":"**"},{"Itemcode":"71700074","Description":"Cath Guiding Grp 1 E","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":676.26,"Note":"**"},{"Itemcode":"71700075","Description":"Cath Guiding Grp 2 B","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":780.3},{"Itemcode":"71700076","Description":"Cath Guiding Grp 2 C","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":858.84,"Note":"**"},{"Itemcode":"71700077","Description":"Cath Guiding Grp 2 D","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":946.56,"Note":"**"},{"Itemcode":"71700078","Description":"GDE SHEATH, STEERABLE 7FR","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2453.1,"Note":"**"},{"Itemcode":"71700100","Description":"Kyphoplasty Kit Ivas","CDM Revenue Code":"278","Standard Price":4834.8},{"Itemcode":"71700101","Description":"Cement Stryker Autoplex","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3412.92},{"Itemcode":"71700104","Description":"Cement Cannula","CDM Revenue Code":"272","Standard Price":474.3},{"Itemcode":"71700105","Description":"Bone Biopsy Kit Stryker","CDM Revenue Code":"272","Standard Price":629.34},{"Itemcode":"71700106","Description":"CORTOSS RESIN/CEMENT CARTRIDGE","CDM Revenue Code":"278","Standard Price":2883.54},{"Itemcode":"71700107","Description":"BONE TAMP KYPHOPLASTY","CDM Revenue Code":"272","Standard Price":3895.38},{"Itemcode":"71700108","Description":"KYPHON BALLOON TRAY, 1st FRACT","CDM Revenue Code":"272","Standard Price":9635.94,"Note":"**"},{"Itemcode":"71700159","Description":"TRAY-PARACENTESIS 3-WAY","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":166.26},{"Itemcode":"71700169","Description":"Stent Wallflex","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":10643.7},{"Itemcode":"71700170","Description":"STENT VASC,SELF EXPANDIN","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3091.62,"Note":"**"},{"Itemcode":"71700177","Description":"Trellis Infusion Cath System","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":9381.96},{"Itemcode":"71700178","Description":"Cath Stabilizer Neuroform3","CDM Revenue Code":"272","Standard Price":5244.84},{"Itemcode":"71700179","Description":"Renegade Cath Preld Coils Neur","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":3103.86},{"Itemcode":"71700184","Description":"Stent Enterprise","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":22027.92,"Note":"**"},{"Itemcode":"71700185","Description":"Stent Protege GRP 2","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4646.1,"Note":"**"},{"Itemcode":"71700186","Description":"Tray Cath Drnage Thoracic Vent","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":1128.12},{"Itemcode":"71700188","Description":"Cone Recovery Bard Fbrc","CDM Revenue Code":"272","Standard Price":2652.0},{"Itemcode":"71700190","Description":"Cath Triple Lumen","CDM Revenue Code":"272","Standard Price":466.14,"Note":"**"},{"Itemcode":"71700191","Description":"Coil Interlock Fibered Idc","CDM Revenue Code":"278","Standard Price":1685.04,"Note":"**"},{"Itemcode":"71700192","Description":"Vascular Plug Amplatz","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":3487.38,"Note":"**"},{"Itemcode":"71700197","Description":"Penumbra Delivery Cath","CDM Revenue Code":"272","Standard Price":2627.52},{"Itemcode":"71700198","Description":"Penumbra Cath Select Neuron","CDM Revenue Code":"272","Standard Price":664.02},{"Itemcode":"71700199","Description":"Penumbra Reperfusion Cath","CDM Revenue Code":"278","CDM HCPCS":"C1757","Standard Price":10110.24},{"Itemcode":"71700200","Description":"Penumbra Seperator Cath","CDM Revenue Code":"278","Standard Price":8051.88},{"Itemcode":"71700201","Description":"Penumbra Aspiration Tubing Sys","CDM Revenue Code":"272","Standard Price":1963.5,"Note":"**"},{"Itemcode":"71700202","Description":"Penumbra- Pump/Canister/Filter","CDM Revenue Code":"270","Standard Price":1060.8},{"Itemcode":"71700208","Description":"Closure Device","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1092.42,"Note":"**"},{"Itemcode":"71700209","Description":"Kit Angiojet Power Pulse Deliv","CDM Revenue Code":"272","Standard Price":221.34},{"Itemcode":"71700210","Description":"Tube Gastrostomy","CDM Revenue Code":"272","Standard Price":235.62,"Note":"**"},{"Itemcode":"71700212","Description":"Cath Guiding Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":429.42,"Note":"**"},{"Itemcode":"71700213","Description":"Cath Dialysis Long Term Grp1","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":670.14,"Note":"**"},{"Itemcode":"71700217","Description":"Cath Infusion","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":718.08,"Note":"**"},{"Itemcode":"71700218","Description":"Cath Occlusion","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":1544.28},{"Itemcode":"71700219","Description":"Embosphere Microspheres S410Gh","CDM Revenue Code":"272","Standard Price":1310.7,"Note":"**"},{"Itemcode":"71700220","Description":"Wire Coil Pusher","CDM Revenue Code":"272","Standard Price":957.78,"Note":"**"},{"Itemcode":"71700222","Description":"Cath Dialysis Long Term Grp2","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":1201.56,"Note":"**"},{"Itemcode":"71700223","Description":"Cath Dialysis Short Term","CDM Revenue Code":"278","CDM HCPCS":"C1752","Standard Price":574.26,"Note":"**"},{"Itemcode":"71700225","Description":"Cath Excelsior Micro","CDM Revenue Code":"272","Standard Price":2954.94},{"Itemcode":"71700226","Description":"Stent Covered W/Delivery Sys","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":6762.6,"Note":"**"},{"Itemcode":"71700227","Description":"Stent Non-Cov w/Del LVL 1","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4473.72,"Note":"**"},{"Itemcode":"71700228","Description":"Stent Graft Endoprosthesis","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":14556.42,"Note":"**"},{"Itemcode":"71700230","Description":"Set Haskal Portal Access","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":2850.9},{"Itemcode":"71700231","Description":"Cath Peripheral Ivus","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":10653.9},{"Itemcode":"71700232","Description":"Cath Guiding Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2044.08,"Note":"**"},{"Itemcode":"71700233","Description":"Cath Guiding Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":3274.2,"Note":"**"},{"Itemcode":"71700234","Description":"Embospheres Micro 820Gh/S620Gh","CDM Revenue Code":"272","Standard Price":929.22,"Note":"**"},{"Itemcode":"71700237","Description":"Cath Balloon Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1423.92,"Note":"**"},{"Itemcode":"71700238","Description":"Cath Balloon Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1768.68,"Note":"**"},{"Itemcode":"71700240","Description":"Cath Dialysis Duraflow","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":1683.0},{"Itemcode":"71700243","Description":"MIC Tube Jejunal","CDM Revenue Code":"272","Standard Price":1196.46,"Note":"**"},{"Itemcode":"71700244","Description":"Kyphon Express Trocar T24/34B","CDM Revenue Code":"272","Standard Price":2122.62},{"Itemcode":"71700245","Description":"Kyphon Bone Filler Device F06A","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"71700246","Description":"Kyphon Bone Biopsy Dev F07/05A","CDM Revenue Code":"272","Standard Price":684.42,"Note":"**"},{"Itemcode":"71700248","Description":"Bone Cement W/Mixer Kypho _01B","CDM Revenue Code":"272","Standard Price":1282.14,"Note":"**"},{"Itemcode":"71700249","Description":"Kyphon Tray Kpt1505/2005","CDM Revenue Code":"272","Standard Price":9051.48},{"Itemcode":"71700250","Description":"Stent Vascular Comlete Se","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6348.48},{"Itemcode":"71700251","Description":"Kyphon Kyphx Latitude Curette","CDM Revenue Code":"272","Standard Price":992.46},{"Itemcode":"71700252","Description":"Cath Trifusion Bard Hickman","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":2627.52},{"Itemcode":"71700253","Description":"Cath Balloon Gateway","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":4169.76},{"Itemcode":"71700254","Description":"Stent Covrd W/Delivry Sys Grp2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8904.6,"Note":"**"},{"Itemcode":"71700255","Description":"Cath Atherectomy","CDM Revenue Code":"272","CDM HCPCS":"C1724","Standard Price":10962.96,"Note":"**"},{"Itemcode":"71700256","Description":"Viper Guidewire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1007.76,"Note":"**"},{"Itemcode":"71700258","Description":"Pleurx Cath Kit","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":2652.0,"Note":"**"},{"Itemcode":"71700260","Description":"Cath Vascu Trak","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":3308.88},{"Itemcode":"71700261","Description":"Cath Eagle Eye Vasc Us","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":3199.74},{"Itemcode":"71700262","Description":"Cath Balloon Grp 4A","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":2601.0,"Note":"**"},{"Itemcode":"71700264","Description":"Mynx Closure System","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1125.06,"Note":"**"},{"Itemcode":"71700265","Description":"FBRC Recovery Cone Removal Sys","CDM Revenue Code":"278","CDM HCPCS":"C1773","Standard Price":2811.12,"Note":"**"},{"Itemcode":"71700266","Description":"MIC Introducer Kit","CDM Revenue Code":"272","Standard Price":1092.42,"Note":"**"},{"Itemcode":"71700267","Description":"Vertaplex Hv Cement +Kit","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3660.78},{"Itemcode":"71700268","Description":"Button Gastrostomy Tube","CDM Revenue Code":"272","Standard Price":664.02},{"Itemcode":"71700269","Description":"IVC Filter Jugular","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":5105.1},{"Itemcode":"71700270","Description":"Jejunostomy Cath Set","CDM Revenue Code":"272","Standard Price":785.4},{"Itemcode":"71700271","Description":"Gastrostomy Cath Set","CDM Revenue Code":"272","Standard Price":682.38,"Note":"**"},{"Itemcode":"71700272","Description":"Stent Covered W/Deliv Sys Grp3","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10872.18,"Note":"**"},{"Itemcode":"71700273","Description":"Stent Covrd W/Delivry Sys Grp4","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":11860.56,"Note":"**"},{"Itemcode":"71700275","Description":"Sheath Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":68.34,"Note":"**"},{"Itemcode":"71700276","Description":"Introducer Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":208.08,"Note":"**"},{"Itemcode":"71700277","Description":"Introducer Sheath Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":281.52,"Note":"**"},{"Itemcode":"71700278","Description":"Introducer Sheath Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":645.66,"Note":"**"},{"Itemcode":"71700279","Description":"Vascutrak Balloon Cath","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":3199.74},{"Itemcode":"71700280","Description":"Stent Cov W/Delivery","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":4333.98},{"Itemcode":"71700281","Description":"Pleurx Cath Kit 50-7000B","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":2346.0,"Note":"**"},{"Itemcode":"71700282","Description":"Cath Atherectomy Lvl 1","CDM Revenue Code":"272","CDM HCPCS":"C1724","Standard Price":10643.7},{"Itemcode":"71700283","Description":"Retrieval Device, Insertable","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1486.14,"Note":"**"},{"Itemcode":"71700284","Description":"Catheter, Extraction","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":1565.7,"Note":"**"},{"Itemcode":"71700285","Description":"Stent Non-Covw/Deliv Sys Lvl2","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":5950.68},{"Itemcode":"71700286","Description":"Renegade Cath Neuro Emboliz","CDM Revenue Code":"272","Standard Price":2346.0},{"Itemcode":"71700287","Description":"Cath Infusion Thrombolysis","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":848.64},{"Itemcode":"71700290","Description":"Cath Guiding Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":740.52,"Note":"**"},{"Itemcode":"71700291","Description":"Cath Guiding Softvu","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":116.28,"Note":"**"},{"Itemcode":"71700292","Description":"Pacemaker Gen Pm1210","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":14083.14},{"Itemcode":"71700293","Description":"Cath Temp Pacing (401760/7)","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"71700294","Description":"Cath Spinal","CDM Revenue Code":"272","CDM HCPCS":"C1755","Standard Price":546.72},{"Itemcode":"71700295","Description":"Cement Tray Vmx00CT Carefusion","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":3003.9},{"Itemcode":"71700296","Description":"Avamax Vertebral Balloon","CDM Revenue Code":"278","Standard Price":5117.34},{"Itemcode":"71700297","Description":"Catheter, IVUS Levl 1","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":3999.42,"Note":"**"},{"Itemcode":"71700298","Description":"Catheter Guiding - Grp 5","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":3465.96,"Note":"**"},{"Itemcode":"71700299","Description":"CathAngio Translum Coated Grp1","CDM Revenue Code":"278","CDM HCPCS":"C2623","Standard Price":6898.26,"Note":"**"},{"Itemcode":"71700300","Description":"Pacemaker Sensia Dr Sedr01","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":12264.48},{"Itemcode":"71700301","Description":"Accent Pm1110 Pacemaker","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":14759.4},{"Itemcode":"71700302","Description":"Sensia Sesr01 Pacemaker","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":10653.9},{"Itemcode":"71700304","Description":"Revo Rvdr01 Pacemaker","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":18536.46},{"Itemcode":"71700305","Description":"Intro/Sheath,Fixed,Peel-Away","CDM Revenue Code":"272","CDM HCPCS":"C1892","Standard Price":419.22},{"Itemcode":"71700306","Description":"Distaflo Stent Graft","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":9299.34},{"Itemcode":"71700307","Description":"Stent Graft Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":2310.3},{"Itemcode":"71700308","Description":"Stent Graft Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":3420.06},{"Itemcode":"71700309","Description":"Stent Graft Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":5981.28},{"Itemcode":"71700310","Description":"Kyphon Addl Kit Kpe1001/1002","CDM Revenue Code":"278","Standard Price":9872.58,"Note":"**"},{"Itemcode":"71700311","Description":"Kit Kyphon First Fracture","CDM Revenue Code":"278","Standard Price":10216.32,"Note":"**"},{"Itemcode":"71700312","Description":"Barricade Coil","CDM Revenue Code":"278","Standard Price":2947.8},{"Itemcode":"71700313","Description":"Penumbra Coil Embolization","CDM Revenue Code":"278","Standard Price":9171.84},{"Itemcode":"71700314","Description":"Coil, Embolization Soft","CDM Revenue Code":"278","Standard Price":7635.72,"Note":"**"},{"Itemcode":"71700315","Description":"Coil, Embolizn Xtra Soft","CDM Revenue Code":"278","Standard Price":5076.54,"Note":"**"},{"Itemcode":"71700316","Description":"Introducer Sheath Grp 5","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":790.5,"Note":"**"},{"Itemcode":"71700355","Description":"Cath Surefire Angiographic","CDM Revenue Code":"272","Standard Price":1138.32},{"Itemcode":"71700356","Description":"Surefire Infusion Cath System","CDM Revenue Code":"272","Standard Price":10643.7},{"Itemcode":"71700357","Description":"IMPL PACEMKR ASSURITY MRI-DC","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":12848.94},{"Itemcode":"71700360","Description":"Coil Gdc Neurovascular","CDM Revenue Code":"278","Standard Price":5386.62},{"Itemcode":"71700361","Description":"Coil Cerecyte","CDM Revenue Code":"278","Standard Price":3342.54,"Note":"**"},{"Itemcode":"71700363","Description":"Microsnare Kit/Retrieval Dev","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2653.02,"Note":"**"},{"Itemcode":"71700366","Description":"Pleurx Kit Pt Starter 50-0071","CDM Revenue Code":"272","Standard Price":1448.4,"Note":"**"},{"Itemcode":"71700367","Description":"CEMENT BONE KPE1003","CDM Revenue Code":"278","Standard Price":13846.5,"Note":"**"},{"Itemcode":"71700368","Description":"PACEMAKER ZEPHYR 5820","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14759.4},{"Itemcode":"71700369","Description":"IVAS STRYKER CURETTE","CDM Revenue Code":"272","Standard Price":2175.66},{"Itemcode":"71700370","Description":"SPHENOCATH","CDM Revenue Code":"272","Standard Price":795.6},{"Itemcode":"71700371","Description":"Kit Cath Midline w/GW 5FR","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":629.34},{"Itemcode":"71700372","Description":"Stent,Biliary Vis Pro","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3626.1,"Note":"**"},{"Itemcode":"71700373","Description":"Introducer Sheath 14FR X 28CM","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":1060.8},{"Itemcode":"71700374","Description":"Catheter Guiding 8FR","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":354.96},{"Itemcode":"71700375","Description":"Controller Coil Detach-Azur","CDM Revenue Code":"272","Standard Price":949.62},{"Itemcode":"71700376","Description":"Stent,Peripheral OTW-SUPERA","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6804.42,"Note":"**"},{"Itemcode":"71700377","Description":"Synergy Coronary Stent","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":3730.14},{"Itemcode":"71700508","Description":"Lead Neurostimulator SC-2316","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":10820.16},{"Itemcode":"71700509","Description":"Kit Patient Trial - Neurostim","CDM Revenue Code":"272","Standard Price":483.48},{"Itemcode":"71700510","Description":"Neuromod Cable w/ Tray","CDM Revenue Code":"272","Standard Price":2652.0},{"Itemcode":"71700511","Description":"Cath GD Softvu - Braided","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":235.62},{"Itemcode":"71701051","Description":"EmbosphereMicroSyr2ml700-900UM","CDM Revenue Code":"272","Standard Price":1310.7},{"Itemcode":"71701202","Description":"Power Port","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":2212.38,"Note":"**"},{"Itemcode":"71701210","Description":"Carey-Alzate-Coons Gastro Jeju","CDM Revenue Code":"278","CDM HCPCS":"C1769","Standard Price":1497.36},{"Itemcode":"71701211","Description":"Carey-Alzate-Coons Gastro Jeju","CDM Revenue Code":"278","CDM HCPCS":"C1729","Standard Price":2059.38},{"Itemcode":"71701212","Description":"Gastrostomy Tube","CDM Revenue Code":"272","Standard Price":198.9,"Note":"**"},{"Itemcode":"71701213","Description":"Liver Access Bx Set","CDM Revenue Code":"278","Standard Price":2536.74},{"Itemcode":"71701215","Description":"MIC Gastrostomy Tube","CDM Revenue Code":"272","Standard Price":154.02,"Note":"**"},{"Itemcode":"71701218","Description":"Re-Entry Cath Endov Outback","CDM Revenue Code":"272","Standard Price":7678.56},{"Itemcode":"71701220","Description":"Catheter 4F Metal Tip 150cm","CDM Revenue Code":"272","CDM HCPCS":"C1728","Standard Price":552.84},{"Itemcode":"71701221","Description":"Guidewire Vasc, Control V18","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":604.86,"Note":"**"},{"Itemcode":"71701222","Description":"CATH SUPPORT TRAILBLZR ANG","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":4264.62,"Note":"**"},{"Itemcode":"71701353","Description":"Cath Guiding Low Cost Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":72.42,"Note":"**"},{"Itemcode":"71701354","Description":"Cath Guiding Low Cost Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":93.84,"Note":"**"},{"Itemcode":"71701355","Description":"Cath Guiding Low Cost Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":114.24},{"Itemcode":"71701356","Description":"Cath Guiding Low Cost Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":145.86,"Note":"**"},{"Itemcode":"71701357","Description":"Cath Guiding Low Cost Grp 5","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":228.48},{"Itemcode":"71701358","Description":"Introducer Sheath Grp 3A","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":348.84,"Note":"**"},{"Itemcode":"71701441","Description":"Patch: Topical","CDM Revenue Code":"272","Standard Price":168.3,"Note":"**"},{"Itemcode":"71701443","Description":"SNARE SYSTEM ENDOVASCULAR 7FR","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1910.46,"Note":"**"},{"Itemcode":"71701444","Description":"Cath PTCA MR Push 15x Emerge","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":718.08,"Note":"**"},{"Itemcode":"71701445","Description":"Cath Central Venous 1 Lumen","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":165.24},{"Itemcode":"71701504","Description":"Cath - Silver Hawk","CDM Revenue Code":"272","CDM HCPCS":"C1714","Standard Price":7917.24},{"Itemcode":"71701505","Description":"Filterwire Es","CDM Revenue Code":"272","CDM HCPCS":"C1884","Standard Price":5250.96,"Note":"**"},{"Itemcode":"71701508","Description":"Sychro 0.14 Guidewire","CDM Revenue Code":"278","CDM HCPCS":"C1769","Standard Price":1558.56,"Note":"**"},{"Itemcode":"71701509","Description":"Transend Ex Guidewire","CDM Revenue Code":"278","CDM HCPCS":"C1769","Standard Price":2502.06,"Note":"**"},{"Itemcode":"71701512","Description":"Ultipaq Microcoil","CDM Revenue Code":"278","Standard Price":4196.28},{"Itemcode":"71701526","Description":"Complex Fill Detachable Coils","CDM Revenue Code":"278","Standard Price":7972.32,"Note":"**"},{"Itemcode":"71701531","Description":"Cath Turbohawk Atherectomy","CDM Revenue Code":"272","CDM HCPCS":"C1714","Standard Price":10643.7},{"Itemcode":"71701532","Description":"Coil Detachable Target 360","CDM Revenue Code":"278","Standard Price":8061.06},{"Itemcode":"71701533","Description":"Coil Detach Sys Inzone/Target","CDM Revenue Code":"278","Standard Price":1544.28,"Note":"**"},{"Itemcode":"71701534","Description":"CathAngio Translum Coated Grp2","CDM Revenue Code":"278","CDM HCPCS":"C2623","Standard Price":6355.62,"Note":"**"},{"Itemcode":"71701535","Description":"Cath Atherectomy Dir-HawkOne","CDM Revenue Code":"278","CDM HCPCS":"C1714","Standard Price":10482.54,"Note":"**"},{"Itemcode":"71701536","Description":"Stent Protege GRP 1","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3802.56,"Note":"**"},{"Itemcode":"71701537","Description":"Filterwire Spider FX V04","CDM Revenue Code":"272","CDM HCPCS":"C1884","Standard Price":6824.82,"Note":"**"},{"Itemcode":"71701538","Description":"Stent Cor DES MR-Synergy","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":3805.62,"Note":"**"},{"Itemcode":"71701708","Description":"Cytology Brush Sheathed","CDM Revenue Code":"272","Standard Price":712.98},{"Itemcode":"71701806","Description":"NS Kit PatientTrial SC-6500-32","CDM Revenue Code":"272","Standard Price":451.86},{"Itemcode":"71701814","Description":"CATH CV-TRIPLE LUMEN GRP 2","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":1740.12,"Note":"**"},{"Itemcode":"71701815","Description":"Guidewire FFR, COMET","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2666.28},{"Itemcode":"71701888","Description":"Port Power 8FR SGL","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":1246.44,"Note":"**"},{"Itemcode":"71702038","Description":"Cath Vascular Bern 4FR","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":164.22,"Note":"**"},{"Itemcode":"71702221","Description":"Stylet Endovenos RFS2-6-12","CDM Revenue Code":"272","Standard Price":2837.64,"Note":"**"},{"Itemcode":"71702369","Description":"Cath/Sheath Guid Pinnacle","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":638.52,"Note":"**"},{"Itemcode":"71702506","Description":"Neuroform Stent","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":14939.94},{"Itemcode":"71702507","Description":"Acculink Carotid Stent","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":9841.98},{"Itemcode":"71702508","Description":"Stent,Biliary Absolute Pro lv2","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4479.84},{"Itemcode":"71702509","Description":"Stent,Peripheral SE","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3199.74,"Note":"**"},{"Itemcode":"71702552","Description":"Impl NS Lead Test Kit","CDM Revenue Code":"278","CDM HCPCS":"C1897","Standard Price":7678.56},{"Itemcode":"71702553","Description":"Impl NS Lead Octrode Trial60cm","CDM Revenue Code":"278","CDM HCPCS":"C1897","Standard Price":10237.74},{"Itemcode":"71702611","Description":"Renegade Cath W/Coils Periph","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":2806.02},{"Itemcode":"71702612","Description":"Fogerty Catheter","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":581.4,"Note":"**"},{"Itemcode":"71702613","Description":"Viatorr Endoprosthesis","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":11801.4,"Note":"**"},{"Itemcode":"71702623","Description":"Cath DX ADVANCE TORCON","CDM Revenue Code":"272","Standard Price":473.28},{"Itemcode":"71702624","Description":"Cath Balloon PTA PE ADVANCE","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":795.6},{"Itemcode":"71702631","Description":"Dermabond Advanced .7ml","CDM Revenue Code":"272","Standard Price":156.06},{"Itemcode":"71702731","Description":"Cath Angio 5FR, Soft-Vu","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":100.98,"Note":"**"},{"Itemcode":"71702788","Description":"Stent Biliary - Express","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4052.46,"Note":"**"},{"Itemcode":"71704058","Description":"Cath: Thrombectomy Trerotola","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":2431.68},{"Itemcode":"71704061","Description":"Cath: Thrombectormy","CDM Revenue Code":"278","CDM HCPCS":"C1757","Standard Price":10127.58},{"Itemcode":"71704062","Description":"Cath: Thrombectormy 6FR","CDM Revenue Code":"278","CDM HCPCS":"C1757","Standard Price":7698.96,"Note":"**"},{"Itemcode":"71704161","Description":"Tray Trach Blue Rhino 263567","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2264.4},{"Itemcode":"71704208","Description":"Shortstop","CDM Revenue Code":"272","Standard Price":45.9},{"Itemcode":"71704225","Description":"Port: Implantable","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":2352.12},{"Itemcode":"71704231","Description":"CATH THROMB SET 8FR ANGIOJET","CDM Revenue Code":"278","CDM HCPCS":"C1757","Standard Price":11496.42,"Note":"**"},{"Itemcode":"71704365","Description":"Angioseal Sp","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1444.32},{"Itemcode":"71704370","Description":"Cath: Angiojet 60Cm","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":3156.9,"Note":"**"},{"Itemcode":"71704375","Description":"Cath: Angiojet 100Cm","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":6419.88},{"Itemcode":"71704380","Description":"Cath: Angiojet","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":6753.42,"Note":"**"},{"Itemcode":"71704423","Description":"Pleurx Drain Kit","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":399.84,"Note":"**"},{"Itemcode":"71704550","Description":"Microspheres","CDM Revenue Code":"272","Standard Price":1060.8},{"Itemcode":"71704552","Description":"BEADS EMBOLIZN 100-300UM 2ML","CDM Revenue Code":"272","Standard Price":8957.64},{"Itemcode":"71704553","Description":"BEADS EMBOLIZN 30-60UM 0.25MG","CDM Revenue Code":"272","Standard Price":6398.46},{"Itemcode":"71704829","Description":"Microcatheter Group 2","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":1976.76},{"Itemcode":"71704830","Description":"Microcatheter Group 1","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":624.24},{"Itemcode":"71704831","Description":"Microcatheter Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":3121.2},{"Itemcode":"71704840","Description":"Cath EP DX/ABL 3D Map","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":8082.48},{"Itemcode":"71705028","Description":"Brush, Cytology","CDM Revenue Code":"272","Standard Price":578.34,"Note":"**"},{"Itemcode":"71705207","Description":"Cath Guiding-Prowler Micro","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":4189.14,"Note":"**"},{"Itemcode":"71705210","Description":"Cutting Ballon","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":3412.92},{"Itemcode":"71705222","Description":"Lead Anchoring Sleeve","CDM Revenue Code":"272","Standard Price":209.1},{"Itemcode":"71705223","Description":"Stylet","CDM Revenue Code":"272","Standard Price":386.58},{"Itemcode":"71705226","Description":"Tunneling Tool Disp","CDM Revenue Code":"272","Standard Price":2291.94},{"Itemcode":"71705460","Description":"Catheter, Guiding Perfusion","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":10621.26,"Note":"**"},{"Itemcode":"71705461","Description":"Catheter 3 MAX","CDM Revenue Code":"272","Standard Price":7209.36,"Note":"**"},{"Itemcode":"71705462","Description":"Catheter, Micro Vel","CDM Revenue Code":"272","Standard Price":4649.16},{"Itemcode":"71705463","Description":"Catheter Indigo","CDM Revenue Code":"272","Standard Price":5502.9},{"Itemcode":"71705464","Description":"Separator Indigo","CDM Revenue Code":"272","Standard Price":3391.5},{"Itemcode":"71705563","Description":"Guidewire Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":757.86,"Note":"**"},{"Itemcode":"71705566","Description":"Pacemaker Adapta Addr01 Sys -D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"71705567","Description":"Pacemaker Generator Addr01","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14150.46},{"Itemcode":"71705568","Description":"PM Lead Ra","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":787.44},{"Itemcode":"71705569","Description":"PM Lead Rv","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":787.44},{"Itemcode":"71705570","Description":"Pacemaker Single Chamber","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":15145.98},{"Itemcode":"71705571","Description":"Pacemaker Dual Chamber","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14759.4},{"Itemcode":"71705572","Description":"Lead Pacemaker","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2652.0},{"Itemcode":"71705573","Description":"Pacemaker Dual Revo Mri","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":21660.72},{"Itemcode":"71705574","Description":"Lead Revo Mri","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":3173.22},{"Itemcode":"71705575","Description":"Lead Adapter","CDM Revenue Code":"272","Standard Price":1045.5},{"Itemcode":"71705576","Description":"Lead Connector","CDM Revenue Code":"272","Standard Price":1282.14},{"Itemcode":"71705578","Description":"Wrench Pacemaker Disp","CDM Revenue Code":"272","Standard Price":304.98},{"Itemcode":"71705580","Description":"Lead Tendril","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2122.62},{"Itemcode":"71705581","Description":"Pacemaker Gen Accent Pm2210","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":15553.98},{"Itemcode":"71705582","Description":"PACER GEN ADDRS1","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":12933.6},{"Itemcode":"71705602","Description":"Cath Guiding Grp 1A","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":525.3,"Note":"**"},{"Itemcode":"71705611","Description":"Quickcross GuideCatheter","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":986.34,"Note":"**"},{"Itemcode":"71705633","Description":"Lead Pacng/Sensng MRI-Ingevity","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2122.62},{"Itemcode":"71705695","Description":"EP INTRACRD FIX GUID INRO/SHTH","CDM Revenue Code":"272","CDM HCPCS":"C1893","Standard Price":770.1},{"Itemcode":"71706001","Description":"Pacemaker Gen Dual Rr Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":13525.2},{"Itemcode":"71706100","Description":"Flexima Biliary Drain Cath","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":532.44,"Note":"**"},{"Itemcode":"71706714","Description":"Handpiece, Bipolar Aquamantys","CDM Revenue Code":"272","Standard Price":2132.82},{"Itemcode":"71706784","Description":"Stent Life Flexstar","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4692.0,"Note":"**"},{"Itemcode":"71706816","Description":"NS Kit Accessory - Cable","CDM Revenue Code":"278","Standard Price":551.82},{"Itemcode":"71707003","Description":"Port,Indwelling Power Slim","CDM Revenue Code":"278","CDM HCPCS":"C1788","Standard Price":1327.02,"Note":"**"},{"Itemcode":"71707005","Description":"Cath Infusion, Central Venous","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":1368.84,"Note":"**"},{"Itemcode":"71707006","Description":"Power PICC - Single Lumen","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":551.82,"Note":"**"},{"Itemcode":"71707008","Description":"Power PICC - Dual Lumen","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":714.0},{"Itemcode":"71707009","Description":"Handle, Detachment for Coil","CDM Revenue Code":"272","Standard Price":1275.0,"Note":"**"},{"Itemcode":"71707010","Description":"Coil, Complex Soft","CDM Revenue Code":"278","Standard Price":9900.12},{"Itemcode":"71707011","Description":"Coil, Curve ES 8cm","CDM Revenue Code":"278","Standard Price":9940.92},{"Itemcode":"71707012","Description":"Coil, Curve ES 4cm","CDM Revenue Code":"278","Standard Price":8236.5},{"Itemcode":"71707013","Description":"Coil, Complex ES 2mmx4cm","CDM Revenue Code":"278","Standard Price":8642.46},{"Itemcode":"71707014","Description":"Catheter, Delivery for Coil","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":4038.18,"Note":"**"},{"Itemcode":"71707021","Description":"Cath Occlusion, Balloon, XC","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":7251.18},{"Itemcode":"71707100","Description":"PICC Set: Double Lumen","CDM Revenue Code":"278","CDM HCPCS":"C1751","Standard Price":683.4},{"Itemcode":"71707106","Description":"Kit: Neff","CDM Revenue Code":"272","Standard Price":700.74},{"Itemcode":"71707109","Description":"Perc-U-Stay","CDM Revenue Code":"272","CDM HCPCS":"A5200","Standard Price":97.92},{"Itemcode":"71707110","Description":"Cath Balloon Low Cost GR 1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":530.4,"Note":"**"},{"Itemcode":"71707115","Description":"Cath Balloon Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1079.16,"Note":"**"},{"Itemcode":"71707150","Description":"Kit Biopsy Bone, Medtronic","CDM Revenue Code":"272","Standard Price":1592.22},{"Itemcode":"71707151","Description":"Currette, Kyphon","CDM Revenue Code":"272","Standard Price":2627.52},{"Itemcode":"71707152","Description":"Syringe Inflation, Kyphon","CDM Revenue Code":"272","Standard Price":689.52},{"Itemcode":"71707153","Description":"Cath Balloon Low Cost GR 2","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":644.64,"Note":"**"},{"Itemcode":"71707154","Description":"Cath Balloon Low Cost GR 3","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":785.4,"Note":"**"},{"Itemcode":"71707155","Description":"Cath Balloon Low Cost GR 4","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":956.76,"Note":"**"},{"Itemcode":"71707220","Description":"Balloon Inflation Device","CDM Revenue Code":"272","Standard Price":196.86,"Note":"**"},{"Itemcode":"71707230","Description":"Cath: Drainage","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":496.74,"Note":"**"},{"Itemcode":"71707231","Description":"Cath: Drainage Centesis Yueh","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":159.12,"Note":"**"},{"Itemcode":"71707250","Description":"Cath: Diagnostic","CDM Revenue Code":"272","Standard Price":167.28,"Note":"**"},{"Itemcode":"71707251","Description":"Cath: Diagnostic GRP 2","CDM Revenue Code":"272","Standard Price":187.68,"Note":"**"},{"Itemcode":"71707252","Description":"Cath: Diagnostic GRP 3","CDM Revenue Code":"272","Standard Price":208.08},{"Itemcode":"71707253","Description":"Cath: Diagnostic GRP 4","CDM Revenue Code":"272","Standard Price":228.48},{"Itemcode":"71707254","Description":"Cath: Diagnostic GRP 5","CDM Revenue Code":"272","Standard Price":260.1,"Note":"**"},{"Itemcode":"71707255","Description":"Cath: Diagnostic GRP 6","CDM Revenue Code":"272","Standard Price":286.62},{"Itemcode":"71707256","Description":"Cath: Diagnostic GRP 7","CDM Revenue Code":"272","Standard Price":312.12,"Note":"**"},{"Itemcode":"71707257","Description":"Cath: Diagnostic GRP 8","CDM Revenue Code":"272","Standard Price":343.74},{"Itemcode":"71707258","Description":"Cath: Diagnostic 4FR STRT","CDM Revenue Code":"272","Standard Price":83.64},{"Itemcode":"71707278","Description":"Cath Balloon Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":2080.8,"Note":"**"},{"Itemcode":"71707279","Description":"Cath Balloon Grp 5","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":2392.92,"Note":"**"},{"Itemcode":"71707280","Description":"Cath Balloon Evercross 9x40cm","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":718.08},{"Itemcode":"71707350","Description":"Cath: Nephrostomy Drain","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":645.66,"Note":"**"},{"Itemcode":"71707420","Description":"Coil: Embolization","CDM Revenue Code":"278","Standard Price":591.6,"Note":"**"},{"Itemcode":"71707421","Description":"Coil: Helical Filling","CDM Revenue Code":"278","Standard Price":2965.14,"Note":"**"},{"Itemcode":"71707422","Description":"Coil: Vascular Grp 1","CDM Revenue Code":"278","Standard Price":364.14,"Note":"**"},{"Itemcode":"71707423","Description":"Coil: Vascular Grp 2","CDM Revenue Code":"278","Standard Price":416.16,"Note":"**"},{"Itemcode":"71707424","Description":"Coil: Vascular Grp 3","CDM Revenue Code":"278","Standard Price":468.18},{"Itemcode":"71707425","Description":"Coil Vascular Detach-Azur","CDM Revenue Code":"278","Standard Price":3849.48,"Note":"**"},{"Itemcode":"71707500","Description":"Filter Vena Cava","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":4330.92,"Note":"**"},{"Itemcode":"71707501","Description":"Filter Vena Cava-Jugular","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":3733.2,"Note":"**"},{"Itemcode":"71707502","Description":"Filter Vena Cava-Group 2","CDM Revenue Code":"278","CDM HCPCS":"C1880","Standard Price":5202.0},{"Itemcode":"71707527","Description":"Pack Fast Closure CFP","CDM Revenue Code":"272","Standard Price":577.32,"Note":"**"},{"Itemcode":"71707559","Description":"Guidewire Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":133.62,"Note":"**"},{"Itemcode":"71707560","Description":"Guidewire Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":379.44,"Note":"**"},{"Itemcode":"71707561","Description":"Guidewire Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1805.4,"Note":"**"},{"Itemcode":"71707562","Description":"Guidewire Hydro","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":802.74},{"Itemcode":"71707563","Description":"Guidewire Journey","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":944.52},{"Itemcode":"71707564","Description":"Guidewire Grp 2B","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":567.12,"Note":"**"},{"Itemcode":"71707566","Description":"Guidewire Grp 2C","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":558.96,"Note":"**"},{"Itemcode":"71707591","Description":"GuideWire Synchro10 300cm/50cm","CDM Revenue Code":"278","CDM HCPCS":"C1769","Standard Price":2879.46,"Note":"**"},{"Itemcode":"71707596","Description":"Guidewire Grp 3A","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":936.36,"Note":"**"},{"Itemcode":"71707597","Description":"Guidewire Grp 3B","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1144.44},{"Itemcode":"71707598","Description":"Guidewire Grp 3C","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1399.44,"Note":"**"},{"Itemcode":"71707599","Description":"Guidewire Grp 2A","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":463.08,"Note":"**"},{"Itemcode":"71707825","Description":"Particles: Pva Emboli","CDM Revenue Code":"278","Standard Price":788.46},{"Itemcode":"71707900","Description":"Sheath Introducer Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":118.32,"Note":"**"},{"Itemcode":"71707901","Description":"Sheath Introducer Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":167.28,"Note":"**"},{"Itemcode":"71707902","Description":"SheathIntroducer- TRIFORCE 5FR","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":1905.36},{"Itemcode":"71707925","Description":"Snare Intravascular","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2175.66,"Note":"**"},{"Itemcode":"71707926","Description":"Snare Gooseneck","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1698.3,"Note":"**"},{"Itemcode":"71707950","Description":"Stent: Ureteral Percuflex","CDM Revenue Code":"278","CDM HCPCS":"C2617","Standard Price":667.08,"Note":"**"},{"Itemcode":"71708268","Description":"AMNIOFIX SHEET 6.0X16CM","CDM Revenue Code":"278","Standard Price":11065.98},{"Itemcode":"71708462","Description":"Cath 3Lu 7F 16C Ask-42703-Pcsj","CDM Revenue Code":"272","Standard Price":750.72},{"Itemcode":"71708645","Description":"TRAY CHEST TUBE DRNG 16FR,20FR","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":1027.14},{"Itemcode":"71708646","Description":"StentEndopros Viabahn 6x25 6Fr","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":21624.0,"Note":"**"},{"Itemcode":"71708746","Description":"D-STAT Flowable Hemostat","CDM Revenue Code":"272","Standard Price":727.26,"Note":"**"},{"Itemcode":"71708846","Description":"Cath Balloon Grp 1 A","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1187.28,"Note":"**"},{"Itemcode":"71708847","Description":"Cath Balloon Grp 1 B","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1305.6,"Note":"**"},{"Itemcode":"71708848","Description":"Cath Balloon 5X135- CHARGER","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":876.18},{"Itemcode":"71708881","Description":"Guidewire Zipwire Stiff 180","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":251.94,"Note":"**"},{"Itemcode":"71708888","Description":"Non-Charge Surg Supply","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"71708893","Description":"Optiflow Tunneled Catheter","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":2610.18},{"Itemcode":"71708896","Description":"Disposable: Needle Holder","CDM Revenue Code":"272","Standard Price":44.88},{"Itemcode":"71708898","Description":"Cath Dialysis ShrtTrm-Niagra","CDM Revenue Code":"278","CDM HCPCS":"C1752","Standard Price":755.82},{"Itemcode":"71708900","Description":"Cath: Triple Lumen","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":517.14},{"Itemcode":"71708901","Description":"Biopsy Set: Liver","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2555.1,"Note":"**"},{"Itemcode":"71708907","Description":"Cath,Infusion,Midline Non-Dial","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":11480.1},{"Itemcode":"71708934","Description":"Stent Coated W/Deliv Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":7657.14},{"Itemcode":"71708952","Description":"Guide Cath Omni Flush","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":86.7,"Note":"**"},{"Itemcode":"71708988","Description":"Coil Emboliz -Free Sample","CDM Revenue Code":"278","Standard Price":0.0},{"Itemcode":"71708995","Description":"Request For Special Procedures","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"71709061","Description":"STENT INNOVA","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":10450.92},{"Itemcode":"71709091","Description":"Retriever Vascular Vrs-6.0-90","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2559.18,"Note":"**"},{"Itemcode":"71709120","Description":"Stent Periph wDel 6x40x125","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":5012.28},{"Itemcode":"71709154","Description":"Cath Dialys Chronc Sport Pack","CDM Revenue Code":"278","CDM HCPCS":"C1750","Standard Price":1533.06},{"Itemcode":"71709191","Description":"STENT BILIARY GPS MINI","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3626.1,"Note":"**"},{"Itemcode":"71709294","Description":"Cath Guid 6FR MultiD, Envoy","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2288.88,"Note":"**"},{"Itemcode":"71709389","Description":"Cath Guiding Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":388.62,"Note":"**"},{"Itemcode":"71709410","Description":"Cath Vascular Bern","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":116.28,"Note":"**"},{"Itemcode":"71709411","Description":"Cath Closure Fast Vnus","CDM Revenue Code":"278","CDM HCPCS":"C1888","Standard Price":4478.82,"Note":"**"},{"Itemcode":"71709456","Description":"Cath Infsn, EKOS Thrombolytic","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":10133.7},{"Itemcode":"71709490","Description":"Cement/Bone Filler","CDM Revenue Code":"278","CDM HCPCS":"C1713","Standard Price":644.64},{"Itemcode":"71709491","Description":"Precise Carotid Stent","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":8739.36,"Note":"**"},{"Itemcode":"71709492","Description":"Pinnacle Long Sheath","CDM Revenue Code":"272","Standard Price":633.42},{"Itemcode":"71709493","Description":"Angioguard Filterwire","CDM Revenue Code":"272","CDM HCPCS":"C1884","Standard Price":8019.24},{"Itemcode":"71709494","Description":"Endurant Stent Graft System","CDM Revenue Code":"278","Standard Price":16326.12},{"Itemcode":"71709626","Description":"Kypho First Fracture Kit/Tray","CDM Revenue Code":"278","Standard Price":10958.88},{"Itemcode":"71709627","Description":"Kyphoplasty Tray","CDM Revenue Code":"278","Standard Price":12156.36},{"Itemcode":"71709628","Description":"VCF Treatment System, KIVA","CDM Revenue Code":"278","Standard Price":12159.42},{"Itemcode":"71709642","Description":"Lead, Neurostimulator Grp 5","CDM Revenue Code":"278","CDM HCPCS":"C1778","Standard Price":13525.2},{"Itemcode":"71709669","Description":"Needle Grp 2","CDM Revenue Code":"272","Standard Price":911.88},{"Itemcode":"71709785","Description":"Skin Adhesive Grp 1","CDM Revenue Code":"272","Standard Price":137.7},{"Itemcode":"7205","Description":"HBO IMAGE TO PACS","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"72100010","Description":"Stent Viabahn Gore 8x7.5 0.018","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":11051.19,"Note":"**"},{"Itemcode":"72100012","Description":"Atherect System Rotapro 1.25mm","CDM Revenue Code":"278","CDM HCPCS":"C1724","Standard Price":7657.65,"Note":"**"},{"Itemcode":"72100014","Description":"Patch Bovine 0.8 X 8 cm","CDM Revenue Code":"272","Standard Price":849.66},{"Itemcode":"72100015","Description":"BIOTRONIK STENT 2.5X15 434887","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4},{"Itemcode":"72100018","Description":"BIOTRONIK STENT 3.5X15 434889","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4},{"Itemcode":"72100021","Description":"Stent Complete Se","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6046.56},{"Itemcode":"72100022","Description":"BIOTRONIK STENT 4X15 434890","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4},{"Itemcode":"72100023","Description":"BIOTRONIK STENT 2.5X20 734893","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4},{"Itemcode":"72100026","Description":"BIOTRONIK STENT 3.5X20 434895","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4},{"Itemcode":"72100028","Description":"BIOTRONIK STENT 4X20 434896","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4,"Note":"**"},{"Itemcode":"72100032","Description":"BIOTRONIK STENT 3X26 434899","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4},{"Itemcode":"72100033","Description":"BIOTRONIK STENT 3.5X26 434900","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8537.4},{"Itemcode":"72100040","Description":"In/Pact Admiral Balloon 0.035","CDM Revenue Code":"278","CDM HCPCS":"C2623","Standard Price":8751.6,"Note":"**"},{"Itemcode":"72100045","Description":"Graft Vascular 10mmX30cm","CDM Revenue Code":"278","CDM HCPCS":"C1768","Standard Price":1955.0136,"Note":"**"},{"Itemcode":"72100063","Description":"CATH/SHEATH GUIDING 8FR","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":564.06},{"Itemcode":"72100205","Description":"Cryoplasty Inflation Unit","CDM Revenue Code":"272","Standard Price":4439.04},{"Itemcode":"72100206","Description":"Cryoplasty (N20) Cartridge","CDM Revenue Code":"272","Standard Price":360.06},{"Itemcode":"72100208","Description":"Cryoplasty Ballon .035","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":2967.18},{"Itemcode":"72100209","Description":"Cryoplasty Ballon .014","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":3952.5},{"Itemcode":"72100211","Description":"Cath C7 Dragonfly","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":4100.4},{"Itemcode":"72100212","Description":"Catheter Set Impella CP VAD","CDM Revenue Code":"278","Standard Price":85950.3,"Note":"**"},{"Itemcode":"72100213","Description":"Cath Balloon Zmed","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":2840.7,"Note":"**"},{"Itemcode":"72100214","Description":"Asahi Tornus Balloon Cath","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":3199.74},{"Itemcode":"72100215","Description":"Asahi Corsair Microcath Csw135","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":4052.46,"Note":"**"},{"Itemcode":"72100216","Description":"Asahi Corsair Microcath Csw150","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":4052.46},{"Itemcode":"72100217","Description":"ENSNARE EN2007030","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1743.18},{"Itemcode":"72100218","Description":"CATH-TRANSLUM-COATD-NONLASR","CDM Revenue Code":"278","CDM HCPCS":"C2623","Standard Price":7709.16,"Note":"**"},{"Itemcode":"72100219","Description":"PM Generator - Single-Assurity","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":13433.4},{"Itemcode":"72100220","Description":"Septal Occluder, Amplatzer","CDM Revenue Code":"278","CDM HCPCS":"C1817","Standard Price":21361.86,"Note":"**"},{"Itemcode":"72100221","Description":"Balloon,Sizing - Amplatzer","CDM Revenue Code":"272","Standard Price":1662.6,"Note":"**"},{"Itemcode":"72100222","Description":"Guidewire, Amplatzer","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":343.74,"Note":"**"},{"Itemcode":"72100223","Description":"Delivery Sys, TorqVue, Amplatz","CDM Revenue Code":"272","Standard Price":3135.48,"Note":"**"},{"Itemcode":"72100224","Description":"Catheter Impella 2.5 VAD","CDM Revenue Code":"278","Standard Price":67626.0,"Note":"**"},{"Itemcode":"72100225","Description":"PM Gen RR - Single-Zephyr 5620","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":8453.76},{"Itemcode":"72100226","Description":"Cath Balloon PTA MR","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":1698.3},{"Itemcode":"72100227","Description":"Evercross Balloon 6x60x135","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":602.82},{"Itemcode":"72100228","Description":"Visi-Pro Stent 7x37x80","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":3345.6},{"Itemcode":"72100229","Description":"Everflex Stent 7x80x120","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":3763.8},{"Itemcode":"72100238","Description":"Cath: Balloon Angio Level 3","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":1602.42},{"Itemcode":"72100239","Description":"Cath Balloon: COR CTO Stingray","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":6522.9},{"Itemcode":"72100270","Description":"Cath Balloon PTA MR Quantum","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":664.02,"Note":"**"},{"Itemcode":"72100290","Description":"Cath Guiding Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":641.58},{"Itemcode":"72100297","Description":"Catheter, IVUS Levl 1","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":3999.42},{"Itemcode":"72100299","Description":"CathAngio Translum Coated Grp1","CDM Revenue Code":"278","Standard Price":6355.62,"Note":"**"},{"Itemcode":"72100376","Description":"Stent,Peripheral OTW-SUPERA","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":5834.4},{"Itemcode":"72100400","Description":"Triever Asp Cath Guide 20Fr","CDM Revenue Code":"272","Standard Price":37944.0},{"Itemcode":"72100401","Description":"Triever Asp Cath Guide 24Fr","CDM Revenue Code":"272","Standard Price":37944.0},{"Itemcode":"72100402","Description":"Triever Asp Cath Guide 16Fr","CDM Revenue Code":"272","Standard Price":37944.0},{"Itemcode":"72101001","Description":"Lunderquist Wire Exchange","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":841.5,"Note":"**"},{"Itemcode":"72101008","Description":"Cath Balloon: Cutting / Cryo","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":3586.32,"Note":"**"},{"Itemcode":"72101010","Description":"Cath Cto","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":893.52},{"Itemcode":"72101011","Description":"Catheter Crossing Occlusion","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":3859.68},{"Itemcode":"72101025","Description":"Stent Cor Cvrd w/Del Sys Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":3121.2,"Note":"**"},{"Itemcode":"72101027","Description":"Stent Cor Cvrd w/Del Sys Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":6242.4},{"Itemcode":"72101028","Description":"Stent Trach Bronc Cvrd 8x59","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":8915.82},{"Itemcode":"72101029","Description":"Stent Cvrd w/Del Sys-Synergy","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":5118.36,"Note":"**"},{"Itemcode":"72101036","Description":"OCCLUDER PFO AMPLATZER","CDM Revenue Code":"278","Standard Price":33796.68,"Note":"**"},{"Itemcode":"72101110","Description":"Stent Cor NoncovWDlvry GRP A","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":2184.84,"Note":"**"},{"Itemcode":"72101128","Description":"EP Intro/Sheath-SafeSheath 7Fr","CDM Revenue Code":"272","CDM HCPCS":"C1892","Standard Price":238.68},{"Itemcode":"72101195","Description":"KIT ARTERIAL FEMORAL","CDM Revenue Code":"272","Standard Price":1195.44},{"Itemcode":"72101441","Description":"Patch: Topical","CDM Revenue Code":"272","Standard Price":193.8},{"Itemcode":"72101443","Description":"SNARE SYSTEM ENDOVASCULAR 7FR","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1910.46},{"Itemcode":"72101498","Description":"Sheath Introducer Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":684.42,"Note":"**"},{"Itemcode":"72101499","Description":"Guidewire Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":355.98,"Note":"**"},{"Itemcode":"72101500","Description":"Lead Ruler Tape","CDM Revenue Code":"272","Standard Price":225.42},{"Itemcode":"72101505","Description":"Sheath Introducer Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":759.9,"Note":"**"},{"Itemcode":"72101535","Description":"Cath Atherectomy Dir-HawkOne","CDM Revenue Code":"278","CDM HCPCS":"C1714","Standard Price":10482.54,"Note":"**"},{"Itemcode":"72101707","Description":"DEVICE,INFLATION-ENCORE 26","CDM Revenue Code":"272","Standard Price":463.08},{"Itemcode":"72102026","Description":"Cath Balloon: Valvuloplasty","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":3306.84},{"Itemcode":"72102305","Description":"Guidewire FFR, COMET","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2666.28},{"Itemcode":"72102369","Description":"Cath/Sheath Guid Pinnacle","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":564.06},{"Itemcode":"72102732","Description":"Central Venous Cath Group 1B","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":702.78,"Note":"**"},{"Itemcode":"72102788","Description":"Stent Biliary - Express","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4052.46},{"Itemcode":"72102930","Description":"Aigis Antibx Pm/Icd Envelope","CDM Revenue Code":"278","Standard Price":3092.64},{"Itemcode":"72104684","Description":"Cath: Silverhawk Atherectomy","CDM Revenue Code":"278","CDM HCPCS":"C1724","Standard Price":8858.7,"Note":"**"},{"Itemcode":"72105243","Description":"Cath Intra Cardiac US 8FR","CDM Revenue Code":"278","CDM HCPCS":"C1759","Standard Price":10267.32,"Note":"**"},{"Itemcode":"72105356","Description":"Pack: Cath Lab Diagnostic","CDM Revenue Code":"272","Standard Price":477.36},{"Itemcode":"72105493","Description":"Guidewire, Low Cost","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":49.98},{"Itemcode":"72105604","Description":"Closure Device","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1056.72,"Note":"**"},{"Itemcode":"72105611","Description":"Quickcross Catheter","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":886.38,"Note":"**"},{"Itemcode":"72105612","Description":"Cath Laser Turbo","CDM Revenue Code":"272","CDM HCPCS":"C1885","Standard Price":2283.78},{"Itemcode":"72105613","Description":"Cath Guide TaperTip 5FR GR2","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2965.14,"Note":"**"},{"Itemcode":"72105614","Description":"Cath Guide TaperTip 5FR GR1","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":2424.54,"Note":"**"},{"Itemcode":"72106424","Description":"Perfusion: Beating Hearts Lv 1","CDM Revenue Code":"272","Standard Price":6740.16,"Note":"**"},{"Itemcode":"72106666","Description":"Lead MRI Ingevity 59cm","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2122.62},{"Itemcode":"72106807","Description":"Stent Cor Cvrd W/Del Sys Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10191.84},{"Itemcode":"72107051","Description":"Cath: Angiojet Coronary Xmi","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":7379.7},{"Itemcode":"72107052","Description":"CATH THROMBECTOMY- 12X106CM","CDM Revenue Code":"278","CDM HCPCS":"C1757","Standard Price":10127.58,"Note":"**"},{"Itemcode":"72107058","Description":"Cath: Balloon GRP 1","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":572.22,"Note":"**"},{"Itemcode":"72107059","Description":"Cath: Balloon GRP 2","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":696.66,"Note":"**"},{"Itemcode":"72107060","Description":"Cath: Balloon GRP 3","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":850.68,"Note":"**"},{"Itemcode":"72107061","Description":"Cath: Angiojet Peripheral Xmi","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":4425.78},{"Itemcode":"72107062","Description":"Cath Jet Stream","CDM Revenue Code":"272","CDM HCPCS":"C1714","Standard Price":12152.28},{"Itemcode":"72107063","Description":"Cath Diagnostic Grp 2","CDM Revenue Code":"272","Standard Price":179.52,"Note":"**"},{"Itemcode":"72107064","Description":"Cath Atherectomy Diamond Orbtl","CDM Revenue Code":"278","CDM HCPCS":"C1724","Standard Price":12832.62,"Note":"**"},{"Itemcode":"72107065","Description":"Guidewire Viper (For Diamond)","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1007.76,"Note":"**"},{"Itemcode":"72107066","Description":"Cath: Balloon Angio Level 4","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":4692.0},{"Itemcode":"72107067","Description":"CATH:Tranluminal Atherectomy","CDM Revenue Code":"278","CDM HCPCS":"C1724","Standard Price":16110.9},{"Itemcode":"72107068","Description":"Cath Diagnostic Grp 3","CDM Revenue Code":"272","Standard Price":208.08,"Note":"**"},{"Itemcode":"72107075","Description":"Cath: Balloon Valvuloplasty","CDM Revenue Code":"272","Standard Price":2951.88},{"Itemcode":"72107077","Description":"CATH VISION IVUS 0.18PV","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":3626.1},{"Itemcode":"72107081","Description":"Cath: Balloon GRP 4","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":1040.4,"Note":"**"},{"Itemcode":"72107082","Description":"Cath: Balloon GRP 5","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":1275.0,"Note":"**"},{"Itemcode":"72107083","Description":"Cath: Balloon GRP 6","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":1560.6},{"Itemcode":"72107084","Description":"Cath: Balloon GRP 7","CDM Revenue Code":"278","CDM HCPCS":"C1725","Standard Price":2101.2},{"Itemcode":"72107100","Description":"Cath: Diagnostic Grp 1","CDM Revenue Code":"272","Standard Price":66.3,"Note":"**"},{"Itemcode":"72107106","Description":"Cath Guide Vascular","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2093.04,"Note":"**"},{"Itemcode":"72107107","Description":"Cath: Frontrunner (Cto)","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":4632.84},{"Itemcode":"72107108","Description":"Cath Guide Front Runner","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":1422.9},{"Itemcode":"72107110","Description":"Cath: Guide","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":250.92,"Note":"**"},{"Itemcode":"72107115","Description":"Cath: Iabp -Cl","CDM Revenue Code":"272","Standard Price":3544.5,"Note":"**"},{"Itemcode":"72107135","Description":"Cath: Infusion","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":1974.72},{"Itemcode":"72107161","Description":"GUIDE CATH CENTER CROSS ULTRA","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":4245.24},{"Itemcode":"72107162","Description":"GUIDE CATH MICRO","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2096.1},{"Itemcode":"72107163","Description":"GUIDE CATH CENTER/MULTI CROSS","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":3817.86},{"Itemcode":"72107180","Description":"Cath: Laser","CDM Revenue Code":"272","CDM HCPCS":"C1885","Standard Price":10390.74},{"Itemcode":"72107187","Description":"Cath: Right Heart","CDM Revenue Code":"272","Standard Price":382.5},{"Itemcode":"72107188","Description":"Cath: Pioneer","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":10544.76},{"Itemcode":"72107190","Description":"Cath: Roto Burr","CDM Revenue Code":"278","CDM HCPCS":"C1724","Standard Price":5433.54,"Note":"**"},{"Itemcode":"72107191","Description":"Cath Guide Coronary Finecross","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":2237.88},{"Itemcode":"72107203","Description":"Jomed: Trak Back","CDM Revenue Code":"272","Standard Price":518.16},{"Itemcode":"72107204","Description":"Cath: Temp Pacing","CDM Revenue Code":"272","Standard Price":722.16,"Note":"**"},{"Itemcode":"72107205","Description":"Cath: Swan Ganz Indwelling","CDM Revenue Code":"272","Standard Price":642.6,"Note":"**"},{"Itemcode":"72107213","Description":"Wire Spidrx","CDM Revenue Code":"272","Standard Price":4338.06},{"Itemcode":"72107221","Description":"Inflator Band Xxrf06","CDM Revenue Code":"272","Standard Price":1134.24},{"Itemcode":"72107222","Description":"Glidesheath Rmafd10Hau","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":243.78},{"Itemcode":"72107224","Description":"R-Band Vascular Closure Dev","CDM Revenue Code":"272","Standard Price":114.24,"Note":"**"},{"Itemcode":"72107227","Description":"Pad, Neptune","CDM Revenue Code":"272","Standard Price":186.66},{"Itemcode":"72107228","Description":"Lead Tendril","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":5820.12},{"Itemcode":"72107229","Description":"Lead Fineline Ii","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2225.64},{"Itemcode":"72107250","Description":"Cath: Ultrasound","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":2794.8},{"Itemcode":"72107251","Description":"CATH IVUS - PLATINUM","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":3626.1,"Note":"**"},{"Itemcode":"72107275","Description":"Circuit: Blood Cps","CDM Revenue Code":"272","Standard Price":6019.02},{"Itemcode":"72107294","Description":"Femostop: Compression","CDM Revenue Code":"272","Standard Price":591.6,"Note":"**"},{"Itemcode":"72107300","Description":"Guidewire Grp 1","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":95.88,"Note":"**"},{"Itemcode":"72107312","Description":"Filterwire Ex","CDM Revenue Code":"272","CDM HCPCS":"C1884","Standard Price":5349.9,"Note":"**"},{"Itemcode":"72107313","Description":"Filter Wire Bareware","CDM Revenue Code":"272","Standard Price":6378.06},{"Itemcode":"72107350","Description":"Guidewire Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":607.92,"Note":"**"},{"Itemcode":"72107351","Description":"Guidewire Grp 4","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":743.58,"Note":"**"},{"Itemcode":"72107370","Description":"Guidewire: Wave Wire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":2954.94,"Note":"**"},{"Itemcode":"72107420","Description":"Inflation Device Kit","CDM Revenue Code":"272","Standard Price":237.66,"Note":"**"},{"Itemcode":"72107432","Description":"Introducer: Balkin","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":268.26},{"Itemcode":"72107441","Description":"Kit Introducer VAD: Impella","CDM Revenue Code":"272","Standard Price":2985.54},{"Itemcode":"72107442","Description":"Sheath Introducer Grp 2A","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":440.64},{"Itemcode":"72107443","Description":"Sheath Introducer Grp 2B","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":540.6,"Note":"**"},{"Itemcode":"72107500","Description":"Kit: Cannula Cps","CDM Revenue Code":"272","Standard Price":1390.26},{"Itemcode":"72107526","Description":"Kit: Essentials Cl","CDM Revenue Code":"272","Standard Price":353.94},{"Itemcode":"72107528","Description":"Microsnare","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2581.62},{"Itemcode":"72107540","Description":"Needle: Smart","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"72107550","Description":"Kit: Cath Lab Custom","CDM Revenue Code":"272","Standard Price":456.96,"Note":"**"},{"Itemcode":"72107596","Description":"Guidewire Grp 3A","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":973.08,"Note":"**"},{"Itemcode":"72107599","Description":"Guidewire Grp 2A","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":463.08,"Note":"**"},{"Itemcode":"72107609","Description":"Percusurge","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":7193.04},{"Itemcode":"72107620","Description":"Set: Angiojet Pump","CDM Revenue Code":"272","Standard Price":1367.82},{"Itemcode":"72107630","Description":"Sheath Introducer Group 1","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":66.3,"Note":"**"},{"Itemcode":"72107635","Description":"Sheath Introducer Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":364.14,"Note":"**"},{"Itemcode":"72107701","Description":"Stent Cor Noncov W/Dlvry GRP B","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":2662.2,"Note":"**"},{"Itemcode":"72107706","Description":"Stent Non Cov W/Deliv Sys Grp1","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":3112.02,"Note":"**"},{"Itemcode":"72107715","Description":"Stent Non-Cov W/Deliv Sys Grp3","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":5078.58,"Note":"**"},{"Itemcode":"72107716","Description":"Stent Veritas Noncov W/Deliv","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6804.42},{"Itemcode":"72107717","Description":"Stent-Non-Coat-w/DelSys-Innova","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":8236.5},{"Itemcode":"72107718","Description":"Stent Non-Cov W/Deliv Sys Grp4","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":6205.68},{"Itemcode":"72107725","Description":"Stent: Drug Eluding Cypher","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":7145.1},{"Itemcode":"72107726","Description":"Stent:Drug Eluting Promus GR2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":5503.92},{"Itemcode":"72107727","Description":"Stent: Drug Eluting Endeavor","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":7948.86},{"Itemcode":"72107728","Description":"Stent-Drug Elutin Resolute GR1","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":6179.16,"Note":"**"},{"Itemcode":"72107729","Description":"Stent Drug Eluting Xience Prm","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":6804.42},{"Itemcode":"72107730","Description":"Stent-Drug Elutin Resolute GR2","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":5652.84},{"Itemcode":"72107770","Description":"Torque Device Td-2","CDM Revenue Code":"272","Standard Price":130.56},{"Itemcode":"72107790","Description":"Tray: Percardiocentesis","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":970.02},{"Itemcode":"72107850","Description":"Cath: Swan Ganz","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":294.78,"Note":"**"},{"Itemcode":"72107959","Description":"Vasc Guide Wire-Stingray","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1791.12},{"Itemcode":"72107979","Description":"GuideWire Cath Extn-Guidezilla","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1857.42,"Note":"**"},{"Itemcode":"72108004","Description":"Stent Non-Cov w/Del Sys Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1876","Standard Price":4134.06,"Note":"**"},{"Itemcode":"72108005","Description":"Stent:Drug Eluting Taxus","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":5758.92},{"Itemcode":"72108010","Description":"Catheter: Export Aspiration","CDM Revenue Code":"272","CDM HCPCS":"C1757","Standard Price":1565.7,"Note":"**"},{"Itemcode":"72108125","Description":"Cannula Artery 17FR","CDM Revenue Code":"272","Standard Price":1723.2594},{"Itemcode":"72108126","Description":"Cannula Fem Ven 23/25","CDM Revenue Code":"272","Standard Price":1625.2986},{"Itemcode":"72108462","Description":"Cath 3Lu 7F 16C Ask-42703-Pcsj","CDM Revenue Code":"272","Standard Price":750.72},{"Itemcode":"72108476","Description":"Wire Spider SM Spd2Us-050","CDM Revenue Code":"272","CDM HCPCS":"C1884","Standard Price":6824.82,"Note":"**"},{"Itemcode":"72108606","Description":"Perclose Proglide 12673","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1373.94,"Note":"**"},{"Itemcode":"72108629","Description":"TAVR VALVE","CDM Revenue Code":"278","Standard Price":107737.5,"Note":"**"},{"Itemcode":"72108633","Description":"Heart-Lung Dispo Kit - ECMO","CDM Revenue Code":"272","Standard Price":44379.18},{"Itemcode":"72108888","Description":"Non-Charge Surg Supply","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"72108889","Description":"Stent - Evaluation","CDM Revenue Code":"278","Standard Price":0.0},{"Itemcode":"72109126","Description":"CATH VISION IVUS 88901","CDM Revenue Code":"272","CDM HCPCS":"C1753","Standard Price":4905.18},{"Itemcode":"72109364","Description":"Cath Angiographic","CDM Revenue Code":"272","Standard Price":763.98},{"Itemcode":"72109410","Description":"Guide Cath Vascular Bern","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":116.28,"Note":"**"},{"Itemcode":"72151441","Description":"Patch: Topical","CDM Revenue Code":"272","Standard Price":437.58},{"Itemcode":"72157294","Description":"Femstop: Compression","CDM Revenue Code":"272","Standard Price":409.02},{"Itemcode":"7219","Description":"Foam Drssing <=16sqin w/oBordr","CDM Revenue Code":"623","CDM HCPCS":"A6209","Standard Price":48.96},{"Itemcode":"72200019","Description":"Pacemaker, Micra","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":32094.3,"Note":"**"},{"Itemcode":"72200020","Description":"Sheath, Micra","CDM Revenue Code":"278","CDM HCPCS":"C1894","Standard Price":2386.8,"Note":"**"},{"Itemcode":"72200021","Description":"Catheter, 3 Fr Diagn","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":2417.4},{"Itemcode":"72200060","Description":"Impl Watchman LAA closure","CDM Revenue Code":"278","Standard Price":40237.98,"Note":"**"},{"Itemcode":"72200061","Description":"Watchman LAA Access Syst Curve","CDM Revenue Code":"272","Standard Price":4265.64,"Note":"**"},{"Itemcode":"72200144","Description":"Cath Irrigation","CDM Revenue Code":"272","Standard Price":483.48,"Note":"**"},{"Itemcode":"72200145","Description":"Device Pouch - ECM - Cangaroo","CDM Revenue Code":"278","Standard Price":4245.24,"Note":"**"},{"Itemcode":"72200224","Description":"LINQ SYS-REVEAL CARD MON","CDM Revenue Code":"278","CDM HCPCS":"C1764","Standard Price":17904.06,"Note":"**"},{"Itemcode":"72200264","Description":"Mynx Vasc Closure Device","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1125.06,"Note":"**"},{"Itemcode":"72200270","Description":"Cath Balloon PTA MR Quantum","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":664.02},{"Itemcode":"72201037","Description":"OCCLUDER PFO AMPLATZER 25MM","CDM Revenue Code":"278","Standard Price":1406.58,"Note":"**"},{"Itemcode":"72201128","Description":"EP Intro/Sheath-SafeSheath 7Fr","CDM Revenue Code":"272","CDM HCPCS":"C1892","Standard Price":238.68,"Note":"**"},{"Itemcode":"72201234","Description":"Glidewire GT 01.018","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":894.744},{"Itemcode":"72201312","Description":"Micro Cath Progreate 2.8fr","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2258.28},{"Itemcode":"72201353","Description":"Cath Guiding Low Cost Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":72.42},{"Itemcode":"72201499","Description":"Glidewire, Angled","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":282.54},{"Itemcode":"72201600","Description":"Gen Pm Dual Explant Partial Cr","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":0.0},{"Itemcode":"72201601","Description":"Gen Pm Dual Explant Full Credt","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":1.02},{"Itemcode":"72201602","Description":"Cath Ep Deflect 6FR Quad 2-5-2","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":1513.68,"Note":"**"},{"Itemcode":"72201700","Description":"Oxygen Therapy-D","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"72202227","Description":"Pad, Neptune","CDM Revenue Code":"272","Standard Price":186.66},{"Itemcode":"72202228","Description":"Lead Cs Replacement/No Cost","CDM Revenue Code":"275","CDM HCPCS":"C1900","Standard Price":1.02},{"Itemcode":"72202229","Description":"Pacemaker Other - Allure RF","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":21978.96,"Note":"**"},{"Itemcode":"72202230","Description":"Lead, LV Quick Flex Micro","CDM Revenue Code":"275","CDM HCPCS":"C1900","Standard Price":7907.04},{"Itemcode":"72202975","Description":"Tilt Table-D","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"72203102","Description":"GEN: AICD DUAL GRP A","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":42136.2},{"Itemcode":"72203168","Description":"Cath: Diagnostic Grp 1","CDM Revenue Code":"272","Standard Price":66.3,"Note":"**"},{"Itemcode":"72203711","Description":"SHEATH DILATION - TIGHTRAIL","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":7230.78},{"Itemcode":"72203712","Description":"CATHGUIDE STRT QUIKCROS 150CM","CDM Revenue Code":"278","Standard Price":886.38},{"Itemcode":"72204054","Description":"PM OTHR, RF ALLURE QUADRA","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":27414.54},{"Itemcode":"72204100","Description":"Pack: Basic Pacer Set Up","CDM Revenue Code":"272","Standard Price":237.66},{"Itemcode":"72204365","Description":"Vasc Closure Device Angioseal","CDM Revenue Code":"278","CDM HCPCS":"C1760","Standard Price":1113.84,"Note":"**"},{"Itemcode":"72204396","Description":"Cath EP <19Elect; 7FR Bipolar","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":3617.94},{"Itemcode":"72204401","Description":"Crtd Concerto Ii D274Trk Biv","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":82622.04},{"Itemcode":"72204402","Description":"ICD Virtuoso Ii D274Drg","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":57801.36},{"Itemcode":"72204403","Description":"ICD Gen Secura Dr D224Drg","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":61708.98},{"Itemcode":"72204404","Description":"Pacemaker Gen Accent Pm1110","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":13530.3,"Note":"**"},{"Itemcode":"72204405","Description":"Gen Icd Sgl Secura Vr D224Vrc","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":55791.96},{"Itemcode":"72204406","Description":"ICD Gen Teligen He Dr E110","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":56221.38},{"Itemcode":"72204407","Description":"Gen Pacemaker Accent Pm2110","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":18044.82},{"Itemcode":"72204408","Description":"Gen Icd Incepta Dr He Df4 E162","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":61732.44},{"Itemcode":"72204409","Description":"Gen Incepta Dr He E163","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":57543.3},{"Itemcode":"72204411","Description":"Energen Dr He Df4 E142","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":45709.26},{"Itemcode":"72204412","Description":"Energen Dr He E143","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":44811.66},{"Itemcode":"72204413","Description":"Gen Incepta Vr He Df4 E160","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":46538.52},{"Itemcode":"72204414","Description":"Gen Incepta Vr He E161","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":56105.1},{"Itemcode":"72204415","Description":"Energen Vr He Df4 E140","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":44102.76},{"Itemcode":"72204416","Description":"Energen Vr He E141","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":43239.84},{"Itemcode":"72204417","Description":"Teligen Rf He Vr E102","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":51959.82},{"Itemcode":"72204418","Description":"Lead Reliance Gore ICD GRP 2","CDM Revenue Code":"275","CDM HCPCS":"C1777","Standard Price":15216.36},{"Itemcode":"72204419","Description":"Gen Crtd Incepta Rdhe Df4 N160","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":69848.58},{"Itemcode":"72204420","Description":"Gen Incepta Rf He N161/N164","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":68397.12},{"Itemcode":"72204421","Description":"Gen Energen Rf He Df4 N140","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":68397.12},{"Itemcode":"72204422","Description":"Gen Energen Rf He N141","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":66825.3},{"Itemcode":"72204423","Description":"Gen Cognis Rf He N118 / N119","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":75773.76},{"Itemcode":"72204424","Description":"Gen Unify Quadra Crt Cd3249","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":74388.6},{"Itemcode":"72204425","Description":"Cath Ep Thermocool Sf Nav","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":10621.26,"Note":"**"},{"Itemcode":"72204426","Description":"Gen Icd Fortify Dr Cd2231-40Q","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":57397.44},{"Itemcode":"72204427","Description":"Gen Pacer Accent Pm2210","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":18360.0},{"Itemcode":"72204428","Description":"Gen Crt-D Protecta Xt D314Trg","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":88188.18},{"Itemcode":"72204429","Description":"Gen Crt-D Protecta D314Drg","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":58402.14},{"Itemcode":"72204430","Description":"Invive Crt-P Is1 Gen V173","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":28741.56},{"Itemcode":"72204431","Description":"Cath Eps Ez Steer Thermo","CDM Revenue Code":"278","CDM HCPCS":"C1733","Standard Price":5835.42,"Note":"**"},{"Itemcode":"72204432","Description":"ICD Protecta Vr D334Vrm","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":50212.56},{"Itemcode":"72204433","Description":"Ingenio Dr K173 Pacemaker","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":15093.96},{"Itemcode":"72204434","Description":"Ingenio Sr K172 Pacemaker","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":13207.98},{"Itemcode":"72204435","Description":"Advantio Sr Pacemaker K062","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":12578.64},{"Itemcode":"72204436","Description":"Advantio Dr Pacemaker K063","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14150.46},{"Itemcode":"72204437","Description":"Lead Quartet Cs","CDM Revenue Code":"275","CDM HCPCS":"C1900","Standard Price":12459.3},{"Itemcode":"72204438","Description":"Cath Dual Access Twin Pass","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":1587.12},{"Itemcode":"72204439","Description":"Cath Balloon","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":1051.62,"Note":"**"},{"Itemcode":"72204440","Description":"Glidecath","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":342.72},{"Itemcode":"72204441","Description":"Arctic Front Ablation Cath","CDM Revenue Code":"278","CDM HCPCS":"C1733","Standard Price":14632.92,"Note":"**"},{"Itemcode":"72204442","Description":"Elipse Vr Cd1311-36Q Defib","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":52281.12},{"Itemcode":"72204443","Description":"ICD Defib Evera Dr Dc Ddbb1D1","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":50963.28},{"Itemcode":"72204444","Description":"Achieve EP Catheter 1-19Elec","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":3412.92,"Note":"**"},{"Itemcode":"72204445","Description":"Arctic Front Retraction Kit","CDM Revenue Code":"272","Standard Price":795.6},{"Itemcode":"72204446","Description":"CATH OCCLUSION","CDM Revenue Code":"278","CDM HCPCS":"C2628","Standard Price":322.32,"Note":"**"},{"Itemcode":"72204447","Description":"ESOPHASTAR MAPPING CATH","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":2642.82},{"Itemcode":"72204448","Description":"VIVA CRT-D GEN DTBA1D1/DTBA1D4","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":65637.0},{"Itemcode":"72204449","Description":"TEMPORARY PACING ELECTRODE","CDM Revenue Code":"272","Standard Price":876.18,"Note":"**"},{"Itemcode":"72204451","Description":"ICD GEN SQ-RX 1010","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":65935.86},{"Itemcode":"72204452","Description":"LEAD Q-TRAK 3010","CDM Revenue Code":"275","CDM HCPCS":"C1896","Standard Price":13525.2},{"Itemcode":"72204453","Description":"CRT-D ELLIPSE DR CD2311-36/Q","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":56468.22},{"Itemcode":"72204454","Description":"CRT-D FORTIFY VR CD1231-40/Q","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":52477.98},{"Itemcode":"72204455","Description":"CRT-D FORTIFY ASSURA CD1257-40","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":49669.92},{"Itemcode":"72204456","Description":"CRT-D ELLIPSE DR CD2411-40/Q","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":44801.46,"Note":"**"},{"Itemcode":"72204457","Description":"ICD GEN EVERA XT VR DVBB1D1","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":53046.12},{"Itemcode":"72204458","Description":"LEAD EXTENDER BULLDOG","CDM Revenue Code":"278","Standard Price":1228.08},{"Itemcode":"72204459","Description":"CATH FREEZOR CRYOABLATION","CDM Revenue Code":"278","Standard Price":4733.82},{"Itemcode":"72204460","Description":"SHEATH CPS DIRECT SL","CDM Revenue Code":"272","CDM HCPCS":"C1893","Standard Price":3264.0,"Note":"**"},{"Itemcode":"72204461","Description":"ELLIPSE VR36 ICD GENER Single","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":40153.32,"Note":"**"},{"Itemcode":"72204462","Description":"Lead Reliance Gore ICD GR 1","CDM Revenue Code":"275","CDM HCPCS":"C1777","Standard Price":12680.64},{"Itemcode":"72204463","Description":"CRT-D AMPLIA MRI Sure Scan","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":73709.28,"Note":"**"},{"Itemcode":"72204464","Description":"Cath EP Non 3-D Map 7FR","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":4249.32},{"Itemcode":"72204465","Description":"Lead ICD Singl Coil-PLEXA DF-1","CDM Revenue Code":"275","CDM HCPCS":"C1777","Standard Price":11022.12,"Note":"**"},{"Itemcode":"72204476","Description":"Lead AICDEndoDualCoil-Optisure","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":11835.06,"Note":"**"},{"Itemcode":"72204477","Description":"AICD DR MRI XT - EVERA","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":57820.74,"Note":"**"},{"Itemcode":"72204478","Description":"Lead Reliance Gore DF4 ICD","CDM Revenue Code":"275","CDM HCPCS":"C1777","Standard Price":12680.64,"Note":"**"},{"Itemcode":"72204481","Description":"Sheath Introducr NonLsr 12x30","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":452.88},{"Itemcode":"72204800","Description":"Pack: Pacermaker","CDM Revenue Code":"272","Standard Price":304.98,"Note":"**"},{"Itemcode":"72204881","Description":"Generator:ICD Dual Cham Grp A","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":44425.08,"Note":"**"},{"Itemcode":"72204882","Description":"Gen: ICD Single Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":39535.2,"Note":"**"},{"Itemcode":"72204883","Description":"Gen: ICD Single Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":45309.42},{"Itemcode":"72204884","Description":"Guidewire Vascular Imaging","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":876.18,"Note":"**"},{"Itemcode":"72205214","Description":"Gen Icd Energen","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":49696.44},{"Itemcode":"72205215","Description":"Cath Ep Dx 1-19 Elec Ascent","CDM Revenue Code":"272","CDM HCPCS":"C1730","Standard Price":361.08},{"Itemcode":"72205216","Description":"Gen Biv Pacer Syncra C2Tr01","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":28741.56},{"Itemcode":"72205217","Description":"EP Cath Lasso Nav 3D Mapping","CDM Revenue Code":"272","CDM HCPCS":"C1732","Standard Price":6316.86,"Note":"**"},{"Itemcode":"72205218","Description":"Lead Pacing Revo Mri","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":3173.22},{"Itemcode":"72205219","Description":"Pacemaker Gen Revo Dvdr01","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":18259.02,"Note":"**"},{"Itemcode":"72205220","Description":"Pacemaker Zephyr Xl Sr 5626","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":15606.0},{"Itemcode":"72205222","Description":"Sleeve, Lead Anchoring","CDM Revenue Code":"272","Standard Price":225.42},{"Itemcode":"72205223","Description":"Stylet","CDM Revenue Code":"272","Standard Price":322.32,"Note":"**"},{"Itemcode":"72205224","Description":"EP Guidewire Grp 1","CDM Revenue Code":"272","Standard Price":257.04},{"Itemcode":"72205225","Description":"EP Guidewire Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":742.56,"Note":"**"},{"Itemcode":"72205226","Description":"Tunneling Tool Disp","CDM Revenue Code":"272","Standard Price":4265.64},{"Itemcode":"72205228","Description":"Pacemaker Gen Dual Rr Grp 3","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":23992.44},{"Itemcode":"72205229","Description":"Crt-D Consulta Biv D224Trk","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":70753.32},{"Itemcode":"72205230","Description":"Crt Consulta Biv D224Trk Sys-D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"72205232","Description":"Lead Sprint Quattro Secure","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":18634.38},{"Itemcode":"72205234","Description":"Gen Crtd Ventak Prizm He1857","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":44202.72},{"Itemcode":"72205235","Description":"Retrieval Set","CDM Revenue Code":"278","CDM HCPCS":"C1773","Standard Price":4952.1},{"Itemcode":"72205236","Description":"Wire Tip Handle G20010","CDM Revenue Code":"272","Standard Price":1562.64},{"Itemcode":"72205237","Description":"Cath Ep Pentaray Nav 3D Map","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":7064.52,"Note":"**"},{"Itemcode":"72205238","Description":"Cath Ep 3D Mapping Decanav","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":4073.88,"Note":"**"},{"Itemcode":"72205239","Description":"Lead Attain Ability Strait Cs","CDM Revenue Code":"275","CDM HCPCS":"C1900","Standard Price":10237.74},{"Itemcode":"72205241","Description":"RETRIEVER ENDO HRD WIR","CDM Revenue Code":"272","Standard Price":2233.8},{"Itemcode":"72205242","Description":"EP Cath, Card US 10Fr SDSTR","CDM Revenue Code":"278","CDM HCPCS":"C1759","Standard Price":4909.26,"Note":"**"},{"Itemcode":"72205243","Description":"Cath Intra Cardiac US 8FR","CDM Revenue Code":"278","CDM HCPCS":"C1759","Standard Price":10267.32},{"Itemcode":"72205250","Description":"Pacemaker Microny Ii Sr 2525T","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":11835.06},{"Itemcode":"72205251","Description":"ICD Gen Dual Cd2211-36","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":61202.04},{"Itemcode":"72205376","Description":"Cath Ep Dx/Abl 3D Map Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":9363.6},{"Itemcode":"72205377","Description":"Cath Ep Dx/Abl 3D Map Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":10404.0},{"Itemcode":"72205405","Description":"Gen Current Plus Vr Cd1211-36","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":56952.72},{"Itemcode":"72205406","Description":"Lead Crtd/Icd Durata 7120Q","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":13379.34,"Note":"**"},{"Itemcode":"72205407","Description":"Gen Promote Plus Cd3211-36","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":71683.56},{"Itemcode":"72205481","Description":"Gen Crt-D Dual Fortify Cd2231","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":63156.36},{"Itemcode":"72205482","Description":"Gen Crt-D Unify Cd3231-40","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":62424.0,"Note":"**"},{"Itemcode":"72205483","Description":"Intro/Sheath Fixed Pl-Awy Grp1","CDM Revenue Code":"272","CDM HCPCS":"C1892","Standard Price":482.46,"Note":"**"},{"Itemcode":"72205484","Description":"Intro/Sheath Fixed Pl-Awy Grp2","CDM Revenue Code":"272","CDM HCPCS":"C1892","Standard Price":1449.42},{"Itemcode":"72205485","Description":"Intro/Shth FixdNon-Peelawy GR1","CDM Revenue Code":"272","CDM HCPCS":"C1893","Standard Price":792.54,"Note":"**"},{"Itemcode":"72205486","Description":"Intro/Sheath Laser","CDM Revenue Code":"272","CDM HCPCS":"C2629","Standard Price":10752.84,"Note":"**"},{"Itemcode":"72205487","Description":"Intro/Sheath Non-Laser","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":148.92,"Note":"**"},{"Itemcode":"72205488","Description":"Intro/Sheath Ep Guiding","CDM Revenue Code":"278","CDM HCPCS":"C1766","Standard Price":4261.56,"Note":"**"},{"Itemcode":"72205489","Description":"Lead Clipper, Disp","CDM Revenue Code":"272","Standard Price":489.6,"Note":"**"},{"Itemcode":"72205490","Description":"Lead Plug, Disp","CDM Revenue Code":"272","Standard Price":613.02,"Note":"**"},{"Itemcode":"72205492","Description":"Guidewire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":643.62,"Note":"**"},{"Itemcode":"72205493","Description":"Guidewire, Low Cost","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":49.98,"Note":"**"},{"Itemcode":"72205494","Description":"Sheath/Introducer Low Cost","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":80.58,"Note":"**"},{"Itemcode":"72205495","Description":"SET,INTRODUCER NONLSR PLVN","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":686.46},{"Itemcode":"72205496","Description":"SHEATH,INTRDCR NONLSR 16FR30CM","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":624.24,"Note":"**"},{"Itemcode":"72205497","Description":"Intro/Shth Fixd NonPeelawy GR3","CDM Revenue Code":"272","CDM HCPCS":"C1893","Standard Price":1125.06,"Note":"**"},{"Itemcode":"72205498","Description":"Kit Intro/Sheath Crvd Femoral","CDM Revenue Code":"272","CDM HCPCS":"C1893","Standard Price":2180.76,"Note":"**"},{"Itemcode":"72205501","Description":"Intro/Shth FixdNon-Peelawy GR2","CDM Revenue Code":"272","CDM HCPCS":"C1893","Standard Price":967.98,"Note":"**"},{"Itemcode":"72205548","Description":"Lead Cs Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1900","Standard Price":9598.2,"Note":"**"},{"Itemcode":"72205549","Description":"Lead Cs Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1900","Standard Price":9929.7,"Note":"**"},{"Itemcode":"72205550","Description":"ICD Gen, Single Chamber Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":62798.34},{"Itemcode":"72205551","Description":"ICD Gen, Single Chamber Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":68947.92},{"Itemcode":"72205552","Description":"Gen, Icd Dual Chamber Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":59518.02},{"Itemcode":"72205553","Description":"Gen, Icd Dual Chamber Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1721","Standard Price":78210.54},{"Itemcode":"72205554","Description":"Generator, Icd Bi-V Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":65961.36,"Note":"**"},{"Itemcode":"72205555","Description":"Generator, Icd Bi-V Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":85996.2},{"Itemcode":"72205556","Description":"Generator, Icd Bi-V Grp 3","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":95779.02},{"Itemcode":"72205557","Description":"Lead Ppm Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2646.9,"Note":"**"},{"Itemcode":"72205558","Description":"Lead Ppm Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2530.62,"Note":"**"},{"Itemcode":"72205559","Description":"Cable Ep Grp 1","CDM Revenue Code":"272","Standard Price":796.62},{"Itemcode":"72205560","Description":"Cath Ep Dx 1-19 Elec Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":1210.74,"Note":"**"},{"Itemcode":"72205561","Description":"Cath Ep Dx 20++Elec Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1731","Standard Price":4078.98},{"Itemcode":"72205562","Description":"Cath Ep Dx/Abl 3D Map Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":9019.86,"Note":"**"},{"Itemcode":"72205563","Description":"Cath Ep Dx/Abl Other Grp1","CDM Revenue Code":"278","CDM HCPCS":"C1733","Standard Price":1249.5},{"Itemcode":"72205564","Description":"CATH EP DX/ABL OTHER GRP 2","CDM Revenue Code":"278","CDM HCPCS":"C1733","Standard Price":2985.54,"Note":"**"},{"Itemcode":"72205565","Description":"Cath Guiding Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":1035.3},{"Itemcode":"72205566","Description":"Cath Guiding Grp 2","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2320.5,"Note":"**"},{"Itemcode":"72205567","Description":"Cath Guiding Grp 3","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":2985.54,"Note":"**"},{"Itemcode":"72205568","Description":"Cath Intracardiac Echo Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1759","Standard Price":6348.48},{"Itemcode":"72205569","Description":"Lead End Cap","CDM Revenue Code":"272","Standard Price":219.3,"Note":"**"},{"Itemcode":"72205570","Description":"Patch External Reference","CDM Revenue Code":"272","Standard Price":1852.32,"Note":"**"},{"Itemcode":"72205571","Description":"Transseptal Needle","CDM Revenue Code":"272","Standard Price":780.3,"Note":"**"},{"Itemcode":"72205572","Description":"Introducer/Sheath Ep Grp 1","CDM Revenue Code":"278","CDM HCPCS":"C1766","Standard Price":5118.36,"Note":"**"},{"Itemcode":"72205575","Description":"PM/NS Lead Adapter/Xtn Implant","CDM Revenue Code":"278","CDM HCPCS":"C1883","Standard Price":1045.5},{"Itemcode":"72205576","Description":"Connector","CDM Revenue Code":"278","Standard Price":1355.58},{"Itemcode":"72205577","Description":"Lead Lock Device (Disp)","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":2652.0,"Note":"**"},{"Itemcode":"72205578","Description":"Wrench Pacemaker/Icd (Disp)","CDM Revenue Code":"272","Standard Price":322.32,"Note":"**"},{"Itemcode":"72205579","Description":"Lead Repair Kit","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"72205587","Description":"Lead PPM Group A","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2028.78},{"Itemcode":"72205589","Description":"Sleeve Upsizing","CDM Revenue Code":"272","Standard Price":322.32},{"Itemcode":"72205590","Description":"Pacemaker Adapta Addr01 Sys -D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"72205591","Description":"Gen Pacer Addr01","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14472.78},{"Itemcode":"72205592","Description":"Lead 1 Medtronic","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2121.6},{"Itemcode":"72205593","Description":"Lead 2 Medtronic","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2593.86},{"Itemcode":"72205594","Description":"Pacemaker Sensia Sedr01 Sys-D","CDM Revenue Code":"275","Standard Price":0.0},{"Itemcode":"72205595","Description":"Gen Ppm Sensia Sedr01","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":8626.14},{"Itemcode":"72205596","Description":"Navistar Ep Cath","CDM Revenue Code":"278","CDM HCPCS":"C1732","Standard Price":7789.74},{"Itemcode":"72205599","Description":"EP Cable Grp 2","CDM Revenue Code":"272","Standard Price":1155.66},{"Itemcode":"72205601","Description":"Needle, Transseptal NRG RF","CDM Revenue Code":"272","Standard Price":2627.52,"Note":"**"},{"Itemcode":"72205602","Description":"Cath Guiding Grp 1A","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":1144.44,"Note":"**"},{"Itemcode":"72205603","Description":"Kit Snare Lead Extrctn Femoral","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":4492.08},{"Itemcode":"72205611","Description":"Lead Ppm Grp 2A","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2590.8},{"Itemcode":"72205613","Description":"SHEATH DIL ROTATNG-TIGHTRL13FR","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":9789.96},{"Itemcode":"72205614","Description":"Cath Ep Dx Deca CSL 6FR","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":2334.78,"Note":"**"},{"Itemcode":"72205618","Description":"Lead Icd Dual Coil Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":15192.9},{"Itemcode":"72205619","Description":"Lead Icd Other Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1896","Standard Price":9371.76},{"Itemcode":"72205621","Description":"Lead ICD Other Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1896","Standard Price":13005.0},{"Itemcode":"72205628","Description":"Cath Ep Dx 1-19 Elec Grp 1A","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":1812.54,"Note":"**"},{"Itemcode":"72205631","Description":"GenratrPM Dual RR MRI-Accolade","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":15892.62,"Note":"**"},{"Itemcode":"72205632","Description":"GenratrPM Sngl RR MRI-Accolade","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":13525.2,"Note":"**"},{"Itemcode":"72205633","Description":"Lead Pacng/Sensng MRI-Ingevity","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2122.62,"Note":"**"},{"Itemcode":"72205634","Description":"GenratrPM Dual RR MRI-ASSURITY","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":13525.2,"Note":"**"},{"Itemcode":"72205635","Description":"Lead PPM MRI CONTENDRIL","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":2122.62,"Note":"**"},{"Itemcode":"72205691","Description":"Lead Ppm Grp 3 C1898","CDM Revenue Code":"275","CDM HCPCS":"C1898","Standard Price":4172.82},{"Itemcode":"72205692","Description":"Cath Ep Dx 20++Elec Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1731","Standard Price":3121.2},{"Itemcode":"72205693","Description":"Cath Ep Dx 20++Elec Grp 3","CDM Revenue Code":"278","CDM HCPCS":"C1731","Standard Price":4161.6},{"Itemcode":"72205694","Description":"Cath Ep Dx 20++Elec Grp 4","CDM Revenue Code":"278","CDM HCPCS":"C1731","Standard Price":5722.2},{"Itemcode":"72205695","Description":"EP INTRACRD FIX GUID INRO/SHTH","CDM Revenue Code":"278","CDM HCPCS":"C1893","Standard Price":1963.5},{"Itemcode":"72205701","Description":"Pacing Lead Adapter 5866-40","CDM Revenue Code":"275","CDM HCPCS":"C1883","Standard Price":483.48},{"Itemcode":"72205735","Description":"Gen: CRT-D Dynagen","CDM Revenue Code":"275","CDM HCPCS":"C1882","Standard Price":69968.94,"Note":"**"},{"Itemcode":"72205739","Description":"Cath Ep Dx 1-19 Elec Grp 2","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":2313.36},{"Itemcode":"72205761","Description":"GENERATOR S-ICD EMBLEM","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":67626.0,"Note":"**"},{"Itemcode":"72205762","Description":"LEAD S-ICD EMBLEM","CDM Revenue Code":"275","CDM HCPCS":"C1896","Standard Price":13525.2,"Note":"**"},{"Itemcode":"72205997","Description":"Pacemaker Gen Sgl Rr Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":13421.16,"Note":"**"},{"Itemcode":"72205998","Description":"Pacemaker Gen Sgl Rr Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":18822.06},{"Itemcode":"72205999","Description":"Pacemaker Gen Bi-V","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":29872.74,"Note":"**"},{"Itemcode":"72206000","Description":"Pacemaker Gen Dual Rr Grp 1","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14474.82,"Note":"**"},{"Itemcode":"72206001","Description":"Pacemaker Gen Dual Rr Grp 2","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":15873.24},{"Itemcode":"72206010","Description":"AICD Gen- Dynagen DF4 D150","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":47919.6,"Note":"**"},{"Itemcode":"72206011","Description":"Pacemaker Gen - Dual Rr Grp 3","CDM Revenue Code":"275","CDM HCPCS":"C1785","Standard Price":14997.06},{"Itemcode":"72206424","Description":"Perfusion: Beating Hearts Lv 1","CDM Revenue Code":"272","Standard Price":6740.16,"Note":"**"},{"Itemcode":"72206511","Description":"Loop Recorder: Reveal","CDM Revenue Code":"278","CDM HCPCS":"C1764","Standard Price":13846.5,"Note":"**"},{"Itemcode":"72206512","Description":"Implantable Cardiac Monitor","CDM Revenue Code":"278","CDM HCPCS":"C1764","Standard Price":15471.36,"Note":"**"},{"Itemcode":"72206714","Description":"Handpiece, Bipolar Aquamantys","CDM Revenue Code":"272","Standard Price":2091.0},{"Itemcode":"72206733","Description":"Tray: Custom Ep","CDM Revenue Code":"272","Standard Price":219.3,"Note":"**"},{"Itemcode":"72206808","Description":"Stent: Covered w/o Delivery Sy","CDM Revenue Code":"278","CDM HCPCS":"C1875","Standard Price":11546.4},{"Itemcode":"72206840","Description":"Stapler: Proximate Prw-35","CDM Revenue Code":"272","Standard Price":188.7},{"Itemcode":"72207000","Description":"Cath: Balloon Bi-V Medt","CDM Revenue Code":"272","Standard Price":644.64},{"Itemcode":"72207004","Description":"Cath Occlusion For Venogram","CDM Revenue Code":"272","CDM HCPCS":"C2628","Standard Price":334.56},{"Itemcode":"72207005","Description":"Cath Occlusion - BRIDGE","CDM Revenue Code":"278","CDM HCPCS":"C2628","Standard Price":3626.1,"Note":"**"},{"Itemcode":"72207058","Description":"Cath: Balloon GRP 1","CDM Revenue Code":"272","CDM HCPCS":"C1725","Standard Price":572.22},{"Itemcode":"72207101","Description":"Dermabond Db12","CDM Revenue Code":"272","Standard Price":200.94,"Note":"**"},{"Itemcode":"72207105","Description":"Cable: Pacing 5833-S","CDM Revenue Code":"272","Standard Price":201.96},{"Itemcode":"72207112","Description":"Cath: Guide","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":310.08},{"Itemcode":"72207130","Description":"Cath: Diagnostic Grp 1","CDM Revenue Code":"272","Standard Price":58.14},{"Itemcode":"72207294","Description":"Femostop: Compression","CDM Revenue Code":"272","Standard Price":557.94},{"Itemcode":"72207313","Description":"Cath EP 1-19 Elec Curved 5F/6F","CDM Revenue Code":"278","CDM HCPCS":"C1730","Standard Price":524.28,"Note":"**"},{"Itemcode":"72207319","Description":"Sheath: Hls And 808150","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":399.84,"Note":"**"},{"Itemcode":"72207421","Description":"Inflation Device Kit","CDM Revenue Code":"272","Standard Price":195.84},{"Itemcode":"72207451","Description":"Generator CRT-P - VIVA","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":25157.28},{"Itemcode":"72207452","Description":"Generator CRT-P ValitudeU125","CDM Revenue Code":"275","CDM HCPCS":"C2621","Standard Price":21978.96,"Note":"**"},{"Itemcode":"72207481","Description":"Wire: Finishing","CDM Revenue Code":"272","Standard Price":742.56},{"Itemcode":"72207526","Description":"Kit: Essentials","CDM Revenue Code":"272","Standard Price":202.98},{"Itemcode":"72207528","Description":"Kit, Retrieval Cath/Snare","CDM Revenue Code":"272","CDM HCPCS":"C1773","Standard Price":1716.66,"Note":"**"},{"Itemcode":"72207599","Description":"Guidewire Grp 2A","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":463.08},{"Itemcode":"72207761","Description":"Pinch On Tool 6056","CDM Revenue Code":"272","Standard Price":168.3,"Note":"**"},{"Itemcode":"72207768","Description":"Pacemaker Gen Sgl Rr Grp A","CDM Revenue Code":"275","CDM HCPCS":"C1786","Standard Price":10820.16},{"Itemcode":"72207790","Description":"Tray: Pericardiocentesis (Ep)","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1008.78,"Note":"**"},{"Itemcode":"72208462","Description":"Cath 3Lu 7F 16C Ask-42703-Pcsj","CDM Revenue Code":"272","Standard Price":750.72},{"Itemcode":"72208502","Description":"Kit Lld Accessory 518-027","CDM Revenue Code":"272","Standard Price":609.96},{"Itemcode":"72208629","Description":"TAVR VALVE","CDM Revenue Code":"278","Standard Price":107737.5},{"Itemcode":"72208888","Description":"Non-Charge Surg Supply","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"72208916","Description":"LEAD SJ4 DC 58CM","CDM Revenue Code":"275","CDM HCPCS":"C1895","Standard Price":11022.12},{"Itemcode":"72208952","Description":"AICD,MRI, SNGL CHMBR, EVERA","CDM Revenue Code":"275","CDM HCPCS":"C1722","Standard Price":54439.44},{"Itemcode":"7221","Description":"Collagen Drssing <=16sqin","CDM Revenue Code":"272","CDM HCPCS":"A6021","Standard Price":82.62},{"Itemcode":"7222","Description":"Collagen Drssing >16,<=48Sq In","CDM Revenue Code":"272","CDM HCPCS":"A6022","Standard Price":61.2},{"Itemcode":"7243","Description":"ALLGRFT PLAC AMNIOFILL 250MG","CDM Revenue Code":"278","Standard Price":2405.16},{"Itemcode":"73100008","Description":"Incentive Spirometer","CDM Revenue Code":"270","Standard Price":67.32,"Note":"**"},{"Itemcode":"73100015","Description":"Circuit: Ippb","CDM Revenue Code":"270","Standard Price":35.7},{"Itemcode":"73100052","Description":"Air-Way Disp Trache Tube","CDM Revenue Code":"272","CDM HCPCS":"A7521","Standard Price":219.3,"Note":"**"},{"Itemcode":"73100053","Description":"Heliox Gas Per Tank","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"73100074","Description":"Oxygen Daily Charge","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"73100088","Description":"Peak Flow Meter; Hand Held","CDM Revenue Code":"270","CDM HCPCS":"A4614","Standard Price":187.68,"Note":"**"},{"Itemcode":"73100203","Description":"Bronch Stent W/Guidewire","CDM Revenue Code":"278","Standard Price":6153.66},{"Itemcode":"73101000","Description":"Retrieval Basket","CDM Revenue Code":"272","Standard Price":1066.92},{"Itemcode":"73101002","Description":"Jagwire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":1479.0},{"Itemcode":"73101004","Description":"Irridium Catheter","CDM Revenue Code":"272","CDM HCPCS":"C1728","Standard Price":648.72},{"Itemcode":"73101006","Description":"Inflation Baloon","CDM Revenue Code":"272","Standard Price":745.62},{"Itemcode":"73103110","Description":"Flutter Valve","CDM Revenue Code":"270","Standard Price":333.54,"Note":"**"},{"Itemcode":"73109853","Description":"Tube Trach Grp 1","CDM Revenue Code":"272","Standard Price":398.82},{"Itemcode":"73200023","Description":"Pulmonary Mini Forceps","CDM Revenue Code":"272","Standard Price":2019.039,"Note":"**"},{"Itemcode":"73200202","Description":"Wang Biopsy Needle","CDM Revenue Code":"272","Standard Price":240.72},{"Itemcode":"73200203","Description":"Kit Bx Disp Superdimension","CDM Revenue Code":"272","Standard Price":4543.08},{"Itemcode":"73200204","Description":"Visicoil Fiducial Marker","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":887.4},{"Itemcode":"73200205","Description":"Marker Gold Seeds Per Vial","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":68.34},{"Itemcode":"73200208","Description":"Superlock Gold Fiducial Marker","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":879.24,"Note":"**"},{"Itemcode":"73200209","Description":"Delivery Kit Fid Mrk Sdmdk1000","CDM Revenue Code":"272","Standard Price":539.58,"Note":"**"},{"Itemcode":"73200210","Description":"Stent Aero Tracheobronchial","CDM Revenue Code":"278","CDM HCPCS":"C1874","Standard Price":10103.1,"Note":"**"},{"Itemcode":"73200211","Description":"Coil Embolization","CDM Revenue Code":"278","Standard Price":684.42,"Note":"**"},{"Itemcode":"73200212","Description":"Cath Brachytherapy","CDM Revenue Code":"272","CDM HCPCS":"C1728","Standard Price":609.96,"Note":"**"},{"Itemcode":"73200213","Description":"Guide Cath Kit Supertrax","CDM Revenue Code":"272","Standard Price":4245.24},{"Itemcode":"73200214","Description":"Probe Fiapc Argon Plasma Coag","CDM Revenue Code":"272","Standard Price":1178.1,"Note":"**"},{"Itemcode":"73200215","Description":"Fiducial Marker Ea Strand Best","CDM Revenue Code":"278","CDM HCPCS":"A4648","Standard Price":644.64},{"Itemcode":"73200216","Description":"Supertrax Superd Asp Needle","CDM Revenue Code":"272","Standard Price":622.2},{"Itemcode":"73200217","Description":"Encore Inflation Device","CDM Revenue Code":"272","Standard Price":465.12},{"Itemcode":"73200218","Description":"Ebus Fna/Biopsy Needle","CDM Revenue Code":"272","Standard Price":460.02,"Note":"**"},{"Itemcode":"73200219","Description":"Cytology Brush Sheathed","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"73200220","Description":"Cath Guide Renegade Stc","CDM Revenue Code":"278","CDM HCPCS":"C1887","Standard Price":2455.14},{"Itemcode":"73200221","Description":"Embolization Coil Vortex","CDM Revenue Code":"278","Standard Price":2409.24},{"Itemcode":"73200222","Description":"Guidewire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":644.64,"Note":"**"},{"Itemcode":"73200223","Description":"Cath Balloon Pulm Dilator","CDM Revenue Code":"272","CDM HCPCS":"C1726","Standard Price":1721.76,"Note":"**"},{"Itemcode":"73200224","Description":"Catheter Balloon B5-2C","CDM Revenue Code":"272","Standard Price":644.64,"Note":"**"},{"Itemcode":"73200225","Description":"Stent Sizing Device","CDM Revenue Code":"272","Standard Price":1327.02,"Note":"**"},{"Itemcode":"73200226","Description":"Pluerx Catheter","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":2346.0,"Note":"**"},{"Itemcode":"73200227","Description":"Pleurx Drain Cath","CDM Revenue Code":"272","CDM HCPCS":"C1729","Standard Price":390.66},{"Itemcode":"73200228","Description":"IBV Valve System","CDM Revenue Code":"278","Standard Price":10653.9,"Note":"**"},{"Itemcode":"73200229","Description":"Cath Edge 180 Super Dimension","CDM Revenue Code":"272","Standard Price":4903.14,"Note":"**"},{"Itemcode":"73200231","Description":"BRONCH BX GUIDE KIT-SPIN EWC","CDM Revenue Code":"272","Standard Price":3626.1},{"Itemcode":"73200232","Description":"Needle Asp-EBUS-TBNA 19GA","CDM Revenue Code":"272","Standard Price":1368.84,"Note":"**"},{"Itemcode":"73200312","Description":"Cyto Brushes","CDM Revenue Code":"270","Standard Price":72.42},{"Itemcode":"73200313","Description":"IBV Deploymnt Cath/Loader","CDM Revenue Code":"272","Standard Price":3043.68,"Note":"**"},{"Itemcode":"73200314","Description":"IBV Balloon Airway Sizer","CDM Revenue Code":"272","Standard Price":1224.0},{"Itemcode":"73200366","Description":"Pleurx Kit Pt Starter 50-0071","CDM Revenue Code":"272","Standard Price":642.6,"Note":"**"},{"Itemcode":"73200800","Description":"Tracker Nav VPad","CDM Revenue Code":"272","Standard Price":1671.78},{"Itemcode":"73200801","Description":"Cath VP Steerable Nav","CDM Revenue Code":"272","Standard Price":2647.92},{"Itemcode":"73200802","Description":"Guidewire Biop Spin Nav","CDM Revenue Code":"272","Standard Price":1327.02},{"Itemcode":"73200803","Description":"Needle Nav Spin Flex","CDM Revenue Code":"272","Standard Price":2985.54},{"Itemcode":"73200804","Description":"Brush Nav Tracker","CDM Revenue Code":"272","Standard Price":2647.92},{"Itemcode":"73200805","Description":"Forcep Nav Serrated","CDM Revenue Code":"272","Standard Price":2471.46},{"Itemcode":"73200806","Description":"Needle Nav Anso Hist","CDM Revenue Code":"272","Standard Price":2647.92},{"Itemcode":"73200807","Description":"Needle Nav Anso Cyto","CDM Revenue Code":"272","Standard Price":10643.7},{"Itemcode":"73200808","Description":"Cable Nav Single VP","CDM Revenue Code":"272","Standard Price":1459.62},{"Itemcode":"73200809","Description":"Forcep/Graspr - Tricep","CDM Revenue Code":"272","Standard Price":948.6},{"Itemcode":"73201000","Description":"Retrieval Basket","CDM Revenue Code":"272","Standard Price":1066.92,"Note":"**"},{"Itemcode":"73201002","Description":"Jagwire","CDM Revenue Code":"272","CDM HCPCS":"C1769","Standard Price":717.06,"Note":"**"},{"Itemcode":"73201004","Description":"Irridium Catheter","CDM Revenue Code":"272","CDM HCPCS":"C1728","Standard Price":648.72},{"Itemcode":"73201006","Description":"Inflation Balloon","CDM Revenue Code":"272","Standard Price":1459.62},{"Itemcode":"73201008","Description":"Bronc Periph Guide Sheath Kit","CDM Revenue Code":"272","Standard Price":642.6,"Note":"**"},{"Itemcode":"73203036","Description":"Circuit Nebulizer Hand Held","CDM Revenue Code":"270","Standard Price":33.66},{"Itemcode":"73203058","Description":"Micro Spec Brush","CDM Revenue Code":"270","Standard Price":121.38},{"Itemcode":"73203059","Description":"Radial Biopsy Forcep","CDM Revenue Code":"270","Standard Price":278.46},{"Itemcode":"73203080","Description":"Stent","CDM Revenue Code":"278","Standard Price":517.14},{"Itemcode":"73203170","Description":"Cath Bronch Thermoplsty Alair","CDM Revenue Code":"278","CDM HCPCS":"C1886","Standard Price":8453.76},{"Itemcode":"73204440","Description":"CATH GUIDE, GLIDE","CDM Revenue Code":"272","CDM HCPCS":"C1887","Standard Price":344.76},{"Itemcode":"73208888","Description":"Bronch Suite Supply","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"74100123","Description":"Chloraseptic Spray 180Ml","CDM Revenue Code":"272","Standard Price":0.0},{"Itemcode":"74100664","Description":"Aveeno For Bath Plain 42Gm Pkt","CDM Revenue Code":"270","Standard Price":60.18,"Note":"**"},{"Itemcode":"74100817","Description":"Povidone-Iodine Sol 120Ml","CDM Revenue Code":"271","Standard Price":6.12,"Note":"**"},{"Itemcode":"74100841","Description":"Povidone-Iodine 1% Oint 30Gm","CDM Revenue Code":"271","Standard Price":6.12,"Note":"**"},{"Itemcode":"74102704","Description":"Fleets Enema Oil 133Ml","CDM Revenue Code":"270","Standard Price":7.13547548638132,"Note":"**"},{"Itemcode":"74102707","Description":"Fleet Enema Ped 67.5Ml","CDM Revenue Code":"270","Standard Price":6.12,"Note":"**"},{"Itemcode":"74102854","Description":"Gelfoam Size 12 3Mm","CDM Revenue Code":"270","Standard Price":34.68,"Note":"**"},{"Itemcode":"74103052","Description":"Chlorhexidine 4% Top Sol 120Ml","CDM Revenue Code":"271","Standard Price":15.2323039106145,"Note":"**"},{"Itemcode":"74103742","Description":"Thera Bath Lot Boz Bottl","CDM Revenue Code":"270","Standard Price":13.26},{"Itemcode":"74103811","Description":"Lanolin 30Gm Cr","CDM Revenue Code":"270","Standard Price":8.16,"Note":"**"},{"Itemcode":"74104870","Description":"Neomycin-Bac-Polymyx Oint 30Gm","CDM Revenue Code":"270","Standard Price":26.11104375,"Note":"**"},{"Itemcode":"74104936","Description":"Nitrazine Paper W/Dispens","CDM Revenue Code":"271","Standard Price":0.0},{"Itemcode":"74106217","Description":"Silver Sulfadiazine 1% Cr 20Gm","CDM Revenue Code":"270","Standard Price":34.2819512195122,"Note":"**"},{"Itemcode":"74106220","Description":"Silver Sulfadiazine 1% Cr 400G","CDM Revenue Code":"270","Standard Price":219.912,"Note":"**"},{"Itemcode":"74106223","Description":"Silver Sulfadiazine Cr 1% 50Gm","CDM Revenue Code":"270","Standard Price":49.9192011235955,"Note":"**"},{"Itemcode":"74106226","Description":"Silver Nitrate Applicator","CDM Revenue Code":"272","Standard Price":6.05116777691712,"Note":"**"},{"Itemcode":"74107114","Description":"Witch Hazel Pads 12 S","CDM Revenue Code":"270","Standard Price":61.5268471232877,"Note":"**"},{"Itemcode":"74107597","Description":"Zinc Oxide 20% Oint 30Gm","CDM Revenue Code":"270","Standard Price":11.22,"Note":"**"},{"Itemcode":"74108453","Description":"Compounded Epidural Cass","CDM Revenue Code":"272","Standard Price":243.78},{"Itemcode":"74108598","Description":"Dakins Soln 0.25% Strength 1L","CDM Revenue Code":"270","Standard Price":151.98},{"Itemcode":"74108835","Description":"Empty Viaflex Container","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"74109061","Description":"Emla Cream 5Gm","CDM Revenue Code":"270","Standard Price":25.1704570194385,"Note":"**"},{"Itemcode":"74110036","Description":"Evacuated Bottle 1000 Ml","CDM Revenue Code":"270","Standard Price":144.84},{"Itemcode":"74118090","Description":"TPN Bag Charge","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"74118252","Description":"Blistick Tube","CDM Revenue Code":"270","Standard Price":6.12},{"Itemcode":"74118308","Description":"Polysporin Top Oint 15Gram","CDM Revenue Code":"270","Standard Price":26.214,"Note":"**"},{"Itemcode":"74118320","Description":"Povidone-Iodine Oint 0.8Gm","CDM Revenue Code":"270","Standard Price":6.12},{"Itemcode":"74118329","Description":"Povidone-Iodine Skin Cl 120Ml","CDM Revenue Code":"271","Standard Price":0.0},{"Itemcode":"74118432","Description":"No-Rinse Shampoo 240Ml","CDM Revenue Code":"270","Standard Price":6.12},{"Itemcode":"74118437","Description":"Chapstick Tube","CDM Revenue Code":"270","Standard Price":6.12},{"Itemcode":"74118461","Description":"Petrolatum White Oinment 30Gm","CDM Revenue Code":"270","Standard Price":11.22,"Note":"**"},{"Itemcode":"74118527","Description":"Nacl Resp 0.9% 3 Ml Inh Sol","CDM Revenue Code":"272","Standard Price":14.48814375,"Note":"**"},{"Itemcode":"74118620","Description":"LTA II Kit (Anesthesia)","CDM Revenue Code":"270","Standard Price":78.7793423780488,"Note":"**"},{"Itemcode":"74118735","Description":"Icy Hot Balm 3.5Oz","CDM Revenue Code":"270","Standard Price":6.12,"Note":"**"},{"Itemcode":"74120053","Description":"Evacuated Bottle 250 Ml","CDM Revenue Code":"270","Standard Price":127.5},{"Itemcode":"74120054","Description":"Evacuated Bottle 500 Ml","CDM Revenue Code":"271","Standard Price":130.56},{"Itemcode":"74120155","Description":"Crash Intubation Bag","CDM Revenue Code":"271","Standard Price":295.587130434782,"Note":"**"},{"Itemcode":"74120345","Description":"Povidone Iodine Soltn 273Ml","CDM Revenue Code":"270","Standard Price":10.1607369863014,"Note":"**"},{"Itemcode":"74120352","Description":"Dove Soap","CDM Revenue Code":"270","Standard Price":63.24},{"Itemcode":"74120410","Description":"Fibrin Sealant Kit 2Ml","CDM Revenue Code":"278","CDM HCPCS":"C2615","Standard Price":1387.2,"Note":"**"},{"Itemcode":"74120485","Description":"Clocortolone 0.1% Cream 45Gm","CDM Revenue Code":"270","Standard Price":1129.14},{"Itemcode":"74120516","Description":"Perfluoron Or Kit","CDM Revenue Code":"272","Standard Price":1548.615,"Note":"**"},{"Itemcode":"74120828","Description":"Dakins 0.25% Irr 480 Ml Bot","CDM Revenue Code":"270","Standard Price":49.6032189973615,"Note":"**"},{"Itemcode":"74120998","Description":"Lidocaine-Prilocain Oint 30 Gm","CDM Revenue Code":"270","Standard Price":144.364,"Note":"**"},{"Itemcode":"74121314","Description":"Collagenase 30 Gm Tub","CDM Revenue Code":"270","Standard Price":893.84,"Note":"**"},{"Itemcode":"74121447","Description":"Clocortolone 0.1% Cream 10 Gm","CDM Revenue Code":"270","Standard Price":299.954965048544,"Note":"**"},{"Itemcode":"74121449","Description":"Silver Sulfadiazine 10 Gm Chg","CDM Revenue Code":"270","Standard Price":18.2823913043479,"Note":"**"},{"Itemcode":"74121450","Description":"Silver Sulfadiazine 50 Gm Noch","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"74121451","Description":"Collagenase 5Gm Charge Topical","CDM Revenue Code":"270","Standard Price":89.4004031117398,"Note":"**"},{"Itemcode":"74121452","Description":"Clocortolone 0.1% Cm 45Gm Noch","CDM Revenue Code":"270","Standard Price":4.8552,"Note":"**"},{"Itemcode":"74122073","Description":"Sodium Chloride 3% 15Ml Neb","CDM Revenue Code":"272","Standard Price":6.12},{"Itemcode":"74122101","Description":"Vasoline 71 Gm Tub","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"74122102","Description":"Dakins-Na Hypochl 0.25% No Chg","CDM Revenue Code":"270","Standard Price":16.167,"Note":"**"},{"Itemcode":"74122103","Description":"Dakins-Na Hypochlor 0.25% Each","CDM Revenue Code":"270","Standard Price":6.12,"Note":"**"},{"Itemcode":"74122137","Description":"Compounded Cassette On-Q Pump","CDM Revenue Code":"272","Standard Price":965.105454545454,"Note":"**"},{"Itemcode":"74122218","Description":"Sodium Chloride 7% 4 Ml Neb","CDM Revenue Code":"272","Standard Price":6.12,"Note":"**"},{"Itemcode":"74122314","Description":"Sodium Chloride 3% Neb Sol 4Ml","CDM Revenue Code":"272","Standard Price":6.12,"Note":"**"},{"Itemcode":"74122335","Description":"Empty Sterile Bag 100 Ml","CDM Revenue Code":"270","Standard Price":0.0},{"Itemcode":"74122390","Description":"Solesta 50-15 MG/ML Syringe","CDM Revenue Code":"278","CDM HCPCS":"L8605","Standard Price":5657.94},{"Itemcode":"74122527","Description":"NEONATE EMERGENCY DRUG BAG","CDM Revenue Code":"271","Standard Price":56.1,"Note":"**"},{"Itemcode":"74122751","Description":"Dakins 0.125%% Irr 480 Ml Bot","CDM Revenue Code":"270","Standard Price":48.45,"Note":"**"},{"Itemcode":"74122807","Description":"Sterile Water 20Ml Vial","CDM Revenue Code":"272","Standard Price":0.0},{"Itemcode":"74128888","Description":"Pharmacy No Charge","CDM Revenue Code":"272","Standard Price":0.0},{"Itemcode":"75100014","Description":"Lavage Disposable","CDM Revenue Code":"272","Standard Price":188.7},{"Itemcode":"75300328","Description":"Passy-Muir Speaking Valve","CDM Revenue Code":"274","CDM HCPCS":"L8501","Standard Price":431.46,"Note":"**"},{"Itemcode":"75301500","Description":"Laryngeal Mirrors","CDM Revenue Code":"270","Standard Price":98.94},{"Itemcode":"75301800","Description":"Vitalstim Electrodes","CDM Revenue Code":"271","Standard Price":142.8},{"Itemcode":"75345621","Description":"OASIS ULTRA 5X7CM 306813000013","CDM Revenue Code":"278","CDM HCPCS":"Q4124","Standard Price":1314.78},{"Itemcode":"75375621","Description":"OASIS ULTRA 5X7CM 306813000013","CDM Revenue Code":"278","CDM HCPCS":"Q4124","Standard Price":1314.78},{"Itemcode":"75390009","Description":"PICC Introducer","CDM Revenue Code":"272","CDM HCPCS":"C1894","Standard Price":187.68},{"Itemcode":"75390017","Description":"Power PICC Triple","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":929.22,"Note":"**"},{"Itemcode":"75390019","Description":"PICC Triple Lumen 6 FR","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":1092.42},{"Itemcode":"75390020","Description":"PICC Dual Lumen- Arrow","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":884.34},{"Itemcode":"75390041","Description":"CATH, PICC 1LUM 5Fr BIOFLO","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":795.6},{"Itemcode":"75390042","Description":"CATH INFSN MIDLINE 1LUM 4.5Fr","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":876.18},{"Itemcode":"75392000","Description":"Power PICC","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":700.74,"Note":"**"},{"Itemcode":"75392001","Description":"PI JACC KIT-TRIPLE LUMEN","CDM Revenue Code":"272","CDM HCPCS":"C1751","Standard Price":1352.52,"Note":"**"},{"Itemcode":"75392003","Description":"KIT CATH 3LUMEN 7FR","CDM Revenue Code":"272","Standard Price":750.72,"Note":"**"},{"Itemcode":"76950005","Description":"Biopsy: Tray","CDM Revenue Code":"272","Standard Price":142.8},{"Itemcode":"76950040","Description":"Cont Ctr Perry Anal Sensor","CDM Revenue Code":"272","Standard Price":297.84},{"Itemcode":"76950041","Description":"Cont Ctr Perry Vaginal Sensor","CDM Revenue Code":"272","Standard Price":297.84},{"Itemcode":"76950063","Description":"Homer Mamalock Needle","CDM Revenue Code":"272","Standard Price":180.54},{"Itemcode":"76950089","Description":"Stereo Biopsy Needle","CDM Revenue Code":"272","Standard Price":1522.86},{"Itemcode":"76950091","Description":"Clip Localization / Marker","CDM Revenue Code":"272","Standard Price":524.28},{"Itemcode":"76950095","Description":"US Biopsy Needle","CDM Revenue Code":"272","Standard Price":187.68},{"Itemcode":"76950097","Description":"US Biopsy Needle Vacuum-Assis","CDM Revenue Code":"272","Standard Price":1444.32},{"Itemcode":"76970120","Description":"Onc Central Line Dressing","CDM Revenue Code":"272","Standard Price":70.38},{"Itemcode":"76972507","Description":"Sponsor supplied Study Drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979000","Description":"Carfilzomib 60mg -study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979001","Description":"IMMU-114-Study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979002","Description":"Ipilimumab 200mg/40ml Study dr","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979003","Description":"Ipilimumab 50mg/10ml Study drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979004","Description":"Nivolumab 100mg/10ml Study drg","CDM Revenue Code":"624","Standard Price":0.0102,"Note":"**"},{"Itemcode":"76979005","Description":"Nivolumab 40mg/4ml Study drug","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979006","Description":"Nivlumb/Plcbo100mg/10mlStdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979007","Description":"Panitumumab 100mg/5ml Stdy Drg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979008","Description":"Panitumumab 400mg/20ml Stdy Dr","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979009","Description":"Pembrolizumab100mg/4ml StdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"76979010","Description":"Pembrolizumab 50mg/2ml StdyDrg","CDM Revenue Code":"624","Standard Price":0.0},{"Itemcode":"0005","Description":"Body Analysis","CDM Revenue Code":"990","Standard Price":44.0},{"Itemcode":"0017","Description":"Galactogram -D","CDM Revenue Code":"320"},{"Itemcode":"0168","Description":"KUB NO CHARGE","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"0264","Description":"Galactogram-D","CDM Revenue Code":"320"},{"Itemcode":"0266","Description":"Galactogram Multiple Ducts-D","CDM Revenue Code":"320"},{"Itemcode":"0440","Description":"Hystosalpingogram-D","CDM Revenue Code":"320"},{"Itemcode":"0500","Description":"Loopogram-D","CDM Revenue Code":"320"},{"Itemcode":"0761","Description":"Sialogram Parotid - Right-D","CDM Revenue Code":"320"},{"Itemcode":"0763","Description":"Sialogram Parotid - Left-D","CDM Revenue Code":"320"},{"Itemcode":"0765","Description":"Arthrogram Ankle - Left-D","CDM Revenue Code":"320"},{"Itemcode":"0768","Description":"Arthrogram Ankle - Right-D","CDM Revenue Code":"320"},{"Itemcode":"0771","Description":"Arthrogram Hip Left-D","CDM Revenue Code":"320"},{"Itemcode":"0774","Description":"Arthrogram Hip Right-D","CDM Revenue Code":"320"},{"Itemcode":"0777","Description":"Arthrogram Knee Left-D","CDM Revenue Code":"320"},{"Itemcode":"0780","Description":"Arthrogram Knee Right-D","CDM Revenue Code":"320"},{"Itemcode":"0783","Description":"Arthrogram Shoulder - Left-D","CDM Revenue Code":"320"},{"Itemcode":"0786","Description":"Arthrogram Shoulder - Right-D","CDM Revenue Code":"320"},{"Itemcode":"0789","Description":"Arthrogram Wrist Left-D","CDM Revenue Code":"320"},{"Itemcode":"0792","Description":"Arthrogram Wrist Right-D","CDM Revenue Code":"320"},{"Itemcode":"0945","Description":"Voiding Cystourethrogram-D","CDM Revenue Code":"320"},{"Itemcode":"0946","Description":"Small Bowel Series-D","CDM Revenue Code":"320"},{"Itemcode":"12345678","Description":"room dummy cdm","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"2001","Description":"Scrn Dig Mam Bi W/TomoW/CAD -D","CDM Revenue Code":"403"},{"Itemcode":"2002","Description":"Scrn Mam Uni Rt 3D/Tomo-D","CDM Revenue Code":"403"},{"Itemcode":"2003","Description":"Scrn Mam Uni Lt 3D/Tomo-D","CDM Revenue Code":"403"},{"Itemcode":"2016","Description":"Dx Mam BI Dgtl W/Tomo W/Cad-D","CDM Revenue Code":"401"},{"Itemcode":"2017","Description":"Dx Mam RT Dgtl W/Tomo W/Cad-D","CDM Revenue Code":"401"},{"Itemcode":"2018","Description":"Dx Mam LT Dgtl W/Tomo W/Cad-D","CDM Revenue Code":"401"},{"Itemcode":"2050","Description":"US Amniocentesis-D","CDM Revenue Code":"402"},{"Itemcode":"2110","Description":"US Guidance For Aspiration-D","CDM Revenue Code":"402"},{"Itemcode":"2139","Description":"US Biopsy: Lung-D","CDM Revenue Code":"402"},{"Itemcode":"2146","Description":"BIOPSY: LIVER-D","CDM Revenue Code":"402"},{"Itemcode":"2152","Description":"US Biopsy: Unspecified-D","CDM Revenue Code":"402"},{"Itemcode":"2153","Description":"US Biopsy: Renal-D","CDM Revenue Code":"402"},{"Itemcode":"2199","Description":"Cystogram-D","CDM Revenue Code":"320"},{"Itemcode":"2212","Description":"Fluoro Guided Hip Injection-D","CDM Revenue Code":"320"},{"Itemcode":"2213","Description":"Fluoro Guided Si Jnt Inject-D","CDM Revenue Code":"320"},{"Itemcode":"2331","Description":"US Guided Pseudoaneurysm Inj-D","CDM Revenue Code":"402"},{"Itemcode":"2354","Description":"Fistulagram Sinus Tract -D","CDM Revenue Code":"320"},{"Itemcode":"2650","Description":"Paracentesis-D","CDM Revenue Code":"402"},{"Itemcode":"2651","Description":"US PseudOAneurysm Compressn-D","CDM Revenue Code":"402"},{"Itemcode":"2695","Description":"Pelvic Histosonogram-D","CDM Revenue Code":"402"},{"Itemcode":"2885","Description":"Thoracentesis U/S Guided -D","CDM Revenue Code":"402"},{"Itemcode":"3002","Description":"PET/CT Limited Initial -D","CDM Revenue Code":"404"},{"Itemcode":"3004","Description":"PET/CT Limited Subsequent -D","CDM Revenue Code":"404"},{"Itemcode":"3006","Description":"PET/CT Bone Initial F-18 Wb -D","CDM Revenue Code":"404"},{"Itemcode":"3007","Description":"PET/CT Bone Subsqt F-18 Wb -D","CDM Revenue Code":"404"},{"Itemcode":"3008","Description":"PET/CT Skull -Thigh Initial -D","CDM Revenue Code":"404"},{"Itemcode":"3010","Description":"PET/CT Skull-Thigh Sub -D","CDM Revenue Code":"404"},{"Itemcode":"3012","Description":"PET/CT Whole Body Initial-D","CDM Revenue Code":"404"},{"Itemcode":"3015","Description":"PET/CT Whole Body Subsequent-D","CDM Revenue Code":"404"},{"Itemcode":"3016","Description":"PET/CT Dementia/Alzheimer'S-D","CDM Revenue Code":"404"},{"Itemcode":"3451","Description":"US Guidance -Abcess Drainge -D","CDM Revenue Code":"402"},{"Itemcode":"4828","Description":"Pelvic Us W/Tv Non-Ob","CDM Revenue Code":"402","Standard Price":0.0},{"Itemcode":"4829","Description":"US Pel Vasc W/Ob Lmt-Tv","CDM Revenue Code":"402","Standard Price":0.0},{"Itemcode":"6101","Description":"Canc. Intervential Breast Proc","CDM Revenue Code":"402","Standard Price":0.0},{"Itemcode":"61059000","Description":"O/P Visit # Of Hours","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"61150255","Description":"IV Inj Adl Seq Push Same Drug","CDM Revenue Code":"260","Standard Price":142.0},{"Itemcode":"61300700","Description":"Extended O/P Counter","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"61409000","Description":"O/P Visit Count 7N","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"61450254","Description":"Hydration Each Addl Hour","CDM Revenue Code":"260","Standard Price":342.0},{"Itemcode":"61459000","Description":"O/P Visit Count 7S","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"61568888","Description":"CH Postpartum Outpatient Room","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"61702996","Description":"IM / Sq Injection","CDM Revenue Code":"260","Standard Price":413.0},{"Itemcode":"63100101","Description":"Hemodialysis (Ip)","CDM Revenue Code":"801","Standard Price":2057.0},{"Itemcode":"63100102","Description":"Visit Counter Hemodialysis","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"63100107","Description":"Cvvh:Cavh:Cavad","CDM Revenue Code":"801","Standard Price":1381.0},{"Itemcode":"63100137","Description":"Peritoneal Dialysis","CDM Revenue Code":"802","Standard Price":2057.0},{"Itemcode":"63101001","Description":"Hemodialysis (Ip)-D","CDM Revenue Code":"801","Standard Price":0.0},{"Itemcode":"63101007","Description":"Cvv:Cavh:Cavad","CDM Revenue Code":"809","Standard Price":0.0},{"Itemcode":"63101037","Description":"Peritoneal Dialysis","CDM Revenue Code":"801","Standard Price":0.0},{"Itemcode":"63200032","Description":"Ser Somatosensory B/Inte","CDM Revenue Code":"986","Standard Price":0.0},{"Itemcode":"63209000","Description":"O/P Visit Count Otoneuro","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"63308999","Description":"O/P Visit Count","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"63309001","Description":"I/P Visit Counter","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"64100640","Description":"O Arm Counter","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"64100794","Description":"Intra-Op Mon Services","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"64159001","Description":"Post Surgery Patient Counter","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"64507030","Description":"GI Patient Counter","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"64509099","Description":"OP Visit Count Bronchoscopy","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"65109617","Description":"Drug Screen: Collection","CDM Revenue Code":"300","Standard Price":106.0},{"Itemcode":"6602","Description":"Fluoro Ndl Plcmnt Aspiration-D","CDM Revenue Code":"320"},{"Itemcode":"68252265","Description":"Chemo Admin:Intralesnl>=7Lesns","CDM Revenue Code":"331","Standard Price":480.0},{"Itemcode":"6900","Description":"Thyroid Biopsy-D","CDM Revenue Code":"402"},{"Itemcode":"6905","Description":"US Thyroid Aspiration-D","CDM Revenue Code":"402"},{"Itemcode":"6915","Description":"Thoracentesis W/Pleural Bpsy-D","CDM Revenue Code":"402"},{"Itemcode":"70100005","Description":"CMP W/ Lft - D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100006","Description":"Type And Screen-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100019","Description":"CMP W/ Rft - D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100020","Description":"Immunoglob Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100028","Description":"CALPROTECTIN FECAL 16796 QST","CDM Revenue Code":"300","Standard Price":794.0},{"Itemcode":"70100210","Description":"A/G Ratio-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100253","Description":"Lymphocyte Mitogen Scr Cc -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100277","Description":"HIV - State Lab","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100300","Description":"Stat Surgical Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100310","Description":"Stat Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100315","Description":"Stat Profile W/Wbc-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100324","Description":"TPN Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100334","Description":"VMA, Rand Ur -D Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100339","Description":"Meningoencephalitis Csf Comp-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100367","Description":"Alk Phos Isoenzymes -D Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100422","Description":"Influenza A H1N1 Rt-Pcr Qst -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100509","Description":"Influenza A&B Dfa -D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100533","Description":"Mayo Direct Immunoflourescnc-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100607","Description":"ENA - D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100640","Description":"Isohemagglutinin Titers -D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100647","Description":"HLA Typing Narcolepsy-D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100681","Description":"West Nile Virus Ab Csf -D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100690","Description":"Chromosome Analysis Amnio Fl-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100699","Description":"N.Meningitidis Igg Maid","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100745","Description":"Giardia Ab Pnl -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100754","Description":"Estronex 2/16 Oh Ratio-D Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100773","Description":"Poliovirus Antibody -D Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100816","Description":"GH Suppression Panel-D Stoever","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100838","Description":"IGA Subclasses - D Qst 31488","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100848","Description":"Tissue Ttg Ab -D Qst 11073","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100860","Description":"PTT Mixing Studies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100865","Description":"Echovirus Antibody Panel -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100872","Description":"L.Pneumophila Total Antibody-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100923","Description":"Leishmania Antibody Ifa -D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100932","Description":"Free Kappa Lambda W/Ratio Ur-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100940","Description":"Ctng Mpl -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100943","Description":"Cyto Bm Mpl -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100949","Description":"Cyto Poc Mpl-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100953","Description":"Cyto St Mpl -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100957","Description":"Cyto Upb Mpl - D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70100964","Description":"F Alk -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100967","Description":"F Bcl 1 -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100970","Description":"F Blc 2 -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100973","Description":"F Egr1 -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100976","Description":"F Her2 -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100979","Description":"F Pml-Rara -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100982","Description":"F Malt -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100985","Description":"F Mm -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100988","Description":"F Bcr Abl -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70100992","Description":"F Myc -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70101020","Description":"HSV 1/2 Igm -D Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101039","Description":"F Gli -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70101071","Description":"F Cll -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70101096","Description":"Warfarin Sensitiv Geno-D Mayo","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101113","Description":"F Mds -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70101122","Description":"Phn -D Mpl","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70101247","Description":"Sensorimotor Neuropathy Profil","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101256","Description":"Admark Apoe Csf -D Athena 177","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101260","Description":"Iron: Tibc-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101296","Description":"SMA Reflex Test-D Athena","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101302","Description":"Glucose Tol 2Hr-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101303","Description":"Glucose Tol 3 Hour-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101304","Description":"Glucose Tol 4 Hour-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101305","Description":"Glucose Tol 5 Hour-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101313","Description":"Platelet Ab Scr Indirect-Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101366","Description":"Fish Subtelomere Scr Mayo -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101370","Description":"Myodarditis Panel-D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101391","Description":"Circulating Tumor Cells -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101395","Description":"Mitochondrial Disorder Eval-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101401","Description":"Cyclospora And Isospora Exam-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101404","Description":"Lupus Anticoag Panel -D Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101410","Description":"Thyroid Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101411","Description":"Thyroid Profile: Hypo-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101414","Description":"Magnesium 24 Hr Urine -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101415","Description":"Citric Acid 24Hr W/Creat Qst-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101418","Description":"Kappa Lt Ch Total Random Ur-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101424","Description":"HSV 1&2 DNA Quant -D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101427","Description":"Candida DNA Qual Pcr Serum-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101434","Description":"Bv Panel -D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101440","Description":"Paraneoplastic Auto Ab Eval-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101457","Description":"Combisnp Poc Fresh Tissue-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101460","Description":"Combibac Ffpe (Slides/Block)-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101466","Description":"Transferrin Carb-Def -D Qst","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101481","Description":"OB-GYN SPEC2 - D","CDM Revenue Code":"300"},{"Itemcode":"70101490","Description":"CARDIOLIPID IGG/IGM -D","CDM Revenue Code":"300"},{"Itemcode":"70101491","Description":"BETA 2 GLYCOPROTEIN AB -D","CDM Revenue Code":"300"},{"Itemcode":"70101605","Description":"CMV Culture-D Quest #2627","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101607","Description":"Chrmosome Analysis: High Res-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101610","Description":"ABO/Rh -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101640","Description":"S.Pneumoniae Igg Ab Maid-Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101656","Description":"MOL Cyto Interphas In Sit Hy-","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101820","Description":"CardioIQ-AdvLipid/InflamPQst-D","CDM Revenue Code":"300"},{"Itemcode":"70101969","Description":"Therapath Nerve Bx - D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70101977","Description":"Therapath Ihc","CDM Revenue Code":"310","Standard Price":906.0},{"Itemcode":"70101980","Description":"Therapath Muscle Bx -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70102011","Description":"Ehrlichia Chaffeensis Abs-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70102014","Description":"Parvoantibodies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70102017","Description":"Cd4:Cd8 Count-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70102023","Description":"Typhus Fever Abs:Igg/Igm-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70102026","Description":"Q Fever Antibodies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70102044","Description":"MIC/Oid-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70102504","Description":"Meningoenceph Serum Pnl A-QS-D","CDM Revenue Code":"300"},{"Itemcode":"70102505","Description":"Southeast RAST Profile 23 - D","CDM Revenue Code":"300"},{"Itemcode":"70102551","Description":"CSF Electrophoresis - D","CDM Revenue Code":"300"},{"Itemcode":"70103815","Description":"Boretella Pertussis Antibds-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70103820","Description":"Concentrated Afb Smear-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70103822","Description":"Bordetella MAID (IGG,IGA) - D","CDM Revenue Code":"300"},{"Itemcode":"70103900","Description":"RAST Food Allergen x12 - D","CDM Revenue Code":"300"},{"Itemcode":"70104040","Description":"Premarital Female-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104055","Description":"Childhood Alergy-Food/Env-D","CDM Revenue Code":"300"},{"Itemcode":"70104083","Description":"CDIFF Toxn/GDH Ag - D","CDM Revenue Code":"300"},{"Itemcode":"70104094","Description":"Southeast RAST Profile 10 - D","CDM Revenue Code":"300"},{"Itemcode":"70104121","Description":"Total & Free Psa-D Quest","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104125","Description":"Anti Gliadin Antibodies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104159","Description":"Hepatitis B Immun Pr-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104160","Description":"Anti Cardiolipin Ab-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104162","Description":"Hepatitis B Monit Pr-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104198","Description":"Herpes I & Ii Serolo-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104216","Description":"Rickettsial Antibodies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104282","Description":"RMSF Serology-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104293","Description":"Sjogren's Antibody-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104467","Description":"Chlamydia Serology-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104666","Description":"Triple Test-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70104802","Description":"Cholinesterase W/Dibucn Qst-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70105017","Description":"Cd 15 R-S Cell","CDM Revenue Code":"310","Standard Price":284.0},{"Itemcode":"70105356","Description":"Meningoenceph Serum Pnl B-QS-D","CDM Revenue Code":"300"},{"Itemcode":"70105357","Description":"Meningoenceph COMP Pnl CSF B-D","CDM Revenue Code":"300"},{"Itemcode":"70106009","Description":"Extended Phenotype -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70106333","Description":"Coxsackie A Ab Panel -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70106341","Description":"Supplemental Newborn Screen-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70107600","Description":"GC/CH Lam Probe - Candler-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70107777","Description":"Lab Procedure Chg Edit","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70107779","Description":"Thyroglobulin Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70108301","Description":"Drug Screens-Hair (Forensic)-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70108504","Description":"Meningoenceph Comp Pnl CSF A-D","CDM Revenue Code":"300"},{"Itemcode":"70108999","Description":"O/P Visit Count","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"70109000","Description":"O/P Visit Count Lab","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"70109002","Description":"O/P Visit Count Optifast","CDM Revenue Code":"990","Standard Price":0.0},{"Itemcode":"70109034","Description":"5HIAA Rand Ur Quest -D","CDM Revenue Code":"300"},{"Itemcode":"70109214","Description":"Fibrospect Liver Fib Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109215","Description":"IBD SGI Dx Prometheus -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109217","Description":"Thiopurine Metabolite-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109218","Description":"TPMT Enzyme Activity Phenoty-","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109245","Description":"Celiac Serology Prometheus-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109290","Description":"Alergy Panel16, Vegetable Grp","CDM Revenue Code":"300"},{"Itemcode":"70109500","Description":"Lab Test Send Out","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109501","Description":"Lab Test","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109617","Description":"Drug Screen: Collection","CDM Revenue Code":"300","Standard Price":106.0},{"Itemcode":"70109654","Description":"O & P Screen-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109702","Description":"Immuno Histo Chemical Stain","CDM Revenue Code":"310","Standard Price":272.0},{"Itemcode":"70109918","Description":"Serum/Plasma Drg Scrn&Alcohol","CDM Revenue Code":"300"},{"Itemcode":"70109921","Description":"Cat Scratch Fever Antibodies-D","CDM Revenue Code":"300"},{"Itemcode":"70109928","Description":"Chromosone Analysis: Blood-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109930","Description":"Chromosome Analysis: Tissue-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109933","Description":"EVEROLIMUS BLOOD 18883 QST","CDM Revenue Code":"300","Standard Price":468.0},{"Itemcode":"70109935","Description":"Second Screen-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109944","Description":"Estrogen: Fractionated-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109948","Description":"Meningoencephalitis Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109954","Description":"Testosterone: Total & Free-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109957","Description":"Glucose Insulin Tolerance-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109978","Description":"Coxsackie B1-6 Serol-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109989","Description":"Lymphocte Enumeration Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109990","Description":"Aspergillus Serology-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70109993","Description":"Hypersen Pneumonitis Scr-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70110002","Description":"ARC Service Call","CDM Revenue Code":"390","Standard Price":20.0},{"Itemcode":"70110158","Description":"Open Number","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70110237","Description":"HIV 1-2 Ab Differentiation (Q)","CDM Revenue Code":"300"},{"Itemcode":"70110294","Description":"Flow Cytometry Mrkrs 1&2 - D","CDM Revenue Code":"300"},{"Itemcode":"70111010","Description":"Lyme Disease: Western Blot-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111015","Description":"Maternal Serum Screen 4-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111019","Description":"Leuk/Lymph Phenotyping-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111020","Description":"West Nile Virus: Ab Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111040","Description":"Chromosome Analysis:Bone Mar-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111192","Description":"Platelet Function-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111713","Description":"HGB/HCT-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111980","Description":"ACIS - KI67 -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111985","Description":"ACIS - PR - D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111990","Description":"ACIS - HER 2 -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70111995","Description":"ACIS - ER -D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112005","Description":"Molecular Cytogenetics/Fish-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112015","Description":"HPV Typing: Thin Prep-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112020","Description":"Alpha 1Antitrypsin Quant/Phn-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112025","Description":"Myositis Assessr Plus-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112030","Description":"Kidney Stone Formation Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112040","Description":"Phenosense Hiv Comp Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112045","Description":"Anti Ena-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112050","Description":"Neutrophilic Cytoplasmic Ab-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112055","Description":"Anti Phospholipid Antibodies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112060","Description":"Bilirubin: Total & Fractiona-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112065","Description":"Celiac Disease Ab Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112070","Description":"Cholesterol/HDL-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112075","Description":"Circulating Immune Complex-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112080","Description":"Coagulation Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112090","Description":"CKMB-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112095","Description":"IGG Subclasses-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112105","Description":"Lupus Anticoagulant Panel-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112110","Description":"Methylmalonic/Homocysteine-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112115","Description":"MI Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112120","Description":"Renin/Aldosterone Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112125","Description":"Respiratory Virus Evaluation-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112130","Description":"Serum Drug Screen-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112135","Description":"Thyroid Autoantibodies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112140","Description":"Herpes Type II - D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112145","Description":"Toxoplasma Antibodies-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112150","Description":"Dizzy Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112155","Description":"Plastic Profile-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112400","Description":"Hepatic Functn Panel-Kuttner-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70112517","Description":"Alk By Fish-D Clarient","CDM Revenue Code":"310","Standard Price":0.0},{"Itemcode":"70115017","Description":"Bortetella (Dfa)-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70115018","Description":"Vap Cholesterol-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70115480","Description":"Plt Mapping TEG - D","CDM Revenue Code":"300"},{"Itemcode":"70115600","Description":"Meconium Drug Screen-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70115625","Description":"Mening/Enceph Panel-Biofire -D","CDM Revenue Code":"300"},{"Itemcode":"70115630","Description":"ToxAssure CompProf Ur-LabCorpD","CDM Revenue Code":"300"},{"Itemcode":"70115633","Description":"Pain Mgmt Prof1 w/ conf-QST-D","CDM Revenue Code":"300"},{"Itemcode":"70115634","Description":"Bact Cult ID(BCID)DNAx12-BF-D","CDM Revenue Code":"306"},{"Itemcode":"70115651","Description":"NuSwab Vaginitis Plus-Quest-D","CDM Revenue Code":"300"},{"Itemcode":"70115652","Description":"NuSwab Vaginitis - Quest - D","CDM Revenue Code":"300"},{"Itemcode":"70115653","Description":"Therapath Muscle Bx -D","CDM Revenue Code":"300"},{"Itemcode":"70115659","Description":"Arkana Labs Renal Bx -D","CDM Revenue Code":"300"},{"Itemcode":"70115707","Description":"Breast Panel (4 Stain) - D","CDM Revenue Code":"300"},{"Itemcode":"70115708","Description":"Mismatch Repair(MMR) IHC Pnl-D","CDM Revenue Code":"300"},{"Itemcode":"70115709","Description":"ER PgR - D","CDM Revenue Code":"300"},{"Itemcode":"70115710","Description":"Breast Panel (3 Stain) - D","CDM Revenue Code":"300"},{"Itemcode":"70115711","Description":"NKX3.1 PSA PSAP/HPAP PSMA - D","CDM Revenue Code":"300"},{"Itemcode":"70115712","Description":"CD99 MyoD1 S100 - D","CDM Revenue Code":"300"},{"Itemcode":"70115713","Description":"CD117 cKIT PDGFR Alpha/Beta-D","CDM Revenue Code":"300"},{"Itemcode":"70115719","Description":"SE Reg Mixed Panel III - D","CDM Revenue Code":"300"},{"Itemcode":"70115724","Description":"M AML","CDM Revenue Code":"300"},{"Itemcode":"70115725","Description":"FLT3 ITD and TKD Mutation","CDM Revenue Code":"300"},{"Itemcode":"70115729","Description":"Peanut Component Panel - Quest","CDM Revenue Code":"300"},{"Itemcode":"70115735","Description":"Western Equine Encephalitis-D","CDM Revenue Code":"300"},{"Itemcode":"70115739","Description":"Myasthenia Gravis Pnl 3 -D Qst","CDM Revenue Code":"300"},{"Itemcode":"70115753","Description":"Global Hemostasis TEG - D","CDM Revenue Code":"300"},{"Itemcode":"70115763","Description":"Myasthenia Gravis Pnl 3 Qst-D","CDM Revenue Code":"300"},{"Itemcode":"70115800","Description":"AFB Sensitivity Xtb-D","CDM Revenue Code":"300","Standard Price":0.0},{"Itemcode":"70115821","Description":"Echovirus Antibody Panel - D","CDM Revenue Code":"300"},{"Itemcode":"70115829","Description":"Arbovirus Panel - Quest","CDM Revenue Code":"300"},{"Itemcode":"70115837","Description":"Arbovirus CSF Panel - ARUP - D","CDM Revenue Code":"300"},{"Itemcode":"70115857","Description":"Pneumococcal Abs, IgG ARUP - D","CDM Revenue Code":"300"},{"Itemcode":"70115870","Description":"Supersaturation Profile, Urine","CDM Revenue Code":"300"},{"Itemcode":"70115876","Description":"Parvovirus Abs, IgG/IgM - D","CDM Revenue Code":"300"},{"Itemcode":"70115891","Description":"Chrom FISH, Interphase - D","CDM Revenue Code":"300"},{"Itemcode":"70115926","Description":"Chrmosome Analysis:Per Bld-D","CDM Revenue Code":"300"},{"Itemcode":"70115958","Description":"HIV-2 Antibody","CDM Revenue Code":"300","Standard Price":200.0},{"Itemcode":"70115983","Description":"PJI Detection (Synovasure) - D","CDM Revenue Code":"300"},{"Itemcode":"70116052","Description":"Leuk/Lymph Pheno, 5 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116053","Description":"Leuk/Lymph Pheno, 6 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116054","Description":"Leuk/Lymph Pheno, 7 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116055","Description":"Leuk/Lymph Pheno, 8 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116056","Description":"Leuk/Lymph Pheno, 9 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116057","Description":"Leuk/Lymph Pheno, 10 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116058","Description":"Leuk/Lymph Pheno, 11 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116059","Description":"Leuk/Lymph Pheno, 12 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116060","Description":"Leuk/Lymph Pheno, 13 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116061","Description":"Leuk/Lymph Pheno, 14 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116062","Description":"Leuk/Lymph Pheno, 15 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116063","Description":"Leuk/Lymph Pheno, 16 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116064","Description":"Leuk/Lymph Pheno, 17 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116065","Description":"Leuk/Lymph Pheno, 18 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116066","Description":"Leuk/Lymph Pheno, 19 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116067","Description":"Leuk/Lymph Pheno, 20 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116068","Description":"Leuk/Lymph Pheno, 21 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116069","Description":"Leuk/Lymph Pheno, 22 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116070","Description":"Leuk/Lymph Pheno, 23 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116071","Description":"Leuk/Lymph Pheno, 24 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116072","Description":"Leuk/Lymph Pheno, 25 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116073","Description":"Leuk/Lymph Pheno, 26 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116074","Description":"Leuk/Lymph Pheno, 27 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116075","Description":"Leuk/Lymph Pheno, 28 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116076","Description":"Leuk/Lymph Pheno, 29 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116077","Description":"Leuk/Lymph Pheno, 30 markers-D","CDM Revenue Code":"300"},{"Itemcode":"70116092","Description":"Antiphospholipid Ab Panel - D","CDM Revenue Code":"300"},{"Itemcode":"70116104","Description":"Arbovirus Serum Panel-ARUP-D","CDM Revenue Code":"300"},{"Itemcode":"70116266","Description":"Lymph Subset 7 Panel - D","CDM Revenue Code":"300"},{"Itemcode":"70116306","Description":"Lymph Ag and Mitogen Panel - D","CDM Revenue Code":"300"},{"Itemcode":"70116307","Description":"Chlamydia Ab Differentiation-D","CDM Revenue Code":"300"},{"Itemcode":"70116355","Description":"Pneumococcal Abs, IgG 23 - D","CDM Revenue Code":"300"},{"Itemcode":"70116371","Description":"Fibrosure CVH - D","CDM Revenue Code":"300"},{"Itemcode":"70116372","Description":"Fibrosure NAFLD - D","CDM Revenue Code":"300"},{"Itemcode":"70116396","Description":"HIV-1 Qt w/Rfx to Phenosense-D","CDM Revenue Code":"300"},{"Itemcode":"70116402","Description":"Reg 3 Respiratory Panel IgE-D","CDM Revenue Code":"300"},{"Itemcode":"70116420","Description":"Bone Specific ALKP","CDM Revenue Code":"300","Standard Price":321.0},{"Itemcode":"70116465","Description":"Forensic Block (to incl 1 H&E)","CDM Revenue Code":"300","Standard Price":12.0},{"Itemcode":"70116466","Description":"Forensic Additional slides(ea)","CDM Revenue Code":"300","Standard Price":2.0},{"Itemcode":"70116467","Description":"Forensic Recut","CDM Revenue Code":"300","Standard Price":5.0},{"Itemcode":"70116533","Description":"Allergen,Inhalant/Food,Pro 2-D","CDM Revenue Code":"300"},{"Itemcode":"70116534","Description":"Chromosome FISH CLL Panel-D","CDM Revenue Code":"300"},{"Itemcode":"70116573","Description":"PNH Panel High Sensitivity -D","CDM Revenue Code":"300"},{"Itemcode":"70116584","Description":"HIV Phenotype Comprehensive-D","CDM Revenue Code":"300"},{"Itemcode":"70116602","Description":"Chromosome FISH Metaphase - D","CDM Revenue Code":"300"},{"Itemcode":"70116603","Description":"Extended Myositis Panel EMP-D","CDM Revenue Code":"300"},{"Itemcode":"70116649","Description":"Lymphoma Panel by FISH - D","CDM Revenue Code":"300"},{"Itemcode":"70116659","Description":"Epitherlial B10MIN","C":"942","D":"99407","F":"25.5"},{"Policy Line":"63601001","B":"Palliative Care Clinic Lvl 1","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"63601002","B":"Palliative Care Clinic Lvl 2","C":"761","D":"G0463","F":"75"},{"Policy Line":"63601003","B":"Palliative Care Clinic Lvl 3","C":"761","D":"G0463","F":"103.5"},{"Policy Line":"63601004","B":"Palliative Care Clinic Lvl 4","C":"761","D":"G0463","F":"117"},{"Policy Line":"63601005","B":"Palliative Care Clinic Lvl 5","C":"761","D":"G0463","F":"144"},{"Policy Line":"63800008","B":"Smoking Cess w/sympt 3-10MIN","C":"942","D":"99406","F":"18.9"},{"Policy Line":"64100190","B":"Or Clinic Visit V","C":"761","D":"G0463","F":"144"},{"Policy Line":"64504740","B":"Peg Button: Removal","C":"761","D":"G0463","F":"144"},{"Policy Line":"64505039","B":"Cdd Clinic Level 1","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"64557104","B":"Transplant Clinic Consult Pre","C":"761","D":"G0463","F":"117"},{"Policy Line":"64557105","B":"Transplant Clinic F/Up","C":"761","D":"G0463","F":"117"},{"Policy Line":"64600065","B":"Clinic Visit I","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"64605540","B":"Tilt Table","C":"480","D":"93660","F":"2084.1"},{"Policy Line":"65100024","B":"Follow Up Visit Ed","C":"450","D":"G0463","F":"52.5"},{"Policy Line":"68201001","B":"Genetic Counseling Visit I","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"68201002","B":"Genetic Counseling Visit Ii","C":"761","D":"G0463","F":"75"},{"Policy Line":"68201003","B":"Genetic Counseling Visit Iii","C":"761","D":"G0463","F":"103.5"},{"Policy Line":"68201004","B":"Genetic Counseling Visit Iv","C":"761","D":"G0463","F":"117"},{"Policy Line":"68201005","B":"Genetic Counseling Visit V","C":"519","D":"G0463","F":"144"},{"Policy Line":"68300300","B":"Prostate Seed Plan Visit","C":"510","D":"G0463","F":"52.5"},{"Policy Line":"71702800","B":"Special Proc Op Clinic I","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"71705540","B":"Tilt Table","C":"480","D":"93660","F":"2084.1"},{"Policy Line":"72050001","B":"Clinic Lvl I Est - up to 30min","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"72050002","B":"Clinic Lvl II Est - 31 - 60Min","C":"761","D":"G0463","F":"75"},{"Policy Line":"72050003","B":"Clinic Lvl III Est > 60 min","C":"761","D":"G0463","F":"103.5"},{"Policy Line":"72050130","B":"Valve Clinic - Initial Eval","C":"761","D":"G0463","F":"117"},{"Policy Line":"72050131","B":"Valve Clinic- Reconsult","C":"761","D":"G0463","F":"75"},{"Policy Line":"72050132","B":"Valve Clinic-Ini Eval PLUS CC","C":"761","D":"G0463","F":"144"},{"Policy Line":"72050140","B":"Valve Clinic-1 WK F-U VISIT","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"72050150","B":"Valve Clin-1 MO/1YR F-U VISIT","C":"761","D":"G0463","F":"75"},{"Policy Line":"72050160","B":"Valve Clinic-Hospital Consult","C":"761","D":"G0463","F":"103.5"},{"Policy Line":"72205325","B":"Intracardiac Echo","C":"480","D":"93662","F":"505.2"},{"Policy Line":"73100511","B":"RT Clinic I","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"74201001","B":"Clinic 1","C":"510","D":"G0463","F":"52.5"},{"Policy Line":"74201002","B":"Clinic II","C":"761","D":"G0463","F":"75"},{"Policy Line":"74201025","B":"SMOKING CESS W/O SYMP 3-10 MIN","C":"942","D":"99406","F":"22.8"},{"Policy Line":"74201026","B":"SMOKING CESS W/OSYMP >10 MIN","C":"942","D":"99407","F":"21"},{"Policy Line":"74201027","B":"Smoking Cess w/ Symp 3-10MN","C":"942","D":"99406","F":"22.8"},{"Policy Line":"74201028","B":"Smoking Cess w/ Symp >10MIN","C":"942","D":"99407","F":"22.8"},{"Policy Line":"74201035","B":"SBG SMOK CES INT>10MIN 1 ON 1","C":"942","D":"99407","F":"21"},{"Policy Line":"74220025","B":"Smoking Cess w/o Sym 3-10MIN","C":"942","D":"99406","F":"22.8"},{"Policy Line":"74220026","B":"Smoking Cess w/o Sym >10MIN","C":"942","D":"99407","F":"22.8"},{"Policy Line":"74221001","B":"Anticoag Clinic 1 Bluffton","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"74221002","B":"Anticoag Clinic Ii Bluffton","C":"761","D":"G0463","F":"75"},{"Policy Line":"74221003","B":"Anticoag Clinic III Bluffton","C":"761","D":"G0463","F":"90"},{"Policy Line":"74221004","B":"Anticoag Clinic IV Bluffton","C":"761","D":"G0463","F":"117"},{"Policy Line":"74221005","B":"Anticoag Clinic V Bluffton","C":"761","D":"G0463","F":"144"},{"Policy Line":"74221027","B":"Smoking Cess w/sympt 3-10MIN","C":"942","D":"99406","F":"18.9"},{"Policy Line":"74221028","B":"Smoking Cess w/ Symp >10MIN","C":"942","D":"99407","F":"21.9"},{"Policy Line":"74221035","B":"SBG SMOK CES INT>10MIN 1 ON 1","C":"942","D":"99407","F":"19.902"},{"Policy Line":"74221036","B":"SBG SMOK CES INT>10MIN 12WK","C":"942","D":"99407","F":"132.183"},{"Policy Line":"74221037","B":"SBG SMOK CES INT>10MIN 4WK","C":"942","D":"99407","F":"25.683"},{"Policy Line":"74401031","B":"Cit Clinic 1","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"74401035","B":"Gilenya Clinic/Cit Clinic 5","C":"761","D":"G0463","F":"144"},{"Policy Line":"75100016","B":"Canalith Repositioning","C":"420","D":"95992","F":"31.2"},{"Policy Line":"75100052","B":"Biofeedback Pelvic 1st 15 min","C":"420","D":"90912","F":"39"},{"Policy Line":"75100053","B":"Biofeedback Pelvic Add 15 min","C":"420","D":"90913","F":"34.5"},{"Policy Line":"75102004","B":"ROM","C":"420","D":"95851","F":"147.3"},{"Policy Line":"75102209","B":"Dressing Change","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"75110052","B":"Biofeedback Pelvic 1st 15 min","C":"420","D":"90912","F":"39"},{"Policy Line":"75110053","B":"Biofeedback Pelvic Add 15 min","C":"420","D":"90913","F":"34.5"},{"Policy Line":"75112004","B":"ROM","C":"420","D":"95851","F":"147.3"},{"Policy Line":"75140016","B":"Canalith Repositioning","C":"420","D":"95992","F":"31.2"},{"Policy Line":"75142004","B":"ROM","C":"420","D":"95851","F":"147.3"},{"Policy Line":"75142210","B":"Dressing Change","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"75150052","B":"Biofeedback Pelvic 1st 15 min","C":"420","D":"90912","F":"39"},{"Policy Line":"75150053","B":"Biofeedback Pelvic Add 15 min","C":"420","D":"90913","F":"34.5"},{"Policy Line":"75152004","B":"ROM","C":"420","D":"95851","F":"147.3"},{"Policy Line":"75160052","B":"Biofeedback Pelvic 1st 15 min","C":"420","D":"90912","F":"39"},{"Policy Line":"75160053","B":"Biofeedback Pelvic Add 15 min","C":"420","D":"90913","F":"34.5"},{"Policy Line":"75162004","B":"ROM","C":"420","D":"95851","F":"147.3"},{"Policy Line":"75200052","B":"Biofeedback Pelvic 1st 15 min","C":"430","D":"90912","F":"39"},{"Policy Line":"75200053","B":"Biofeedback Pelvic Add 15 min","C":"430","D":"90913","F":"34.5"},{"Policy Line":"75202004","B":"ROM","C":"430","D":"95851","F":"147.3"},{"Policy Line":"75202209","B":"Dressing Change","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"75340001","B":"SBG SMOK CESS W/OSYMP 3-10 MIN","C":"942","D":"99406","F":"19.8"},{"Policy Line":"75375620","B":"OP Ostomy Clinic","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"75800070","B":"Chd Cardiac Rehab Phase 2","C":"943","D":"93798","F":"73.5"},{"Policy Line":"75800086","B":"Chd Cardiac Rehab w/o ECG","C":"943","D":"93797","F":"73.5"},{"Policy Line":"75800087","B":"Chd Cardiac Rehab w/o ECG","C":"943","D":"93797","F":"73.5"},{"Policy Line":"75800097","B":"Pulmonary Rehab Each Hour","C":"948","D":"G0424","F":"73.5"},{"Policy Line":"75800098","B":"PAD Rehab Per Session","C":"480","D":"93668","F":"82.2"},{"Policy Line":"75800200","B":"Disease Mgmt Card Rehab Phase2","C":"943","D":"93798","F":"1414.8"},{"Policy Line":"76950036","B":"Cont Ctr Biofeedback","C":"940","D":"90911","F":"52.8"},{"Policy Line":"76950039","B":"Continence Center Management","C":"761","D":"G0463","F":"52.5"},{"Policy Line":"76951053","B":"Clinic Visit III","C":"761","D":"G0463","F":"103.5"},{"Policy Line":"76970190","B":"Established Patient 1","C":"510","D":"G0463","F":"52.5"},{"Policy Line":"76970195","B":"Established Patient 2","C":"510","D":"G0463","F":"75"},{"Policy Line":"76970200","B":"Established Patient 3","C":"510","D":"G0463","F":"103.5"},{"Policy Line":"76970205","B":"Established Patient 4","C":"510","D":"G0463","F":"117"},{"Policy Line":"76970210","B":"OP Visit Estab Patient Lvl5","C":"510","D":"G0463","F":"144"},{"Policy Line":"0116","B":"Digi Mammo Diag Uni RT w/CAD","C":"401","D":"77065","F":"128.1"},{"Policy Line":"0129","B":"Digi Mam Diag Uni LT W/CAD&Mag","C":"401","D":"77065","F":"128.1"},{"Policy Line":"0131","B":"Digi Mam Diag Uni RT W/CAD&Mag","C":"401","D":"77065","F":"128.1"},{"Policy Line":"0134","B":"Digi Mam Diag BI W/CAD&Mag","C":"401","D":"77066","F":"139.2"},{"Policy Line":"0138","B":"SCREEN Mammo Uni LT W/CAD","C":"403","D":"77067","F":"120"},{"Policy Line":"0139","B":"SCREEN Mammo Uni RT W/CAD","C":"403","D":"77067","F":"120"},{"Policy Line":"0143","B":"SCREEN Mammo BI W/CAD&IMPLANT","C":"403","D":"77067","F":"139.2"},{"Policy Line":"0147","B":"Xray Biopsy Surg Specimen","C":"320","D":"76098","F":"127.8"},{"Policy Line":"0163","B":"SCREEN Mammo BI W/CAD","C":"403","D":"77067","F":"139.2"},{"Policy Line":"0212","B":"Digi Mam Diag BI w/CAD","C":"401","D":"77066","F":"139.2"},{"Policy Line":"0221","B":"Digi Mam Diag Uni RT W/CAD&Mag","C":"401","D":"77065","F":"128.1"},{"Policy Line":"0265","B":"Galactogram","C":"320","D":"77053","F":"225"},{"Policy Line":"0267","B":"Galactogram Multi Ducts","C":"320","D":"77054","F":"201.3"},{"Policy Line":"2013","B":"DIAGN BREAST TOMOSYNTHESIS, LT","C":"401","D":"G0279","F":"30.9"},{"Policy Line":"2014","B":"DIAG BREAST TOMOSYNTHESIS, RT","C":"401","D":"G0279","F":"30.9"},{"Policy Line":"2015","B":"DIAGN BREAST TOMOSYNTHESIS, BI","C":"401","D":"G0279","F":"30.9"},{"Policy Line":"2115","B":"Digi Mammo Diag Uni Lt w/CAD","C":"401","D":"77065","F":"128.1"},{"Policy Line":"2141","B":"XR Chest Decubitus/2Vw - Left","C":"320","D":"71046","F":"150.6"},{"Policy Line":"2150","B":"XR Chest Single View","C":"320","D":"71045","F":"142.5"},{"Policy Line":"2155","B":"XR Chest 2V","C":"320","D":"71046","F":"150.6"},{"Policy Line":"2156","B":"XR Chest Decubitus 2Vw - Right","C":"320","D":"71046","F":"150.6"},{"Policy Line":"2157","B":"XR Chest Flouro 2vw Frnt&Latrl","C":"320","D":"71046","F":"150.6"},{"Policy Line":"2159","B":"XR Chest - Lordotic/Sngl Vw","C":"320","D":"71045","F":"142.5"},{"Policy Line":"2161","B":"XR Chest Oblique Projectn 2viw","C":"320","D":"71046","F":"150.6"},{"Policy Line":"2162","B":"XR Chest Portable","C":"320","D":"71045","F":"142.5"},{"Policy Line":"6091","B":"Breast Tomosynthesis Screen-BI","C":"403","D":"77063","F":"18.9"},{"Policy Line":"6092","B":"Breast Tomosynthesis Scrn-Uni","C":"403","D":"77063","F":"16.2"},{"Policy Line":"64131617","B":"Chest Xray - 1 View Frontal","C":"320","D":"71045","F":"142.5"},{"Policy Line":"2301","B":"CT Maxillo Facial W/Contrast","C":"351","D":"70487","F":"755.1"},{"Policy Line":"5070","B":"CT - Brain W/Contrast","C":"351","D":"70460","F":"603.3"},{"Policy Line":"5075","B":"CT - Brain W/O Contrast","C":"351","D":"70450","F":"441.9"},{"Policy Line":"5080","B":"CT - Brain Wo/W Contrast","C":"351","D":"70470","F":"714.9"},{"Policy Line":"5085","B":"CT Brain Wo Contrast - Stroke","C":"351","D":"70450","F":"441.9"},{"Policy Line":"5086","B":"CTA Head W/Wo With Ct Head","C":"350","D":"70496","F":"1483.8"},{"Policy Line":"5149","B":"CTA Neck Parathyroid wo/w cont","C":"351","D":"70498","F":"1485.3"},{"Policy Line":"5150","B":"CT Angio Head Wo/W Cont","C":"351","D":"70496","F":"1483.8"},{"Policy Line":"5151","B":"CTA Angio Neck Wo/W Cont","C":"351","D":"70498","F":"1485.3"},{"Policy Line":"5235","B":"CT Spine Cervic Post Myelogram","C":"352","D":"72126","F":"588.9"},{"Policy Line":"5245","B":"CT maxillofacial w/wo con","C":"350","D":"70488","F":"779.4"},{"Policy Line":"5250","B":"CT Maxillo Facial W/O Contrast","C":"351","D":"70486","F":"556.2"},{"Policy Line":"5550","B":"CT Neck W/Contrast","C":"351","D":"70491","F":"810.9"},{"Policy Line":"5555","B":"CT Neck W/O Contrast","C":"351","D":"70490","F":"577.8"},{"Policy Line":"5560","B":"CT Neck Wo/W Contrast","C":"351","D":"70492","F":"921.6"},{"Policy Line":"5600","B":"CT Orbits/Sella/Ear W/Contrast","C":"351","D":"70481","F":"790.2"},{"Policy Line":"5605","B":"CT-Orbit/Sella/Ear W/OContrast","C":"351","D":"70480","F":"531.9"},{"Policy Line":"5610","B":"Orbits/Sella/Ear Wo/W Contrast","C":"351","D":"70482","F":"911.4"},{"Policy Line":"5750","B":"CT Spine Cervical W/Contrast","C":"352","D":"72126","F":"588.9"},{"Policy Line":"5755","B":"CT Spine Cervical W/O Contrast","C":"352","D":"72125","F":"457.8"},{"Policy Line":"5756","B":"CT CERVICAL SPINE W/O&W CONTR","C":"352","D":"72127","F":"268.2"},{"Policy Line":"0999","B":"CT Abdomen Kidne Stne W/O C","C":"352","D":"74150","F":"897"},{"Policy Line":"2149","B":"Screening Calcium Scoring","C":"350","D":"75571","F":"55.2"},{"Policy Line":"2234","B":"CT Guid: Needle Place - Head","C":"351","D":"77012","F":"360"},{"Policy Line":"2235","B":"CT Guid Needle Plmnt-Body S&I","C":"352","D":"77012","F":"360"},{"Policy Line":"2236","B":"CT Guid:Needle Place-Extrm S&I","C":"350","D":"77012","F":"360"},{"Policy Line":"2250","B":"Cardiac Ct Gated W/O Contrast","C":"350","D":"75571","F":"312.3"},{"Policy Line":"2700","B":"CT Heart W/O Dye W/Calc Scorin","C":"350","D":"75571","F":"312.3"},{"Policy Line":"2702","B":"CCTA W/O Calcium Scoring","C":"350","D":"75574","F":"1418.4"},{"Policy Line":"2703","B":"CCTA W/ Calcium Scoring","C":"350","D":"75574","F":"1418.4"},{"Policy Line":"2704","B":"CCTA Strxr W/O Calcium Scor","C":"350","D":"75574","F":"1418.4"},{"Policy Line":"2705","B":"CCTA Strxr W/Calcium Scor","C":"350","D":"75574","F":"1418.4"},{"Policy Line":"2706","B":"CT Heart Structure/Morphology","C":"350","D":"75572","F":"928.5"},{"Policy Line":"2707","B":"CCTA W/Contrast","C":"350","D":"75574","F":"1418.4"},{"Policy Line":"2708","B":"CT Chest W/O Super D Protocol","C":"350","D":"76497","F":"468.6"},{"Policy Line":"2709","B":"CT Chest W/C Super D Protocol","C":"350","D":"76497","F":"468.6"},{"Policy Line":"2764","B":"CT Abdomen&Pelvis W/O Cont","C":"352","D":"74176","F":"1485"},{"Policy Line":"2765","B":"CT Abdomen & Pelvis W Contrast","C":"352","D":"74177","F":"1746.9"},{"Policy Line":"2766","B":"CT Abdomen&Pelvis 1-2 W/WO Con","C":"352","D":"74178","F":"1886.7"},{"Policy Line":"3175","B":"CT -Radiation Tx Planning","C":"333","D":"77014","F":"528.3"},{"Policy Line":"4234","B":"CT Guidance Tissue Ablation","C":"350","D":"77013","F":"413.4"},{"Policy Line":"5020","B":"CT Abdomen W/Contrast","C":"352","D":"74160","F":"907.5"},{"Policy Line":"5025","B":"CT Abdomen W/O Contrast","C":"352","D":"74150","F":"897"},{"Policy Line":"5030","B":"CT Abdomen Wo/W Contrast","C":"352","D":"74170","F":"1008.3"},{"Policy Line":"5152","B":"CT Angio Chest Wo/W Cont","C":"352","D":"71275","F":"1287.6"},{"Policy Line":"5153","B":"CT Angio Pelvis Wo/W Cont","C":"352","D":"72191","F":"1427.7"},{"Policy Line":"5154","B":"CT ANGIO UPR EXTRM W/O&W/DYE L","C":"352","D":"73206","F":"1378.5"},{"Policy Line":"5155","B":"CT Angio Upper Ext Wo/W- Rt","C":"352","D":"73206","F":"1378.5"},{"Policy Line":"5157","B":"CT Angio Lower Ext Wo/W - Lt","C":"352","D":"73706","F":"1246.8"},{"Policy Line":"5158","B":"CT Angio Lower Ext Wo/W - Rt","C":"352","D":"73706","F":"1246.8"},{"Policy Line":"5160","B":"CT Angio Abdomen Wo/W Cont","C":"352","D":"74175","F":"1408.2"},{"Policy Line":"5161","B":"CT Angio Aorta/Bi Iliofem Wo/W","C":"352","D":"75635","F":"1546.5"},{"Policy Line":"5162","B":"CTA Chest Pe Protocol","C":"352","D":"71275","F":"1287.6"},{"Policy Line":"5163","B":"CTA Abdomen & Pelvis W&W/O","C":"352","D":"74174","F":"2538.9"},{"Policy Line":"5164","B":"CTA Chest For Tavr","C":"350","D":"71275","F":"1287.6"},{"Policy Line":"5165","B":"CTA Chest Pulmonary Vein Study","C":"350","D":"71275","F":"1287.6"},{"Policy Line":"5166","B":"CTA CHEST W/CONTRAST","C":"350","D":"71275","F":"1287.6"},{"Policy Line":"5167","B":"CTA ABDOMEN W/CONTRAST","C":"350","D":"74175","F":"1408.2"},{"Policy Line":"5168","B":"CT-Low Dose Lung CA Screen","C":"352","D":"G0297","F":"96"},{"Policy Line":"5169","B":"CT-Chest LowDose Lung Followup","C":"352","D":"G0297","F":"96"},{"Policy Line":"5201","B":"CT Lower Extrem W/Cont - Rt","C":"352","D":"73701","F":"697.2"},{"Policy Line":"5202","B":"CT Lower Extrem W/Cont - Bil","C":"352","D":"73701","F":"766.8"},{"Policy Line":"5203","B":"CT Lower Extrem W/Cont - Lt","C":"352","D":"73701","F":"697.2"},{"Policy Line":"5206","B":"CT Lower Extrem W/O Cont - Rt","C":"352","D":"73700","F":"405"},{"Policy Line":"5207","B":"CT Lower Extrem W/O Cont - Bil","C":"352","D":"73700","F":"572.7"},{"Policy Line":"5208","B":"CT Lower Extrem W/O Cont - Lt","C":"352","D":"73700","F":"405"},{"Policy Line":"5211","B":"CT Lower Extrem Wo/W Cont- Rt","C":"352","D":"73702","F":"1090.2"},{"Policy Line":"5212","B":"CT Lower Extrem Wo/W Cont- Bil","C":"352","D":"73702","F":"1460.1"},{"Policy Line":"5213","B":"CT Lower Extrem Wo/W Cont- Lt","C":"352","D":"73702","F":"1090.2"},{"Policy Line":"5216","B":"CT Upper Extrem W/Cont - RT","C":"352","D":"73201","F":"592.2"},{"Policy Line":"5217","B":"CT Upper Extrem W/Cont - BI","C":"352","D":"73201","F":"938.4"},{"Policy Line":"5218","B":"CT Upper Extrem W/Cont - LT","C":"352","D":"73201","F":"592.2"},{"Policy Line":"5221","B":"CT Upper Extrem W/O Cont - Rt","C":"352","D":"73200","F":"412.5"},{"Policy Line":"5222","B":"CT Upper Extrem W/O Cont - BI","C":"352","D":"73200","F":"561.3"},{"Policy Line":"5223","B":"CT Upper Extrem W/O Cont - LT","C":"352","D":"73200","F":"412.5"},{"Policy Line":"5226","B":"CT Upper Extrem Wo/W Cont - RT","C":"352","D":"73202","F":"1633.2"},{"Policy Line":"5227","B":"CT Upper Extrem Wo/W Cont -BI","C":"352","D":"73202","F":"2107.8"},{"Policy Line":"5228","B":"CT Upper Extrem Wo/W Cont - Lt","C":"352","D":"73202","F":"1633.2"},{"Policy Line":"5236","B":"CT Spine Lumbar Post Myelogram","C":"352","D":"72132","F":"613.8"},{"Policy Line":"5237","B":"CT Spine Thorac Post Myelogram","C":"352","D":"72129","F":"614.1"},{"Policy Line":"5396","B":"CT Sinus","C":"351","D":"76380","F":"969.3"},{"Policy Line":"5650","B":"CT Pelvis W/Contrast","C":"352","D":"72193","F":"771.9"},{"Policy Line":"5655","B":"CT Pelvis W/O Contrast","C":"352","D":"72192","F":"464.7"},{"Policy Line":"5660","B":"CT Pelvis Wo/W Contrast","C":"352","D":"72194","F":"979.8"},{"Policy Line":"5760","B":"CT Spine Lumbar Contrast","C":"352","D":"72132","F":"613.8"},{"Policy Line":"5765","B":"CT Spine Lumbar W/O Contrast","C":"352","D":"72131","F":"475.2"},{"Policy Line":"5770","B":"CT LUMBAR SPINE W/WO CNTRST","C":"352","D":"72133","F":"1140"},{"Policy Line":"5775","B":"CT Spine Thoracic W/Contrast","C":"352","D":"72129","F":"614.1"},{"Policy Line":"5780","B":"CT Spine Thoracic W/O Contrast","C":"352","D":"72128","F":"488.1"},{"Policy Line":"5785","B":"CT THORAC SPINE W/O&W CONTR","C":"352","D":"72130","F":"268.2"},{"Policy Line":"5800","B":"Stereotaxis","C":"352","D":"77011","F":"413.4"},{"Policy Line":"5850","B":"CT Thorax W/Contrast","C":"352","D":"71260","F":"774.3"},{"Policy Line":"5855","B":"CT-Thorax W/O Contrast","C":"352","D":"71250","F":"468.6"},{"Policy Line":"5860","B":"CT Thorax Wo/W Contrast","C":"352","D":"71270","F":"936"},{"Policy Line":"68300019","B":"CT Guidance","C":"333","D":"77014","F":"528.3"},{"Policy Line":"68300029","B":"SRS CT Guidance, Ajnc Code","C":"333","D":"77014","F":"528.3"},{"Policy Line":"68300175","B":"CT Phys Plcmt Rad Fields","C":"333","D":"77014","F":"528.3"},{"Policy Line":"71500060","B":"CTA Calcium Scoring - Screen","C":"350","D":"75571","F":"30"},{"Policy Line":"71555157","B":"CT Angio Lower Ext Wo/W - Lt","C":"352","D":"73706","F":"1246.8"},{"Policy Line":"71555158","B":"CT Angio Lower Ext Wo/W - Rt","C":"352","D":"73706","F":"1246.8"},{"Policy Line":"6200","B":"Carotid:Bil DuplxXtracan Scan","C":"921","D":"93880","F":"524.1"},{"Policy Line":"6206","B":"Carotid: Unilat - Rt","C":"921","D":"93882","F":"391.8"},{"Policy Line":"6208","B":"Carotid: Unilat - Lt","C":"921","D":"93882","F":"391.8"},{"Policy Line":"6910","B":"US Transcranial Art, Complete","C":"921","D":"93886","F":"578.1"},{"Policy Line":"6911","B":"XTRACRANL DuplxUNI/LTD Scan","C":"921","D":"93882","F":"391.8"},{"Policy Line":"72102500","B":"IVUS Ea Addtl Vessel","C":"480","D":"92979","F":"1693.5"},{"Policy Line":"72106650","B":"IVUS","C":"480","D":"92978","F":"3384.9"},{"Policy Line":"72300014","B":"Echocardiogram M Mode","C":"480","D":"93308","F":"248.7"},{"Policy Line":"72300015","B":"Echocardiography (Limited)","C":"480","D":"93308","F":"248.7"},{"Policy Line":"72300016","B":"Echocardiogram M Mode2D","C":"483","D":"93307","F":"295.5"},{"Policy Line":"72300017","B":"Doppler Echo Limited","C":"480","D":"93321","F":"64.2"},{"Policy Line":"72300018","B":"Doppler Echo Complete","C":"480","D":"93320","F":"105.3"},{"Policy Line":"72300035","B":"Echo Transesophageal","C":"483","D":"93312","F":"484.2"},{"Policy Line":"72300036","B":"Tee Transesopha Echo-Or","C":"483","D":"93312","F":"484.2"},{"Policy Line":"72300040","B":"Doppler Color Flow","C":"480","D":"93325","F":"107.7"},{"Policy Line":"72300044","B":"Stress Echocardiography","C":"483","D":"93350","F":"1060.8"},{"Policy Line":"72300045","B":"Stress Echo W/ Contin Monitor","C":"480","D":"93351","F":"1111.2"},{"Policy Line":"72300048","B":"Echo M-Mode/Doppler/Color","C":"483","D":"93306","F":"472.8"},{"Policy Line":"72300115","B":"Echocardiography (Limited) W/C","C":"480","D":"93308","F":"248.7"},{"Policy Line":"72300500","B":"Echocardiogram M Mode2D W/Cont","C":"480","D":"93307","F":"606.3"},{"Policy Line":"72300501","B":"Echocardiogram M Mode2D W/Bubb","C":"480","D":"93307","F":"606.3"},{"Policy Line":"72306606","B":"Echo Transthoracic Comp; congn","C":"483","D":"C8921","F":"906"},{"Policy Line":"0058","B":"US Guidance Needle Plcmnt S&I","C":"402","D":"76942","F":"565.2"},{"Policy Line":"0192","B":"US Extrem Nonvascular Complete","C":"402","D":"76881","F":"273.6"},{"Policy Line":"0193","B":"US Extrem Nonvascular Limited","C":"402","D":"76882","F":"197.7"},{"Policy Line":"0201","B":"US Soft Tissue Chest Wall","C":"402","D":"76604","F":"228.6"},{"Policy Line":"0202","B":"US Soft Tissue Upper Back","C":"402","D":"76604","F":"228.6"},{"Policy Line":"0203","B":"US Soft Tissue Lower Back","C":"402","D":"76705","F":"215.4"},{"Policy Line":"0204","B":"US Soft Tissue Abdominal Wall","C":"402","D":"76705","F":"215.4"},{"Policy Line":"0205","B":"US Soft Tiss Pelvic Wall-LTD","C":"402","D":"76857","F":"309"},{"Policy Line":"0206","B":"US Soft Tissue Buttock-LTD","C":"402","D":"76857","F":"309"},{"Policy Line":"0207","B":"US Soft Tissue Neck","C":"402","D":"76536","F":"224.1"},{"Policy Line":"0208","B":"US Retroperitoneal Limited","C":"402","D":"76775","F":"209.7"},{"Policy Line":"0209","B":"US Doppler Transplanted Kidney","C":"402","D":"76776","F":"207.9"},{"Policy Line":"0274","B":"US Breast Complete LFT","C":"402","D":"76641","F":"271.8"},{"Policy Line":"0275","B":"US Breast Complete - RT","C":"402","D":"76641","F":"271.8"},{"Policy Line":"0276","B":"US Breast Complete - BI","C":"402","D":"76641","F":"271.8"},{"Policy Line":"0277","B":"US Breast Limited LT","C":"402","D":"76642","F":"251.4"},{"Policy Line":"0278","B":"US Breast Limited - RT","C":"402","D":"76642","F":"251.4"},{"Policy Line":"0279","B":"US Breast Limited BI","C":"402","D":"76642","F":"251.4"},{"Policy Line":"0280","B":"US Extremity Non-Vasc LTD - LT","C":"402","D":"76882","F":"197.7"},{"Policy Line":"0281","B":"US Extremity Non-Vasc LTD - RT","C":"402","D":"76882","F":"197.7"},{"Policy Line":"2931","B":"US Transvag: Pregnant Uterus","C":"402","D":"76817","F":"227.7"},{"Policy Line":"3450","B":"US Guidance- Abcess Drainage","C":"402","D":"76942","F":"565.2"},{"Policy Line":"3453","B":"US Ob Follow Up per Fetus","C":"402","D":"76816","F":"207.9"},{"Policy Line":"5259","B":"US Guidance Non-vascular","C":"402","D":"76942","F":"565.2"},{"Policy Line":"5300","B":"Duplx Flow Pelvic Vasc-Compl","C":"921","D":"93975","F":"299.7"},{"Policy Line":"5302","B":"Intraop Venous Doppler - L Leg","C":"921","D":"93971","F":"249.9"},{"Policy Line":"5304","B":"Intraop Venous Doppler - R Leg","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6010","B":"US- Abdomen General (Complete)","C":"402","D":"76700","F":"236.1"},{"Policy Line":"6020","B":"US - Abdomen Limited","C":"402","D":"76705","F":"215.4"},{"Policy Line":"6030","B":"DuplxAbdomen Vasc Complete","C":"921","D":"93975","F":"299.7"},{"Policy Line":"6031","B":"US Exam - AAA Screen","C":"402","D":"76706","F":"208.8"},{"Policy Line":"6035","B":"DuplxTesticular Vasc Study","C":"921","D":"93975","F":"299.7"},{"Policy Line":"6040","B":"Aorta: Duplx Scan W/Graft Eval","C":"921","D":"93978","F":"178.5"},{"Policy Line":"6050","B":"US Guided Amniocentesis S&I","C":"402","D":"76946","F":"261.6"},{"Policy Line":"6060","B":"Aorta Abdomen Deep","C":"402","D":"76705","F":"215.4"},{"Policy Line":"6070","B":"US - Appendix","C":"402","D":"76705","F":"215.4"},{"Policy Line":"6080","B":"ART DUPLX BPG UPPER EXTR -BI","C":"921","D":"93930","F":"633.9"},{"Policy Line":"6083","B":"Art Duplex Upper Extr - LT/LTD","C":"921","D":"93931","F":"416.4"},{"Policy Line":"6084","B":"Art Duplex BPG Upper Extr - BI","C":"921","D":"93930","F":"633.9"},{"Policy Line":"6086","B":"Art Duplex Upper Extr - RT/LTD","C":"921","D":"93931","F":"416.4"},{"Policy Line":"6090","B":"DUPLEX ART LOWER EXT BIL","C":"921","D":"93925","F":"273"},{"Policy Line":"6096","B":"ART DUPLEX LOWER EXTR - RT/LTD","C":"921","D":"93926","F":"234.3"},{"Policy Line":"6098","B":"ART DUPLEX LOWER EXTR - LT/LTD","C":"921","D":"93926","F":"234.3"},{"Policy Line":"6220","B":"US - Chest Localize","C":"402","D":"76604","F":"228.6"},{"Policy Line":"6300","B":"US - Diaphragm","C":"402","D":"76705","F":"215.4"},{"Policy Line":"6331","B":"US Guided Pseudoaneurysm Inje","C":"402","D":"76942","F":"565.2"},{"Policy Line":"6351","B":"US LTD Non-Vasc Extremity: RT","C":"402","D":"76882","F":"197.7"},{"Policy Line":"6353","B":"US LTD NonVasc Extremity: LT","C":"402","D":"76882","F":"197.7"},{"Policy Line":"6375","B":"Duplx Art Groin Complt - BI","C":"921","D":"93925","F":"273"},{"Policy Line":"6376","B":"ART DPLX BPG Groin - RT","C":"921","D":"93926","F":"234.3"},{"Policy Line":"6377","B":"ART DPLX BPG Groin - LT","C":"921","D":"93926","F":"234.3"},{"Policy Line":"6400","B":"Head Neonatal","C":"402","D":"76506","F":"240.9"},{"Policy Line":"6401","B":"US Head and Neck - Adult","C":"402","D":"76536","F":"224.1"},{"Policy Line":"6420","B":"US - Hip Baby","C":"402","D":"76885","F":"315.6"},{"Policy Line":"64400150","B":"US Guidance","C":"402","D":"76942","F":"565.2"},{"Policy Line":"64502029","B":"RUS","C":"402","D":"76872","F":"154.5"},{"Policy Line":"64600058","B":"US Guidance Non-vascular","C":"402","D":"76942","F":"565.2"},{"Policy Line":"64608905","B":"ULTRASOUND GUIDANCE VASCULAR","C":"402","D":"76937","F":"147.9"},{"Policy Line":"6501","B":"US Inguinal Canal - Right","C":"402","D":"76882","F":"197.7"},{"Policy Line":"6503","B":"US Inguinal Canal - Left","C":"402","D":"76882","F":"197.7"},{"Policy Line":"6551","B":"Jugular Vein Doppler Bilateral","C":"921","D":"93970","F":"314.4"},{"Policy Line":"6552","B":"Jugular Vein Doppler Uni- Rt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6553","B":"Jugular Vein Doppler Uni- Lt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6575","B":"US LIVER LOC S&I","C":"402","D":"76942","F":"565.2"},{"Policy Line":"6600","B":"OB Biophys ProfileW/ONonStress","C":"402","D":"76819","F":"266.7"},{"Policy Line":"6605","B":"OB Doppler","C":"402","D":"76827","F":"164.7"},{"Policy Line":"6608","B":"US OB Singl Gest 1St Trimester","C":"402","D":"76801","F":"254.7"},{"Policy Line":"6609","B":"OB Comp- 1St Tri- Ea Addl Gest","C":"402","D":"76802","F":"236.4"},{"Policy Line":"6610","B":"US OB Singl Gest-2/3 Trimester","C":"402","D":"76805","F":"220.5"},{"Policy Line":"6611","B":"US OB- 2/3 Tri- Ea Addl Gest","C":"402","D":"76810","F":"214.2"},{"Policy Line":"6615","B":"OB Limited/Emergency/Position","C":"402","D":"76815","F":"173.4"},{"Policy Line":"6675","B":"US Pelvic Complete","C":"402","D":"76856","F":"208.2"},{"Policy Line":"6676","B":"Pelvic US Complete- For Driver","C":"402","D":"76856","F":"208.2"},{"Policy Line":"6695","B":"Pelvic Histosonogram","C":"402","D":"76831","F":"307.8"},{"Policy Line":"6750","B":"Renal Ultrasound","C":"402","D":"76770","F":"282.6"},{"Policy Line":"6780","B":"DuplxRenal Art Doppler Comp","C":"921","D":"93975","F":"299.7"},{"Policy Line":"6801","B":"Venous: Saphenous Mapping - Rt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6802","B":"Venous: Saphenous Mapping - Lt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6805","B":"Venous Duplx:Saphenous Map-BI","C":"921","D":"93970","F":"314.4"},{"Policy Line":"6825","B":"US Spine","C":"402","D":"76800","F":"316.2"},{"Policy Line":"68300246","B":"US Prostate Vol for Brachy Tmt","C":"402","D":"76873","F":"113.7"},{"Policy Line":"6850","B":"Intraoperative Ultrasound","C":"402","D":"76998","F":"291"},{"Policy Line":"6851","B":"Intra Op Us For D&C","C":"402","D":"76998","F":"291"},{"Policy Line":"6855","B":"Intraoperative Us: Extended","C":"402","D":"76998","F":"291"},{"Policy Line":"6860","B":"Duplx Art Sma Doppler Comp","C":"921","D":"93975","F":"299.7"},{"Policy Line":"6875","B":"US Testicular Scrotum&Contents","C":"402","D":"76870","F":"350.4"},{"Policy Line":"6881","B":"US EXT Superficial NonVasc RT","C":"402","D":"76882","F":"197.7"},{"Policy Line":"6883","B":"US EXT Superficial NonVasc LT","C":"402","D":"76882","F":"197.7"},{"Policy Line":"6895","B":"US - Thyroid","C":"402","D":"76536","F":"224.1"},{"Policy Line":"6920","B":"Transvaginal Non-Ob Us","C":"402","D":"76830","F":"200.1"},{"Policy Line":"6925","B":"US Transvaginal Add Non-OB","C":"402","D":"76830","F":"200.1"},{"Policy Line":"6940","B":"Venous Extrm Duplx Arm - BI","C":"921","D":"93970","F":"314.4"},{"Policy Line":"6941","B":"Venous Upper & Lower Extrm Bi","C":"921","D":"93970","F":"314.4"},{"Policy Line":"6946","B":"Venous Arm Unilat - Rt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6947","B":"Venous Arm Unilat - Lt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6965","B":"Venous: Upper Extr Mapping-Bi","C":"921","D":"93970","F":"314.4"},{"Policy Line":"6967","B":"Venous: Upper Extr Mapping-Rt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6968","B":"Venous: Upper Extr Mapping-Lt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6970","B":"Venous Doppler Lower Ext - Rt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6971","B":"Venous Doppler Lower Ext - Lt","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6972","B":"Venous Doppler Lower Ext - Bil","C":"921","D":"93970","F":"314.4"},{"Policy Line":"6973","B":"US Duplex/Reflux Extrem - RT","C":"921","D":"93971","F":"249.9"},{"Policy Line":"6985","B":"Venous Doppler Reflux Study-BI","C":"921","D":"93970","F":"633.9"},{"Policy Line":"7052","B":"Arterial Lower Extre Dig-Rt","C":"921","D":"93926","F":"234.3"},{"Policy Line":"7053","B":"Duplx Art LwXtr Dig Compl-BI","C":"921","D":"93925","F":"273"},{"Policy Line":"7056","B":"Art Bypass Grft Upper Extr -Rt","C":"921","D":"93931","F":"416.4"},{"Policy Line":"7058","B":"Arterial Lower Extre Dig-Lt","C":"921","D":"93926","F":"234.3"},{"Policy Line":"7060","B":"Art Bypass Grft Upper Extr -LT","C":"921","D":"93931","F":"416.4"},{"Policy Line":"7065","B":"Art Duplx BPG Lower Extr -Rt","C":"921","D":"93926","F":"234.3"},{"Policy Line":"7066","B":"Art Bypass Grft Lower Extr -LT","C":"921","D":"93926","F":"234.3"},{"Policy Line":"7067","B":"Duplx Art Bypas Grf Lwr Ext-Bi","C":"921","D":"93925","F":"273"},{"Policy Line":"7080","B":"Arterial Upper Extr Digits -Rt","C":"921","D":"93931","F":"416.4"},{"Policy Line":"7081","B":"Arterial Upper Extr Digits -Lt","C":"921","D":"93931","F":"416.4"},{"Policy Line":"7098","B":"US Guidance Vascular Access","C":"402","D":"76937","F":"147.9"},{"Policy Line":"7103","B":"US Duplex/Reflux Extrem - LT","C":"921","D":"93971","F":"249.9"},{"Policy Line":"72300046","B":"Echo TEE for Guidance","C":"483","D":"93355","F":"960"},{"Policy Line":"72306506","B":"Fetal Echocardiogram (M-Mode)","C":"402","D":"76825","F":"457.2"},{"Policy Line":"72306605","B":"Fetal Echo-Doppler Complete","C":"402","D":"76827","F":"164.7"},{"Policy Line":"8905","B":"ULTRASOUND GUIDANCE VASCULAR","C":"402","D":"76937","F":"147.9"},{"Policy Line":"0001","B":"MRI Brain/Brain Stem Wo/W Con","C":"611","D":"70553","F":"1586.4"},{"Policy Line":"0008","B":"MRI Brain/Brain Stem W/Contr","C":"611","D":"70552","F":"762.6"},{"Policy Line":"0009","B":"MRI Cervical Spine W/O Cont","C":"612","D":"72141","F":"688.5"},{"Policy Line":"0010","B":"MRI Spine Cervical W/Contrast","C":"612","D":"72142","F":"1232.1"},{"Policy Line":"0024","B":"MRI Brain/Brain Stem W/O Contr","C":"611","D":"70551","F":"746.1"},{"Policy Line":"0047","B":"MRI Cervical Spine Wo/W Contr","C":"610","D":"72156","F":"1644"},{"Policy Line":"0061","B":"MRI Iacs Wo/W Contrast","C":"611","D":"70553","F":"1586.4"},{"Policy Line":"0062","B":"MRI Pituitary Wo/W Contrast","C":"610","D":"70553","F":"1586.4"},{"Policy Line":"0067","B":"MRI Orbit/Face &/Or Neck W/Wo","C":"610","D":"70543","F":"1931.7"},{"Policy Line":"0124","B":"MRI ORBITS/FACE &OR nECK W/O","C":"610","D":"70540","F":"950.1"},{"Policy Line":"0146","B":"MRI Orbits/Face &Or Neck W/C","C":"610","D":"70542","F":"1109.1"},{"Policy Line":"0160","B":"MRA Neck W/O Contrast","C":"610","D":"70547","F":"590.1"},{"Policy Line":"0161","B":"MRA Neck W/Contrast","C":"610","D":"70548","F":"1211.4"},{"Policy Line":"0162","B":"MRA Neck Wo/W Contrast","C":"610","D":"70549","F":"1259.4"},{"Policy Line":"0164","B":"MRA Head W/O Contrast","C":"610","D":"70544","F":"606.6"},{"Policy Line":"0165","B":"MRA Head W/Contrast","C":"610","D":"70545","F":"810.3"},{"Policy Line":"0166","B":"MRA Head Wo/W Contrast","C":"610","D":"70546","F":"1262.4"},{"Policy Line":"0006","B":"MRI Abdomen W/O Contrast","C":"610","D":"74181","F":"1065"},{"Policy Line":"0011","B":"MRI Chest W/O Contrast","C":"610","D":"71550","F":"1061.7"},{"Policy Line":"0012","B":"MRI Lower Ext Jnt Wo/W Cont-Rt","C":"610","D":"73720","F":"1607.4"},{"Policy Line":"0014","B":"MRI Lumbar Spine W/O Cont","C":"612","D":"72148","F":"701.7"},{"Policy Line":"0015","B":"MRI Lumbar Spine W/Cont","C":"612","D":"72149","F":"1147.5"},{"Policy Line":"0016","B":"MRI Lower Ext Jnt Wo/W Cont-Lt","C":"610","D":"73720","F":"1607.4"},{"Policy Line":"0018","B":"MRI Pelvis W/O Contrast","C":"610","D":"72195","F":"906.9"},{"Policy Line":"0020","B":"MRI Thoracic Spine W/O Cont","C":"612","D":"72146","F":"756.3"},{"Policy Line":"0021","B":"MRI Thoracic Spine W/Cont","C":"612","D":"72147","F":"1524.9"},{"Policy Line":"0022","B":"MRI Upper Ext W/O Cont -Lt","C":"610","D":"73218","F":"681.9"},{"Policy Line":"0023","B":"MRI Upper Ext Jnt W/O Cont -Lt","C":"610","D":"73221","F":"845.4"},{"Policy Line":"0030","B":"MRI Lumbar Spine Wo/W Cont","C":"612","D":"72158","F":"1389.9"},{"Policy Line":"0033","B":"MRI Abdomen Ltd W/O Contrast","C":"610","D":"74181","F":"1065"},{"Policy Line":"0044","B":"MRA Abdomen Wo/W Contrast","C":"610","D":"C8902","F":"1725.9"},{"Policy Line":"0045","B":"MRA Chest Wo/W Contrast","C":"610","D":"C8911","F":"1560.3"},{"Policy Line":"0048","B":"MRI Thoracic Spine Wo/W Contr","C":"610","D":"72157","F":"1644"},{"Policy Line":"0056","B":"MRI Temporomandibular Joint","C":"610","D":"70336","F":"1394.7"},{"Policy Line":"0070","B":"MRI Upper Ext Jnt Wo/W Cont-Lt","C":"610","D":"73223","F":"1547.4"},{"Policy Line":"0075","B":"MRI Pelvis Wo/W Contrast","C":"610","D":"72197","F":"1844.4"},{"Policy Line":"0076","B":"MRA Abdomen W/O Contrast","C":"610","D":"C8901","F":"870.9"},{"Policy Line":"0077","B":"MRI Lower Ext W/O Cont - Lt","C":"610","D":"73718","F":"867.6"},{"Policy Line":"0080","B":"MRI Upper Ext Wo/W Cont -LT","C":"610","D":"73220","F":"1222.2"},{"Policy Line":"0087","B":"MRA Upper Ext Wo/W Cont - Lt","C":"610","D":"C8936","F":"1851.3"},{"Policy Line":"0106","B":"MRI Lower Ext W/O Cont - Rt","C":"610","D":"73718","F":"867.6"},{"Policy Line":"0107","B":"MRI Lower Ext W/O Cont - Bi","C":"610","D":"73718","F":"954.3"},{"Policy Line":"0109","B":"MRI Lower Ext Jnt Wo/W Cont-Bi","C":"610","D":"73720","F":"1768.2"},{"Policy Line":"0135","B":"MRA Upper Extremity W/Cont -Bi","C":"610","D":"C8934","F":"1266"},{"Policy Line":"0136","B":"MRA Upper Ext W/Cont - LT","C":"610","D":"C8934","F":"633"},{"Policy Line":"0137","B":"MRA Upper Ext W/Cont - Rt","C":"610","D":"C8934","F":"633"},{"Policy Line":"0144","B":"MRA Chest W/Contrast","C":"610","D":"C8909","F":"1260"},{"Policy Line":"0145","B":"MRA Abdomen W/Contrast","C":"610","D":"C8900","F":"1102.8"},{"Policy Line":"0148","B":"MRA CHEST W/O Contrast","C":"618","D":"C8910","F":"1116.3"},{"Policy Line":"0170","B":"MRI Breast Wo/W Cont - Bilat","C":"610","D":"C8908","F":"2400"},{"Policy Line":"0176","B":"MRI Breast W/O Cont - Bilat","C":"610","D":"77047","F":"1953.3"},{"Policy Line":"0181","B":"C MRI W/O CONTRAST, MORPH","C":"610","D":"75557","F":"719.1"},{"Policy Line":"0183","B":"CMRI W/O Con W/Stress Imaging","C":"610","D":"75559","F":"1014.9"},{"Policy Line":"0184","B":"C MRI Morph W/Wo Contrast","C":"610","D":"75561","F":"1005.9"},{"Policy Line":"0186","B":"CMRI W/Wo Con W/Stress Imaging","C":"610","D":"75563","F":"1213.8"},{"Policy Line":"0188","B":"C MRI Velocity Flow Mapping","C":"610","D":"75565","F":"498.6"},{"Policy Line":"0190","B":"MRI Spectroscopy","C":"610","D":"76390","F":"1609.2"},{"Policy Line":"1011","B":"MRI CHEST W/CONTRAST","C":"610","D":"71551","F":"473.1"},{"Policy Line":"1012","B":"MRI Chest Wo/W Contrast","C":"610","D":"71552","F":"1866.9"},{"Policy Line":"1015","B":"MRI ABDOMEN LTD W/CON","C":"610","D":"74182","F":"1196.7"},{"Policy Line":"1016","B":"MRI Abdomen Wo/W Contrast","C":"610","D":"74183","F":"1831.8"},{"Policy Line":"1017","B":"MRI Abdomen W/Contrast","C":"610","D":"74182","F":"1196.7"},{"Policy Line":"1200","B":"MRI LWER EXT NOT JNT W/CON LT","C":"610","D":"73719","F":"489"},{"Policy Line":"1201","B":"MRI LWER EXT NOT JNT W/CON RT","C":"610","D":"73719","F":"489"},{"Policy Line":"1202","B":"MRI LWER EXT NOT JNT W/CON BI","C":"610","D":"73719","F":"977.4"},{"Policy Line":"1300","B":"MRI Lower Ext Jnt W/Cont - LT","C":"610","D":"73722","F":"1566.9"},{"Policy Line":"1301","B":"MRI Lower Ext Jnt W/Cont - Rt","C":"610","D":"73722","F":"1566.9"},{"Policy Line":"1302","B":"MRI Lower Ext Jnt W/Cont - BI","C":"610","D":"73722","F":"1950"},{"Policy Line":"1303","B":"MRI Lower Ext Jnt W/O Cont -LT","C":"610","D":"73721","F":"932.4"},{"Policy Line":"1304","B":"MRI Lower Ext Jnt W/O Cont -RT","C":"610","D":"73721","F":"932.4"},{"Policy Line":"1305","B":"MRI Lower Ext Jnt W/O Cont -Bi","C":"610","D":"73721","F":"1533.3"},{"Policy Line":"1306","B":"MRI Lower Ext Jnt Wo/W Cont-Lt","C":"610","D":"73723","F":"1698.6"},{"Policy Line":"1307","B":"MRI Lower Ext Jnt Wo/W Cont-Rt","C":"610","D":"73723","F":"1698.6"},{"Policy Line":"1308","B":"MRI Lower Ext Jnt Wo/W Cont-Bi","C":"610","D":"73723","F":"2100"},{"Policy Line":"1309","B":"MRA Lower Ext W/O Cont - Lt","C":"610","D":"C8913","F":"1533.3"},{"Policy Line":"1310","B":"MRA Lower Ext W/O Cont - Rt","C":"610","D":"C8913","F":"1533.3"},{"Policy Line":"1311","B":"MRA Lower Ext W/O Cont - Bi","C":"610","D":"C8913","F":"1980"},{"Policy Line":"1312","B":"MRA Lower Ext Wo/W Cont - Lt","C":"610","D":"C8914","F":"3655.8"},{"Policy Line":"1313","B":"MRA Lower Ext Wo/W Cont - Rt","C":"610","D":"C8914","F":"3655.8"},{"Policy Line":"1314","B":"MRA Lower Ext Wo/W Cont - BI","C":"610","D":"C8914","F":"4080"},{"Policy Line":"1315","B":"MRA Pelvis W/O","C":"610","D":"C8919","F":"805.8"},{"Policy Line":"1316","B":"MRI Pelvis Ltd W/Contrast","C":"610","D":"72196","F":"1511.1"},{"Policy Line":"1317","B":"MRA Pelvis With Contrast","C":"610","D":"C8918","F":"1153.8"},{"Policy Line":"1318","B":"MRI Abdomen W/O Cont W/Mrcp","C":"610","D":"74181","F":"1609.5"},{"Policy Line":"1319","B":"MRA Pelvis W & W/O Contrast","C":"610","D":"C8920","F":"1269.3"},{"Policy Line":"1900","B":"MRI Upper Ext W/O Cont - RT","C":"610","D":"73218","F":"681.9"},{"Policy Line":"1901","B":"MRI Upper Ext W/O Cont - Bi","C":"610","D":"73218","F":"862.5"},{"Policy Line":"1902","B":"MRI UPPR EXT NOT JNT W/CON LT","C":"610","D":"73219","F":"489"},{"Policy Line":"1903","B":"MRI UPPR EXT NOT JNT W/CON RT","C":"610","D":"73219","F":"489"},{"Policy Line":"1904","B":"MRI UPPR EXT NOT JNT W/CON BI","C":"610","D":"73219","F":"977.4"},{"Policy Line":"1905","B":"MRI Upper Ext Wo/W Cont - Rt","C":"610","D":"73220","F":"1222.2"},{"Policy Line":"1906","B":"MRI Up Ext Nt Jt Wo/WCont - Bi","C":"610","D":"73220","F":"1740"},{"Policy Line":"1907","B":"MRI Upper Ext Jnt W/O Cont -Rt","C":"610","D":"73221","F":"845.4"},{"Policy Line":"1908","B":"MRI Upper Ext Jnt W/O Cont -Bi","C":"610","D":"73221","F":"960"},{"Policy Line":"1909","B":"MRI Upper Ext Jnt W/Cont - Lt","C":"610","D":"73222","F":"1242"},{"Policy Line":"1910","B":"MRI Upper Ext Jnt W/Cont - RT","C":"610","D":"73222","F":"1242"},{"Policy Line":"1911","B":"MRI Upper Ext Jnt W/Cont - Bi","C":"610","D":"73222","F":"1242"},{"Policy Line":"1912","B":"MRI Upper Ext Jnt Wo/W Cont-Rt","C":"610","D":"73223","F":"1547.4"},{"Policy Line":"1915","B":"MRI BREAST UNI W/O CON LT","C":"610","D":"77046","F":"976.8"},{"Policy Line":"1916","B":"MRI BREAST UNI W/O CON RT","C":"610","D":"77046","F":"976.8"},{"Policy Line":"1917","B":"MRI BREAST UNI W&W/O CON LT","C":"610","D":"C8905","F":"1200"},{"Policy Line":"1918","B":"MRI BREAST UNI W&W/O CON RT","C":"610","D":"C8905","F":"1200"},{"Policy Line":"2655","B":"MRI Guided Breast Biopsy S&I","C":"610","D":"77021","F":"360"},{"Policy Line":"2659","B":"MRA Spinal Cord w/Contrast","C":"610","D":"C8931","F":"296.1"},{"Policy Line":"2660","B":"MRA Spinal Cord w/o Contrast","C":"610","D":"C8932","F":"198.6"},{"Policy Line":"2662","B":"MRA Spinal Cord w&w/o Contrast","C":"610","D":"C8933","F":"334.8"},{"Policy Line":"71600180","B":"Cardiac MRI-Morph W/O Contrast","C":"610","D":"75557","F":"719.1"},{"Policy Line":"0057","B":"Dexa Bone Density Study","C":"320","D":"77080","F":"51.9"},{"Policy Line":"0140","B":"POST OP HIP 1 VIEW","C":"320","D":"73501","F":"192.6"},{"Policy Line":"0142","B":"XR POST OP PELVIS 1-2 V","C":"320","D":"72170","F":"188.1"},{"Policy Line":"0151","B":"Dexa Bone Dens -Forearm","C":"320","D":"77081","F":"61.2"},{"Policy Line":"0199","B":"Cephalometrics","C":"320","D":"70140","F":"95.1"},{"Policy Line":"0766","B":"Arthrogram Ankle - Lt","C":"320","D":"73615","F":"216.9"},{"Policy Line":"0769","B":"Arthrogram Ankle - Rt","C":"320","D":"73615","F":"216.9"},{"Policy Line":"0778","B":"Arthrogram Knee - Lt","C":"320","D":"73580","F":"311.7"},{"Policy Line":"0781","B":"Arthrogram Knee - Rt","C":"320","D":"73580","F":"311.7"},{"Policy Line":"0790","B":"Arthrogram Wrist - Lt","C":"320","D":"73115","F":"99.6"},{"Policy Line":"0793","B":"Arthrogram Wrist - Rt","C":"320","D":"73115","F":"99.6"},{"Policy Line":"1211","B":"XR HIP UNI W/PELVIS 1VIEW","C":"320","D":"73501","F":"192.6"},{"Policy Line":"1212","B":"XR HIP LT W/PELVIS 2-3 VIEWS","C":"320","D":"73502","F":"198.3"},{"Policy Line":"1213","B":"XR HIP UNI W/PELVIS MIN 4VWS","C":"320","D":"73503","F":"215.1"},{"Policy Line":"1215","B":"XR HIPS BI W/PELVIS 3-4 VIEWS","C":"320","D":"73522","F":"324"},{"Policy Line":"1216","B":"XR HIPS BI W/PELVIS MIN5VWS","C":"320","D":"73523","F":"351.3"},{"Policy Line":"1217","B":"XR HIP RT W/PELVIS 2-3 VIEWS","C":"320","D":"73502","F":"198.3"},{"Policy Line":"2035","B":"AC Joints","C":"320","D":"73050","F":"119.7"},{"Policy Line":"2046","B":"XR Ankle 2 View - Rt","C":"320","D":"73600","F":"186"},{"Policy Line":"2048","B":"XR Ankle 2 View - Lt","C":"320","D":"73600","F":"186"},{"Policy Line":"2051","B":"XR Ankle >=3 View - Rt","C":"320","D":"73610","F":"180.6"},{"Policy Line":"2053","B":"XR Ankle >=3 View - Lt","C":"320","D":"73610","F":"180.6"},{"Policy Line":"2055","B":"Arthritis Survey 10 Joints","C":"320","D":"77077","F":"211.2"},{"Policy Line":"2120","B":"Bone Age Survey Studies","C":"320","D":"77072","F":"122.1"},{"Policy Line":"2125","B":"XR Bone Length Studies","C":"320","D":"77073","F":"158.4"},{"Policy Line":"2129","B":"XR Bone Survey Complete","C":"320","D":"77075","F":"332.7"},{"Policy Line":"2166","B":"XR Chest Ribs >= 3 View - RT","C":"320","D":"71101","F":"194.4"},{"Policy Line":"2169","B":"Chest Ribs Unilat - Lt","C":"320","D":"71101","F":"194.4"},{"Policy Line":"2186","B":"XR - Clavicle: Rt","C":"320","D":"73000","F":"162"},{"Policy Line":"2188","B":"XR Clavicle: Lt","C":"320","D":"73000","F":"162"},{"Policy Line":"2245","B":"Elbow 2 Views - Rt","C":"320","D":"73070","F":"189.6"},{"Policy Line":"2246","B":"XR Elbow 2 Views - Lt","C":"320","D":"73070","F":"189.6"},{"Policy Line":"2310","B":"XR Extremity Upper Infant RT","C":"320","D":"73092","F":"146.1"},{"Policy Line":"2313","B":"XR Extremity Upper Infant - Lt","C":"320","D":"73092","F":"146.1"},{"Policy Line":"2327","B":"XR Finger(S)/Thumb>=2Views-Rt","C":"320","D":"73140","F":"151.2"},{"Policy Line":"2328","B":"XR Finger(S)/Thumb >=2Views-Lt","C":"320","D":"73140","F":"151.2"},{"Policy Line":"2335","B":"Facial Bones Complete","C":"320","D":"70150","F":"178.8"},{"Policy Line":"2344","B":"XR FEMUR 1 VIEW","C":"320","D":"73551","F":"168.9"},{"Policy Line":"2345","B":"XR FEMUR MIN 2 VIEWS - LT","C":"320","D":"73552","F":"177.6"},{"Policy Line":"2346","B":"XR FEMUR MIN 2 VIEWS - RT","C":"320","D":"73552","F":"177.6"},{"Policy Line":"2347","B":"XR FEMUR MIN 2 VIEWS - BI","C":"320","D":"73552","F":"206.4"},{"Policy Line":"2371","B":"XR Foot 2 View - Rt","C":"320","D":"73620","F":"189.9"},{"Policy Line":"2373","B":"XR Foot 2 View Lt","C":"320","D":"73620","F":"189.9"},{"Policy Line":"2376","B":"XR Foot >=3 View - Rt","C":"320","D":"73630","F":"200.1"},{"Policy Line":"2378","B":"XR Foot >=3.0 Views Lt","C":"320","D":"73630","F":"200.1"},{"Policy Line":"2381","B":"XR Forearm 2 View - Rt","C":"320","D":"73090","F":"171"},{"Policy Line":"2383","B":"XR Forearm 2 View - Lt","C":"320","D":"73090","F":"171"},{"Policy Line":"2401","B":"XR Hand >=3 Views - Rt","C":"320","D":"73130","F":"167.7"},{"Policy Line":"2403","B":"XR Hand >=3 Views - Lt","C":"320","D":"73130","F":"167.7"},{"Policy Line":"2407","B":"XR HIPS W/PELVIS BI 2 VIEWS","C":"320","D":"73521","F":"288.9"},{"Policy Line":"2409","B":"XR HIPS W/PELVIS BI 3-4 VIEWS","C":"320","D":"73522","F":"324"},{"Policy Line":"2426","B":"XR Humerus >= 2 VIEWS- Rt","C":"320","D":"73060","F":"183.9"},{"Policy Line":"2428","B":"XR Humerus >=2 VIEWS - Lt","C":"320","D":"73060","F":"183.9"},{"Policy Line":"2476","B":"XR Knee 1 Or 2 View - Rt","C":"320","D":"73560","F":"167.4"},{"Policy Line":"2477","B":"XR Knee 1 Or 2 View - BI","C":"320","D":"73560","F":"251.1"},{"Policy Line":"2478","B":"XR Knee 1 Or 2 View - LT","C":"320","D":"73560","F":"167.4"},{"Policy Line":"2481","B":"XR Knee 3 View - Rt","C":"320","D":"73562","F":"159.6"},{"Policy Line":"2483","B":"XR Knee 3 View - Lt","C":"320","D":"73562","F":"159.6"},{"Policy Line":"2485","B":"XR Knee BI Stnding Ap(Wght Bea","C":"320","D":"73565","F":"198.3"},{"Policy Line":"2486","B":"XR Knee 3 View - BI","C":"320","D":"73562","F":"326.1"},{"Policy Line":"2505","B":"XR Knee 4 View Min - LT","C":"320","D":"73564","F":"197.1"},{"Policy Line":"2506","B":"XR Knee 4 View Min - RT","C":"320","D":"73564","F":"197.1"},{"Policy Line":"2508","B":"Spine Cervical - 4 View Min","C":"320","D":"72050","F":"163.2"},{"Policy Line":"2550","B":"Mandible Complete","C":"320","D":"70110","F":"175.2"},{"Policy Line":"2600","B":"Nasal Bones Complete","C":"320","D":"70160","F":"122.1"},{"Policy Line":"2652","B":"Orbits Complete - Bilat","C":"320","D":"70200","F":"186.9"},{"Policy Line":"2661","B":"XR Heel >=2 Views- Rt","C":"320","D":"73650","F":"192.9"},{"Policy Line":"2663","B":"XR Heel >= 2.0 Views - LT","C":"320","D":"73650","F":"192.9"},{"Policy Line":"2665","B":"Panorex","C":"320","D":"70355","F":"167.1"},{"Policy Line":"2671","B":"XR Patella 4 View- Rt","C":"320","D":"73564","F":"197.1"},{"Policy Line":"2673","B":"XR Patella - Lt","C":"320","D":"73564","F":"197.1"},{"Policy Line":"2675","B":"XR Pelvis: Ap","C":"320","D":"72170","F":"188.1"},{"Policy Line":"2690","B":"Ribs: Bilateral 3 Views","C":"320","D":"71110","F":"191.7"},{"Policy Line":"2696","B":"Ribs: Unilateral - Rt","C":"320","D":"71100","F":"194.4"},{"Policy Line":"2697","B":"Ribs: Unilateral - Lt","C":"320","D":"71100","F":"194.4"},{"Policy Line":"2710","B":"Sacroiliac Joints","C":"320","D":"72202","F":"159.9"},{"Policy Line":"2715","B":"XR Sacrum-Coccyx","C":"320","D":"72220","F":"197.1"},{"Policy Line":"2726","B":"XR Scapula - Rt","C":"320","D":"73010","F":"172.5"},{"Policy Line":"2728","B":"XR Scapula - Lt","C":"320","D":"73010","F":"172.5"},{"Policy Line":"2730","B":"X-R SternoClaviclar Jnts 3+Vws","C":"320","D":"71130","F":"40.8"},{"Policy Line":"2746","B":"XR Shoulder 2 View Min -Rt","C":"320","D":"73030","F":"163.2"},{"Policy Line":"2748","B":"XR Shoulder 2 View Min -Lt","C":"320","D":"73030","F":"163.2"},{"Policy Line":"2749","B":"XR Shoulder 2 View Min -BI","C":"320","D":"73030","F":"319.2"},{"Policy Line":"2751","B":"XR Shoulder - Rt, Single View","C":"320","D":"73020","F":"107.1"},{"Policy Line":"2753","B":"XR Shoulder - Lt, Single View","C":"320","D":"73020","F":"107.1"},{"Policy Line":"2770","B":"Sinuses Paranasal Complete","C":"320","D":"70220","F":"215.1"},{"Policy Line":"2780","B":"Skull Complete","C":"320","D":"70260","F":"191.7"},{"Policy Line":"2785","B":"Skull Limited","C":"320","D":"70250","F":"182.1"},{"Policy Line":"2800","B":"Spine Cerv Complete","C":"320","D":"72052","F":"209.7"},{"Policy Line":"2805","B":"Spine Cervical - 2 Or 3 Views","C":"320","D":"72040","F":"171.3"},{"Policy Line":"2807","B":"XR Spine Cervical 1 Vw","C":"320","D":"72020","F":"110.4"},{"Policy Line":"2811","B":"XR SPI ENTIRE SCOLI EVAL)2/3VW","C":"320","D":"72082","F":"219"},{"Policy Line":"2815","B":"Spine Lumbar - 2 Or 3 Views","C":"320","D":"72100","F":"216.6"},{"Policy Line":"2820","B":"Spine Lumbar 4 View Minimum","C":"320","D":"72110","F":"182.4"},{"Policy Line":"2828","B":"XR Spine Thoracic 1 View","C":"320","D":"72020","F":"110.4"},{"Policy Line":"2830","B":"Spine Thoracic 2 View","C":"320","D":"72070","F":"205.2"},{"Policy Line":"2831","B":"Spine Thoracolumbar - 2 Views","C":"320","D":"72080","F":"222"},{"Policy Line":"2840","B":"X-Ray Sternum min 2views","C":"320","D":"71120","F":"198.9"},{"Policy Line":"2852","B":"XR Toe(S) Lt Foot >=2Views- LT","C":"320","D":"73660","F":"158.1"},{"Policy Line":"2857","B":"XR Toe(S) Rt Foot >=2Views-RT","C":"320","D":"73660","F":"158.1"},{"Policy Line":"2875","B":"XR Tibia&Fibula 2vews - RT","C":"320","D":"73590","F":"184.8"},{"Policy Line":"2877","B":"XR Tibia&Fibula 2Vews- LT","C":"320","D":"73590","F":"184.8"},{"Policy Line":"2878","B":"X-ray Tibia&Fibula 2Vws- BI","C":"320","D":"73590","F":"275.4"},{"Policy Line":"2880","B":"XR TMJ Joint BI","C":"320","D":"70330","F":"240.9"},{"Policy Line":"2976","B":"XR Wrist >=3 View - Rt","C":"320","D":"73110","F":"161.7"},{"Policy Line":"2978","B":"XR Wrist >=3 View - Lt","C":"320","D":"73110","F":"161.7"},{"Policy Line":"2981","B":"XR Wrist 2 View - Rt","C":"320","D":"73100","F":"185.7"},{"Policy Line":"2983","B":"XR Wrist 2 View - Lt","C":"320","D":"73100","F":"185.7"},{"Policy Line":"3505","B":"Ribs:Bilat W/Pa Chest Min 4 Vw","C":"320","D":"71111","F":"195.3"},{"Policy Line":"3860","B":"XR TMJ Joint RT","C":"320","D":"70328","F":"223.8"},{"Policy Line":"3861","B":"XR TMJ Joint LT","C":"320","D":"70328","F":"223.8"},{"Policy Line":"64100612","B":"Post Op Skull No Charge","C":"320","D":"70250","F":"0"},{"Policy Line":"64101140","B":"Mandible","C":"320","D":"70100","F":"211.5"},{"Policy Line":"64608300","B":"Diskography: Lumbar S&I","C":"320","D":"72295","F":"1674.3"},{"Policy Line":"8300","B":"Diskography: Lumbar S&I","C":"320","D":"72295","F":"1674.3"},{"Policy Line":"8301","B":"DISCOGRAPHY CER/T EA LEVEL S&I","C":"320","D":"72285","F":"1116"},{"Policy Line":"8447","B":"Spine Thoracic 3 View","C":"320","D":"72072","F":"206.4"},{"Policy Line":"8448","B":"Spine Lumbar Comp W/ Bending","C":"320","D":"72114","F":"204"},{"Policy Line":"8449","B":"XR Elbow >=3 Views - LT","C":"320","D":"73080","F":"196.2"},{"Policy Line":"8471","B":"XR Elbow >=3 Views - Rt","C":"320","D":"73080","F":"196.2"},{"Policy Line":"8475","B":"XR Hand 2 Views - RT","C":"320","D":"73120","F":"163.5"},{"Policy Line":"8481","B":"XR Extremity Lower Infant - Rt","C":"320","D":"73592","F":"185.4"},{"Policy Line":"8482","B":"XR Extremity Lower Infant - BI","C":"320","D":"73592","F":"275.4"},{"Policy Line":"8501","B":"XR Hand 2 Views - Lt","C":"320","D":"73120","F":"163.5"},{"Policy Line":"8502","B":"XR Extremity Lower Infant - Lt","C":"320","D":"73592","F":"185.4"},{"Policy Line":"0004","B":"Brain Imaging <4V W/Vasc Flow","C":"340","D":"78601","F":"687.9"},{"Policy Line":"0073","B":"NM - Lymphoscintigraphy","C":"341","D":"78195","F":"677.4"},{"Policy Line":"0102","B":"Liver Imaging Static Only","C":"340","D":"78201","F":"283.2"},{"Policy Line":"0103","B":"Liver Spect","C":"341","D":"78205","F":"1147.2"},{"Policy Line":"0178","B":"Theraputic Administation","C":"342","D":"79101","F":"245.1"},{"Policy Line":"0196","B":"Implanted Pump Injection Scan","C":"340","D":"78499","F":"1080.6"},{"Policy Line":"3003","B":"PET/CT Limited Initial","C":"404","D":"78814","F":"2242.5"},{"Policy Line":"3005","B":"PET/CT Limited Subsequent","C":"404","D":"78814","F":"2242.5"},{"Policy Line":"3009","B":"PET/CT Skull-Thigh Initial","C":"404","D":"78815","F":"2361"},{"Policy Line":"3011","B":"PET/CT Skull-Thigh Sub","C":"404","D":"78815","F":"2361"},{"Policy Line":"3013","B":"PET/CT Whole Body Initial","C":"404","D":"78816","F":"2491.8"},{"Policy Line":"3014","B":"PET/CT Whole Body Subsequent","C":"404","D":"78816","F":"2491.8"},{"Policy Line":"3017","B":"PET/CT Dementia /Alzheimer'S","C":"404","D":"78608","F":"4228.8"},{"Policy Line":"3022","B":"PET Limited Initial","C":"404","D":"78811","F":"1438.5"},{"Policy Line":"3024","B":"PET Limited Subsequent","C":"404","D":"78811","F":"1438.5"},{"Policy Line":"3026","B":"PET Skull Base -Thigh Initial","C":"404","D":"78812","F":"1088.4"},{"Policy Line":"3028","B":"PET Skull Base-Thigh Subsequnt","C":"404","D":"78812","F":"1088.4"},{"Policy Line":"3030","B":"PET Full Body Initial","C":"404","D":"78813","F":"1088.4"},{"Policy Line":"3032","B":"PET Full Body Subsequent","C":"404","D":"78813","F":"1088.4"},{"Policy Line":"3061","B":"Radioactive Inj Non Imgaging","C":"340","D":"78808","F":"852"},{"Policy Line":"3101","B":"I131 Migb Scan","C":"341","D":"78075","F":"5745.3"},{"Policy Line":"4020","B":"NM - Abscess Loc Limited","C":"341","D":"78805","F":"765.9"},{"Policy Line":"4025","B":"Abscess Loc Spect","C":"341","D":"78807","F":"326.1"},{"Policy Line":"4030","B":"NM - Abscess L0C Wb","C":"341","D":"78806","F":"532.2"},{"Policy Line":"4050","B":"NM - Bone Image Limited","C":"341","D":"78300","F":"408"},{"Policy Line":"4055","B":"NM - Bone Image Spect","C":"341","D":"78320","F":"846.9"},{"Policy Line":"4060","B":"NM - Bone Image Three Phase","C":"341","D":"78315","F":"841.2"},{"Policy Line":"4065","B":"NM - Bone Scan Wb","C":"341","D":"78306","F":"432.3"},{"Policy Line":"4095","B":"Brain: Image Spect","C":"341","D":"78607","F":"624.6"},{"Policy Line":"4125","B":"NM - HIDA (Hepatobiliary Scan)","C":"341","D":"78226","F":"940.2"},{"Policy Line":"4135","B":"Cisternogram","C":"341","D":"78630","F":"3266.1"},{"Policy Line":"4150","B":"CSF Leakage","C":"341","D":"78650","F":"472.5"},{"Policy Line":"4155","B":"CSF Shunt Evaluation","C":"341","D":"78645","F":"736.8"},{"Policy Line":"4175","B":"Cystogram Vcu","C":"341","D":"78740","F":"541.2"},{"Policy Line":"4270","B":"NM - Gastric Emptying","C":"341","D":"78264","F":"860.1"},{"Policy Line":"4280","B":"NM - Abdominal Rbc Scan","C":"341","D":"78278","F":"1090.8"},{"Policy Line":"4295","B":"NM - HIDA Scan (Quantitative)","C":"341","D":"78227","F":"940.2"},{"Policy Line":"4300","B":"NM - Hyperthyroidism Therapy","C":"342","D":"79005","F":"786.3"},{"Policy Line":"4360","B":"NM - Kidney: Triple Renal","C":"341","D":"78707","F":"727.8"},{"Policy Line":"4400","B":"NM - Liver/Spleen Scan","C":"341","D":"78215","F":"416.1"},{"Policy Line":"4415","B":"Hemangioma Scan","C":"341","D":"78206","F":"1334.7"},{"Policy Line":"4440","B":"NM - Lung Perfusion","C":"341","D":"78580","F":"289.8"},{"Policy Line":"4445","B":"NM - Lung Perfusion/Vent","C":"341","D":"78582","F":"609.3"},{"Policy Line":"4500","B":"Meckels Diverticulum","C":"341","D":"78290","F":"1149.9"},{"Policy Line":"4540","B":"NM - MUGA","C":"341","D":"78453","F":"842.7"},{"Policy Line":"4545","B":"NM - Myocardial Spect Single","C":"341","D":"78451","F":"2148.3"},{"Policy Line":"4551","B":"NM - Myocardial Spect Multiple","C":"341","D":"78452","F":"2151"},{"Policy Line":"4600","B":"NM - Parathyroid Planar","C":"341","D":"78070","F":"837"},{"Policy Line":"4625","B":"NM - Pulmonary Quant Function","C":"341","D":"78598","F":"493.2"},{"Policy Line":"4770","B":"NM - Thyroid Ablation","C":"342","D":"79005","F":"786.3"},{"Policy Line":"4780","B":"NM - S Iodine Whole Body Scan","C":"341","D":"78018","F":"977.1"},{"Policy Line":"4785","B":"NM - Thyroid Scan Only","C":"341","D":"78013","F":"327"},{"Policy Line":"4795","B":"NM - Thyroid Uptake Scan","C":"341","D":"78014","F":"433.8"},{"Policy Line":"4800","B":"Thyroid Uptake Single","C":"341","D":"78012","F":"1599.6"},{"Policy Line":"4810","B":"NM Trpl Renal-SglStud W/WoDrug","C":"341","D":"78708","F":"698.7"},{"Policy Line":"4811","B":"Renal Scan Static","C":"341","D":"78700","F":"1085.1"},{"Policy Line":"4825","B":"Tumor: Localization Limited","C":"341","D":"78800","F":"461.7"},{"Policy Line":"4830","B":"NM - Tumor: Localization Spect","C":"341","D":"78803","F":"457.2"},{"Policy Line":"4835","B":"NM-Tumor Loc Whole Body-2+ Dys","C":"341","D":"78804","F":"1228.8"},{"Policy Line":"4836","B":"Tumor Loc Whole Bdy-Single Day","C":"341","D":"78802","F":"1046.7"},{"Policy Line":"4955","B":"NM -Gated Blood Pool Stdy-Rest","C":"341","D":"78472","F":"663.9"},{"Policy Line":"6052","B":"Bone Scan - Multiple Areas","C":"341","D":"78305","F":"1591.2"},{"Policy Line":"6053","B":"NM - IMAGING CARDIAC SHUNT","C":"341","D":"78428","F":"654"},{"Policy Line":"6054","B":"NM - IMAGING LUNG VENTILATION","C":"341","D":"78579","F":"369"},{"Policy Line":"71401015","B":"Radiopharm Tx Intra-Arterial","C":"342","D":"79445","F":"3400.5"},{"Policy Line":"3000","B":"PET/CT Fdg Dose","C":"343","D":"A9552","F":"603.9"},{"Policy Line":"3001","B":"F-18 Study Dose Up To 30Mci","C":"343","D":"A9580","F":"297.9"},{"Policy Line":"71400070","B":"TC99M Sulfur Colloid<=20.00mci","C":"343","D":"A9541","F":"752.4"},{"Policy Line":"71402100","B":"Cold Pyp LbldRBC TC-99m<=30mci","C":"343","D":"A9560","F":"728.7"},{"Policy Line":"71402200","B":"GA-67 Citrate 6Mci","C":"343","D":"A9556","F":"1815.3"},{"Policy Line":"71402300","B":"I-123 Cap: 200 Microcuries","C":"343","D":"A9516","F":"595.5"},{"Policy Line":"71402301","B":"I-123 Cap:100 Microcuries","C":"343","D":"A9516","F":"595.5"},{"Policy Line":"71402302","B":"XOFIGO per MicroCurie","C":"344","D":"A9606","F":"183.9"},{"Policy Line":"71402304","B":"TC99M-LYMPHOSEEK <=0.5mci","C":"343","D":"A9520","F":"851.7"},{"Policy Line":"71402320","B":"Indium-111 Dtpa Per 0.5 Mci","C":"343","D":"A9548","F":"8642.1"},{"Policy Line":"71402330","B":"Octreoscan Up To 6 Mci","C":"343","D":"A9572","F":"18536.1"},{"Policy Line":"71402340","B":"Indium 111 AUTOWbc Per 0.5 Mci","C":"343","D":"A9570","F":"7106.4"},{"Policy Line":"71402750","B":"TC99M Sestamibi / Study Dose","C":"343","D":"A9500","F":"639.3"},{"Policy Line":"71402765","B":"TC 99M Ceretec","C":"343","D":"A9569","F":"9630.9"},{"Policy Line":"71402775","B":"TC99M Choletec","C":"343","D":"A9537","F":"342.3"},{"Policy Line":"71402810","B":"TC 99M Hmpao Wbc","C":"343","D":"A9569","F":"9630.9"},{"Policy Line":"71402830","B":"TC99M Maa Per Study Dose 10Mci","C":"343","D":"A9540","F":"179.4"},{"Policy Line":"71402840","B":"TC99M Mag-3 /Study Dose 10Mci","C":"343","D":"A9562","F":"1662.6"},{"Policy Line":"71402850","B":"TC99M Mdp Up To 30 Mci","C":"343","D":"A9503","F":"189"},{"Policy Line":"71402875","B":"TC99M Na TC04 Per Mci","C":"343","D":"A9512","F":"60.3"},{"Policy Line":"71402885","B":"TC99M Pyp Per Study Dose 25Mci","C":"343","D":"A9538","F":"474.6"},{"Policy Line":"71402930","B":"TC99M Sulfur Colloid-Lymphocen","C":"343","D":"A9541","F":"752.4"},{"Policy Line":"71402975","B":"XE-133 20Mci","C":"343","D":"A9558","F":"771"},{"Policy Line":"71404837","B":"Prostascint Up To 10 Mci","C":"343","D":"A9507","F":"16735.2"},{"Policy Line":"71404939","B":"Ultratag LbldRBC TC-99m<=30mci","C":"343","D":"A9560","F":"728.7"},{"Policy Line":"71405340","B":"Quadramet Per 150 Mci","C":"344","D":"A9604","F":"42579.3"},{"Policy Line":"71406000","B":"Thallium Tl-201 Cl Ea Mci","C":"343","D":"A9505","F":"193.5"},{"Policy Line":"71407070","B":"I 131 Cap Per Mci, Theraputic","C":"344","D":"A9517","F":"127.5"},{"Policy Line":"71407071","B":"I 131 Cap Per Mci, Diagnostic","C":"343","D":"A9509","F":"261.9"},{"Policy Line":"0013","B":"Perc Plcmnt- Enteroclysis Tube","C":"320","D":"74355","F":"671.4"},{"Policy Line":"0105","B":"FL RETROGRADE PYELOGRAM","C":"320","D":"74420","F":"244.8"},{"Policy Line":"0167","B":"KUB","C":"320","D":"74018","F":"143.4"},{"Policy Line":"0189","B":"Sm Bow W/ Enterovu","C":"320","D":"74250","F":"963"},{"Policy Line":"0197","B":"Peritoneal Shuntogram S&I","C":"320","D":"75809","F":"231.9"},{"Policy Line":"0367","B":"XR Shunt: Series S&I","C":"320","D":"75809","F":"231.9"},{"Policy Line":"1600","B":"INTRA OP CHOLANGIOGRAM S&I","C":"320","D":"74300","F":"150.9"},{"Policy Line":"2020","B":"Abdomen 1 View","C":"320","D":"74018","F":"143.4"},{"Policy Line":"2025","B":"XR Abdomen 2 View","C":"320","D":"74019","F":"198"},{"Policy Line":"2030","B":"XR Abdomen Complete/KUB","C":"320","D":"74018","F":"218.4"},{"Policy Line":"2031","B":"Abdomen Obstruc Series W/Pa","C":"320","D":"74022","F":"235.2"},{"Policy Line":"2090","B":"XR Babygram for FB 1View","C":"320","D":"76010","F":"129.3"},{"Policy Line":"2100","B":"Barium Swallow Mod/Video","C":"320","D":"74230","F":"210"},{"Policy Line":"2101","B":"Esophagus W/Mod Barium Swallow","C":"320","D":"74230","F":"210"},{"Policy Line":"2200","B":"Cystogram >= 3Views","C":"320","D":"74430","F":"366.3"},{"Policy Line":"2260","B":"Enema: Barium","C":"320","D":"74270","F":"337.2"},{"Policy Line":"2265","B":"XR Barium Air Contrast","C":"320","D":"74280","F":"320.4"},{"Policy Line":"2270","B":"Enema: Barium Thru Colostomy","C":"320","D":"74270","F":"337.2"},{"Policy Line":"2290","B":"ERCP Pancreatic Ductal S&I","C":"320","D":"74329","F":"243.9"},{"Policy Line":"2300","B":"XR Esophagus","C":"320","D":"74220","F":"154.8"},{"Policy Line":"2355","B":"Fistula Tract Stdy (Non Dial)","C":"320","D":"76080","F":"228.9"},{"Policy Line":"2356","B":"SINUS TRACT STUDY","C":"320","D":"76080","F":"228.9"},{"Policy Line":"2440","B":"Hysterosalpingogram","C":"320","D":"74740","F":"227.4"},{"Policy Line":"2450","B":"IVP","C":"320","D":"74400","F":"394.8"},{"Policy Line":"2460","B":"IVP Pedi","C":"320","D":"74400","F":"394.8"},{"Policy Line":"2500","B":"Loopogram","C":"320","D":"74425","F":"1398.3"},{"Policy Line":"2620","B":"XR -Neck Soft Tissue","C":"320","D":"70360","F":"125.1"},{"Policy Line":"2630","B":"XR Nephrostogram, Antegrade","C":"320","D":"74425","F":"1398.3"},{"Policy Line":"2761","B":"Sialogram Parotid - Rt","C":"320","D":"70390","F":"378.9"},{"Policy Line":"2763","B":"Sialogram Parotid - Lt","C":"320","D":"70390","F":"378.9"},{"Policy Line":"2795","B":"XR Small Bowel Series","C":"320","D":"74250","F":"963"},{"Policy Line":"2915","B":"XR UGI W/Kub","C":"320","D":"74241","F":"180.9"},{"Policy Line":"2920","B":"UGI Single Contrast","C":"320","D":"74241","F":"180.9"},{"Policy Line":"2922","B":"Barium Swallow/Ugi W/Air Cont","C":"320","D":"74247","F":"180.9"},{"Policy Line":"2923","B":"Barium Swallow W/Ugi","C":"320","D":"74240","F":"181.8"},{"Policy Line":"2925","B":"XR UGI Air Contrast","C":"320","D":"74246","F":"180"},{"Policy Line":"2926","B":"UGI Small Bowel Single","C":"320","D":"74245","F":"961.5"},{"Policy Line":"4827","B":"Renal Cyst Aspir/Scler W/CONTR","C":"320","D":"74470","F":"2355.9"},{"Policy Line":"5130","B":"CT Drainage Cath Guidance","C":"350","D":"75989","F":"403.2"},{"Policy Line":"5246","B":"Peritoneogram Aft Air/Cont S&I","C":"320","D":"74190","F":"533.1"},{"Policy Line":"5258","B":"Transcatheter Biopsy","C":"320","D":"75970","F":"1792.5"},{"Policy Line":"64100094","B":"ERCP Pancreatic Duct S&I","C":"320","D":"74329","F":"243.9"},{"Policy Line":"64100101","B":"Cystography 3++ Views","C":"320","D":"74430","F":"366.3"},{"Policy Line":"64101130","B":"Hysterosalpingography S&I","C":"320","D":"74740","F":"227.4"},{"Policy Line":"64139947","B":"Embolization Transcath-S&I","C":"320","D":"75894","F":"3378.6"},{"Policy Line":"64139959","B":"Antegrade Pyelogram","C":"320","D":"74425","F":"1398.3"},{"Policy Line":"64600197","B":"Peritoneal Shuntogram S&I","C":"320","D":"75809","F":"231.9"},{"Policy Line":"64604827","B":"Renal Cyst Aspir/Scler W/CONTR","C":"320","D":"74470","F":"2355.9"},{"Policy Line":"64605258","B":"Transcatheter Biopsy","C":"320","D":"75970","F":"1792.5"},{"Policy Line":"64608266","B":"Perc Drain W/Cath Plcmt-Guide","C":"320","D":"75989","F":"403.2"},{"Policy Line":"64608294","B":"Antegrade Pyelogram","C":"320","D":"74425","F":"1398.3"},{"Policy Line":"64608350","B":"Embolization Transcath, S&I","C":"320","D":"75894","F":"3378.6"},{"Policy Line":"64608468","B":"Biliary Dilation- Guidance S&I","C":"320","D":"74363","F":"2163.6"},{"Policy Line":"64608825","B":"PercutaneusTube Chng XR Contrl","C":"320","D":"75984","F":"1403.7"},{"Policy Line":"64608845","B":"Ureteral Dilation-Guidance S&I","C":"320","D":"74485","F":"816.6"},{"Policy Line":"71106100","B":"UGI w/Air Double Follow Thru","C":"320","D":"74246","F":"180"},{"Policy Line":"71106101","B":"Hypotonic Duodenography","C":"320","D":"74251","F":"180"},{"Policy Line":"71106103","B":"Barium Swallow with Air","C":"320","D":"74221","F":"180.9"},{"Policy Line":"71106104","B":"Small Bowel follow thru Study","C":"320","D":"74248","F":"180.9"},{"Policy Line":"71106105","B":"UGI Small Bowel Double","C":"320","D":"74240","F":"181.8"},{"Policy Line":"8266","B":"Perc Drain W/Cath Plcmt-Guide","C":"320","D":"75989","F":"403.2"},{"Policy Line":"8292","B":"Biliary Duct PTHD Stent Placem","C":"320","D":"74363","F":"2163.6"},{"Policy Line":"8294","B":"Antegrade Pyelogram","C":"320","D":"74425","F":"1398.3"},{"Policy Line":"8309","B":"FLUORO GUIDANCE DRAIN W/CATH","C":"320","D":"75989","F":"403.2"},{"Policy Line":"8350","B":"Embolization Transcath, S&I","C":"320","D":"75894","F":"3378.6"},{"Policy Line":"8457","B":"ERCP BILIARY S&I","C":"320","D":"74328","F":"397.5"},{"Policy Line":"8458","B":"ERCP CombBiliary/PancreaticS&I","C":"320","D":"74330","F":"356.1"},{"Policy Line":"8461","B":"Esophageal Dilatation","C":"320","D":"74360","F":"198.9"},{"Policy Line":"8463","B":"Urography Retrograde S&I","C":"320","D":"74450","F":"228.9"},{"Policy Line":"8464","B":"Urethrocystography Voiding","C":"320","D":"74455","F":"228.9"},{"Policy Line":"8468","B":"Biliary Dilation- Guidance S&I","C":"320","D":"74363","F":"2163.6"},{"Policy Line":"8825","B":"PercutaneusTube Chng XR Contrl","C":"320","D":"75984","F":"1403.7"},{"Policy Line":"8845","B":"Ureteral Dilation-Guidance S&I","C":"320","D":"74485","F":"816.6"},{"Policy Line":"0150","B":"Angio Post Embolization Periph","C":"320","D":"75898","F":"1086.3"},{"Policy Line":"0152","B":"Transcath Embolization F/Up","C":"320","D":"75898","F":"1086.3"},{"Policy Line":"0153","B":"Lumbar Punct -Fluoro Guidance","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"0182","B":"Fluoro Guided Spinal Injection","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"0238","B":"Breast Tomography, DX Radiogra","C":"320","D":"76499","F":"82.2"},{"Policy Line":"0441","B":"HYSTEROSALPINGOGRAM INJECT","C":"361","D":"58340","F":"23.4"},{"Policy Line":"0767","B":"Inject Proc Arthro Ankle - Lt","C":"361","D":"27648","F":"124.2"},{"Policy Line":"0770","B":"Inject Proc Arthro Ankle - Rt","C":"361","D":"27648","F":"124.2"},{"Policy Line":"0772","B":"Arthrogram Hip - LT","C":"320","D":"73525","F":"296.1"},{"Policy Line":"0773","B":"Inj HIP Arthrogram w/Anest -Lt","C":"361","D":"27095","F":"16.5"},{"Policy Line":"0775","B":"XR Arthrogram Hip - RT","C":"320","D":"73525","F":"296.1"},{"Policy Line":"0776","B":"Inj HIP Arthrogram w/Anest -Rt","C":"361","D":"27095","F":"16.5"},{"Policy Line":"0784","B":"Arthrogram Shoulder - LT","C":"320","D":"73040","F":"297.3"},{"Policy Line":"0785","B":"Inject Proc Arthro Shoulder-Lt","C":"361","D":"23350","F":"16.8"},{"Policy Line":"0787","B":"Arthrogram Shoulder - Rt","C":"320","D":"73040","F":"297.3"},{"Policy Line":"0788","B":"Inject Proc Arthro Shoulder-Rt","C":"361","D":"23350","F":"16.8"},{"Policy Line":"0791","B":"Inject Proc Arthrogrm Wrist-Lt","C":"361","D":"25246","F":"304.8"},{"Policy Line":"0794","B":"Inject Proc Arthrogrm Wrist-Rt","C":"361","D":"25246","F":"304.8"},{"Policy Line":"0796","B":"Arthrogram Elbow Injection","C":"361","D":"24220","F":"62.4"},{"Policy Line":"0797","B":"Arthrogram Elbow","C":"320","D":"73085","F":"105"},{"Policy Line":"0947","B":"Therapeutic Enema Rad","C":"320","D":"74283","F":"198.3"},{"Policy Line":"2201","B":"CYSTOGRAM INJECTION","C":"361","D":"51600","F":"14.1"},{"Policy Line":"2238","B":"CT 3D Rendering","C":"350","D":"76377","F":"164.4"},{"Policy Line":"2360","B":"Fluoroscopy Up To 1 Hour","C":"320","D":"76000","F":"638.1"},{"Policy Line":"2361","B":"Fluoro: Needle Placemnt-Biopsy","C":"320","D":"77002","F":"356.7"},{"Policy Line":"2362","B":"Fluoro: Needle/Cath Tip-Spine","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"2510","B":"Jugular Venogram S&I","C":"320","D":"75860","F":"202.2"},{"Policy Line":"2560","B":"Myelogram: Cervical S&I","C":"320","D":"72240","F":"1576.2"},{"Policy Line":"2565","B":"XR Myelogram: Complete","C":"320","D":"72270","F":"1706.1"},{"Policy Line":"2570","B":"Myelogram: Lumbar S&I","C":"320","D":"72265","F":"1567.5"},{"Policy Line":"2575","B":"Myelogram: Thoracic S&I","C":"320","D":"72255","F":"1588.8"},{"Policy Line":"2612","B":"Therapeutic Enema","C":"320","D":"74283","F":"198.3"},{"Policy Line":"2640","B":"Nerve Root Injection","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"3501","B":"Fluoro LOC Ndl Plcmnt Aspiratn","C":"320","D":"77002","F":"356.7"},{"Policy Line":"3502","B":"INJ PROC CHOLANGIOGRAM THRU CA","C":"361","D":"47531","F":"291.3"},{"Policy Line":"3503","B":"INJ PROC LOOPOGRAM","C":"361","D":"50690","F":"37.2"},{"Policy Line":"4550","B":"CT 3D W/O Post Processing","C":"350","D":"76376","F":"78.3"},{"Policy Line":"4826","B":"Fluoro Guided Abscess Drainage","C":"320","D":"77002","F":"356.7"},{"Policy Line":"5238","B":"Angio: Spinal Selective S&I","C":"320","D":"75705","F":"1630.2"},{"Policy Line":"5252","B":"Tips Proc W/O Hemodyn Eval S&I","C":"320","D":"75887","F":"422.7"},{"Policy Line":"5254","B":"Mech Rmvl Pericath Mtrl Cvad","C":"320","D":"75901","F":"1676.7"},{"Policy Line":"5256","B":"REM CVD Intralum Obst Mtrl S&I","C":"320","D":"75902","F":"2515.5"},{"Policy Line":"6330","B":"Pseudo-Aneurysm Compression","C":"402","D":"76936","F":"324"},{"Policy Line":"64107814","B":"Stent Taa & L Subclavian Origi","C":"320","D":"75956","F":"2136.6"},{"Policy Line":"64107815","B":"Stent Taa S&I","C":"320","D":"75957","F":"738.3"},{"Policy Line":"64107816","B":"Endoleak Prox Thoracic Aorta","C":"320","D":"75958","F":"3208.5"},{"Policy Line":"64107817","B":"Endoleak Dist Thoracic Aorta","C":"320","D":"75959","F":"1717.5"},{"Policy Line":"64139936","B":"Thrombolytic Declot Cv Cath","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"64139938","B":"Mech Rmv Pericath Mtrl CVD S&I","C":"320","D":"75901","F":"1676.7"},{"Policy Line":"64139972","B":"Angio: Existing Cath (F/U)","C":"320","D":"75898","F":"1086.3"},{"Policy Line":"64139976","B":"Angio: Spinal Selective S&I","C":"320","D":"75705","F":"1630.2"},{"Policy Line":"64139984","B":"Angio: Pulmonary Nonselect S&I","C":"320","D":"75746","F":"383.7"},{"Policy Line":"64601152","B":"F-U Angio, Embolization","C":"320","D":"75898","F":"1086.3"},{"Policy Line":"64602360","B":"Fluoroscopy Up To 1 Hour","C":"320","D":"76000","F":"638.1"},{"Policy Line":"64602362","B":"Fluoroguide for Spine Injectn","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"64602510","B":"Jugular Venogram S&I","C":"320","D":"75860","F":"202.2"},{"Policy Line":"64604826","B":"Fluoro Guided Needle Localiza","C":"320","D":"77002","F":"356.7"},{"Policy Line":"64605238","B":"Angio: Spinal Selective S&I","C":"320","D":"75705","F":"1630.2"},{"Policy Line":"64605254","B":"Mech Rmvl Pericath Mtrl Cvad","C":"320","D":"75901","F":"1676.7"},{"Policy Line":"64605256","B":"REM CVD Intralum Obst Mtrl S&I","C":"320","D":"75902","F":"2515.5"},{"Policy Line":"64608080","B":"Angio: Extremity Bilateral S&I","C":"320","D":"75716","F":"1678.2"},{"Policy Line":"64608090","B":"Angio: Extremity RT S&I","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"64608100","B":"Angio:Pulmonary Select BI S&I","C":"320","D":"75743","F":"1738.2"},{"Policy Line":"64608120","B":"Angio: Thoracic S&I","C":"320","D":"75605","F":"907.2"},{"Policy Line":"64608220","B":"Aortogram: Iliac Femoral/Ro","C":"320","D":"75630","F":"1563.3"},{"Policy Line":"64608221","B":"Aortogram: Abdominal","C":"320","D":"75625","F":"1587.6"},{"Policy Line":"64608230","B":"Angio:Pelvic Select/Supra1 S&I","C":"320","D":"75736","F":"1456.8"},{"Policy Line":"64608236","B":"Angio Pelvic Selct/Supra 2 S&I","C":"320","D":"75736","F":"1456.8"},{"Policy Line":"64608260","B":"Angio Viscrl Select/Supra1 S&I","C":"320","D":"75726","F":"2020.2"},{"Policy Line":"64608261","B":"Angio Viscerl Selec/Supra2 S&I","C":"320","D":"75726","F":"2020.2"},{"Policy Line":"64608262","B":"Angio Viscrl SelEct/Supra3 S&I","C":"320","D":"75726","F":"2020.2"},{"Policy Line":"64608306","B":"Portography W/Hemodynamics S&I","C":"320","D":"75885","F":"2899.2"},{"Policy Line":"64608307","B":"Venogram Hepatic W/Hemodyn S&I","C":"320","D":"75889","F":"891"},{"Policy Line":"64608308","B":"Venogram Hepatic W/OHemodynS&I","C":"320","D":"75891","F":"1087.2"},{"Policy Line":"64608314","B":"Fluroguidance for Vein Device","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"64608506","B":"Angio: Extremity S&I LT","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"64608523","B":"Angio Pulmonary Select S&I LT","C":"320","D":"75741","F":"2718.3"},{"Policy Line":"64608524","B":"Angio: Pulmonary Select S&I RT","C":"320","D":"75741","F":"2718.3"},{"Policy Line":"64608891","B":"Venogram: Vena Cava Superior","C":"320","D":"75827","F":"1143.6"},{"Policy Line":"64608910","B":"Venogram: Extremity S&I BI","C":"320","D":"75822","F":"1308.3"},{"Policy Line":"64608915","B":"Venogram: Extremity S&I RT","C":"320","D":"75820","F":"780"},{"Policy Line":"64608917","B":"Venogram: Extremity Left","C":"320","D":"75820","F":"780"},{"Policy Line":"64608918","B":"VENOGRAM: VENA CAVA INFERIOR","C":"320","D":"75825","F":"1111.8"},{"Policy Line":"64608935","B":"Venogram Renal Select S&I RT","C":"320","D":"75831","F":"2041.5"},{"Policy Line":"64608938","B":"Venogram: Renal Select Lt","C":"320","D":"75831","F":"2041.5"},{"Policy Line":"64608975","B":"Renin Venous Sampling S&I","C":"320","D":"75893","F":"869.4"},{"Policy Line":"64609995","B":"ANGIO S&I BRACHIAL RETROGRADE","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"6696","B":"HYSTROSONOGRAM INFUSION","C":"361","D":"58340","F":"23.4"},{"Policy Line":"6751","B":"US- UMBILICAL ARTERY DOPPLER","C":"402","D":"76820","F":"91.5"},{"Policy Line":"68300027","B":"Guidance for Radia Tx Deliver","C":"333","D":"G6002","F":"428.7"},{"Policy Line":"71400074","B":"Injection Id Sntl Node:Non Img","C":"341","D":"38792","F":"275.7"},{"Policy Line":"71600153","B":"Lumbar Punct -Fluoro Guidance","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"71708302","B":"Angio: Select Ea Addl Vessel","C":"320","D":"75774","F":"205.5"},{"Policy Line":"72100210","B":"Flouro Up To 1 Hour","C":"320","D":"76000","F":"638.1"},{"Policy Line":"72101175","B":"Venogram VenaCava Inferior S&I","C":"320","D":"75825","F":"1111.8"},{"Policy Line":"72101176","B":"Venogram Extrem Iliac S&I Uni","C":"320","D":"75820","F":"780"},{"Policy Line":"72102300","B":"Abd AortogrmW/CC NonSelect S&I","C":"320","D":"75625","F":"1587.6"},{"Policy Line":"72102301","B":"BI Run-Off W/Cc NonSelect S&I","C":"320","D":"G0278","F":"1678.2"},{"Policy Line":"72102304","B":"Angio: Select Ea Addl Vessel","C":"320","D":"75774","F":"205.5"},{"Policy Line":"72106110","B":"Angiogram: Extrem S&I BI","C":"320","D":"75716","F":"1678.2"},{"Policy Line":"72106116","B":"Angiogram: Extrem Uni S&I -RT","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"72106117","B":"Angiogram: Extrem UnI S&I -LT","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"72106125","B":"Aortogram Abd","C":"320","D":"75625","F":"1587.6"},{"Policy Line":"72106130","B":"Aortogram Abd Run-Off BI S&I","C":"320","D":"75630","F":"1563.3"},{"Policy Line":"72106960","B":"Transcath Infusion F-Up Cor","C":"320","D":"75898","F":"1086.3"},{"Policy Line":"72108120","B":"Angio: Thoracic Aorta","C":"320","D":"75605","F":"907.2"},{"Policy Line":"72208891","B":"Venogram: Vena Cava Superior","C":"320","D":"75827","F":"1143.6"},{"Policy Line":"72300033","B":"3D Reconstruction For Tee","C":"350","D":"76376","F":"78.3"},{"Policy Line":"76953000","B":"Needle Loc Lesion Axill - RT","C":"361","D":"10035","F":"450"},{"Policy Line":"76953001","B":"Needle Loc Lesion Axill - LT","C":"361","D":"10035","F":"450"},{"Policy Line":"8080","B":"Angio: Extremity Bilateral S&I","C":"320","D":"75716","F":"1678.2"},{"Policy Line":"8090","B":"Angio: Extremity RT S&I","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"8100","B":"Angio:Pulmonary Select BI S&I","C":"320","D":"75743","F":"1738.2"},{"Policy Line":"8120","B":"Angio: Thoracic S&I","C":"320","D":"75605","F":"907.2"},{"Policy Line":"8171","B":"Implantable Port Removal","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"8220","B":"Aortogram: Iliac Femoral/Ro","C":"320","D":"75630","F":"1563.3"},{"Policy Line":"8221","B":"Aortogram: Abdominal","C":"320","D":"75625","F":"1587.6"},{"Policy Line":"8222","B":"CV Catheter Repair","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"8223","B":"CV Catheter Replacement","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"8230","B":"Angio:Pelvic Select/Supra1 S&I","C":"320","D":"75736","F":"1456.8"},{"Policy Line":"8236","B":"Angio Pelvic Selct/Supra 2 S&I","C":"320","D":"75736","F":"1456.8"},{"Policy Line":"8260","B":"Angio Viscrl Select/Supra1 S&I","C":"320","D":"75726","F":"2020.2"},{"Policy Line":"8261","B":"Angio Viscerl Selec/Supra2 S&I","C":"320","D":"75726","F":"2020.2"},{"Policy Line":"8262","B":"Angio Viscrl SelEct/Supra3 S&I","C":"320","D":"75726","F":"2020.2"},{"Policy Line":"8302","B":"Angio: Select Ea Addl Vessel","C":"320","D":"75774","F":"205.5"},{"Policy Line":"8303","B":"FLUORO GUIDANCE EPIDURAL INJ","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"8304","B":"FLURO GUIDNC NEEDL PLCMNT LOC","C":"320","D":"77002","F":"356.7"},{"Policy Line":"8306","B":"Portography W/Hemodynamics S&I","C":"320","D":"75885","F":"2899.2"},{"Policy Line":"8307","B":"Venogram: Hepatic W/Hemodyn","C":"320","D":"75889","F":"891"},{"Policy Line":"8308","B":"Venogram: Hepatic W/O Hemodyn","C":"320","D":"75891","F":"1087.2"},{"Policy Line":"8314","B":"Fluroguidance for Vein Device","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"8441","B":"INJECTION FOR MYELOGRAM","C":"361","D":"62284","F":"17.4"},{"Policy Line":"8450","B":"Defecogram","C":"320","D":"76499","F":"82.2"},{"Policy Line":"8486","B":"INJECT PROC SIALOGRAPHY -RT","C":"361","D":"42550","F":"13.8"},{"Policy Line":"8496","B":"INJECT PROC SIALOGRAPHY -LT","C":"361","D":"42550","F":"13.8"},{"Policy Line":"8506","B":"Angio: Extremity S&I LT","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"8523","B":"Angio Pulmonary Select S&I LT","C":"320","D":"75741","F":"2718.3"},{"Policy Line":"8524","B":"Angio: Pulmonary Select S&I RT","C":"320","D":"75741","F":"2718.3"},{"Policy Line":"8610","B":"IR NEUROSTIMULATOR IMPLANT","C":"320","D":"77003","F":"1387.8"},{"Policy Line":"8854","B":"Catheter Removal: Tunneled","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"8891","B":"Venogram: Vena Cava Superior","C":"320","D":"75827","F":"1143.6"},{"Policy Line":"8910","B":"Venogram: Extremity S&I BI","C":"320","D":"75822","F":"1308.3"},{"Policy Line":"8915","B":"Venogram: Extremity S&I RT","C":"320","D":"75820","F":"780"},{"Policy Line":"8917","B":"Venogram: Extremity Left","C":"320","D":"75820","F":"780"},{"Policy Line":"8918","B":"VENOGRAM: VENA CAVA INFERIOR","C":"320","D":"75825","F":"1111.8"},{"Policy Line":"8920","B":"Fluoroscopy for Injection","C":"320","D":"77002","F":"356.7"},{"Policy Line":"8935","B":"Venogram Renal Select S&I RT","C":"320","D":"75831","F":"2041.5"},{"Policy Line":"8937","B":"Venogram Renal Select S&I BI","C":"320","D":"75833","F":"2178.3"},{"Policy Line":"8938","B":"Venogram: Renal Select Lt","C":"320","D":"75831","F":"2041.5"},{"Policy Line":"8950","B":"CV Catheter Placement External","C":"320","D":"77001","F":"1136.1"},{"Policy Line":"8975","B":"Renin Venous Sampling S&I","C":"320","D":"75893","F":"869.4"},{"Policy Line":"9970","B":"ANGIO: EXTREMITY BILATERAL S&I","C":"320","D":"75716","F":"1678.2"},{"Policy Line":"9995","B":"ANGIO S&I BRACHIAL RETROGRADE","C":"320","D":"75710","F":"1480.8"},{"Policy Line":"64101901","B":"STAT - Surgical Profile - D","C":"300","D":"82947","F":"19.8"},{"Policy Line":"64101902","B":"Glucose","C":"300","D":"82947","F":"19.8"},{"Policy Line":"64101904","B":"Calcium: Ionized","C":"300","D":"82330","F":"51"},{"Policy Line":"64101905","B":"Blood Gases","C":"300","D":"82803","F":"96"},{"Policy Line":"64504480","B":"Hemocult Analysis Feces","C":"300","D":"82270","F":"69.9"},{"Policy Line":"68269721","B":"Creatinine, Blood","C":"300","D":"82565","F":"25.5"},{"Policy Line":"70100008","B":"Occult Blood: Stool","C":"300","D":"82272","F":"26.4"},{"Policy Line":"70100021","B":"Total Protein: Serum","C":"300","D":"84155","F":"34.2"},{"Policy Line":"70100022","B":"Albumin-Serum,Plasma,orWholeBl","C":"300","D":"82040","F":"27.9"},{"Policy Line":"70100023","B":"Calcium Total","C":"300","D":"82310","F":"21"},{"Policy Line":"70100024","B":"Phosphorus","C":"300","D":"84100","F":"30"},{"Policy Line":"70100025","B":"Cholesterol","C":"300","D":"82465","F":"28.5"},{"Policy Line":"70100026","B":"Uric Acid: Blood","C":"300","D":"84550","F":"28.2"},{"Policy Line":"70100027","B":"Bilirubin: Total","C":"300","D":"82247","F":"31.8"},{"Policy Line":"70100029","B":"SGOT","C":"300","D":"84450","F":"24"},{"Policy Line":"70100031","B":"BUN - QUANT","C":"300","D":"84520","F":"24"},{"Policy Line":"70100032","B":"Sodium: Serum","C":"300","D":"84295","F":"26.4"},{"Policy Line":"70100033","B":"Potassium: Serum","C":"300","D":"84132","F":"25.2"},{"Policy Line":"70100034","B":"Chloride Blood","C":"300","D":"82435","F":"26.7"},{"Policy Line":"70100035","B":"CO2","C":"300","D":"82374","F":"39.6"},{"Policy Line":"70100036","B":"Glucose","C":"300","D":"82947","F":"22.8"},{"Policy Line":"70100037","B":"Creatinine - Blood","C":"300","D":"82565","F":"27.9"},{"Policy Line":"70100038","B":"Glyco Hemoglobin","C":"300","D":"83036","F":"15.9"},{"Policy Line":"70100039","B":"Carbohydrate Deficient Trans","C":"300","D":"82373","F":"166.2"},{"Policy Line":"70100050","B":"Alkaline Phosphatase","C":"300","D":"84075","F":"30"},{"Policy Line":"70100051","B":"Cpk Total","C":"300","D":"82550","F":"30"},{"Policy Line":"70100052","B":"LDH","C":"300","D":"83615","F":"31.5"},{"Policy Line":"70100056","B":"SGPT","C":"300","D":"84460","F":"24"},{"Policy Line":"70100057","B":"Glucose 1Hr No Fastng Specimen","C":"300","D":"82950","F":"45.9"},{"Policy Line":"70100058","B":"Protein Electrophoresis","C":"300","D":"84165","F":"142.8"},{"Policy Line":"70100059","B":"H Pylori (C-13) Breath Test","C":"300","D":"83013","F":"112.5"},{"Policy Line":"70100060","B":"Vitamin B2 Riboflavin","C":"300","D":"84252","F":"71.4"},{"Policy Line":"70100068","B":"Glucose 2Hr Pp","C":"300","D":"82947","F":"22.8"},{"Policy Line":"70100069","B":"HCG: Qualitative","C":"300","D":"84703","F":"39.6"},{"Policy Line":"70100076","B":"Lipase","C":"300","D":"83690","F":"36.6"},{"Policy Line":"70100077","B":"Triglycerides","C":"300","D":"84478","F":"39.6"},{"Policy Line":"70100078","B":"Amylase","C":"300","D":"82150","F":"31.2"},{"Policy Line":"70100086","B":"Gamma Gt","C":"300","D":"82977","F":"47.7"},{"Policy Line":"70100096","B":"Oligoclonal Banding","C":"300","D":"83916","F":"116.4"},{"Policy Line":"70100101","B":"Fetal Lung Maturity","C":"300","D":"83663","F":"148.2"},{"Policy Line":"70100106","B":"Acylcarnitines; Quant","C":"300","D":"82017","F":"368.1"},{"Policy Line":"70100123","B":"Antigliadin Iga Elisa","C":"300","D":"83520","F":"151.5"},{"Policy Line":"70100124","B":"Antigliadin Igg Elisa","C":"300","D":"83520","F":"151.5"},{"Policy Line":"70100144","B":"Hyaluronic Acid Elisa Quant","C":"300","D":"83520","F":"272.4"},{"Policy Line":"70100145","B":"Timp-1 Elisa Quant","C":"300","D":"83520","F":"200.4"},{"Policy Line":"70100173","B":"Anti-Ompc Elisa Iga","C":"300","D":"83520","F":"82.2"},{"Policy Line":"70100174","B":"Anti Cbir1 Elisa","C":"300","D":"83520","F":"82.2"},{"Policy Line":"70100177","B":"Salivary Hormone Assay","C":"300","D":"84144","F":"406.8"},{"Policy Line":"70100200","B":"Estrogens Fractionated","C":"300","D":"82671","F":"80.4"},{"Policy Line":"70100205","B":"IGG","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70100206","B":"IGA","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70100207","B":"IGM","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70100208","B":"Haptoglobin","C":"300","D":"83010","F":"67.8"},{"Policy Line":"70100209","B":"Alpha 1 Antitrypsin","C":"300","D":"82103","F":"81.3"},{"Policy Line":"70100211","B":"Luteinizing Hormone","C":"300","D":"83002","F":"48"},{"Policy Line":"70100214","B":"IGA Total By Nephmtry (Celiac)","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70100217","B":"IGG For Immunoglobin Profile","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70100221","B":"Lactoferrin Fecal Qual","C":"300","D":"83630","F":"511.2"},{"Policy Line":"70100223","B":"Prostaglandin Ea","C":"300","D":"84150","F":"688.8"},{"Policy Line":"70100224","B":"Tissue Tgab Iga","C":"300","D":"83516","F":"294.6"},{"Policy Line":"70100236","B":"FSH","C":"300","D":"83001","F":"45.9"},{"Policy Line":"70100251","B":"HDL Cholesterol","C":"300","D":"83718","F":"119.7"},{"Policy Line":"70100259","B":"Pregnenolone","C":"300","D":"84140","F":"106.5"},{"Policy Line":"70100260","B":"Deoxycorticosterone","C":"300","D":"82633","F":"854.7"},{"Policy Line":"70100263","B":"Iron","C":"300","D":"83540","F":"27.9"},{"Policy Line":"70100265","B":"Iron Binding Capacity-T (TIBC)","C":"300","D":"83550","F":"31.8"},{"Policy Line":"70100266","B":"Prolactin","C":"300","D":"84146","F":"57.3"},{"Policy Line":"70100279","B":"Magnesium -Quest Cathartic Lax","C":"300","D":"83735","F":"42"},{"Policy Line":"70100280","B":"Phosphorus -Quest Cathartic Lx","C":"300","D":"84100","F":"43.5"},{"Policy Line":"70100303","B":"Glucose Tolerance 1St Hr","C":"300","D":"82951","F":"53.7"},{"Policy Line":"70100314","B":"Magnesium","C":"300","D":"83735","F":"25.5"},{"Policy Line":"70100325","B":"Amnisure Test","C":"300","D":"84112","F":"142.2"},{"Policy Line":"70100335","B":"Vanillylmandelic Acid -Quest","C":"300","D":"84585","F":"35.7"},{"Policy Line":"70100336","B":"Creatinine Random Urine-Quest","C":"300","D":"82570","F":"27.9"},{"Policy Line":"70100363","B":"Interleukin-6,Highly Sensitive","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70100368","B":"Phosphatase Alkaline -Quest","C":"300","D":"84075","F":"57"},{"Policy Line":"70100399","B":"Prealbumin","C":"300","D":"84134","F":"33"},{"Policy Line":"70100400","B":"Oxcarbazepine -Quest","C":"300","D":"83789","F":"134.7"},{"Policy Line":"70100401","B":"Risperidone -Quest","C":"300","D":"83789","F":"166.2"},{"Policy Line":"70100402","B":"T-4 Total","C":"300","D":"84436","F":"22.8"},{"Policy Line":"70100404","B":"Tsh:Thyroid Stimulate Hormon","C":"300","D":"84443","F":"27.3"},{"Policy Line":"70100408","B":"Galactose-1-Phosphate Rbc Mayo","C":"300","D":"84378","F":"318.3"},{"Policy Line":"70100409","B":"Galactose P Mayo","C":"300","D":"82760","F":"309.3"},{"Policy Line":"70100410","B":"Metanephrines Frac Pl -Quest","C":"300","D":"83835","F":"329.1"},{"Policy Line":"70100411","B":"T3: Uptake","C":"300","D":"84479","F":"21"},{"Policy Line":"70100414","B":"Cea: Carcinoembryonic Antigen","C":"300","D":"82378","F":"30.6"},{"Policy Line":"70100415","B":"Cortisol:Serum Or Plasma Total","C":"300","D":"82533","F":"52.2"},{"Policy Line":"70100416","B":"Cortisol: Salivary","C":"300","D":"82533","F":"161.1"},{"Policy Line":"70100421","B":"Free PSA Quest","C":"300","D":"84154","F":"105.6"},{"Policy Line":"70100430","B":"Osmolality: Blood","C":"300","D":"83930","F":"78.9"},{"Policy Line":"70100431","B":"Osmolality:Urine","C":"300","D":"83935","F":"79.2"},{"Policy Line":"70100435","B":"Ferritin","C":"300","D":"82728","F":"30.3"},{"Policy Line":"70100436","B":"Pancreatic Elastase-1 Qst14693","C":"300","D":"82656","F":"294.6"},{"Policy Line":"70100438","B":"Mucopolysaccharides Qn Ur Qst","C":"300","D":"83864","F":"550.2"},{"Policy Line":"70100442","B":"Spice Test Qst-Nms 4281U","C":"300","D":"83789","F":"166.2"},{"Policy Line":"70100443","B":"Hydroxyproline P Qst","C":"300","D":"83500","F":"159.3"},{"Policy Line":"70100469","B":"HCG: Quantitative","C":"300","D":"84702","F":"15.6"},{"Policy Line":"70100479","B":"Folate Serum","C":"300","D":"82746","F":"46.2"},{"Policy Line":"70100480","B":"Vitamin B-12 Level","C":"300","D":"82607","F":"34.8"},{"Policy Line":"70100482","B":"Folic Acid Rbc 82747","C":"300","D":"82747","F":"61.2"},{"Policy Line":"70100502","B":"LDH Isoenzymes","C":"300","D":"83625","F":"54.9"},{"Policy Line":"70100503","B":"HCG Quantitative -Quest","C":"300","D":"84702","F":"23.1"},{"Policy Line":"70100504","B":"AFP - Quest Triple Test","C":"300","D":"82105","F":"36.3"},{"Policy Line":"70100506","B":"Stool Lactoferrin Quant Qst","C":"300","D":"83631","F":"182.7"},{"Policy Line":"70100525","B":"HSP-70 Ab (Anti 68 Kd Ag) Qst","C":"300","D":"84181","F":"253.2"},{"Policy Line":"70100527","B":"Lamellar Bodies","C":"300","D":"83664","F":"119.1"},{"Policy Line":"70100528","B":"L/S Ratio","C":"300","D":"83661","F":"135.6"},{"Policy Line":"70100622","B":"Cryoglobulins","C":"300","D":"82595","F":"63.3"},{"Policy Line":"70100659","B":"N Telopeptide(Ntx),Random Ur","C":"300","D":"82523","F":"109.8"},{"Policy Line":"70100665","B":"G6PD Screen","C":"300","D":"82955","F":"62.4"},{"Policy Line":"70100672","B":"Selenium Serum -Quest","C":"300","D":"84255","F":"102.6"},{"Policy Line":"70100673","B":"Selenium Blood -Quest","C":"300","D":"84255","F":"245.7"},{"Policy Line":"70100676","B":"Vitamin B1 Plasma -Quest","C":"300","D":"84425","F":"115.8"},{"Policy Line":"70100677","B":"Vitamin B1 Whole Blood -Quest","C":"300","D":"84425","F":"115.8"},{"Policy Line":"70100678","B":"ACHR Modulating Ab -Quest","C":"300","D":"83519","F":"342.9"},{"Policy Line":"70100679","B":"ACHR Blocking Ab -Quest","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70100680","B":"ACHR Binding Ab -Quest","C":"300","D":"83519","F":"120"},{"Policy Line":"70100689","B":"Bile Acids, Total","C":"300","D":"82239","F":"99"},{"Policy Line":"70100721","B":"Protein: Urine","C":"300","D":"84156","F":"39"},{"Policy Line":"70100723","B":"Calcium Urine","C":"300","D":"82340","F":"58.2"},{"Policy Line":"70100724","B":"Phosphorus: Urine","C":"300","D":"84105","F":"58.2"},{"Policy Line":"70100726","B":"Uric Acid: Other Source","C":"300","D":"84560","F":"22.2"},{"Policy Line":"70100731","B":"Urea Nitrogen: Urine","C":"300","D":"84540","F":"62.4"},{"Policy Line":"70100732","B":"Sodium: Urine 24Hr","C":"300","D":"84300","F":"24.9"},{"Policy Line":"70100733","B":"Potassium: Urine","C":"300","D":"84133","F":"27.9"},{"Policy Line":"70100750","B":"Anti Mullerian Hormone -Repros","C":"300","D":"83516","F":"105.9"},{"Policy Line":"70100755","B":"Estrone 2-Alphahydrox (Quest)","C":"300","D":"82679","F":"426"},{"Policy Line":"70100756","B":"Estrone 16-Alphahydrox (Quest)","C":"300","D":"82679","F":"426"},{"Policy Line":"70100757","B":"Creatinine (Estronex) (Quest)","C":"300","D":"82570","F":"27.9"},{"Policy Line":"70100758","B":"Protein Elect-Urine","C":"300","D":"84166","F":"193.5"},{"Policy Line":"70100772","B":"IA Multiple Step Method","C":"300","D":"83516","F":"189.6"},{"Policy Line":"70100777","B":"Somatostatin (Quest)","C":"300","D":"84307","F":"284.7"},{"Policy Line":"70100779","B":"Acetone","C":"300","D":"82009","F":"28.5"},{"Policy Line":"70100780","B":"Acetone Titer","C":"300","D":"82010","F":"93.9"},{"Policy Line":"70100781","B":"Triglycerides -Quest Vap","C":"300","D":"84478","F":"90"},{"Policy Line":"70100801","B":"Ribosomal Antibodies -Quest","C":"300","D":"83516","F":"102.3"},{"Policy Line":"70100803","B":"Ph -Stool Quest","C":"300","D":"83986","F":"81.6"},{"Policy Line":"70100815","B":"Fatty Acid Peroxisomal-Quest","C":"300","D":"82726","F":"166.2"},{"Policy Line":"70100818","B":"Lactic Acid","C":"300","D":"83605","F":"43.5"},{"Policy Line":"70100819","B":"Lactic Acid-Arterial","C":"300","D":"83605","F":"43.5"},{"Policy Line":"70100821","B":"Total Protein Oth Src: Fluid","C":"300","D":"84157","F":"57"},{"Policy Line":"70100823","B":"Fetal Hgb Qst 513","C":"300","D":"83021","F":"15.9"},{"Policy Line":"70100824","B":"Free Hemoglobin Plasma Qst 514","C":"300","D":"83051","F":"33.9"},{"Policy Line":"70100829","B":"Pinworm Ova Prep","C":"300","D":"Q0113","F":"34.8"},{"Policy Line":"70100830","B":"Osmolality-Stool","C":"300","D":"84999","F":"81.3"},{"Policy Line":"70100832","B":"Sodium: Stool","C":"300","D":"84302","F":"78.3"},{"Policy Line":"70100833","B":"Potassium: Stool","C":"300","D":"84311","F":"58.5"},{"Policy Line":"70100839","B":"IGA1 (Qst 31488)","C":"300","D":"82787","F":"44.1"},{"Policy Line":"70100840","B":"IGA2 (Qst 31488)","C":"300","D":"82787","F":"44.1"},{"Policy Line":"70100841","B":"Total Iga (Qst 31488)","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70100845","B":"Beta-Hydroxybutyrate Qst 37054","C":"300","D":"82010","F":"93.9"},{"Policy Line":"70100849","B":"Tissue Ttg Antibody Igg","C":"300","D":"83516","F":"117.3"},{"Policy Line":"70100850","B":"Tissue Ttg Antibody Iga","C":"300","D":"83516","F":"117.3"},{"Policy Line":"70100853","B":"Sugars, Qual Single Sp-Stool","C":"300","D":"84376","F":"27.6"},{"Policy Line":"70100878","B":"Amylase-Fluid","C":"300","D":"82150","F":"31.2"},{"Policy Line":"70100879","B":"Oxygen Dissociation P50","C":"300","D":"82820","F":"276"},{"Policy Line":"70100885","B":"HU Antibody Western Blot Qst","C":"300","D":"84181","F":"42.9"},{"Policy Line":"70100888","B":"RI Antibody Western Blot","C":"300","D":"84181","F":"98.4"},{"Policy Line":"70100892","B":"Thallium Blood","C":"300","D":"83018","F":"76.2"},{"Policy Line":"70100897","B":"Bile Acids Fract/Total Qst","C":"300","D":"83789","F":"222.3"},{"Policy Line":"70100900","B":"Calcium Ionized Qst","C":"300","D":"82330","F":"51"},{"Policy Line":"70100901","B":"Ammonia","C":"300","D":"82140","F":"70.5"},{"Policy Line":"70100902","B":"Ammonia: Arterial","C":"300","D":"82140","F":"70.5"},{"Policy Line":"70100912","B":"11-Deoxycortisol Lc/Ms/Ms Qst","C":"300","D":"82634","F":"89.7"},{"Policy Line":"70100915","B":"Fungitell (1-3)-B-D-Glucan Qst","C":"300","D":"84311","F":"193.5"},{"Policy Line":"70100917","B":"Fatty Acid Profile Comp -Qst","C":"300","D":"82554","F":"328.2"},{"Policy Line":"70100921","B":"Protein Total: CSF","C":"300","D":"84157","F":"57"},{"Policy Line":"70100933","B":"Kappa Light Chain Ur Qst","C":"300","D":"83883","F":"152.1"},{"Policy Line":"70100935","B":"Lambda Light Chain Ur Qst","C":"300","D":"83883","F":"152.1"},{"Policy Line":"70100936","B":"Glucose Body Fluid: Not Blood","C":"300","D":"82945","F":"69.6"},{"Policy Line":"70100958","B":"Protein Elec Urine/Csf","C":"300","D":"84166","F":"193.5"},{"Policy Line":"70100996","B":"IGG:Csf","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70101079","B":"Chloride CSF","C":"300","D":"82438","F":"11.4"},{"Policy Line":"70101248","B":"Anti-Mag Ab Elisa","C":"300","D":"83520","F":"323.1"},{"Policy Line":"70101249","B":"Anti-Sgpg Ab Elisa","C":"300","D":"83520","F":"323.1"},{"Policy Line":"70101250","B":"Anti-Gm1 Ab Elisa","C":"300","D":"83520","F":"323.1"},{"Policy Line":"70101251","B":"Anti-Gd1B Ab Elisa","C":"300","D":"83520","F":"323.1"},{"Policy Line":"70101252","B":"Anti-Asialo Gm1 Ab Elisa","C":"300","D":"83520","F":"323.1"},{"Policy Line":"70101253","B":"Anti-Gq1B Ab Elisa","C":"300","D":"83520","F":"323.1"},{"Policy Line":"70101254","B":"Anti-Sulfatide Ab Elisa","C":"300","D":"83520","F":"323.1"},{"Policy Line":"70101255","B":"Anti-Hu Ab","C":"300","D":"83516","F":"294.6"},{"Policy Line":"70101257","B":"Phosphorylated-Tau","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70101258","B":"Total Tau","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70101259","B":"AB42","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70101318","B":"Glycomark","C":"300","D":"84378","F":"180.9"},{"Policy Line":"70101319","B":"Phenylalanine Qst","C":"300","D":"84030","F":"152.1"},{"Policy Line":"70101320","B":"Tyrosine Qst","C":"300","D":"84510","F":"182.1"},{"Policy Line":"70101339","B":"Procalcitonin","C":"300","D":"84145","F":"141.9"},{"Policy Line":"70101367","B":"Iron Liver Tissue Mayo","C":"300","D":"83540","F":"179.1"},{"Policy Line":"70101407","B":"Cv2 Antibody Test Athena","C":"300","D":"84182","F":"496.8"},{"Policy Line":"70101409","B":"VWF Collagen Binding Assay Qs","C":"300","D":"83520","F":"186.6"},{"Policy Line":"70101412","B":"Lead Serum/Plasma - Nms","C":"300","D":"83655","F":"264.6"},{"Policy Line":"70101413","B":"Phenolphthalein Stool/Feces","C":"300","D":"84311","F":"72.3"},{"Policy Line":"70101416","B":"Citrate 24 Hr Urine","C":"300","D":"82507","F":"24.3"},{"Policy Line":"70101421","B":"Fatty Acid Prof Mayo","C":"300","D":"82726","F":"166.2"},{"Policy Line":"70101423","B":"PSA Total Quest","C":"300","D":"84153","F":"20.7"},{"Policy Line":"70101441","B":"Neuronal V-G K+ Channel Ab S","C":"300","D":"83519","F":"178.2"},{"Policy Line":"70101442","B":"Ach Receptor (Mcsl) Bind Ab","C":"300","D":"83519","F":"178.2"},{"Policy Line":"70101443","B":"Striational (Stri Mscl) Ab S","C":"300","D":"83520","F":"170.7"},{"Policy Line":"70101444","B":"N-Type Calcium Channel Ab","C":"300","D":"83519","F":"178.2"},{"Policy Line":"70101445","B":"P/Q Type Calcium Channel Ab","C":"300","D":"83519","F":"178.2"},{"Policy Line":"70101450","B":"ACHR Ganglionic Neuronal Ab S","C":"300","D":"83519","F":"213.3"},{"Policy Line":"70101465","B":"Corticosterone Lc/Ms/Ms Qst","C":"300","D":"82528","F":"42"},{"Policy Line":"70101602","B":"Ethylene Glycol","C":"300","D":"82693","F":"105.6"},{"Policy Line":"70101603","B":"Amino Acids: Quant","C":"300","D":"82139","F":"407.4"},{"Policy Line":"70101620","B":"17-Hydroxypregnenolone","C":"300","D":"84143","F":"97.5"},{"Policy Line":"70101622","B":"Homovanillic Acid (Hva)","C":"300","D":"83150","F":"534.3"},{"Policy Line":"70101664","B":"Chromatography Quant","C":"300","D":"82542","F":"744.3"},{"Policy Line":"70101670","B":"Pyruvate","C":"300","D":"84210","F":"108"},{"Policy Line":"70101673","B":"Volatiles","C":"300","D":"84600","F":"381"},{"Policy Line":"70101674","B":"Kappa Light Chain - Serum","C":"300","D":"83883","F":"39.6"},{"Policy Line":"70101675","B":"Lambda Light Chain - Serum","C":"300","D":"83883","F":"39.6"},{"Policy Line":"70101703","B":"Ph Urine","C":"300","D":"83986","F":"33.9"},{"Policy Line":"70101724","B":"Protein-Urine","C":"300","D":"84156","F":"39"},{"Policy Line":"70101725","B":"Glucose: Urine","C":"300","D":"82945","F":"69.6"},{"Policy Line":"70101817","B":"Cystatin C","C":"300","D":"82610","F":"54.6"},{"Policy Line":"70101818","B":"AssayMyeloperoxidase CardioIQ","C":"300","D":"83876","F":"52.2"},{"Policy Line":"70101819","B":"Assay Lipoprotein PLA2/PLAC Q","C":"301","D":"83698","F":"99"},{"Policy Line":"70102037","B":"Gtt Each Additional Hour 1","C":"300","D":"82952","F":"17.1"},{"Policy Line":"70102038","B":"Gtt Each Additional Hour 2","C":"300","D":"82952","F":"17.1"},{"Policy Line":"70102039","B":"Gtt Each Additional Hour 3","C":"300","D":"82952","F":"17.1"},{"Policy Line":"70102041","B":"Trypsin","C":"300","D":"83519","F":"116.4"},{"Policy Line":"70102092","B":"Mass Spec Nes; Quant","C":"300","D":"83789","F":"166.2"},{"Policy Line":"70102093","B":"Biotinidase, Adult","C":"300","D":"82261","F":"71.7"},{"Policy Line":"70102380","B":"Fetal Hgb,Qual By Copper Sulfa","C":"300","D":"83033","F":"165"},{"Policy Line":"70102381","B":"Cholinesterase; RBC","C":"300","D":"82482","F":"209.7"},{"Policy Line":"70102565","B":"Cholesterol, Body Fluid","C":"300","D":"84999","F":"28.5"},{"Policy Line":"70102702","B":"Bilirubin: Direct","C":"300","D":"82248","F":"26.4"},{"Policy Line":"70102804","B":"IGF Binding Protein-1","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70102805","B":"IGF Binding Protein-2","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70102806","B":"Insulin-Like Growth Factor-Ii","C":"300","D":"83519","F":"203.1"},{"Policy Line":"70102807","B":"Luteinizing Releasing Factor","C":"300","D":"83727","F":"475.2"},{"Policy Line":"70102850","B":"Glucagon","C":"300","D":"82943","F":"94.8"},{"Policy Line":"70103100","B":"Lipoprotein (a)","C":"300","D":"83695","F":"61.2"},{"Policy Line":"70103308","B":"Calcium: Ionized","C":"300","D":"82330","F":"51"},{"Policy Line":"70103600","B":"Glucose: Blood By Monitor Dev","C":"300","D":"82962","F":"10.2"},{"Policy Line":"70103655","B":"Angiotensin Ii","C":"300","D":"82163","F":"156.6"},{"Policy Line":"70104001","B":"Acetylchol Recept Ab","C":"300","D":"84238","F":"812.4"},{"Policy Line":"70104003","B":"ACTH","C":"300","D":"82024","F":"148.2"},{"Policy Line":"70104004","B":"Aldolase","C":"300","D":"82085","F":"45"},{"Policy Line":"70104006","B":"Aldosterone","C":"300","D":"82088","F":"69.6"},{"Policy Line":"70104008","B":"AFP Serum Tumor Marker","C":"300","D":"82105","F":"68.1"},{"Policy Line":"70104010","B":"Alkaline Phos Isoenzymes","C":"300","D":"84080","F":"115.2"},{"Policy Line":"70104013","B":"Amino Acids Quantitative","C":"300","D":"82139","F":"213.3"},{"Policy Line":"70104017","B":"Amino Levulinic-Ur24","C":"300","D":"82135","F":"128.1"},{"Policy Line":"70104023","B":"Androstenedione","C":"300","D":"82157","F":"111.3"},{"Policy Line":"70104024","B":"Angiotensin Converting Enzy","C":"300","D":"82164","F":"242.7"},{"Policy Line":"70104035","B":"Arsenic","C":"300","D":"82175","F":"99.6"},{"Policy Line":"70104049","B":"Oxalate","C":"300","D":"83945","F":"205.8"},{"Policy Line":"70104054","B":"C-Peptide","C":"300","D":"84681","F":"96.9"},{"Policy Line":"70104056","B":"Calcitonin","C":"300","D":"82308","F":"173.4"},{"Policy Line":"70104061","B":"Carotene","C":"300","D":"82380","F":"54.9"},{"Policy Line":"70104062","B":"Catechol: Fra-Urn 24Hr","C":"300","D":"82384","F":"150"},{"Policy Line":"70104065","B":"Catecholamines:Fractionated","C":"300","D":"82384","F":"135"},{"Policy Line":"70104074","B":"FR T4 By Equilibrium Dialysis","C":"300","D":"84439","F":"49.2"},{"Policy Line":"70104081","B":"PTH - Parathyroid Hormone","C":"300","D":"83970","F":"90.6"},{"Policy Line":"70104091","B":"Copper","C":"300","D":"82525","F":"70.5"},{"Policy Line":"70104095","B":"Cortisol Free","C":"300","D":"82530","F":"167.1"},{"Policy Line":"70104097","B":"Tsh Receptor Antibody","C":"300","D":"82397","F":"82.2"},{"Policy Line":"70104101","B":"Erythropoietin","C":"300","D":"82668","F":"122.4"},{"Policy Line":"70104105","B":"Cyanide","C":"300","D":"82600","F":"73.8"},{"Policy Line":"70104106","B":"Lipid Associated Sialic Acid","C":"300","D":"84275","F":"371.1"},{"Policy Line":"70104108","B":"Cystine-Urn 24Hr","C":"300","D":"82131","F":"281.1"},{"Policy Line":"70104114","B":"Dhea","C":"300","D":"82626","F":"156.9"},{"Policy Line":"70104115","B":"Dhea Sulfate","C":"300","D":"82627","F":"71.1"},{"Policy Line":"70104123","B":"Estradiol","C":"300","D":"82670","F":"62.4"},{"Policy Line":"70104134","B":"Quantitative Fat","C":"300","D":"82710","F":"208.2"},{"Policy Line":"70104141","B":"Gastrin","C":"300","D":"82941","F":"78.3"},{"Policy Line":"70104143","B":"Hemoglobin, Glycated","C":"300","D":"83036","F":"22.2"},{"Policy Line":"70104144","B":"Aluminum","C":"300","D":"82108","F":"42"},{"Policy Line":"70104145","B":"Growth Hormone","C":"300","D":"83003","F":"77.4"},{"Policy Line":"70104149","B":"Histamine","C":"300","D":"83088","F":"117.6"},{"Policy Line":"70104152","B":"Fructosamine","C":"300","D":"82985","F":"46.8"},{"Policy Line":"70104169","B":"Amino Acids Each Quant","C":"300","D":"82131","F":"281.1"},{"Policy Line":"70104173","B":"Beta 2 - Microglobulin","C":"300","D":"82232","F":"83.4"},{"Policy Line":"70104181","B":"Anti Histone Antibodies","C":"300","D":"83516","F":"39"},{"Policy Line":"70104182","B":"Hydroxypro Total-U24","C":"300","D":"83505","F":"155.4"},{"Policy Line":"70104185","B":"IGD","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70104191","B":"Insulin: Assay Total","C":"300","D":"83525","F":"45"},{"Policy Line":"70104195","B":"Ketogenicsteroids: 17","C":"300","D":"83586","F":"112.2"},{"Policy Line":"70104201","B":"Lead","C":"300","D":"83655","F":"25.5"},{"Policy Line":"70104217","B":"Mercury","C":"300","D":"83825","F":"366.9"},{"Policy Line":"70104223","B":"Metanephrines","C":"300","D":"83835","F":"152.1"},{"Policy Line":"70104224","B":"Metanephrines:Tot U2","C":"300","D":"83835","F":"467.7"},{"Policy Line":"70104233","B":"Myelin Basic Protein: Csf","C":"300","D":"83873","F":"88.8"},{"Policy Line":"70104234","B":"Myoglobin","C":"300","D":"83874","F":"116.4"},{"Policy Line":"70104248","B":"5-Nucleotidase","C":"300","D":"83915","F":"42"},{"Policy Line":"70104259","B":"Porphobilinogen-Quan","C":"300","D":"84110","F":"152.1"},{"Policy Line":"70104260","B":"Porphyrins-Quant","C":"300","D":"84120","F":"83.4"},{"Policy Line":"70104265","B":"Progesterone","C":"300","D":"84144","F":"45.9"},{"Policy Line":"70104268","B":"Parathormone","C":"300","D":"83970","F":"324.9"},{"Policy Line":"70104276","B":"Renin","C":"300","D":"84244","F":"61.2"},{"Policy Line":"70104290","B":"Hemoglobin Electrophoresis","C":"300","D":"83020","F":"90"},{"Policy Line":"70104291","B":"Serotonin","C":"300","D":"84260","F":"473.4"},{"Policy Line":"70104294","B":"Somatomedin-C","C":"300","D":"84305","F":"120"},{"Policy Line":"70104296","B":"Stone Analysis","C":"300","D":"82365","F":"189"},{"Policy Line":"70104299","B":"Lipoprotein-Blood; By Nmr","C":"300","D":"83704","F":"213.3"},{"Policy Line":"70104300","B":"IGE Gammaglobulin","C":"300","D":"82785","F":"27"},{"Policy Line":"70104303","B":"T03: Total-Triiodothyronine","C":"300","D":"84480","F":"54.9"},{"Policy Line":"70104304","B":"T-4: Free","C":"300","D":"84439","F":"49.2"},{"Policy Line":"70104306","B":"Testosterone: Total","C":"300","D":"84403","F":"51.9"},{"Policy Line":"70104313","B":"Thyroxine Bind Glob","C":"300","D":"84442","F":"173.4"},{"Policy Line":"70104321","B":"Transferrin","C":"300","D":"84466","F":"58.8"},{"Policy Line":"70104332","B":"Vasoactive Intestinal Peptide","C":"300","D":"84586","F":"270"},{"Policy Line":"70104336","B":"Vitamin A","C":"300","D":"84590","F":"90.9"},{"Policy Line":"70104337","B":"Vitamin C Asc Acid Level","C":"300","D":"82180","F":"66.6"},{"Policy Line":"70104341","B":"Vitamin D 1-25-Dihydroxy","C":"300","D":"82652","F":"50.1"},{"Policy Line":"70104342","B":"Vitamin D-25 Hydroxy","C":"300","D":"82306","F":"46.2"},{"Policy Line":"70104343","B":"Vitamin E","C":"300","D":"84446","F":"50.4"},{"Policy Line":"70104344","B":"VMA","C":"300","D":"84585","F":"83.4"},{"Policy Line":"70104350","B":"Anti Gbm (Glomer Base Mem)","C":"300","D":"83520","F":"137.4"},{"Policy Line":"70104351","B":"Xylose Tolerance","C":"300","D":"84620","F":"294.6"},{"Policy Line":"70104356","B":"Zinc","C":"300","D":"84630","F":"68.7"},{"Policy Line":"70104406","B":"Troponin T","C":"300","D":"84484","F":"50.4"},{"Policy Line":"70104466","B":"Ceruloplasmin","C":"300","D":"82390","F":"54.9"},{"Policy Line":"70104478","B":"Hydroxyprogesterone 17D","C":"300","D":"83498","F":"108.6"},{"Policy Line":"70104515","B":"Prostatic Acid Phosphatase","C":"300","D":"84066","F":"27"},{"Policy Line":"70104710","B":"Microalbumin","C":"300","D":"82043","F":"31.8"},{"Policy Line":"70104743","B":"Porphyrins:Qualitative:Urine","C":"300","D":"84120","F":"157.2"},{"Policy Line":"70104754","B":"Myoglobin-Urine","C":"300","D":"83874","F":"116.4"},{"Policy Line":"70104803","B":"Cholinesterase: Pseudo","C":"300","D":"82480","F":"90.3"},{"Policy Line":"70104804","B":"Dibucaine -Quest","C":"300","D":"82638","F":"26.7"},{"Policy Line":"70104805","B":"Cholinesterase Serum -Quest","C":"300","D":"82480","F":"19.8"},{"Policy Line":"70104989","B":"T3: Reverse","C":"300","D":"84482","F":"90.9"},{"Policy Line":"70104990","B":"Organic Acids, Urine","C":"300","D":"83918","F":"292.8"},{"Policy Line":"70105014","B":"Cpk Mb","C":"300","D":"82553","F":"38.7"},{"Policy Line":"70105079","B":"Hemosiderin Qualitative","C":"300","D":"83070","F":"71.7"},{"Policy Line":"70105152","B":"LDH With Isos If Ele","C":"300","D":"83615","F":"92.4"},{"Policy Line":"70105153","B":"Cpk With Ckmb If Ele","C":"300","D":"82550","F":"30"},{"Policy Line":"70105550","B":"Spe Western Blot: Bld/Fld Prob","C":"300","D":"84182","F":"496.8"},{"Policy Line":"70106342","B":"Mass Spectrometry Nes Qualnbsc","C":"300","D":"83789","F":"18"},{"Policy Line":"70106343","B":"Biotinidase, Nb Screen","C":"300","D":"82261","F":"29.1"},{"Policy Line":"70106344","B":"Hydroxyprogesterone 17D, Nbsc","C":"300","D":"83498","F":"108.6"},{"Policy Line":"70106345","B":"G6PD, NB Screen","C":"300","D":"82960","F":"76.2"},{"Policy Line":"70106346","B":"IA CF; Cystic Fibrosis Nb Sc","C":"300","D":"83516","F":"58.5"},{"Policy Line":"70106435","B":"Apolipoprotein","C":"300","D":"82172","F":"53.7"},{"Policy Line":"70106500","B":"Gases Blood Ph Only","C":"300","D":"82800","F":"18.9"},{"Policy Line":"70106501","B":"Insulin Free","C":"300","D":"83527","F":"358.2"},{"Policy Line":"70106502","B":"Carboxyhemoglobin","C":"300","D":"82375","F":"80.1"},{"Policy Line":"70106503","B":"Osteocalcin (Bone Gla Protein)","C":"300","D":"83937","F":"128.4"},{"Policy Line":"70106721","B":"Preg-Assoc Plasma Protein-A","C":"300","D":"84163","F":"177.6"},{"Policy Line":"70107078","B":"Amylase Urine","C":"300","D":"82150","F":"31.2"},{"Policy Line":"70107310","B":"Urea Nitrogen Clearance","C":"300","D":"84545","F":"58.5"},{"Policy Line":"70107370","B":"Creatinine Clearance","C":"300","D":"82575","F":"54"},{"Policy Line":"70107721","B":"Protein: Ur Quan Ran","C":"300","D":"84156","F":"39"},{"Policy Line":"70107726","B":"Uric Acid-Urine Rand","C":"300","D":"84560","F":"67.8"},{"Policy Line":"70107732","B":"Sodium: Urine","C":"300","D":"84300","F":"24.9"},{"Policy Line":"70107733","B":"Potassium-Urn Rand","C":"300","D":"84133","F":"27.9"},{"Policy Line":"70107734","B":"Chloride Urine","C":"300","D":"82436","F":"38.7"},{"Policy Line":"70107737","B":"Creatinine Oth Src- Urine","C":"300","D":"82570","F":"20.7"},{"Policy Line":"70107780","B":"Thyroglobulin","C":"300","D":"84432","F":"93.9"},{"Policy Line":"70108012","B":"PTH-Related Protein","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70108020","B":"GAD 65 Decarboxylase","C":"301","D":"83519","F":"78.9"},{"Policy Line":"70108025","B":"Immunoassay Quant Nos","C":"300","D":"83520","F":"186.6"},{"Policy Line":"70108026","B":"IGF Binding Protein-3","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70108028","B":"Beta Glucosidase: Leukocytes","C":"300","D":"82963","F":"593.4"},{"Policy Line":"70108051","B":"LDH -Fluid","C":"300","D":"83615","F":"31.5"},{"Policy Line":"70108171","B":"Ph Body Fld - Not Blood","C":"300","D":"83986","F":"64.2"},{"Policy Line":"70108496","B":"Phosphorous Inorg-QstCathrtics","C":"300","D":"84100","F":"102.3"},{"Policy Line":"70108497","B":"Magnesium - Quest Cathartics","C":"300","D":"83735","F":"42"},{"Policy Line":"70108498","B":"Chromatography, Thin Layer Nes","C":"300","D":"84999","F":"90.6"},{"Policy Line":"70108557","B":"Fluoride","C":"300","D":"82735","F":"464.1"},{"Policy Line":"70108558","B":"Mass Spectrometry Nes Qual","C":"300","D":"83789","F":"33"},{"Policy Line":"70108559","B":"Cadmium","C":"300","D":"82300","F":"462.3"},{"Policy Line":"70108560","B":"Chromium","C":"300","D":"82495","F":"57.9"},{"Policy Line":"70108561","B":"Spectrometry Nos 2","C":"300","D":"84311","F":"92.4"},{"Policy Line":"70108563","B":"Manganese","C":"300","D":"83785","F":"76.8"},{"Policy Line":"70108564","B":"Fatty Acids: Nonesterfied","C":"300","D":"82725","F":"287.7"},{"Policy Line":"70108702","B":"Specific Gravity-Fld","C":"300","D":"84315","F":"12.9"},{"Policy Line":"70109023","B":"Antiendomysial Ab Iga","C":"300","D":"83516","F":"294.6"},{"Policy Line":"70109026","B":"5HIAA 24 Hour Urine","C":"300","D":"83497","F":"68.7"},{"Policy Line":"70109027","B":"5HIAA: Random Urine","C":"300","D":"83497","F":"61.2"},{"Policy Line":"70109035","B":"Creatinine Ur Quest","C":"300","D":"82570","F":"27.9"},{"Policy Line":"70109200","B":"Drug Quantitation Nos","C":"300","D":"83789","F":"166.2"},{"Policy Line":"70109202","B":"Vit B12 Binding Capacity","C":"300","D":"82608","F":"66.9"},{"Policy Line":"70109204","B":"Soluble Transferrin Receptor","C":"300","D":"84238","F":"196.8"},{"Policy Line":"70109208","B":"Nephelometry Ea Analyte Nos","C":"300","D":"83883","F":"296.7"},{"Policy Line":"70109226","B":"Autoantibody Elisa","C":"300","D":"83520","F":"150.6"},{"Policy Line":"70109239","B":"HPLC Quant For 6-Mmpn","C":"300","D":"82542","F":"166.2"},{"Policy Line":"70109264","B":"TPMT Enz Activity Rbc Promet","C":"300","D":"82657","F":"166.2"},{"Policy Line":"70109265","B":"HPLC Quant 6-Mthyl-Thioguanine","C":"300","D":"82542","F":"166.2"},{"Policy Line":"70109266","B":"Amg By Nephelometry Prometheus","C":"300","D":"83883","F":"296.7"},{"Policy Line":"70109268","B":"Anca Elisa Igg","C":"300","D":"83520","F":"82.2"},{"Policy Line":"70109269","B":"Anti-A4-Fla2 Elisa","C":"300","D":"83520","F":"82.2"},{"Policy Line":"70109270","B":"Anti-Fla-X Elisa","C":"300","D":"83520","F":"82.2"},{"Policy Line":"70109271","B":"VEGF Elisa","C":"300","D":"83520","F":"82.2"},{"Policy Line":"70109272","B":"Icam Chemiluminescent Assay","C":"300","D":"82397","F":"82.2"},{"Policy Line":"70109273","B":"Vcam Chemilluminescent Assay","C":"300","D":"82397","F":"82.2"},{"Policy Line":"70109274","B":"SAA Chemiluminescent Assay","C":"300","D":"82397","F":"82.2"},{"Policy Line":"70109282","B":"HPLC Quant For 6-Tgn","C":"300","D":"82542","F":"166.2"},{"Policy Line":"70109283","B":"Hu-Ttg Elisa Iga Recombinant","C":"300","D":"83520","F":"151.5"},{"Policy Line":"70109284","B":"Prometheus Anser Ifx","C":"300","D":"84999","F":"744.9"},{"Policy Line":"70109600","B":"IGG Index","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70109721","B":"Estriol: Unconj","C":"300","D":"82677","F":"81.6"},{"Policy Line":"70109804","B":"Antigliadin Ab:Igg","C":"300","D":"83516","F":"33.3"},{"Policy Line":"70109807","B":"Antigliadin Ab:Iga","C":"300","D":"83516","F":"33.3"},{"Policy Line":"70109818","B":"Estriol","C":"300","D":"82677","F":"122.4"},{"Policy Line":"70109819","B":"Estrogens;Total","C":"300","D":"82672","F":"123"},{"Policy Line":"70109820","B":"Estrone","C":"300","D":"82679","F":"143.1"},{"Policy Line":"70109822","B":"17-Ketosteroid Fractionation","C":"300","D":"83593","F":"401.1"},{"Policy Line":"70109823","B":"Adh Anti Diuretic Hormone","C":"300","D":"84588","F":"88.8"},{"Policy Line":"70109825","B":"Free T3","C":"300","D":"84481","F":"51"},{"Policy Line":"70109830","B":"Thiocyanate","C":"300","D":"84430","F":"24.3"},{"Policy Line":"70109832","B":"Gtt Each Additional Hour 5","C":"300","D":"82952","F":"17.1"},{"Policy Line":"70109834","B":"Thyroid Stimulating Immunogl","C":"300","D":"84445","F":"123.6"},{"Policy Line":"70109840","B":"Heavy Metals Screen","C":"300","D":"83015","F":"258.3"},{"Policy Line":"70109841","B":"Estrogen Receptor Assay","C":"300","D":"84233","F":"1107.3"},{"Policy Line":"70109844","B":"Cpk Isoenzyme","C":"300","D":"82552","F":"68.1"},{"Policy Line":"70109846","B":"Progesterone Receptor Assay","C":"300","D":"84234","F":"1442.4"},{"Policy Line":"70109852","B":"17-Hydroxycorticosteroids","C":"300","D":"83491","F":"67.5"},{"Policy Line":"70109853","B":"Gastroccult For Ph/Hb","C":"300","D":"82271","F":"28.5"},{"Policy Line":"70109863","B":"Pg (Phosphatidylglycerol)","C":"300","D":"84081","F":"305.4"},{"Policy Line":"70109866","B":"Methylamalonic Acid","C":"300","D":"83921","F":"199.2"},{"Policy Line":"70109867","B":"Chemiluminescent Assay","C":"300","D":"82397","F":"82.2"},{"Policy Line":"70109868","B":"Blood Gases","C":"300","D":"82803","F":"96"},{"Policy Line":"70109900","B":"IGG","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70109912","B":"LDL Subparticles","C":"300","D":"82664","F":"418.2"},{"Policy Line":"70109915","B":"Cea: Fluid","C":"300","D":"82378","F":"64.5"},{"Policy Line":"70109932","B":"Albumin -Quest","C":"300","D":"82040","F":"27.9"},{"Policy Line":"70109934","B":"LDL Cholesterol Direct","C":"300","D":"83721","F":"36.3"},{"Policy Line":"70109938","B":"Sex Hormone Binding Globulin","C":"300","D":"84270","F":"33.3"},{"Policy Line":"70109940","B":"Testoserone Total-Quest","C":"300","D":"84403","F":"202.2"},{"Policy Line":"70109955","B":"Testosterone Free -Quest","C":"300","D":"84402","F":"87"},{"Policy Line":"70109956","B":"Testoserone Total Profile","C":"300","D":"84403","F":"75.9"},{"Policy Line":"70109959","B":"Total PSA Screening","C":"300","D":"G0103","F":"29.1"},{"Policy Line":"70109999","B":"PSA Total","C":"300","D":"84153","F":"29.1"},{"Policy Line":"70110014","B":"Citrate 24Hr Urine","C":"300","D":"82507","F":"213.9"},{"Policy Line":"70110015","B":"TRH - Thyrotropin Rel Hormone","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70110035","B":"Albumin Urine Or Other","C":"300","D":"82042","F":"28.2"},{"Policy Line":"70110041","B":"N-Telopeptide (Ntx)","C":"300","D":"82523","F":"176.7"},{"Policy Line":"70110060","B":"Thyrotropin Blocking Ab","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70110090","B":"Homocysteine","C":"300","D":"83090","F":"88.2"},{"Policy Line":"70110135","B":"Fibronectin: Fetal","C":"300","D":"82731","F":"242.7"},{"Policy Line":"70110166","B":"Vitamin B6","C":"300","D":"84207","F":"112.2"},{"Policy Line":"70110167","B":"Proinsulin","C":"300","D":"84206","F":"100.2"},{"Policy Line":"70110168","B":"Niacin","C":"300","D":"84591","F":"183.9"},{"Policy Line":"70110190","B":"Selenium","C":"300","D":"84255","F":"618.3"},{"Policy Line":"70110195","B":"Zinc Protoporphyrin","C":"300","D":"84202","F":"115.2"},{"Policy Line":"70110200","B":"Thiamine (Vitamin B1)","C":"300","D":"84425","F":"104.7"},{"Policy Line":"70110220","B":"Alpha 1 Antitrypsin - Pheno","C":"300","D":"82104","F":"85.8"},{"Policy Line":"70110221","B":"PL-7 Auto Abs","C":"300","D":"83516","F":"218.1"},{"Policy Line":"70110222","B":"PL-12 Auto Abs","C":"300","D":"83516","F":"218.1"},{"Policy Line":"70110224","B":"KU Auto Abs","C":"300","D":"83516","F":"218.1"},{"Policy Line":"70110225","B":"Ej Auto Abs","C":"300","D":"83516","F":"218.1"},{"Policy Line":"70110226","B":"OJ Auto Abs","C":"300","D":"83516","F":"218.1"},{"Policy Line":"70110230","B":"Sulfate: Urine","C":"300","D":"84392","F":"42.3"},{"Policy Line":"70110332","B":"Tissue Tgab Iga","C":"300","D":"83516","F":"123.3"},{"Policy Line":"70110340","B":"IGG Subclass 1","C":"300","D":"82787","F":"44.1"},{"Policy Line":"70110341","B":"IGG Subclass 2","C":"300","D":"82787","F":"44.1"},{"Policy Line":"70110342","B":"IGG Subclass 3","C":"300","D":"82787","F":"44.1"},{"Policy Line":"70110343","B":"IGG Subclass 4","C":"300","D":"82787","F":"44.1"},{"Policy Line":"70110344","B":"Total Igg -Qst","C":"300","D":"82784","F":"63.3"},{"Policy Line":"70110363","B":"Phospholipid Ab Igm","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70110364","B":"Phospholipid Ab Igm","C":"300","D":"83520","F":"352.8"},{"Policy Line":"70110365","B":"Phospholipid Ab Igm","C":"300","D":"83520","F":"352.8"},{"Policy Line":"70110366","B":"Phospholipid Ab Igm","C":"300","D":"83520","F":"352.8"},{"Policy Line":"70110367","B":"Phospholipid Ab Igg","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70110368","B":"Phospholipid Ab Igg","C":"300","D":"83520","F":"317.1"},{"Policy Line":"70110369","B":"Phospholipid Ab Igg","C":"300","D":"83520","F":"317.1"},{"Policy Line":"70110370","B":"Phospholipid Ab Igg","C":"300","D":"83520","F":"317.1"},{"Policy Line":"70110371","B":"Phospholipid Ab Igg","C":"300","D":"83520","F":"317.1"},{"Policy Line":"70110372","B":"Phospholipid Ab Iga","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70110373","B":"Phospholipid Ab Iga","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70110374","B":"Phospholipid Ab Iga","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70110375","B":"Phospholipid Ab Iga","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70110376","B":"Phospholipid Ab Igm","C":"300","D":"83520","F":"352.8"},{"Policy Line":"70110377","B":"Phospholipid Ab Iga","C":"300","D":"83520","F":"357.6"},{"Policy Line":"70110402","B":"Benzene","C":"300","D":"84600","F":"443.7"},{"Policy Line":"70110405","B":"Immunoassay: Quantitative","C":"300","D":"83519","F":"373.2"},{"Policy Line":"70110406","B":"Bnp (Pro-B Type Natriuretic) P","C":"300","D":"83880","F":"126.9"},{"Policy Line":"70110435","B":"Chlorinated Hydrocarbon:Screen","C":"300","D":"82441","F":"166.2"},{"Policy Line":"70112010","B":"Carnitine; Quant 1Specimen","C":"300","D":"82379","F":"88.8"},{"Policy Line":"70115011","B":"Spectrophotometry Nos","C":"300","D":"84311","F":"193.5"},{"Policy Line":"70115012","B":"Hemoglobin, Urine","C":"300","D":"83069","F":"109.5"},{"Policy Line":"70115019","B":"Lipoprotein High Resolution","C":"300","D":"83701","F":"104.1"},{"Policy Line":"70115056","B":"Pyruvate Kinase","C":"300","D":"84220","F":"260.7"},{"Policy Line":"70115717","B":"Anti-HMGCR Ab (EIA)","C":"300","D":"83516","F":"270.9"},{"Policy Line":"70115740","B":"NT5C1A IgG - WUSM","C":"300","D":"84182","F":"239.1"},{"Policy Line":"70115773","B":"Mitochondrial Antibody IgG","C":"300","D":"83516","F":"27.9"},{"Policy Line":"70115774","B":"Anti-GBM Antibody","C":"300","D":"83516","F":"55.5"},{"Policy Line":"70115775","B":"Serine Protease3,IgG (C-ANCA)","C":"300","D":"83516","F":"39"},{"Policy Line":"70115776","B":"Myeloperoxidase Ab (P-ANCA)","C":"300","D":"83516","F":"39"},{"Policy Line":"70115778","B":"PTH-Related Peptide (PTH-RP)","C":"300","D":"82542","F":"138.9"},{"Policy Line":"70115781","B":"Inhibin B","C":"300","D":"83520","F":"135.3"},{"Policy Line":"70115790","B":"5-HIAA","C":"300","D":"83497","F":"36.9"},{"Policy Line":"70115795","B":"PL-12 Ab","C":"300","D":"83516","F":"47.7"},{"Policy Line":"70115796","B":"PL-7 Ab","C":"300","D":"83516","F":"47.7"},{"Policy Line":"70115797","B":"OJ Ab","C":"300","D":"83516","F":"47.7"},{"Policy Line":"70115798","B":"EJ Ab","C":"300","D":"83516","F":"47.7"},{"Policy Line":"70115799","B":"SRP Ab","C":"300","D":"83516","F":"47.7"},{"Policy Line":"70115811","B":"Parietal Cell Antibody, IgG","C":"300","D":"83516","F":"44.4"},{"Policy Line":"70115812","B":"Centromere Antibody, IgG","C":"300","D":"83516","F":"33.3"},{"Policy Line":"70115814","B":"Cobalt","C":"300","D":"83018","F":"61.2"},{"Policy Line":"70115815","B":"Iodine, Serum","C":"300","D":"83018","F":"148.2"},{"Policy Line":"70115838","B":"Thyroglobulin, S/P (CIA)","C":"300","D":"84432","F":"55.5"},{"Policy Line":"70115839","B":"Thyroglobulin, S/P (LC-MS/MS)","C":"300","D":"84432","F":"148.2"},{"Policy Line":"70115859","B":"Calcium, Urine","C":"300","D":"82340","F":"24.9"},{"Policy Line":"70115860","B":"Chloride, Urine","C":"300","D":"82436","F":"24.9"},{"Policy Line":"70115861","B":"Citrate","C":"300","D":"82507","F":"39"},{"Policy Line":"70115862","B":"Uric Acid, other source","C":"300","D":"84560","F":"24.9"},{"Policy Line":"70115863","B":"Magnesium","C":"300","D":"83735","F":"24.9"},{"Policy Line":"70115864","B":"Oxalate","C":"300","D":"83945","F":"24.9"},{"Policy Line":"70115865","B":"Phosphorus, Urine","C":"300","D":"84105","F":"24.9"},{"Policy Line":"70115866","B":"Potassium, Urine","C":"300","D":"84133","F":"24.9"},{"Policy Line":"70115867","B":"Sodium, Urine","C":"300","D":"84300","F":"24.9"},{"Policy Line":"70115868","B":"Sulfate, Urine","C":"300","D":"84392","F":"24.9"},{"Policy Line":"70115869","B":"pH; body fluid, NOS","C":"300","D":"83986","F":"24.9"},{"Policy Line":"70115871","B":"Acetylcholine Recep Block Ab","C":"300","D":"83516","F":"105.6"},{"Policy Line":"70115872","B":"Acetylcholine Modulat Block Ab","C":"300","D":"83516","F":"125.1"},{"Policy Line":"70115892","B":"Maternal Serum Screen AFP","C":"300","D":"82105","F":"42"},{"Policy Line":"70115911","B":"Free PSA","C":"300","D":"84154","F":"42"},{"Policy Line":"70115921","B":"Hgb Evaluation w/ Reflex","C":"300","D":"83021","F":"83.4"},{"Policy Line":"70115985","B":"Hemoglobin-SF","C":"300","D":"84311","F":"31.2"},{"Policy Line":"70115986","B":"Alpha Defensins-SF","C":"300","D":"83516","F":"31.2"},{"Policy Line":"70115994","B":"RNA Polymerase III Ab, IgG","C":"300","D":"83516","F":"194.7"},{"Policy Line":"70115996","B":"Chromatin Antibody, IgG","C":"300","D":"83516","F":"138.9"},{"Policy Line":"70116001","B":"Celiac Dis Dual Ag Screen","C":"300","D":"83516","F":"138.9"},{"Policy Line":"70116002","B":"DGP Antibody, IgG","C":"300","D":"83516","F":"33.3"},{"Policy Line":"70116003","B":"DGP Antibody, IgA","C":"300","D":"83516","F":"33.3"},{"Policy Line":"70116004","B":"tTG Ab, IgG","C":"300","D":"83516","F":"69.6"},{"Policy Line":"70116005","B":"tTG Ab, IgA","C":"300","D":"83516","F":"27.9"},{"Policy Line":"70116007","B":"Immunglobulin A","C":"300","D":"82784","F":"25.2"},{"Policy Line":"70116015","B":"Neuronal Ab (Amphiphysin)","C":"300","D":"83516","F":"106.8"},{"Policy Line":"70116018","B":"Neuronal Nuclear Abs IgG, IB","C":"300","D":"83516","F":"222.3"},{"Policy Line":"70116080","B":"Serum Protein Electrophoresis","C":"300","D":"84165","F":"22.2"},{"Policy Line":"70116081","B":"Prot,total,by refract,any src","C":"300","D":"84160","F":"22.2"},{"Policy Line":"70116082","B":"Total Protein Other Specimen","C":"300","D":"84157","F":"33.3"},{"Policy Line":"70116083","B":"Protein E-Phoresis/Urine/CSF","C":"300","D":"84166","F":"33.3"},{"Policy Line":"70116088","B":"Adalimumab Neutralizing Ab","C":"300","D":"82397","F":"470.7"},{"Policy Line":"70116090","B":"Thiopur Methyltransferase,RBC","C":"300","D":"82657","F":"277.8"},{"Policy Line":"70116094","B":"Infliximab Neutralizing Ab","C":"300","D":"82397","F":"470.7"},{"Policy Line":"70116095","B":"Muscle-Specific Kinase(MuSK)Ab","C":"300","D":"83519","F":"207.6"},{"Policy Line":"70116102","B":"Vasoactive Intestinal Peptide","C":"300","D":"84586","F":"111.3"},{"Policy Line":"70116103","B":"Pancreatic Polypeptide","C":"300","D":"83519","F":"194.7"},{"Policy Line":"70116107","B":"Pancreatic Elastase, Fecal","C":"300","D":"83520","F":"259.5"},{"Policy Line":"70116178","B":"Insulin-Like Growth Factor 2","C":"300","D":"83520","F":"203.1"},{"Policy Line":"70116205","B":"Vitamin B2 Riboflavin","C":"300","D":"84252","F":"138.9"},{"Policy Line":"70116210","B":"Adenoise Deaminase, RBC","C":"300","D":"84311","F":"148.2"},{"Policy Line":"70116211","B":"Adenoise Deaminase,Pleural Fld","C":"300","D":"84311","F":"111.3"},{"Policy Line":"70116213","B":"Arsenic","C":"300","D":"82175","F":"42"},{"Policy Line":"70116214","B":"Lead","C":"300","D":"83655","F":"42"},{"Policy Line":"70116215","B":"Mercury, quantitative","C":"300","D":"83825","F":"42"},{"Policy Line":"70116216","B":"Arsenic","C":"300","D":"82175","F":"171"},{"Policy Line":"70116221","B":"Estriol","C":"300","D":"82677","F":"42"},{"Policy Line":"70116222","B":"Fecal Fat, Quant Random","C":"300","D":"82710","F":"83.4"},{"Policy Line":"70116223","B":"Fecal Fat, Quant 24-hr","C":"300","D":"82710","F":"111.3"},{"Policy Line":"70116224","B":"Fecal Fat, Quant 48-hr","C":"300","D":"82710","F":"166.8"},{"Policy Line":"70116225","B":"Fecal Fat, Quant 72-hr","C":"300","D":"82710","F":"138.9"},{"Policy Line":"70116231","B":"Immunglobulin A","C":"300","D":"82784","F":"53.7"},{"Policy Line":"70116232","B":"Immunglobulin A Subclass 1","C":"300","D":"82787","F":"53.7"},{"Policy Line":"70116233","B":"Immunglobulin A Subclass 2","C":"300","D":"82787","F":"53.7"},{"Policy Line":"70116241","B":"Anti-Mullerian Hormone","C":"300","D":"83520","F":"110.1"},{"Policy Line":"70116245","B":"ACE, CSF","C":"300","D":"82164","F":"83.4"},{"Policy Line":"70116248","B":"AQP4 ELISA","C":"300","D":"83516","F":"463.5"},{"Policy Line":"70116261","B":"Coenzyme Q10, Total","C":"300","D":"82542","F":"148.2"},{"Policy Line":"70116267","B":"Mannose Binding Lectin","C":"300","D":"83520","F":"203.1"},{"Policy Line":"70116293","B":"Bismuth, Blood","C":"300","D":"83018","F":"83.4"},{"Policy Line":"70116294","B":"Androstenedione","C":"300","D":"82157","F":"58.2"},{"Policy Line":"70116295","B":"Dehydroepiandrosterone (DHEA)","C":"300","D":"83498","F":"58.2"},{"Policy Line":"70116296","B":"Testosterone; total","C":"300","D":"84403","F":"58.2"},{"Policy Line":"70116297","B":"17-Hydroxyprogesterone","C":"300","D":"82634","F":"58.2"},{"Policy Line":"70116298","B":"11-Deoxycortisol, HPLC-MS/MS","C":"300","D":"82626","F":"58.2"},{"Policy Line":"70116301","B":"Vitamin B12 Binding Capacity","C":"300","D":"82608","F":"69.6"},{"Policy Line":"70116314","B":"ADAMTS13 Antibody","C":"300","D":"83520","F":"420.6"},{"Policy Line":"70116317","B":"Myelin Assoc Glycoprotein, IgM","C":"300","D":"83516","F":"64.2"},{"Policy Line":"70116318","B":"GM1 Antibody, IgG","C":"300","D":"83516","F":"55.5"},{"Policy Line":"70116319","B":"GM1 Antibody, IgM","C":"300","D":"83516","F":"55.5"},{"Policy Line":"70116320","B":"GD1b Antibody, IgG","C":"300","D":"83516","F":"55.5"},{"Policy Line":"70116321","B":"GD1b Antibody, IgM","C":"300","D":"83516","F":"55.5"},{"Policy Line":"70116322","B":"GQ1b Antibody, IgG","C":"300","D":"83516","F":"55.5"},{"Policy Line":"70116323","B":"GQ1b Antibody, IgM","C":"300","D":"83516","F":"55.5"},{"Policy Line":"70116324","B":"VGKC Antibody","C":"300","D":"83519","F":"309"},{"Policy Line":"70116325","B":"Aquaporin-4 Receptor Antibody","C":"300","D":"83516","F":"309"},{"Policy Line":"70116335","B":"Ph, Fecal","C":"300","D":"83986","F":"33.3"},{"Policy Line":"70116336","B":"Potassium, Stool","C":"300","D":"84999","F":"39"},{"Policy Line":"70116337","B":"Sodium, Stool","C":"300","D":"84302","F":"39"},{"Policy Line":"70116338","B":"Chloride, Stool","C":"300","D":"82438","F":"39"},{"Policy Line":"70116341","B":"PAPP-A","C":"300","D":"84163","F":"100.5"},{"Policy Line":"70116342","B":"VGCC Antibody","C":"300","D":"83519","F":"309"},{"Policy Line":"70116343","B":"Titin Antibody","C":"300","D":"83516","F":"240.9"},{"Policy Line":"70116344","B":"Melanocyte Stim Hormone,Alpha","C":"300","D":"83519","F":"256.8"},{"Policy Line":"70116359","B":"AST, FibroMeter","C":"300","D":"84450","F":"50.1"},{"Policy Line":"70116360","B":"ALT, FibroMeter","C":"300","D":"84460","F":"50.1"},{"Policy Line":"70116361","B":"Ferritin, FibroMeter","C":"300","D":"82728","F":"50.1"},{"Policy Line":"70116362","B":"Glucose, FibroMeter","C":"300","D":"82947","F":"50.1"},{"Policy Line":"70116375","B":"SGPG Antibody, IgM","C":"300","D":"83516","F":"82.2"},{"Policy Line":"70116382","B":"Insulin, Total","C":"300","D":"83525","F":"23.1"},{"Policy Line":"70116383","B":"Insulin, Free","C":"300","D":"83527","F":"23.1"},{"Policy Line":"70116399","B":"Vitamin B7 (Biotin)","C":"300","D":"84591","F":"149.7"},{"Policy Line":"70116421","B":"Dihydrotestosterone (DHT)","C":"300","D":"82642","F":"62.7"},{"Policy Line":"70116455","B":"F-Actin Ab, IgG","C":"300","D":"83516","F":"15"},{"Policy Line":"70116456","B":"14-3-3 eta Protein","C":"300","D":"83520","F":"193.5"},{"Policy Line":"70116457","B":"Acylglycines, Quant, Ur","C":"300","D":"82542","F":"207.6"},{"Policy Line":"70116459","B":"Porphyrins, Total, Pl or Ser","C":"300","D":"84311","F":"36"},{"Policy Line":"70116479","B":"Fat, Fecal Qualitative","C":"300","D":"82705","F":"33.6"},{"Policy Line":"70116490","B":"Magnesium, RBC","C":"300","D":"83735","F":"68.7"},{"Policy Line":"70116493","B":"Thyroglobulin, FNA","C":"300","D":"84432","F":"52.5"},{"Policy Line":"70116497","B":"Phencyclidine (PCP),S/P,Quant","C":"300","D":"83992","F":"127.8"},{"Policy Line":"70116501","B":"Immunglobulin A","C":"300","D":"82784","F":"25.2"},{"Policy Line":"70116502","B":"Heavy Metal Quant","C":"300","D":"83018","F":"497.4"},{"Policy Line":"70116503","B":"Vitamin K","C":"300","D":"84597","F":"146.1"},{"Policy Line":"70116504","B":"SGPG Antibody, IgM","C":"300","D":"83516","F":"26.7"},{"Policy Line":"70116505","B":"MAG Antibody, IgM Elisa","C":"300","D":"83516","F":"26.7"},{"Policy Line":"70116506","B":"Asialo-GM1 Antibodies, IgG/IgM","C":"300","D":"83516","F":"26.7"},{"Policy Line":"70116507","B":"GM1 Antibodies, IgG/IgM","C":"300","D":"83516","F":"26.7"},{"Policy Line":"70116508","B":"GD1a Antibodies, IgG/IgM","C":"300","D":"83516","F":"26.7"},{"Policy Line":"70116509","B":"GD1b Antibodies, IgG/IgM","C":"300","D":"83516","F":"26.7"},{"Policy Line":"70116510","B":"GQ1b Antibodies, IgG/IgM","C":"300","D":"83516","F":"26.7"},{"Policy Line":"70116515","B":"Alpha-1-antitrypsin; phenotype","C":"300","D":"82104","F":"53.7"},{"Policy Line":"70116536","B":"Hydroxycorticosteroids,17,Ur","C":"300","D":"83491","F":"94.5"},{"Policy Line":"70116539","B":"Copper Level Urine","C":"300","D":"82525","F":"21.3"},{"Policy Line":"70116540","B":"Creatinine Body Fluid","C":"300","D":"82570","F":"15"},{"Policy Line":"70116548","B":"Oxalate, Total, Urine","C":"300","D":"83945","F":"38.4"},{"Policy Line":"70116549","B":"Thyroxine binding globulin","C":"300","D":"84442","F":"30.3"},{"Policy Line":"70116550","B":"Bullous Pemphigoid Ag 180, IgG","C":"300","D":"83516","F":"114.9"},{"Policy Line":"70116551","B":"Bullous Pemphigoid Ag 230, IgG","C":"300","D":"83516","F":"114.9"},{"Policy Line":"70116552","B":"Lead, Urine","C":"300","D":"83655","F":"19.2"},{"Policy Line":"70116553","B":"Carboxyhemoglobin;quantitative","C":"300","D":"82375","F":"152.4"},{"Policy Line":"70116560","B":"21-Hydroxylase Antibody","C":"300","D":"83519","F":"97.8"},{"Policy Line":"70116568","B":"Porphyrins Total, Plasma","C":"300","D":"84311","F":"199.2"},{"Policy Line":"70116569","B":"Porphyrins, Fractionation,Plas","C":"300","D":"82542","F":"276"},{"Policy Line":"70116581","B":"Leptin Quant by CIA","C":"300","D":"83520","F":"111.9"},{"Policy Line":"70116599","B":"Pompe (GAA),Enz Act Leukocytes","C":"300","D":"82657","F":"186.3"},{"Policy Line":"70116600","B":"F-Actin (Smooth Muscle) Ab,IgA","C":"300","D":"83516","F":"118.5"},{"Policy Line":"70116604","B":"SAE1 Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116605","B":"NXP2 Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116606","B":"MDA5 Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116607","B":"TIF-1 gamma Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116608","B":"Mi-2 Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116609","B":"P155/140 Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116610","B":"PL-12 Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116611","B":"PL-7 Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116612","B":"OJ Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116613","B":"EJ Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116614","B":"SRP Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116615","B":"Ku Ab-EMP","C":"300","D":"83516","F":"27.3"},{"Policy Line":"70116627","B":"IGF Binding Protein-3","C":"301","D":"82397","F":"34.2"},{"Policy Line":"70116630","B":"Interleukin 5","C":"300","D":"83520","F":"158.4"},{"Policy Line":"70116631","B":"Chylomicron Screen, Body Fluid","C":"300","D":"82664","F":"63.6"},{"Policy Line":"70116632","B":"Glucose, Urine","C":"301","D":"82945","F":"29.4"},{"Policy Line":"70116638","B":"Uric Acid, Urine","C":"301","D":"84560","F":"13.8"},{"Policy Line":"70116639","B":"Insulin, Fasting","C":"301","D":"83525","F":"17.4"},{"Policy Line":"70116644","B":"Immunoglobulin E","C":"301","D":"82785","F":"15"},{"Policy Line":"70116646","B":"Alpha Fetoprotein Tumor Marker","C":"301","D":"82105","F":"24.6"},{"Policy Line":"70116648","B":"Homocysteine, Total","C":"300","D":"83090","F":"38.1"},{"Policy Line":"70116651","B":"Chromium, RBC","C":"301","D":"82495","F":"194.1"},{"Policy Line":"70116652","B":"Alpha Galactosidase, Serum","C":"301","D":"82657","F":"440.4"},{"Policy Line":"70116653","B":"IgA","C":"301","D":"82784","F":"18"},{"Policy Line":"70116654","B":"IgG","C":"301","D":"82784","F":"18"},{"Policy Line":"70116655","B":"IgM","C":"301","D":"82784","F":"18"},{"Policy Line":"70116656","B":"Total Protein","C":"301","D":"84155","F":"18"},{"Policy Line":"70116657","B":"SPE","C":"300","D":"84165","F":"18"},{"Policy Line":"70116673","B":"Pyruvate kinase","C":"301","D":"84220","F":"97.5"},{"Policy Line":"70116674","B":"Total PSA","C":"301","D":"84153","F":"145.2"},{"Policy Line":"70116675","B":"Free PSA","C":"301","D":"84154","F":"186.3"},{"Policy Line":"70116681","B":"Methemoglobin Reductase, Bld","C":"300","D":"82657","F":"390"},{"Policy Line":"70116683","B":"Interferon gamma","C":"300","D":"83520","F":"158.7"},{"Policy Line":"70116684","B":"Cholinesterase, RBC","C":"300","D":"82482","F":"31.8"},{"Policy Line":"70116731","B":"Immunoassay Quant Nos 4","C":"301","D":"83520","F":"13.2"},{"Policy Line":"70116732","B":"Immunoassay Quant Nos 5","C":"301","D":"83520","F":"13.2"},{"Policy Line":"70118028","B":"Very Long Chain Fatty Acids","C":"300","D":"82726","F":"166.2"},{"Policy Line":"70118029","B":"Enzyme: Radioactive Substrate","C":"300","D":"82658","F":"166.2"},{"Policy Line":"70118468","B":"Column Chromatography/Ms Quani","C":"300","D":"82542","F":"166.2"},{"Policy Line":"70118489","B":"Immunoassay Quant Nos 3","C":"300","D":"83520","F":"177.6"},{"Policy Line":"70118494","B":"Arsenic: Nail","C":"300","D":"82175","F":"258.3"},{"Policy Line":"70119500","B":"Nags:Hexosam. A & Total Serum","C":"300","D":"83080","F":"416.7"},{"Policy Line":"70124320","B":"Electrophoresis, Nes","C":"300","D":"82664","F":"352.8"},{"Policy Line":"73100003","B":"Blood Gases","C":"300","D":"82803","F":"96"},{"Policy Line":"73100110","B":"Calcium Ionized","C":"300","D":"82330","F":"51"},{"Policy Line":"73100111","B":"Lactate","C":"300","D":"83605","F":"43.5"},{"Policy Line":"73100114","B":"Sodium: Serum","C":"300","D":"84295","F":"26.4"},{"Policy Line":"73100115","B":"Potassium: Serum","C":"300","D":"84132","F":"25.2"},{"Policy Line":"73100116","B":"Chloride Blood","C":"300","D":"82435","F":"26.7"},{"Policy Line":"73100117","B":"Glucose; Blood, Quant","C":"300","D":"82947","F":"22.8"},{"Policy Line":"73100221","B":"BG W/ POC ELECTROLYTES","C":"300","D":"82803","F":"100.2"},{"Policy Line":"73100222","B":"BG W/ POC ELECTROLW/GLU","C":"300","D":"82803","F":"104.1"},{"Policy Line":"74201024","B":"Glucose","C":"300","D":"82947","F":"21"},{"Policy Line":"74221019","B":"AST - Med Mgmt","C":"300","D":"84450","F":"24"},{"Policy Line":"74221020","B":"Alt - Med Mgmt","C":"300","D":"84460","F":"24"},{"Policy Line":"74221021","B":"Creatinine, Blood","C":"300","D":"82565","F":"27.9"},{"Policy Line":"74221022","B":"BUN - QUANT","C":"300","D":"84520","F":"24"},{"Policy Line":"74221024","B":"Glucose","C":"300","D":"82947","F":"21"},{"Policy Line":"74221025","B":"A1C","C":"300","D":"83036","F":"22.2"},{"Policy Line":"75452025","B":"Go Strong Fasting Glucose","C":"300","D":"82962","F":"2.7"},{"Policy Line":"75452026","B":"Go Strong Hgba1C","C":"300","D":"83036","F":"4.5"},{"Policy Line":"70100215","B":"Clozapine (Clozaril) Qst","C":"300","D":"80159","F":"174.9"},{"Policy Line":"70100645","B":"Acetaminophen Assay","C":"300","D":"G0480","F":"52.2"},{"Policy Line":"70100740","B":"Salicylate Assay","C":"300","D":"G0480","F":"45.9"},{"Policy Line":"70100751","B":"Alcohol Ethyl","C":"300","D":"G0480","F":"65.1"},{"Policy Line":"70100842","B":"Fentanyl Drug Screen","C":"300","D":"G0659","F":"61.2"},{"Policy Line":"70100843","B":"Fentanyl Drug Confirmation","C":"300","D":"G0480","F":"132.3"},{"Policy Line":"70101019","B":"Methadone","C":"300","D":"G0480","F":"87"},{"Policy Line":"70101099","B":"Drug Screen ADOS KIMS CEDIA EI","C":"300","D":"80307","F":"253.2"},{"Policy Line":"70101310","B":"Drug Screen B Single;Ea Proc","C":"300","D":"G0659","F":"74.7"},{"Policy Line":"70101663","B":"Zonisamide","C":"300","D":"80203","F":"75"},{"Policy Line":"70104247","B":"Nortriptyline,1-2 Definitive","C":"300","D":"G0480","F":"118.8"},{"Policy Line":"70106234","B":"Amitriptylin/ElavilAntidepTric","C":"300","D":"G0480","F":"93"},{"Policy Line":"70109024","B":"Gabapentin Level","C":"300","D":"80171","F":"31.8"},{"Policy Line":"70109889","B":"SedrugscrTricyclic, 3-5Antidep","C":"300","D":"G0480","F":"42.3"},{"Policy Line":"70110008","B":"Drug Confirmation: Amphet","C":"300","D":"G0480","F":"125.1"},{"Policy Line":"70110009","B":"Drug Confirmation:Opiates >=1","C":"300","D":"G0480","F":"132.3"},{"Policy Line":"70110010","B":"Drug Confirmation: Benzo","C":"300","D":"G0480","F":"116.7"},{"Policy Line":"70110011","B":"Drug Confirmation: Cocaine","C":"300","D":"G0480","F":"108.9"},{"Policy Line":"70110033","B":"Lamotrigine","C":"300","D":"80175","F":"161.1"},{"Policy Line":"70110145","B":"Oxycodone","C":"300","D":"G0480","F":"490.8"},{"Policy Line":"70110350","B":"Drug Confirmation:Barbiturates","C":"300","D":"G0480","F":"62.4"},{"Policy Line":"70115014","B":"Dihydrotestosterone (Dht)","C":"300","D":"G0480","F":"222"},{"Policy Line":"70115505","B":"Nicotine, Assay","C":"300","D":"G0480","F":"128.4"},{"Policy Line":"70115611","B":"Tricyclic Antidepres Eval -QST","C":"301","D":"G0480","F":"80.1"},{"Policy Line":"70115631","B":"Drug Test Presumptive","C":"300","D":"G0659","F":"173.4"},{"Policy Line":"70115632","B":"Drug Test Def 22++ - LabCorp","C":"300","D":"G0483","F":"173.4"},{"Policy Line":"70115754","B":"Drug Screen Amphetamines","C":"300","D":"G0480","F":"42.3"},{"Policy Line":"70115755","B":"Drug Screen Barbiturates","C":"300","D":"G0480","F":"42.3"},{"Policy Line":"70115756","B":"Drug Screen Benzodiazepines","C":"300","D":"G0480","F":"42.3"},{"Policy Line":"70115757","B":"Drug Screen Cannabinoids","C":"300","D":"G0480","F":"42.3"},{"Policy Line":"70115758","B":"Drug Screen Cocaine","C":"300","D":"G0480","F":"42.3"},{"Policy Line":"70115759","B":"Drug Screen Opiates","C":"300","D":"G0480","F":"42.3"},{"Policy Line":"70115764","B":"Drug Screening Buprenorphine","C":"301","D":"G0480","F":"47.4"},{"Policy Line":"70115771","B":"Drug Test Prsmv Chem Analyzr","C":"300","D":"80307","F":"134.1"},{"Policy Line":"70115783","B":"TSH Receptor Ab (ARUP)","C":"300","D":"80353","F":"57.6"},{"Policy Line":"70115877","B":"Methanol","C":"300","D":"G0480","F":"58.5"},{"Policy Line":"70115882","B":"Oxcarbazepine","C":"300","D":"80183","F":"45.3"},{"Policy Line":"70115901","B":"Drug Pan 9,Se/Pl,Scr Rflx Conf","C":"300","D":"80307","F":"147.3"},{"Policy Line":"70115902","B":"Amphetamines, Se/Pl, Quant","C":"300","D":"G0480","F":"163.8"},{"Policy Line":"70115903","B":"Barbiturates, Se/Pl, Quant","C":"300","D":"G0480","F":"124.8"},{"Policy Line":"70115904","B":"Benzodiazepines, Se/Pl, Quant","C":"300","D":"G0480","F":"124.8"},{"Policy Line":"70115905","B":"THC Metabolite, Se/Pl, Quant","C":"300","D":"G0480","F":"163.8"},{"Policy Line":"70115906","B":"Cocaine Metabolite, Se/Pl, Qnt","C":"300","D":"G0480","F":"140.4"},{"Policy Line":"70115907","B":"Methadone and Metab, Se/Pl, Qt","C":"300","D":"G0480","F":"163.8"},{"Policy Line":"70115908","B":"Opiates, Se/Pl, Quant","C":"300","D":"G0480","F":"163.8"},{"Policy Line":"70115909","B":"Buprenorphine & Metab,Se/Pl,Qt","C":"300","D":"G0480","F":"163.8"},{"Policy Line":"70115910","B":"Phencyclidine (PCP), Se/Pl, Qt","C":"300","D":"G0480","F":"124.8"},{"Policy Line":"70115912","B":"Amphetmines, Confirm, Mec","C":"300","D":"G0480","F":"241.8"},{"Policy Line":"70115913","B":"Barbiturates, Confirm, Mec","C":"300","D":"G0480","F":"241.8"},{"Policy Line":"70115914","B":"Benzodiazepines, Confirm, Mec","C":"300","D":"G0480","F":"234"},{"Policy Line":"70115915","B":"Buprenorphine,Confirm, Mec","C":"300","D":"G0480","F":"174"},{"Policy Line":"70115916","B":"Cannabinoids, Confirm, Mec","C":"300","D":"G0480","F":"187.2"},{"Policy Line":"70115917","B":"Cocaine, Confirm, Mec","C":"300","D":"G0480","F":"187.2"},{"Policy Line":"70115918","B":"Methadone, Confirm, Mec","C":"300","D":"G0480","F":"187.2"},{"Policy Line":"70115919","B":"Opiates, Confirm, Mec","C":"300","D":"G0480","F":"187.2"},{"Policy Line":"70115920","B":"Phencyclidine, Confirm, Mec","C":"300","D":"G0480","F":"234"},{"Policy Line":"70115971","B":"Drug Panel 9,U,Scr w/Rflx Conf","C":"300","D":"80307","F":"67.8"},{"Policy Line":"70115972","B":"Amphetamines Confirm, Ur","C":"300","D":"80324","F":"52.8"},{"Policy Line":"70115973","B":"MDMA, Confirm, Ur","C":"300","D":"G0480","F":"52.8"},{"Policy Line":"70115974","B":"Barbiturates Confirm, Ur","C":"300","D":"G0480","F":"163.8"},{"Policy Line":"70115975","B":"Benzodiazepines Confirm, Ur","C":"300","D":"G0480","F":"105.3"},{"Policy Line":"70115976","B":"THC Confirm, Ur","C":"300","D":"G0480","F":"93.6"},{"Policy Line":"70115977","B":"Cocaine Confirm, Ur","C":"300","D":"G0480","F":"93.6"},{"Policy Line":"70115978","B":"Methadone Confirm, Ur","C":"300","D":"G0480","F":"105.3"},{"Policy Line":"70115979","B":"Opiates Confirm, Ur","C":"300","D":"G0480","F":"41.1"},{"Policy Line":"70115980","B":"Oxycodone Confirm, Ur","C":"300","D":"G0480","F":"41.1"},{"Policy Line":"70115981","B":"Propoxyphene Confirm, Ur","C":"300","D":"G0480","F":"124.8"},{"Policy Line":"70115982","B":"PCP, Confirm, Ur","C":"300","D":"G0480","F":"124.8"},{"Policy Line":"70116105","B":"Ethyl Glucoronide/Sulfate,U,Qt","C":"300","D":"G0480","F":"98.4"},{"Policy Line":"70116212","B":"Hypoglycemia Pan,Sylfonylureas","C":"300","D":"G0480","F":"117"},{"Policy Line":"70116251","B":"Phosphatidylethanol (PEth)","C":"300","D":"G0480","F":"174"},{"Policy Line":"70116494","B":"Amphetamines/Methamphetamines","C":"300","D":"80324","F":"50.1"},{"Policy Line":"70116495","B":"MDA, MDEA, MDMA","C":"300","D":"80359","F":"50.1"},{"Policy Line":"70116496","B":"Alcohol, Urine, Quant","C":"300","D":"80320","F":"38.4"},{"Policy Line":"70116498","B":"Propoxyphene & Met, S/P, Quant","C":"300","D":"80367","F":"131.7"},{"Policy Line":"70116499","B":"Fluoxetine & Met, S/P","C":"300","D":"80332","F":"162"},{"Policy Line":"70116574","B":"Clobazam Quantitative, S/P","C":"300","D":"80339","F":"151.2"},{"Policy Line":"70116583","B":"Drug Screen (Nonforensic), Ser","C":"300","D":"80307","F":"123"},{"Policy Line":"70116597","B":"Lacosamide, Serum or Plasma","C":"300","D":"80339","F":"171"},{"Policy Line":"70116678","B":"Amitriptyline/Nortriptyline","C":"300","D":"G0480","F":"51"},{"Policy Line":"70118460","B":"Levetiracetam","C":"300","D":"80177","F":"191.4"},{"Policy Line":"70121000","B":"Mycophenolic Acid","C":"300","D":"80180","F":"120"},{"Policy Line":"61700154","B":"Activated Clotting Time","C":"300","D":"85347","F":"107.7"},{"Policy Line":"61800080","B":"Activated Clotting Time","C":"300","D":"85347","F":"107.7"},{"Policy Line":"68269753","B":"CBC, AUTO, DIFF PLTLTS","C":"300","D":"85025","F":"14.1"},{"Policy Line":"70100016","B":"Sedimentation Rate","C":"300","D":"85651","F":"35.7"},{"Policy Line":"70100018","B":"Platelet Count","C":"300","D":"85049","F":"28.5"},{"Policy Line":"70100041","B":"Protime","C":"300","D":"85610","F":"23.7"},{"Policy Line":"70100042","B":"PTT","C":"300","D":"85730","F":"32.7"},{"Policy Line":"70100071","B":"CBC Without DIFF-AUTOM PLTLT","C":"300","D":"85027","F":"10.5"},{"Policy Line":"70100072","B":"Differential: Manual","C":"300","D":"85007","F":"6.3"},{"Policy Line":"70100098","B":"D-Dimer","C":"300","D":"85379","F":"84.6"},{"Policy Line":"70100198","B":"Fibrinogen","C":"300","D":"85384","F":"63.6"},{"Policy Line":"70100434","B":"Factor II Activity - Qst","C":"300","D":"85210","F":"106.5"},{"Policy Line":"70100517","B":"Fibrin Split Products","C":"300","D":"85362","F":"89.1"},{"Policy Line":"70100518","B":"Thrombin Time","C":"300","D":"85670","F":"38.1"},{"Policy Line":"70100608","B":"VWF Protease Activity","C":"300","D":"85397","F":"187.2"},{"Policy Line":"70100609","B":"VWF Protease Inhibitor","C":"300","D":"85335","F":"228"},{"Policy Line":"70100646","B":"Kleihauer-Betke","C":"300","D":"85460","F":"68.7"},{"Policy Line":"70100660","B":"Sickle Cell Prep","C":"300","D":"85660","F":"66.6"},{"Policy Line":"70100663","B":"Leuk Alk Phos","C":"300","D":"85540","F":"101.7"},{"Policy Line":"70100711","B":"WBC - Automated","C":"300","D":"85048","F":"38.7"},{"Policy Line":"70100713","B":"Hemoglobin","C":"300","D":"85018","F":"23.4"},{"Policy Line":"70100714","B":"Hematocrit","C":"300","D":"85014","F":"23.4"},{"Policy Line":"70100715","B":"Reticulocyte Count - Auto","C":"300","D":"85045","F":"34.8"},{"Policy Line":"70100825","B":"WBC Stool","C":"300","D":"89055","F":"51.9"},{"Policy Line":"70100861","B":"PTT Mixing 1","C":"300","D":"85730","F":"32.7"},{"Policy Line":"70100862","B":"PTT Mixing 2","C":"300","D":"85730","F":"32.7"},{"Policy Line":"70101029","B":"PTT La Screen Qs","C":"300","D":"85730","F":"16.5"},{"Policy Line":"70101030","B":"PTT La Hexagonal Phase Confir","C":"300","D":"85598","F":"82.2"},{"Policy Line":"70101295","B":"Fibrinogen Antigen Neph -Quest","C":"300","D":"85385","F":"33.6"},{"Policy Line":"70101368","B":"Euglobulin Clot Lysis Time Qst","C":"300","D":"85360","F":"129.6"},{"Policy Line":"70101405","B":"PTT -La (Lupus Panel Quest)","C":"300","D":"85730","F":"32.7"},{"Policy Line":"70101406","B":"Drvvt For Lupus Panel Quest","C":"300","D":"85613","F":"99"},{"Policy Line":"70101408","B":"PTT Vw Panel Quest 15540","C":"300","D":"85730","F":"32.7"},{"Policy Line":"70101422","B":"Protein S Free Quest","C":"300","D":"85306","F":"39.3"},{"Policy Line":"70101468","B":"FETOMATERNAL HEMORRHAGE ROSETT","C":"300","D":"85461","F":"109.5"},{"Policy Line":"70101604","B":"Factor V Activity Clotting","C":"300","D":"85220","F":"60.9"},{"Policy Line":"70102018","B":"WBC (DIFF)","C":"300","D":"85004","F":"91.8"},{"Policy Line":"70102382","B":"Nijmegen Assay","C":"300","D":"85335","F":"363.9"},{"Policy Line":"70104033","B":"Anti Thrombin III, Activ Assay","C":"300","D":"85300","F":"145.5"},{"Policy Line":"70104063","B":"Viscosity","C":"300","D":"85810","F":"28.2"},{"Policy Line":"70104209","B":"Lupus Anticoagulant","C":"300","D":"85300","F":"335.4"},{"Policy Line":"70104214","B":"Lysozyme(Muramidase)","C":"300","D":"85549","F":"46.8"},{"Policy Line":"70104239","B":"Protein C","C":"300","D":"85302","F":"177.9"},{"Policy Line":"70104240","B":"Protein S","C":"300","D":"85305","F":"201"},{"Policy Line":"70104289","B":"Factor VIII Assay","C":"300","D":"85240","F":"205.8"},{"Policy Line":"70106790","B":"Hemolysin: Acid","C":"300","D":"85475","F":"147.6"},{"Policy Line":"70108027","B":"Factor X Activity Clotting","C":"300","D":"85260","F":"70.2"},{"Policy Line":"70109025","B":"Osmotic Fragility: Rbc","C":"300","D":"85557","F":"378"},{"Policy Line":"70109749","B":"Russell Viper Venom","C":"300","D":"85613","F":"99"},{"Policy Line":"70109752","B":"Factor Inhibitor Test","C":"300","D":"85335","F":"201"},{"Policy Line":"70109753","B":"CBC, AUTO, DIFF PLTLTS","C":"300","D":"85025","F":"12.9"},{"Policy Line":"70109755","B":"Von Willebrand Factor","C":"300","D":"85246","F":"405.9"},{"Policy Line":"70109757","B":"Factor IX Assay","C":"300","D":"85250","F":"131.1"},{"Policy Line":"70109910","B":"Reticulocyte Count Manual","C":"300","D":"85044","F":"84.3"},{"Policy Line":"70110045","B":"Factor VII","C":"300","D":"85230","F":"75"},{"Policy Line":"70110050","B":"Factor XI Activity","C":"300","D":"85270","F":"123.9"},{"Policy Line":"70110051","B":"Factor XII Activity","C":"300","D":"85280","F":"117"},{"Policy Line":"70110055","B":"Factor XIII","C":"300","D":"85290","F":"233.1"},{"Policy Line":"70110075","B":"Protein S Functional","C":"300","D":"85306","F":"153.6"},{"Policy Line":"70110076","B":"Protein C Functional","C":"300","D":"85303","F":"145.8"},{"Policy Line":"70110160","B":"Protime - Capillary","C":"300","D":"85610","F":"52.5"},{"Policy Line":"70110180","B":"Ristocetin Cofactor","C":"300","D":"85245","F":"77.1"},{"Policy Line":"70110185","B":"Von Willebrand Factor Antigen","C":"300","D":"85246","F":"114"},{"Policy Line":"70110186","B":"Von Willebrand Ag: Multimeric","C":"300","D":"85247","F":"163.8"},{"Policy Line":"70110192","B":"Platelet Functn InVitro 1 Epi","C":"300","D":"85576","F":"73.5"},{"Policy Line":"70110193","B":"Platelet Function 2 Adp","C":"300","D":"85576","F":"73.5"},{"Policy Line":"70110400","B":"Heparin Assay","C":"300","D":"85520","F":"96.3"},{"Policy Line":"70115022","B":"Fletcher Factor Assay","C":"300","D":"85292","F":"535.2"},{"Policy Line":"70115030","B":"Platelet Neutralization","C":"300","D":"85597","F":"507.9"},{"Policy Line":"70115741","B":"K (Kinetics) TEG","C":"305","D":"85384","F":"4.8"},{"Policy Line":"70115742","B":"Angle TEG","C":"305","D":"85384","F":"4.8"},{"Policy Line":"70115743","B":"Fibrinogen Functional TEG","C":"305","D":"85384","F":"4.8"},{"Policy Line":"70115744","B":"MA (Max Clot) TEG","C":"305","D":"85576","F":"12"},{"Policy Line":"70115745","B":"MA (Max Clot) Rapid TEG","C":"305","D":"85576","F":"12"},{"Policy Line":"70115746","B":"MA HKH TEG","C":"305","D":"85576","F":"12"},{"Policy Line":"70115747","B":"MA ADP TEG","C":"305","D":"85576","F":"12"},{"Policy Line":"70115748","B":"MA Act F TEG","C":"305","D":"85576","F":"12"},{"Policy Line":"70115749","B":"%% Inhibition ADP TEG","C":"305","D":"85576","F":"12"},{"Policy Line":"70115750","B":"R (Reaction) TEG","C":"305","D":"85347","F":"4.8"},{"Policy Line":"70115751","B":"R (Reaction) TEG w/ Hep","C":"305","D":"85347","F":"4.8"},{"Policy Line":"70115752","B":"Fibrinogen Level TEG","C":"305","D":"85370","F":"12.6"},{"Policy Line":"70115782","B":"VWFactor Collagen Binding","C":"300","D":"85246","F":"207.6"},{"Policy Line":"70115883","B":"Protein S Ag, Free","C":"300","D":"85306","F":"140.4"},{"Policy Line":"70115959","B":"PT- ARUP","C":"300","D":"85610","F":"29.7"},{"Policy Line":"70115960","B":"aPTT- ARUP","C":"300","D":"85730","F":"29.7"},{"Policy Line":"70115961","B":"dRVVT - ARUP","C":"300","D":"85613","F":"29.7"},{"Policy Line":"70115962","B":"TT - ARUP","C":"300","D":"85670","F":"37.5"},{"Policy Line":"70115963","B":"Reptilase Time - ARUP","C":"300","D":"85635","F":"70.2"},{"Policy Line":"70115964","B":"PTT - D - ARUP","C":"300","D":"85730","F":"52.8"},{"Policy Line":"70115965","B":"Heparin neutralization - ARUP","C":"300","D":"85525","F":"52.8"},{"Policy Line":"70115966","B":"aPTT-D 1:1 Mix - ARUP","C":"300","D":"85732","F":"30.3"},{"Policy Line":"70115967","B":"Plt Neutralization - ARUP","C":"300","D":"85597","F":"81.9"},{"Policy Line":"70115968","B":"dRVVT 1:1 Mix - ARUP","C":"300","D":"85613","F":"30.3"},{"Policy Line":"70115969","B":"dRVVT Confrim - ARUP","C":"300","D":"85613","F":"56.1"},{"Policy Line":"70115970","B":"Hex Phos - ARUP","C":"300","D":"85598","F":"124.8"},{"Policy Line":"70116129","B":"Antithrombin Iii Antigenic","C":"300","D":"85301","F":"306"},{"Policy Line":"70116174","B":"Fibrinogen Antigen","C":"300","D":"85385","F":"123.9"},{"Policy Line":"70116243","B":"Osmotic Fragility Erythrocyte","C":"300","D":"85555","F":"175.5"},{"Policy Line":"70116244","B":"Ureaplasma and Mycoplasma PCR","C":"300","D":"85555","F":"258"},{"Policy Line":"70116299","B":"Heparin Cofactor II, Plasma","C":"300","D":"85130","F":"168"},{"Policy Line":"70116576","B":"Factor IX, Activity","C":"300","D":"85250","F":"63.9"},{"Policy Line":"70116577","B":"Factor VIII, Activity","C":"300","D":"85240","F":"40.2"},{"Policy Line":"70116640","B":"Protein C, Functional","C":"300","D":"85303","F":"45.6"},{"Policy Line":"70116641","B":"Protein S, Functional","C":"305","D":"85306","F":"65.1"},{"Policy Line":"70118476","B":"Activated Protein Resistance","C":"300","D":"85307","F":"90.6"},{"Policy Line":"70118478","B":"Plasminogen Activator Inhibito","C":"300","D":"85415","F":"485.7"},{"Policy Line":"70118480","B":"Functional Plasminogen","C":"300","D":"85420","F":"184.8"},{"Policy Line":"70118490","B":"High Molecular Wt. Kininogen","C":"300","D":"85293","F":"535.2"},{"Policy Line":"71700365","B":"Activated Clotting Time","C":"300","D":"85347","F":"107.7"},{"Policy Line":"72106025","B":"Activated Clotting Time","C":"300","D":"85347","F":"107.7"},{"Policy Line":"72205100","B":"Activated Clotting Time","C":"300","D":"85347","F":"107.7"},{"Policy Line":"74201006","B":"INR","C":"300","D":"85610","F":"13.8"},{"Policy Line":"74221006","B":"INR","C":"300","D":"85610","F":"13.8"},{"Policy Line":"70100001","B":"RPR; non-treponemal Qual","C":"300","D":"86592","F":"12.3"},{"Policy Line":"70100074","B":"Cryptococcus Ab","C":"300","D":"86641","F":"148.8"},{"Policy Line":"70100075","B":"Mono","C":"300","D":"86308","F":"38.4"},{"Policy Line":"70100083","B":"Immunoelectrophoresis;Serum","C":"300","D":"86320","F":"182.4"},{"Policy Line":"70100087","B":"Rotavirus","C":"300","D":"86759","F":"84.3"},{"Policy Line":"70100112","B":"Stronglyoides Ab Igg","C":"300","D":"86682","F":"117"},{"Policy Line":"70100163","B":"Immunofixation Electrophoresis","C":"300","D":"86334","F":"181.5"},{"Policy Line":"70100180","B":"Cryptococcal Ag","C":"300","D":"86403","F":"52.2"},{"Policy Line":"70100203","B":"Complement: C3","C":"300","D":"86160","F":"29.4"},{"Policy Line":"70100204","B":"Complement: C4","C":"300","D":"86160","F":"29.4"},{"Policy Line":"70100226","B":"RMSF Igm By Ifa -Quest","C":"300","D":"86757","F":"46.8"},{"Policy Line":"70100227","B":"RMSF Igg By Ifa -Quest","C":"300","D":"86757","F":"46.8"},{"Policy Line":"70100254","B":"Mitogen Induced Blastogen 1","C":"300","D":"86353","F":"138.6"},{"Policy Line":"70100255","B":"Mitogen Induced Blastogen 2","C":"300","D":"86353","F":"286.5"},{"Policy Line":"70100256","B":"Mitogen Induced Blastogen 3","C":"300","D":"86353","F":"315.3"},{"Policy Line":"70100258","B":"B Cells Total Count","C":"300","D":"86355","F":"396.3"},{"Policy Line":"70100272","B":"ASO","C":"300","D":"86063","F":"57.9"},{"Policy Line":"70100276","B":"HIV 1/2 Rapid","C":"300","D":"86701","F":"50.1"},{"Policy Line":"70100307","B":"Serotype 56 (18C)","C":"300","D":"86317","F":"42.6"},{"Policy Line":"70100308","B":"Serotype 68(9V)","C":"300","D":"86317","F":"21.6"},{"Policy Line":"70100326","B":"RA Quantitative","C":"300","D":"86431","F":"29.7"},{"Policy Line":"70100340","B":"CMV Anbibody IgG Elisa","C":"300","D":"86644","F":"50.7"},{"Policy Line":"70100341","B":"California Encephalitis Virus","C":"300","D":"86651","F":"33"},{"Policy Line":"70100342","B":"Encephalitis Eastern Equine","C":"300","D":"86652","F":"26.7"},{"Policy Line":"70100343","B":"Encephalitis St Louis","C":"300","D":"86653","F":"33"},{"Policy Line":"70100344","B":"Encephalitis Western Equine","C":"300","D":"86654","F":"21.6"},{"Policy Line":"70100345","B":"Enterovirus","C":"300","D":"86658","F":"97.8"},{"Policy Line":"70100346","B":"HSV Type 1","C":"300","D":"86695","F":"32.7"},{"Policy Line":"70100347","B":"HSV Type 2","C":"300","D":"86696","F":"32.4"},{"Policy Line":"70100348","B":"Influenza Ab","C":"300","D":"86710","F":"50.1"},{"Policy Line":"70100349","B":"Lymphocytic Choriomeningitis","C":"300","D":"86727","F":"21"},{"Policy Line":"70100350","B":"Mumps","C":"300","D":"86735","F":"126.6"},{"Policy Line":"70100351","B":"Measles","C":"300","D":"86765","F":"34.2"},{"Policy Line":"70100352","B":"Varicella Zoster","C":"300","D":"86787","F":"35.1"},{"Policy Line":"70100353","B":"Adenovirus","C":"300","D":"86603","F":"27.6"},{"Policy Line":"70100355","B":"C-Reactive Protein","C":"300","D":"86140","F":"22.5"},{"Policy Line":"70100364","B":"NSE - Neuron Specific Enolase","C":"300","D":"86316","F":"96.9"},{"Policy Line":"70100365","B":"R.Typhi Igg -Quest","C":"300","D":"86757","F":"94.2"},{"Policy Line":"70100366","B":"R.Typhi Igm -Quest","C":"300","D":"86757","F":"94.2"},{"Policy Line":"70100369","B":"Brucella Ab Igg -Quest","C":"300","D":"86622","F":"65.4"},{"Policy Line":"70100370","B":"Brucella Ab Igm -Quest","C":"300","D":"86622","F":"65.4"},{"Policy Line":"70100432","B":"M Pneumo Igg Ab -Quest","C":"300","D":"86738","F":"46.8"},{"Policy Line":"70100439","B":"Lactoferrin Quant Stool Qst","C":"300","D":"86361","F":"186.9"},{"Policy Line":"70100444","B":"Smooth Muscle Antibody Titer","C":"300","D":"86256","F":"30.6"},{"Policy Line":"70100468","B":"Neutrophil Ab Fcl -Quest","C":"300","D":"86021","F":"241.8"},{"Policy Line":"70100507","B":"Cysticercus Ab Elisa Serum Qst","C":"300","D":"86682","F":"143.1"},{"Policy Line":"70100618","B":"Post Transfusion Reaction","C":"300","D":"86078","F":"85.2"},{"Policy Line":"70100623","B":"Cold Agglutinins","C":"300","D":"86157","F":"66.3"},{"Policy Line":"70100644","B":"RF Fluid Titer Qst","C":"300","D":"86431","F":"41.4"},{"Policy Line":"70100656","B":"Jo-1 Antibody -Quest","C":"300","D":"86235","F":"28.2"},{"Policy Line":"70100657","B":"HTLV Antibody I/Ii -Quest","C":"300","D":"86790","F":"63.9"},{"Policy Line":"70100658","B":"Dengue Fever Igg -Quest","C":"300","D":"86790","F":"224.4"},{"Policy Line":"70100666","B":"Rabies Titer Response Qst","C":"300","D":"86382","F":"174.3"},{"Policy Line":"70100667","B":"Fluorescent Antibody Titer Ea","C":"300","D":"86256","F":"122.1"},{"Policy Line":"70100674","B":"Heparin-Induced Platelet Ab","C":"300","D":"86022","F":"356.7"},{"Policy Line":"70100675","B":"Serotonin Release Assay -Qst","C":"300","D":"86022","F":"409.8"},{"Policy Line":"70100682","B":"West Nile Virus Ab Igm Csf","C":"300","D":"86788","F":"84"},{"Policy Line":"70100683","B":"West Nile Virus Ab Igg Csf","C":"300","D":"86789","F":"84"},{"Policy Line":"70100686","B":"Nuclear Matrix Proteins -Quest","C":"300","D":"86316","F":"443.7"},{"Policy Line":"70100695","B":"N.Meningitidis Igg Serogrp A","C":"300","D":"86317","F":"19.8"},{"Policy Line":"70100696","B":"N.Meningitidis Igg Serogrp C","C":"300","D":"86317","F":"19.8"},{"Policy Line":"70100697","B":"N.Meningitidis Igg Serogrp Y","C":"300","D":"86317","F":"19.8"},{"Policy Line":"70100698","B":"N.Meningitidis Igg Serogrpw135","C":"300","D":"86317","F":"19.8"},{"Policy Line":"70100716","B":"T Cells Total Count -Quest","C":"300","D":"86359","F":"48"},{"Policy Line":"70100717","B":"T Cells Cd4:Cd8 Quest Lym Pnl","C":"300","D":"86360","F":"73.8"},{"Policy Line":"70100746","B":"Giardia Ab Igg","C":"300","D":"86674","F":"87.6"},{"Policy Line":"70100747","B":"Giardia Ab Iga","C":"300","D":"86674","F":"87.6"},{"Policy Line":"70100748","B":"Giardia Ab Agm","C":"300","D":"86674","F":"87.6"},{"Policy Line":"70100752","B":"Whole Egg (IgG) Eia - Quest","C":"300","D":"86001","F":"98.4"},{"Policy Line":"70100774","B":"Poliovirus Antibody Type1","C":"300","D":"86382","F":"74.7"},{"Policy Line":"70100775","B":"Poliovirus Antibody Type 2","C":"300","D":"86382","F":"50.1"},{"Policy Line":"70100776","B":"Poliovirus Antibody Type 3","C":"300","D":"86382","F":"74.7"},{"Policy Line":"70100783","B":"Immunoelec-Other Fluids(Conc)","C":"300","D":"86335","F":"78.6"},{"Policy Line":"70100804","B":"H.Pylori Ab IgA","C":"300","D":"86677","F":"109.8"},{"Policy Line":"70100805","B":"H.Pylori Ab Igg -Quest","C":"300","D":"86317","F":"51.9"},{"Policy Line":"70100806","B":"H.Pylori Ab IgM","C":"300","D":"86677","F":"109.8"},{"Policy Line":"70100807","B":"Hep B Ab Quant Liver Trans","C":"300","D":"86317","F":"54"},{"Policy Line":"70100808","B":"Hep B Surface Ab Quant -Quest","C":"300","D":"86317","F":"25.2"},{"Policy Line":"70100809","B":"Hep B Core Ab Igm -Quest","C":"300","D":"86705","F":"35.7"},{"Policy Line":"70100810","B":"Ca 27.29 Immunoassay Quant","C":"300","D":"86300","F":"65.4"},{"Policy Line":"70100812","B":"IMMUNO ELPHORS, OTHER FLUIDS","C":"300","D":"86335","F":"401.7"},{"Policy Line":"70100847","B":"Rnp Antibody Qst 19887","C":"300","D":"86235","F":"36"},{"Policy Line":"70100851","B":"Chromatin Nucleosomal Antibody","C":"300","D":"86235","F":"78.6"},{"Policy Line":"70100856","B":"C4 Binding Protein Plasma","C":"300","D":"86329","F":"104.7"},{"Policy Line":"70100864","B":"Herpesvirus 8 Igg Antibody Ifa","C":"300","D":"86790","F":"87.3"},{"Policy Line":"70100866","B":"Echovirus 4 Ab","C":"300","D":"86658","F":"16.2"},{"Policy Line":"70100867","B":"Echovirus 7 Ab","C":"300","D":"86658","F":"16.2"},{"Policy Line":"70100868","B":"Echovirus 9 Ab","C":"300","D":"86658","F":"16.2"},{"Policy Line":"70100869","B":"Echovirus 11 Ab","C":"300","D":"86658","F":"16.2"},{"Policy Line":"70100870","B":"Echovirus 30 Ab","C":"300","D":"86658","F":"16.2"},{"Policy Line":"70100873","B":"L.Pneumophila Serogrp 1","C":"300","D":"86713","F":"64.5"},{"Policy Line":"70100874","B":"L.Pneumophila Serogrp 2-6,8","C":"300","D":"86713","F":"64.5"},{"Policy Line":"70100875","B":"American Cockroach IgE","C":"300","D":"86003","F":"48"},{"Policy Line":"70100877","B":"S.Pneumoniae Igg Maid 23 Serot","C":"300","D":"86317","F":"267.9"},{"Policy Line":"70100886","B":"HU Antibody Titer Qst","C":"300","D":"86256","F":"21.3"},{"Policy Line":"70100887","B":"Neuronal Nuclear Ri Ab Screen","C":"300","D":"86255","F":"144"},{"Policy Line":"70100889","B":"RI Antibody Titer","C":"300","D":"86256","F":"36"},{"Policy Line":"70100924","B":"L Donovani Igg","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100925","B":"L Donovani Igm","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100926","B":"L Braziliensis Igg","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100927","B":"L Braziliensis Igm","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100928","B":"L Mexicana Igg","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100929","B":"L Mexicana Igm","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100930","B":"L Tropicalis Igg","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100931","B":"L Tropicalis Igm","C":"300","D":"86717","F":"43.5"},{"Policy Line":"70100938","B":"Natural Killer Cells Total Qst","C":"300","D":"86357","F":"149.1"},{"Policy Line":"70101000","B":"RPR Titer QN, non Treponemal","C":"300","D":"86593","F":"32.7"},{"Policy Line":"70101007","B":"Neuronal Nuc Ab Hu Scrn -Quest","C":"300","D":"86255","F":"219.6"},{"Policy Line":"70101008","B":"Quantiferon Tb Gold - Quest","C":"300","D":"86480","F":"309"},{"Policy Line":"70101049","B":"Jcv Antibody Qst","C":"300","D":"86711","F":"259.5"},{"Policy Line":"70101078","B":"Jcv Ab Inhibition Assay Qst","C":"300","D":"86711","F":"259.5"},{"Policy Line":"70101311","B":"DSDNA Screen","C":"300","D":"86255","F":"30.3"},{"Policy Line":"70101312","B":"Fluorescent AB - DsDNA Titer","C":"300","D":"86256","F":"48"},{"Policy Line":"70101314","B":"Platelet Antibody ID 2B/3A","C":"300","D":"86022","F":"67.8"},{"Policy Line":"70101371","B":"Influenza A Ab Qst","C":"300","D":"86710","F":"9.3"},{"Policy Line":"70101372","B":"Influenza Type B Ab Qst","C":"300","D":"86710","F":"9.3"},{"Policy Line":"70101373","B":"C. Pneumoniae Igm","C":"300","D":"86632","F":"8.4"},{"Policy Line":"70101374","B":"C. Pneumoniae Igg","C":"300","D":"86631","F":"8.4"},{"Policy Line":"70101376","B":"C. Pneumoniae Iga","C":"300","D":"86631","F":"8.4"},{"Policy Line":"70101377","B":"Coxsackie B Type 1","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101378","B":"Coxsackie B Type 2","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101379","B":"Coxsackie B Type 3","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101380","B":"Coxsackie B Type 4","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101381","B":"Coxsackie B Type 5","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101382","B":"Coxsackie B Type 6","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101383","B":"Echovirus Serotype 4","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101384","B":"Echovirus Serotype 7","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101385","B":"Echovirus Serotype 9","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101386","B":"Echovirus Serotype 11","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101387","B":"Echovirus Serotype 30","C":"300","D":"86658","F":"8.7"},{"Policy Line":"70101392","B":"Circulating Tumor Cells","C":"300","D":"86152","F":"981"},{"Policy Line":"70101419","B":"Immunofixation For Kappa Lt Ch","C":"300","D":"86334","F":"81.6"},{"Policy Line":"70101433","B":"Neuromyelitis Optica Mayo","C":"300","D":"86255","F":"459"},{"Policy Line":"70101446","B":"Purkinje Cell Cyto Ab Type Tr","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101447","B":"Crmp-5-IgG","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101448","B":"Anti-Neuronal Ab Type 3","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101449","B":"Purkinje Cell Cyto Ab Type 2","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101451","B":"Anti-Neuronal Nuclear Ab Type1","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101452","B":"Anti-Neuronal Nuclear Ab Type2","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101453","B":"Purkinje Cell Cyto Ab Type 1","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101454","B":"Amphyiphysin Ab","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101455","B":"Anti-Glial Nuclear Ab Type 1","C":"300","D":"86256","F":"116.4"},{"Policy Line":"70101467","B":"HISTAMINE RELEASE (CU)","C":"300","D":"86343","F":"160.5"},{"Policy Line":"70101524","B":"Ampiphysin Ab MAYO","C":"300","D":"86256","F":"498.3"},{"Policy Line":"70101525","B":"CRMP-5 IgG MAYO","C":"300","D":"86256","F":"498.3"},{"Policy Line":"70101641","B":"INF AGENT AB QNT Serotype 1","C":"300","D":"86317","F":"37.8"},{"Policy Line":"70101642","B":"IA INF AGENT AB QNT Serotype 3","C":"300","D":"86317","F":"37.8"},{"Policy Line":"70101643","B":"IA INF AGENT AB QNT Serotype 4","C":"300","D":"86317","F":"37.8"},{"Policy Line":"70101644","B":"IA INF AGENT AB QNT Serotype 5","C":"300","D":"86317","F":"36.6"},{"Policy Line":"70101645","B":"IA INF AGENT AB QNT Serotype 8","C":"300","D":"86317","F":"37.8"},{"Policy Line":"70101646","B":"Serotype (9) 9N","C":"300","D":"86317","F":"37.8"},{"Policy Line":"70101647","B":"IA INFAGNT AB QNT Sero 12(12F)","C":"300","D":"86317","F":"36.6"},{"Policy Line":"70101648","B":"IA INF AGNT AB QNT Serotype 14","C":"300","D":"86317","F":"36.6"},{"Policy Line":"70101649","B":"IA INFAGNT AB QNT Sero 19(19F)","C":"300","D":"86317","F":"36.6"},{"Policy Line":"70101650","B":"IA INFAGNT AB QNT Sero 23(23F)","C":"300","D":"86317","F":"36.6"},{"Policy Line":"70101661","B":"Immunoassay For Tumor Ag Qual","C":"300","D":"86316","F":"275.7"},{"Policy Line":"70101666","B":"Beta 2 Glycoprotein 1 Ea- Ab 1","C":"300","D":"86146","F":"81.3"},{"Policy Line":"70101667","B":"Beta 2 Glycoprotein 1 Ea- Ab 2","C":"300","D":"86146","F":"81.3"},{"Policy Line":"70101668","B":"Beta 2 Glycoprotein 1 Ea- Ab 3","C":"300","D":"86146","F":"81.3"},{"Policy Line":"70101800","B":"Cryptococcal Ag Titr","C":"300","D":"86406","F":"64.8"},{"Policy Line":"70102001","B":"Virus Ab-Not Elsewhere Spec","C":"300","D":"86790","F":"98.4"},{"Policy Line":"70102009","B":"Chlamydia Serology","C":"300","D":"86631","F":"74.7"},{"Policy Line":"70102012","B":"IA INFAGNT AB QNT Sero 26(6B)","C":"300","D":"86317","F":"37.8"},{"Policy Line":"70102013","B":"IA INFAGNT AB QNT Sero 51(7F)","C":"300","D":"86317","F":"37.2"},{"Policy Line":"70102015","B":"Antibody: Parvovirus","C":"300","D":"86747","F":"58.8"},{"Policy Line":"70102016","B":"Antibody: Parvovirus","C":"300","D":"86747","F":"58.8"},{"Policy Line":"70102019","B":"T Cells - Cd4:Cd8","C":"300","D":"86360","F":"176.7"},{"Policy Line":"70102024","B":"Fluorescent Antibody 2","C":"300","D":"86255","F":"131.4"},{"Policy Line":"70102025","B":"Fluorescent Antibody 3","C":"300","D":"86255","F":"143.7"},{"Policy Line":"70102027","B":"Coxiella Brunetii 1","C":"300","D":"86638","F":"53.1"},{"Policy Line":"70102028","B":"Coxiella Brunetii 2","C":"300","D":"86638","F":"53.1"},{"Policy Line":"70102029","B":"Coxiella Brunetii 3","C":"300","D":"86638","F":"53.1"},{"Policy Line":"70102030","B":"Coxiella Brunetii0 4","C":"300","D":"86638","F":"53.1"},{"Policy Line":"70102643","B":"Cyclic Citrullinated Peptide","C":"300","D":"86200","F":"119.1"},{"Policy Line":"70102675","B":"Endomysial Antibody, IgG","C":"300","D":"86256","F":"127.5"},{"Policy Line":"70102720","B":"ASO Titer","C":"300","D":"86060","F":"44.4"},{"Policy Line":"70103016","B":"RAST Bahia Grass","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103017","B":"RAST Birch Tree","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103018","B":"RAST Tree, Mountain Cedar, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103019","B":"RAST Mouse Urine Proteins,IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103021","B":"RAST,Tree Pecan/Hickory IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103022","B":"RAST, Penicillium notatum IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103023","B":"RAST SheepSorrel Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103024","B":"RAST, Nettle,Allergen IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70103813","B":"Antibody; Hepatitis, Delta","C":"300","D":"86692","F":"50.4"},{"Policy Line":"70103816","B":"Bordetella Ab Igg","C":"300","D":"86615","F":"129.9"},{"Policy Line":"70103817","B":"Bordetella Ab Igm","C":"300","D":"86615","F":"129.9"},{"Policy Line":"70103818","B":"Bordetella Ab Iga","C":"300","D":"86615","F":"129.9"},{"Policy Line":"70103819","B":"Bordetella Ab FHA IgG","C":"300","D":"86615","F":"129.9"},{"Policy Line":"70103821","B":"Bordetella Ab FHA IGA","C":"300","D":"86615","F":"129.9"},{"Policy Line":"70104000","B":"Rast Soybean IgE Qnt/SmiQnt","C":"300","D":"86003","F":"34.8"},{"Policy Line":"70104002","B":"Adenovirus Serology","C":"300","D":"86603","F":"90"},{"Policy Line":"70104007","B":"Rast Egg White","C":"300","D":"86003","F":"34.2"},{"Policy Line":"70104015","B":"Rast Milk","C":"300","D":"86003","F":"35.1"},{"Policy Line":"70104016","B":"Rast Wheat","C":"300","D":"86003","F":"34.8"},{"Policy Line":"70104018","B":"Amoeba Antibody","C":"300","D":"86753","F":"104.1"},{"Policy Line":"70104019","B":"Rast Peanut","C":"300","D":"86003","F":"35.1"},{"Policy Line":"70104020","B":"Rast Shrimp","C":"300","D":"86003","F":"35.4"},{"Policy Line":"70104021","B":"Rast Tomato","C":"300","D":"86003","F":"22.8"},{"Policy Line":"70104022","B":"Rast Pork","C":"300","D":"86003","F":"55.5"},{"Policy Line":"70104025","B":"Rast Corn","C":"300","D":"86003","F":"34.8"},{"Policy Line":"70104026","B":"Antimyeloperoxidase Ab","C":"300","D":"86021","F":"74.1"},{"Policy Line":"70104027","B":"Anti Centromere Ab","C":"300","D":"86038","F":"42.6"},{"Policy Line":"70104029","B":"Rast Beef","C":"300","D":"86003","F":"34.8"},{"Policy Line":"70104030","B":"Rast Potato","C":"300","D":"86003","F":"42"},{"Policy Line":"70104031","B":"Anti Mitochondrial Antibody","C":"300","D":"86255","F":"77.4"},{"Policy Line":"70104032","B":"Anti Smooth Muscle Ab","C":"300","D":"86255","F":"68.1"},{"Policy Line":"70104041","B":"Rast Onion","C":"300","D":"86003","F":"50.4"},{"Policy Line":"70104043","B":"Blastomycoses Serology","C":"300","D":"86612","F":"70.5"},{"Policy Line":"70104045","B":"Brucella Serology -D Quest","C":"300","D":"86622","F":"0"},{"Policy Line":"70104046","B":"Rast Flounder","C":"300","D":"86003","F":"45.9"},{"Policy Line":"70104047","B":"Rast Egg Yolk","C":"300","D":"86003","F":"34.2"},{"Policy Line":"70104048","B":"Ca 15-3 (Ca 27.29)","C":"300","D":"86300","F":"65.4"},{"Policy Line":"70104050","B":"Rast Oat","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70104053","B":"Immune Complex C1Q Binding","C":"300","D":"86160","F":"159"},{"Policy Line":"70104059","B":"Anti Dna","C":"300","D":"86225","F":"45.6"},{"Policy Line":"70104060","B":"Rast Cockroach, Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70104069","B":"Ca-125","C":"300","D":"86304","F":"30.9"},{"Policy Line":"70104070","B":"Anti DNA By Farr","C":"300","D":"86225","F":"45.6"},{"Policy Line":"70104072","B":"Rast Scallop","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70104073","B":"Rast Clam","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70104075","B":"Rast Walnut","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70104076","B":"Rast Codfish","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70104085","B":"Coccidiodes Serology","C":"300","D":"86635","F":"30.6"},{"Policy Line":"70104088","B":"Complement: Tot Ch50","C":"300","D":"86162","F":"60.3"},{"Policy Line":"70104093","B":"Rast Sesame Seed","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70104109","B":"Diptheria Antibody","C":"300","D":"86648","F":"206.4"},{"Policy Line":"70104129","B":"Anti Ena","C":"300","D":"86235","F":"67.5"},{"Policy Line":"70104138","B":"FTA(ABS); Pallidum,Treponema","C":"300","D":"86780","F":"39"},{"Policy Line":"70104148","B":"Hepatitis B Core AB IgM","C":"300","D":"86705","F":"102.3"},{"Policy Line":"70104150","B":"C-1 Esterase Inhibitor","C":"300","D":"86161","F":"76.5"},{"Policy Line":"70104155","B":"Platelet Antibodies","C":"300","D":"86023","F":"198.9"},{"Policy Line":"70104156","B":"Hepatitis A Ab - Total","C":"300","D":"86708","F":"79.5"},{"Policy Line":"70104157","B":"Hepatitis A Ab-Igm","C":"300","D":"86709","F":"59.4"},{"Policy Line":"70104158","B":"Anti Islet Cell (Pancreatic)","C":"300","D":"86341","F":"105.9"},{"Policy Line":"70104161","B":"Hepatitis B Core Ab Total","C":"300","D":"86704","F":"49.8"},{"Policy Line":"70104163","B":"Hepatitis B Surf Ab (Hbsab)","C":"300","D":"86317","F":"18.9"},{"Policy Line":"70104165","B":"Hepatitis Be Ab","C":"300","D":"86707","F":"43.8"},{"Policy Line":"70104171","B":"HSV 1 Igm, Ifa Quest 17369","C":"300","D":"86695","F":"21.3"},{"Policy Line":"70104172","B":"HSV 2 Igm, Ifa Quest 17369","C":"300","D":"86696","F":"30"},{"Policy Line":"70104174","B":"Histoplasma Serology","C":"300","D":"86698","F":"57"},{"Policy Line":"70104175","B":"HLA B 27","C":"300","D":"86812","F":"109.8"},{"Policy Line":"70104176","B":"Antibody; HIV - 1","C":"300","D":"86701","F":"30"},{"Policy Line":"70104179","B":"HIV or HTLV Ab Confirmation","C":"300","D":"86689","F":"68.7"},{"Policy Line":"70104186","B":"Influenza Virus Ab","C":"300","D":"86710","F":"50.1"},{"Policy Line":"70104192","B":"Insulin Antibodies - Titer","C":"300","D":"86337","F":"283.8"},{"Policy Line":"70104197","B":"Hepatitis C Antibody","C":"300","D":"86803","F":"46.5"},{"Policy Line":"70104200","B":"Antibody; HIV - 2","C":"300","D":"86702","F":"41.1"},{"Policy Line":"70104203","B":"Legionella Titer","C":"300","D":"86713","F":"64.5"},{"Policy Line":"70104204","B":"Leptospira Serology","C":"300","D":"86720","F":"118.8"},{"Policy Line":"70104218","B":"Rubeola","C":"300","D":"86765","F":"39.6"},{"Policy Line":"70104231","B":"Mumps Serology","C":"300","D":"86735","F":"126.6"},{"Policy Line":"70104237","B":"Mycoplasma","C":"300","D":"86738","F":"123.6"},{"Policy Line":"70104238","B":"Ca 19-9","C":"300","D":"86301","F":"55.2"},{"Policy Line":"70104252","B":"Anti Parietal Ab","C":"300","D":"86255","F":"126.3"},{"Policy Line":"70104269","B":"Parvovirus Ab","C":"300","D":"86747","F":"58.8"},{"Policy Line":"70104271","B":"Immune Complex-Raji Cell","C":"300","D":"86332","F":"560.4"},{"Policy Line":"70104274","B":"Rast Other","C":"300","D":"86003","F":"33"},{"Policy Line":"70104281","B":"RSV Serology","C":"300","D":"86756","F":"227.7"},{"Policy Line":"70104284","B":"Rubella Antibody-Igm","C":"300","D":"86762","F":"39.3"},{"Policy Line":"70104311","B":"Tetanus Ab","C":"300","D":"86774","F":"164.1"},{"Policy Line":"70104312","B":"Thyroglobulin Antibody","C":"300","D":"86800","F":"43.2"},{"Policy Line":"70104322","B":"Trichinella Serology","C":"309","D":"86784","F":"77.7"},{"Policy Line":"70104328","B":"Toxoplasma","C":"300","D":"86777","F":"97.2"},{"Policy Line":"70104330","B":"Toxoplasma Igm-Ab","C":"300","D":"86778","F":"47.7"},{"Policy Line":"70104331","B":"Varicella Zoster Ab","C":"300","D":"86787","F":"35.1"},{"Policy Line":"70104334","B":"VDRL-CSF Non-treponemal, Qual","C":"300","D":"86592","F":"15.3"},{"Policy Line":"70104355","B":"CMV Antibody Serology","C":"300","D":"86644","F":"57"},{"Policy Line":"70104358","B":"Lyme Disease Antibodies","C":"300","D":"86618","F":"143.7"},{"Policy Line":"70104360","B":"H. Pylori IgG Antibody","C":"300","D":"86677","F":"37.8"},{"Policy Line":"70104431","B":"Varicilla Zoster Igm","C":"300","D":"86787","F":"46.5"},{"Policy Line":"70104469","B":"Anti Scleroderma Ab","C":"300","D":"86235","F":"69.9"},{"Policy Line":"70104470","B":"SmAntibody (Smith AB) ENA Qst","C":"300","D":"86235","F":"13.2"},{"Policy Line":"70104471","B":"Sm RNP ENA Qst","C":"300","D":"86235","F":"13.2"},{"Policy Line":"70104477","B":"Intrinsic Factor Antibody","C":"300","D":"86340","F":"124.5"},{"Policy Line":"70104483","B":"CMV IgM Antibody","C":"300","D":"86645","F":"55.2"},{"Policy Line":"70104551","B":"Ana Titer","C":"300","D":"86039","F":"27.6"},{"Policy Line":"70104985","B":"Rubella","C":"300","D":"86762","F":"30"},{"Policy Line":"70105070","B":"Antireticulin Ab: Iga","C":"300","D":"86255","F":"181.8"},{"Policy Line":"70106054","B":"Rast Penicillin G","C":"300","D":"86003","F":"35.1"},{"Policy Line":"70106055","B":"Rast Penicillin V","C":"300","D":"86003","F":"34.2"},{"Policy Line":"70106056","B":"Bermuda Grass, Allergen IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106057","B":"Meadow Fescue","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106058","B":"Perrenial Rye Grass","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106059","B":"Timothy Grass, Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106060","B":"June Grass","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70106061","B":"Common Ragweed, Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106062","B":"Giant Ragweed","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106063","B":"Lambs Quarter Ea Allergen, IgE","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106064","B":"Goldenrod","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106065","B":"Maple Tree, Allergen IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106066","B":"Beech Tree","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106067","B":"Oak Tree, Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106068","B":"Elm Tree, Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106069","B":"Cat Epithilium, Allergen IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106070","B":"Horse Dander","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106071","B":"Dog Dander, Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106072","B":"Allergen IgE Penicillum","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106073","B":"Cladosporium, Allergen IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106074","B":"Aspergillus, Allergen IgE ea","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106075","B":"Mucor","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106076","B":"Alternaria, Allergen IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106077","B":"Greer House Dust","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106078","B":"Hollister Stier","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106080","B":"DPteronyssinMite,Allergen,IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106081","B":"D Farinae Mite, Allergen, IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106082","B":"English Plaintain","C":"300","D":"86003","F":"104.7"},{"Policy Line":"70106083","B":"RAST Rough Pigweed,AllergenIgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70106123","B":"Antithyroid Peroxidase Ab-D","C":"300","D":"86376","F":"80.1"},{"Policy Line":"70106124","B":"Liver-Kidney Microsomal Ab","C":"300","D":"86376","F":"80.1"},{"Policy Line":"70106204","B":"Fungus Ab, Nos","C":"300","D":"86671","F":"273.3"},{"Policy Line":"70106281","B":"Histoplasma Ab","C":"300","D":"86698","F":"57"},{"Policy Line":"70106334","B":"Coxsackie A2 Ab","C":"300","D":"86658","F":"13.2"},{"Policy Line":"70106335","B":"Coxsackie A4 Ab","C":"300","D":"86658","F":"13.2"},{"Policy Line":"70106336","B":"Coxsackie A7 Ab","C":"300","D":"86658","F":"13.2"},{"Policy Line":"70106337","B":"Coxsackie A9 Ab","C":"300","D":"86658","F":"13.2"},{"Policy Line":"70106338","B":"Coxsackie A10 Ab","C":"300","D":"86658","F":"13.2"},{"Policy Line":"70106339","B":"Coxsackie A16 Ab","C":"300","D":"86658","F":"13.2"},{"Policy Line":"70108010","B":"Antibody To Pm-1","C":"300","D":"86235","F":"82.8"},{"Policy Line":"70108011","B":"HCV Riba","C":"300","D":"86804","F":"134.4"},{"Policy Line":"70108013","B":"Complement C2","C":"300","D":"86160","F":"54.9"},{"Policy Line":"70109206","B":"Asca Elisa Iga","C":"300","D":"86671","F":"104.7"},{"Policy Line":"70109207","B":"Asca Elisa Igg","C":"300","D":"86671","F":"104.7"},{"Policy Line":"70109223","B":"HSV Igm Ab Screen","C":"300","D":"86694","F":"45.9"},{"Policy Line":"70109224","B":"HSV Igm Titer","C":"300","D":"86694","F":"49.2"},{"Policy Line":"70109225","B":"DNA Antibody Single Stranded","C":"300","D":"86226","F":"270"},{"Policy Line":"70109275","B":"Crp","C":"300","D":"86140","F":"22.5"},{"Policy Line":"70109300","B":"Rast, Carrot","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70109301","B":"Rast, Pea","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70109302","B":"Rast, White Bean","C":"300","D":"86003","F":"32.7"},{"Policy Line":"70109762","B":"Ana","C":"300","D":"86038","F":"18"},{"Policy Line":"70109784","B":"Fluorescent Antibody 1","C":"300","D":"86255","F":"144"},{"Policy Line":"70109790","B":"HIV 1/2 Antibodies/Ag IMASY","C":"300","D":"G0475","F":"21.9"},{"Policy Line":"70109793","B":"Toxoplasma Igm","C":"300","D":"86778","F":"192.6"},{"Policy Line":"70109795","B":"SSA","C":"300","D":"86235","F":"73.2"},{"Policy Line":"70109797","B":"SSB","C":"300","D":"86235","F":"73.2"},{"Policy Line":"70109798","B":"RMSF -Igm","C":"300","D":"86757","F":"71.4"},{"Policy Line":"70109800","B":"RMSF -Igg","C":"300","D":"86757","F":"71.4"},{"Policy Line":"70109801","B":"Ehrilichia Chaffensis Ab Igg","C":"300","D":"86666","F":"93"},{"Policy Line":"70109802","B":"Ehrilichia Chaffensis Ab Igm","C":"300","D":"86666","F":"93"},{"Policy Line":"70109803","B":"Chlamydia: Igg","C":"300","D":"86631","F":"87.9"},{"Policy Line":"70109805","B":"Cardiolipin Ig Class Ea Ab","C":"300","D":"86147","F":"40.2"},{"Policy Line":"70109806","B":"ImmuneGlobulin Cardiolipin IgM","C":"300","D":"86147","F":"40.2"},{"Policy Line":"70109809","B":"EBV VCA, IgG","C":"300","D":"86665","F":"19.8"},{"Policy Line":"70109810","B":"Q Fever","C":"300","D":"86638","F":"97.8"},{"Policy Line":"70109811","B":"Epstein Barr Early Ag (Ea)","C":"300","D":"86663","F":"19.8"},{"Policy Line":"70109812","B":"Herpes Type Ii","C":"300","D":"86696","F":"34.8"},{"Policy Line":"70109813","B":"Epstein Barr Nuclear Ag(Ebna)","C":"300","D":"86664","F":"19.8"},{"Policy Line":"70109814","B":"Chlamydia: Igm","C":"300","D":"86632","F":"86.4"},{"Policy Line":"70109815","B":"Herpes Type I","C":"300","D":"86695","F":"34.8"},{"Policy Line":"70109817","B":"Chlamydia: Iga","C":"300","D":"86631","F":"87"},{"Policy Line":"70109902","B":"Typhus Fever Ab","C":"300","D":"86757","F":"71.4"},{"Policy Line":"70109903","B":"Typhus Fever Ab","C":"300","D":"86757","F":"71.4"},{"Policy Line":"70109914","B":"Chlamydia Trachomatis","C":"300","D":"86631","F":"182.7"},{"Policy Line":"70109916","B":"RA - Fluid","C":"300","D":"86430","F":"30.6"},{"Policy Line":"70109922","B":"B. Hensalae Igg","C":"300","D":"86611","F":"41.4"},{"Policy Line":"70109923","B":"B. Hensalae Igm","C":"300","D":"86611","F":"41.4"},{"Policy Line":"70109924","B":"B.Quintana Igg","C":"300","D":"86611","F":"41.4"},{"Policy Line":"70109925","B":"B Quintana Igm","C":"300","D":"86611","F":"41.4"},{"Policy Line":"70109949","B":"Lymphocytic Choriomeningitis A","C":"300","D":"86727","F":"21"},{"Policy Line":"70109950","B":"Encephalitis Ab-Eastern Equine","C":"300","D":"86652","F":"26.7"},{"Policy Line":"70109951","B":"Encephalits Ab (California)","C":"300","D":"86651","F":"33"},{"Policy Line":"70109952","B":"Encephalitis Ab (St Louis)","C":"300","D":"86653","F":"37.2"},{"Policy Line":"70109953","B":"Encephalitis Ab","C":"300","D":"86654","F":"44.1"},{"Policy Line":"70109960","B":"Coxsackie Ab","C":"300","D":"86658","F":"50.7"},{"Policy Line":"70109961","B":"Coxsackie Ab","C":"300","D":"86658","F":"50.7"},{"Policy Line":"70109962","B":"Coxsackie Ab","C":"300","D":"86658","F":"50.7"},{"Policy Line":"70109963","B":"Coxsackie Ab","C":"300","D":"86658","F":"50.7"},{"Policy Line":"70109964","B":"Coxsackie Ab","C":"300","D":"86658","F":"50.7"},{"Policy Line":"70109965","B":"Coxsackie Ab","C":"300","D":"86658","F":"47.1"},{"Policy Line":"70109966","B":"Virus Ab-Not Elsewhere Spec","C":"300","D":"86790","F":"67.8"},{"Policy Line":"70109967","B":"Mumps Serology","C":"300","D":"86735","F":"126.6"},{"Policy Line":"70109970","B":"A Fumagatus","C":"300","D":"86606","F":"24.6"},{"Policy Line":"70109971","B":"M Faeni","C":"300","D":"86609","F":"32.1"},{"Policy Line":"70109972","B":"S Viridis","C":"300","D":"86609","F":"32.1"},{"Policy Line":"70109973","B":"Encephalitis Ab-Western Equine","C":"300","D":"86654","F":"21"},{"Policy Line":"70109985","B":"Aspergillus Niger","C":"300","D":"86606","F":"24.6"},{"Policy Line":"70109986","B":"Aspergillus Fla Vus","C":"300","D":"86606","F":"24.6"},{"Policy Line":"70109987","B":"Casa (Cancer Assoc Serum Ag)","C":"300","D":"86316","F":"464.4"},{"Policy Line":"70109988","B":"Aspergillus Fumagatus","C":"300","D":"86606","F":"24.6"},{"Policy Line":"70109992","B":"Tularemia Ab","C":"300","D":"86668","F":"189.6"},{"Policy Line":"70109994","B":"Nocardia Ab","C":"300","D":"86744","F":"33.6"},{"Policy Line":"70109995","B":"Pigeon Serum","C":"300","D":"86331","F":"42"},{"Policy Line":"70109996","B":"T Candidus","C":"300","D":"86609","F":"42"},{"Policy Line":"70109997","B":"Therm Sacchari","C":"300","D":"86331","F":"116.7"},{"Policy Line":"70109998","B":"T Vulgaris","C":"300","D":"86609","F":"42"},{"Policy Line":"70110012","B":"C-Reactive Protein (Cardio)","C":"300","D":"86141","F":"27.6"},{"Policy Line":"70110013","B":"Narcolepsy (Dr/Dq)","C":"300","D":"86817","F":"472.5"},{"Policy Line":"70110018","B":"C6 Lyme Peptide Elisa","C":"300","D":"86618","F":"266.4"},{"Policy Line":"70110082","B":"West Nile Virus: Igm","C":"300","D":"86788","F":"48.3"},{"Policy Line":"70110083","B":"West Nile Virus: Igg","C":"300","D":"86789","F":"48.3"},{"Policy Line":"70110085","B":"Salmonella Antibody","C":"300","D":"86768","F":"101.4"},{"Policy Line":"70110091","B":"Cd4 Absolute Count","C":"300","D":"86361","F":"311.1"},{"Policy Line":"70110101","B":"Lyme Igg: Western Blot","C":"300","D":"86617","F":"90.6"},{"Policy Line":"70110102","B":"Lyme Igm: Western Blot","C":"300","D":"86617","F":"90.6"},{"Policy Line":"70110115","B":"Inhibin A","C":"300","D":"86336","F":"96.9"},{"Policy Line":"70110130","B":"Dnase Bab","C":"300","D":"86215","F":"30.6"},{"Policy Line":"70110205","B":"Reproductive Immunophenotype","C":"300","D":"86357","F":"176.4"},{"Policy Line":"70110223","B":"MI-2 Auto Abs","C":"300","D":"86235","F":"157.5"},{"Policy Line":"70110227","B":"SRP Auto Abs","C":"300","D":"86235","F":"179.1"},{"Policy Line":"70110228","B":"U2 Snrnp Auto Abs","C":"300","D":"86235","F":"34.2"},{"Policy Line":"70110229","B":"Jo-1 Auto Abs","C":"300","D":"86235","F":"160.2"},{"Policy Line":"70110236","B":"HPV: Amp Probe (High Risk)","C":"300","D":"G0476","F":"141.6"},{"Policy Line":"70110295","B":"Insulin Antibodies Rflx Titer","C":"300","D":"86337","F":"16.2"},{"Policy Line":"70110325","B":"Proteinase 3 Ab","C":"300","D":"86021","F":"72.9"},{"Policy Line":"70110360","B":"Cardiolipin AB - IgM","C":"300","D":"86147","F":"40.2"},{"Policy Line":"70110361","B":"Cardiolipin AB IgG","C":"300","D":"86147","F":"40.2"},{"Policy Line":"70110362","B":"Cardiolipin AB IgA","C":"300","D":"86147","F":"40.2"},{"Policy Line":"70110398","B":"Influenza Virus Ab","C":"300","D":"86710","F":"50.1"},{"Policy Line":"70110399","B":"Mycoplasma","C":"300","D":"86738","F":"51.9"},{"Policy Line":"70110401","B":"Anti Cardiolipin Screen","C":"300","D":"86147","F":"40.2"},{"Policy Line":"70112827","B":"Mumps IgG","C":"300","D":"86735","F":"51"},{"Policy Line":"70115032","B":"Candida Antibody","C":"300","D":"86628","F":"156.6"},{"Policy Line":"70115714","B":"Fecal Globin - Quest","C":"300","D":"G0328","F":"70.5"},{"Policy Line":"70115718","B":"Johnson Grass, Allergen IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70115726","B":"Brazil Nut Quant IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70115727","B":"Hazelnut Quant IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70115728","B":"Macadamia Nut Quant IgE","C":"300","D":"86003","F":"8.7"},{"Policy Line":"70115730","B":"Peanut-Ara h 2 Quant IgE","C":"300","D":"86008","F":"9.9"},{"Policy Line":"70115731","B":"Peanut-Ara h 1 Quant IgE","C":"300","D":"86008","F":"9.9"},{"Policy Line":"70115732","B":"Peanut-Ara h 3 Quant IgE","C":"300","D":"86008","F":"9.9"},{"Policy Line":"70115733","B":"Peanut-Ara h 9 Quant IgE","C":"300","D":"86008","F":"9.9"},{"Policy Line":"70115734","B":"Peanut-Ara h 8 Quant IgE","C":"300","D":"86008","F":"9.9"},{"Policy Line":"70115779","B":"Plt Abs Direct,IgG","C":"300","D":"86023","F":"56.1"},{"Policy Line":"70115780","B":"Plt Abs Direct,IgM","C":"300","D":"86023","F":"56.1"},{"Policy Line":"70115784","B":"A.fumigatus #1 Ab Precipitin","C":"300","D":"86606","F":"11.7"},{"Policy Line":"70115785","B":"A.fumigatus #6 Ab Precipitin","C":"300","D":"86606","F":"11.7"},{"Policy Line":"70115786","B":"A.pullulans Ab, Precipitin","C":"300","D":"86331","F":"11.7"},{"Policy Line":"70115787","B":"Pigeon Serum Ab, Precipitin","C":"300","D":"86331","F":"11.7"},{"Policy Line":"70115788","B":"M.faeni Ab, Precipitin","C":"300","D":"86331","F":"11.7"},{"Policy Line":"70115789","B":"T.vulgaris #1 Ab, Precipitin","C":"300","D":"86331","F":"11.7"},{"Policy Line":"70115791","B":"Tetanus Antibody, IgG","C":"300","D":"86317","F":"30.6"},{"Policy Line":"70115792","B":"Immunofix electroph,Other Flds","C":"300","D":"86335","F":"78.6"},{"Policy Line":"70115794","B":"Jo-1 Ab, IgG","C":"300","D":"86235","F":"43.8"},{"Policy Line":"70115813","B":"Platelet Antibody Indirect","C":"300","D":"86022","F":"186.9"},{"Policy Line":"70115816","B":"Echovirus Antibody Type 6","C":"300","D":"86658","F":"47.7"},{"Policy Line":"70115817","B":"Echovirus Antibody Type 7","C":"300","D":"86658","F":"47.7"},{"Policy Line":"70115818","B":"Echovirus Antibody Type 9","C":"300","D":"86658","F":"47.7"},{"Policy Line":"70115819","B":"Echovirus Antibody Type 11","C":"300","D":"86658","F":"47.7"},{"Policy Line":"70115820","B":"Echovirus Antibody Type 30","C":"300","D":"86658","F":"47.7"},{"Policy Line":"70115822","B":"HSV 1,2 Ab Screen IgG, CSF","C":"300","D":"86694","F":"56.1"},{"Policy Line":"70115823","B":"Influenza A Virus Ab IgG","C":"300","D":"86710","F":"28.2"},{"Policy Line":"70115824","B":"Influenza A Virus Ab IgM","C":"300","D":"86710","F":"28.2"},{"Policy Line":"70115825","B":"Influenza B Virus Ab IgG","C":"300","D":"86710","F":"28.2"},{"Policy Line":"70115826","B":"Influenza B Virus Ab IgM","C":"300","D":"86710","F":"28.2"},{"Policy Line":"70115827","B":"Varicella Zoster Ab IgG","C":"300","D":"86787","F":"45.9"},{"Policy Line":"70115828","B":"Mumps IgM","C":"300","D":"86735","F":"51"},{"Policy Line":"70115830","B":"Varicella Zoster Ab IgM","C":"300","D":"86787","F":"45.9"},{"Policy Line":"70115831","B":"Measles (Rubeola) IgG","C":"300","D":"86765","F":"51"},{"Policy Line":"70115832","B":"HSV Type 1 Ab, IgG","C":"300","D":"86695","F":"76.5"},{"Policy Line":"70115833","B":"LCM Virus Ab, IgG","C":"300","D":"86727","F":"56.1"},{"Policy Line":"70115834","B":"LCM Virus Ab, IgM","C":"300","D":"86727","F":"56.1"},{"Policy Line":"70115835","B":"Measles (Rubeola) IgM","C":"300","D":"86765","F":"63.9"},{"Policy Line":"70115836","B":"HSV Type 2 Ab IgG","C":"300","D":"86696","F":"76.5"},{"Policy Line":"70115843","B":"Pneumo Serotype 1 IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115844","B":"Pneumo Serotype 2 IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115845","B":"Pneumo Serotype 4 IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115846","B":"Pneumo Serotype 5 IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115847","B":"Pneumo Serotype 6B IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115848","B":"Pneumo Serotype 7F IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115849","B":"Pneumo Serotype 8 IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115850","B":"Pneumo Serotype 9N IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115851","B":"Pneumo Serotype 9V IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115852","B":"Pneumo Serotype 12F IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115853","B":"Pneumo Serotype 14 IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115854","B":"Pneumo Serotype 18C IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115855","B":"Pneumo Serotype 19F IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115856","B":"Pneumo Serotype 23F IgG","C":"300","D":"86317","F":"7.2"},{"Policy Line":"70115858","B":"Antibody, Aspergillus","C":"300","D":"86606","F":"30.6"},{"Policy Line":"70115873","B":"C1-Esterase Inhibitor","C":"300","D":"86160","F":"38.4"},{"Policy Line":"70115874","B":"Parvovirus B19 Ab IgG","C":"300","D":"86747","F":"38.4"},{"Policy Line":"70115875","B":"Parvovirus B19 Ab IgM","C":"300","D":"86747","F":"38.4"},{"Policy Line":"70115879","B":"Insulin Antibody","C":"300","D":"86337","F":"114.9"},{"Policy Line":"70115880","B":"Mycoplasma pneumoniae Ab IgG","C":"300","D":"86738","F":"30.6"},{"Policy Line":"70115881","B":"Mycoplasma pneumoniae Ab IgM","C":"300","D":"86738","F":"30.6"},{"Policy Line":"70115885","B":"Peanut IgE","C":"302","D":"86003","F":"42.9"},{"Policy Line":"70115886","B":"Peanut Sev Ara h 1","C":"302","D":"86008","F":"42.9"},{"Policy Line":"70115887","B":"Peanut Sev Ara h 2","C":"302","D":"86008","F":"42.9"},{"Policy Line":"70115888","B":"Peanut Sev Ara h 3","C":"302","D":"86008","F":"42.9"},{"Policy Line":"70115889","B":"Peanut Sev Ara h 9","C":"302","D":"86008","F":"42.9"},{"Policy Line":"70115890","B":"Peanut Mild Ara h 8","C":"302","D":"86008","F":"42.9"},{"Policy Line":"70115896","B":"HTLV I/II Antibodies by ELISA","C":"300","D":"86790","F":"33.9"},{"Policy Line":"70115897","B":"HTLV I/II Antibodies, WB","C":"300","D":"86689","F":"141.3"},{"Policy Line":"70115898","B":"Borrelia burgdorferi Abs","C":"300","D":"86618","F":"28.2"},{"Policy Line":"70115899","B":"Borrelia burgdorferi IgG, WB","C":"300","D":"86617","F":"51"},{"Policy Line":"70115900","B":"Borrelia burgdorferi IgM, WB","C":"300","D":"86617","F":"51"},{"Policy Line":"70115922","B":"VDRL with reflex to titer","C":"300","D":"86592","F":"20.4"},{"Policy Line":"70115923","B":"VDRL titer","C":"300","D":"86593","F":"63.9"},{"Policy Line":"70115929","B":"Peanut IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115930","B":"Lobster IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115931","B":"Crab IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115932","B":"Egg Yolk IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115933","B":"Egg White IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115934","B":"D farinae IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115935","B":"Scallop IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115936","B":"Milk (Cow's) IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115937","B":"Codfish IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115938","B":"Pecan IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115939","B":"Oyster IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115940","B":"Dog Dander IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115941","B":"Alternaria alternata IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115942","B":"Soybean IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115943","B":"Tomato IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115944","B":"Pistachio IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115945","B":"Walnut IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115956","B":"Shrimp IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70115957","B":"HIV-1 Antibody","C":"300","D":"86701","F":"65.4"},{"Policy Line":"70115984","B":"CRP-SF","C":"300","D":"86140","F":"28.5"},{"Policy Line":"70115987","B":"ANA","C":"300","D":"86039","F":"40.8"},{"Policy Line":"70115988","B":"Smith (ENA) Antibody, IgG","C":"300","D":"86235","F":"38.4"},{"Policy Line":"70115989","B":"dsDNA Ab, IgG","C":"300","D":"86225","F":"33"},{"Policy Line":"70115990","B":"dsDNA (Crithidia) Ab, IgG","C":"300","D":"86256","F":"76.5"},{"Policy Line":"70115991","B":"Ribonucleic Protein Ab, IgG","C":"300","D":"86235","F":"38.4"},{"Policy Line":"70115992","B":"Scl-70 Antibody, IgG","C":"300","D":"86235","F":"38.4"},{"Policy Line":"70115993","B":"SSB (La) (ENA) Ab, IgG","C":"300","D":"86235","F":"38.4"},{"Policy Line":"70115995","B":"PM/Scl 100 Antibody, IgG","C":"300","D":"86235","F":"137.4"},{"Policy Line":"70115997","B":"SSA-52 (Ro52) Antibody, IgG","C":"300","D":"86235","F":"38.4"},{"Policy Line":"70115998","B":"SSA-60 (Ro60) Antibody, IgG","C":"300","D":"86235","F":"38.4"},{"Policy Line":"70115999","B":"Fibrillarin (U3 RNP) Ab, IgG","C":"300","D":"86235","F":"156.9"},{"Policy Line":"70116006","B":"Endomysial Ab, IgA","C":"300","D":"86256","F":"76.5"},{"Policy Line":"70116008","B":"ANCA","C":"300","D":"86255","F":"63.9"},{"Policy Line":"70116009","B":"ANCA Titer","C":"300","D":"86256","F":"107.4"},{"Policy Line":"70116013","B":"CV2.1 Antibody IgG, Screen","C":"300","D":"86255","F":"98.1"},{"Policy Line":"70116014","B":"PCCA/ANNA IgG Screen","C":"300","D":"86255","F":"98.1"},{"Policy Line":"70116016","B":"Neuronal Nuclear Ab Ttr, IgG","C":"300","D":"86256","F":"204"},{"Policy Line":"70116017","B":"Purkinje Cell Antibody Ttr IgG","C":"300","D":"86256","F":"170.1"},{"Policy Line":"70116019","B":"CV2.1 Antibody Titer, IgG","C":"300","D":"86256","F":"457.8"},{"Policy Line":"70116098","B":"B. pertussis Ab, IgA by ELISA","C":"300","D":"86615","F":"38.4"},{"Policy Line":"70116099","B":"B. pertussis Ab, IgG by ELISA","C":"300","D":"86615","F":"38.4"},{"Policy Line":"70116100","B":"B. pertussis Ab, IgA by IB","C":"300","D":"86615","F":"81.6"},{"Policy Line":"70116101","B":"B. pertussis Ab, IgG by IB","C":"300","D":"86615","F":"81.6"},{"Policy Line":"70116108","B":"Tuna IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116109","B":"Almond IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116110","B":"Brazil Nut IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116111","B":"Cashew IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116112","B":"Hazelnut IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116113","B":"Chestnut IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116114","B":"Whole Egg IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116115","B":"Alpha-lactalbumin IgE","C":"300","D":"86008","F":"15.9"},{"Policy Line":"70116116","B":"Bahia Grass IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116117","B":"Barley IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116118","B":"Beef IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116119","B":"Bermuda Grass IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116120","B":"Beta-lactoglobulin IgE","C":"300","D":"86008","F":"15.9"},{"Policy Line":"70116121","B":"Birch Tree IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116122","B":"Black Pepper IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116123","B":"Blue Mussel IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116124","B":"Casein IgE","C":"300","D":"86008","F":"15.9"},{"Policy Line":"70116125","B":"Cat Dander IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116126","B":"Chili Pepper IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116127","B":"Clam IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116128","B":"German Cockroach IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116130","B":"Coconut IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116131","B":"Common/Short Ragweed IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116132","B":"Corn IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116133","B":"D. pteronyssinus IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116134","B":"Yellow Dock IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116135","B":"English Plantain IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116136","B":"Fire Ant IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116137","B":"Garlic IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116138","B":"Gluten IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116139","B":"Honey Bee Venom IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116140","B":"Latex IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116141","B":"Macadamia Nut IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116142","B":"Box Elder/Maple Tree IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116143","B":"Oak Tree IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116144","B":"Onion IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116145","B":"Orange IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116146","B":"Paper Wasp IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116147","B":"Bell Pepper IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116148","B":"Penicillin G IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116149","B":"Penicillin V IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116150","B":"White Pine Tree IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116151","B":"Pineapple IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116152","B":"Pigweed IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116153","B":"Sesame Seed IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116154","B":"Sheep Sorrell IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116155","B":"Oat IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116156","B":"Strawberry IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116157","B":"A. alternata IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116158","B":"C. albicans IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116159","B":"Hormodendrum IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116160","B":"Meadow Fescue IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116161","B":"A. fumigatus IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116162","B":"P. notatum IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116163","B":"Houst Dust Greer IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116164","B":"Trout IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116165","B":"Tuna IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116166","B":"Wheat IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116167","B":"Whey IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116168","B":"White-faced Hornet IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116169","B":"Baker/Brewer's Yeast IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116170","B":"YellowFaced Hornet IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116171","B":"Yellow Jacket Venom IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116172","B":"Chocolate Ige","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116175","B":"Herpesvirus 6 Antibody, IgG","C":"300","D":"86790","F":"130.8"},{"Policy Line":"70116176","B":"Herpesvirus 6 Antibody, IgM","C":"300","D":"86790","F":"191.4"},{"Policy Line":"70116177","B":"Herpesvirus 6 Ab, IgM Titer","C":"300","D":"86790","F":"176.7"},{"Policy Line":"70116179","B":"June/Kentucky Blue Grass IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116180","B":"Johnson Grass IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116181","B":"Chicken IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116182","B":"Cheddar Cheese IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116183","B":"Gulf Flounder IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116184","B":"Lamb's Quarters IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116185","B":"House Dust Stier IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116186","B":"Amoxicillin IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116187","B":"Banana IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116188","B":"Carrot IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116189","B":"Oregano IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116190","B":"Perennial Rye Grass IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116191","B":"Potato IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116192","B":"Pork IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116193","B":"Ampicillin IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116194","B":"Horse Hair/Dander IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116195","B":"Pea IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116196","B":"Lima Bean/White Bean IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116197","B":"Rice IgE","C":"300","D":"86003","F":"15.9"},{"Policy Line":"70116198","B":"Feather Mix IgE","C":"300","D":"86005","F":"22.8"},{"Policy Line":"70116199","B":"Striated Muscle Abs","C":"300","D":"86255","F":"43.5"},{"Policy Line":"70116200","B":"Striated Muscle Abs IgG Titer","C":"300","D":"86256","F":"127.5"},{"Policy Line":"70116201","B":"Adenovirus Antibody, Serum","C":"300","D":"86603","F":"155.1"},{"Policy Line":"70116202","B":"Beta-2 Transferrin","C":"300","D":"86335","F":"144.6"},{"Policy Line":"70116206","B":"T cells;total counts - LSP 3","C":"300","D":"86359","F":"48.3"},{"Policy Line":"70116207","B":"T cells; Abs CD4 and CD8-LSP3","C":"300","D":"86360","F":"48.3"},{"Policy Line":"70116208","B":"T cells;total counts-LSP4","C":"300","D":"86359","F":"76.5"},{"Policy Line":"70116209","B":"T cells; Abs CD4 and CD8-LSP4","C":"300","D":"86360","F":"76.5"},{"Policy Line":"70116217","B":"Myocardial Ab IgG","C":"300","D":"86255","F":"51"},{"Policy Line":"70116218","B":"Myocardial Ab IgG Titer","C":"300","D":"86256","F":"165.9"},{"Policy Line":"70116226","B":"Complement Component 2","C":"300","D":"86160","F":"96.9"},{"Policy Line":"70116227","B":"Histoplasma Mycelia, CF","C":"300","D":"86698","F":"31.5"},{"Policy Line":"70116228","B":"Histoplasma yeast, CF","C":"300","D":"86698","F":"31.5"},{"Policy Line":"70116229","B":"Histoplasma spp.Abs,Precipitin","C":"300","D":"86698","F":"31.5"},{"Policy Line":"70116242","B":"Raji Cell Immune Complex Assay","C":"300","D":"86332","F":"182.7"},{"Policy Line":"70116247","B":"Diphtheria Antibody, IgG","C":"300","D":"86317","F":"45.9"},{"Policy Line":"70116249","B":"AQP4, IgG by IFA","C":"300","D":"86255","F":"300.9"},{"Policy Line":"70116250","B":"AQP4, IgG by IFA, Serum Titer","C":"300","D":"86256","F":"222.3"},{"Policy Line":"70116255","B":"C. pneumoniae IgM Titer","C":"300","D":"86632","F":"25.5"},{"Policy Line":"70116256","B":"C. trachomatis IgM Titer","C":"300","D":"86632","F":"25.5"},{"Policy Line":"70116257","B":"C. psittaci IgM Titer","C":"300","D":"86632","F":"25.5"},{"Policy Line":"70116258","B":"C. pneumoniae IgG Titer","C":"300","D":"86631","F":"25.5"},{"Policy Line":"70116259","B":"C. trachomatis IgG Titer","C":"300","D":"86631","F":"25.5"},{"Policy Line":"70116260","B":"C. psittaci IgG Titer","C":"300","D":"86631","F":"25.5"},{"Policy Line":"70116262","B":"Toxoplasma gondii Ab, IgG CSF","C":"300","D":"86777","F":"186.9"},{"Policy Line":"70116263","B":"Neutrophil Oxidative Burst","C":"300","D":"86352","F":"248.4"},{"Policy Line":"70116268","B":"B cells, total count","C":"300","D":"86355","F":"32.1"},{"Policy Line":"70116269","B":"NK cells, total count","C":"300","D":"86357","F":"32.1"},{"Policy Line":"70116270","B":"T cells; total count","C":"300","D":"86359","F":"32.1"},{"Policy Line":"70116271","B":"T Cells; Absol CD4 and CD8","C":"300","D":"86360","F":"32.1"},{"Policy Line":"70116272","B":"Mononuclear cell ag 1, qt","C":"300","D":"86356","F":"32.1"},{"Policy Line":"70116273","B":"Mononuclear cell ag 2, qt","C":"300","D":"86356","F":"32.1"},{"Policy Line":"70116274","B":"Mononuclear cell ag 3, qt","C":"300","D":"86356","F":"32.1"},{"Policy Line":"70116275","B":"Mononuclear cell ag 4, qt","C":"300","D":"86356","F":"32.1"},{"Policy Line":"70116276","B":"Lymph Response to Candida","C":"300","D":"86353","F":"162.3"},{"Policy Line":"70116277","B":"Lymph Response to Tetanus","C":"300","D":"86353","F":"162.3"},{"Policy Line":"70116278","B":"Lymph Response to PHA","C":"300","D":"86353","F":"162.3"},{"Policy Line":"70116279","B":"Lymph Response to Con A","C":"300","D":"86353","F":"162.3"},{"Policy Line":"70116280","B":"Lymph Response to PWM","C":"300","D":"86353","F":"162.3"},{"Policy Line":"70116281","B":"C.Trachomatis (L1) IgG","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116282","B":"C.Trachomatis (L1) IgA","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116283","B":"C. trachomatis (D-K) IgG","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116284","B":"C. trachomatis (D-K) IgA","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116285","B":"C. pneumoniae IgG","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116286","B":"C. pneumoniae IgA","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116287","B":"C. psittaci IgG","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116288","B":"C. psittaci IgA","C":"300","D":"86631","F":"11.4"},{"Policy Line":"70116289","B":"C.Trachomatis (L1) IgM","C":"300","D":"86632","F":"11.4"},{"Policy Line":"70116290","B":"C. trachomatis (D-K) IgM","C":"300","D":"86632","F":"11.4"},{"Policy Line":"70116291","B":"C. pneumoniae IgM","C":"300","D":"86632","F":"11.4"},{"Policy Line":"70116292","B":"C. psittaci IgM","C":"300","D":"86632","F":"11.4"},{"Policy Line":"70116302","B":"Neisseria gonorrhoea Abs,Total","C":"300","D":"86609","F":"111.9"},{"Policy Line":"70116305","B":"Filaria Ab IgG4 by ELISA,Serum","C":"300","D":"86682","F":"162.3"},{"Policy Line":"70116312","B":"Poliovirus Ab Type 1","C":"300","D":"86658","F":"76.5"},{"Policy Line":"70116313","B":"Poliovirus Ab Type 3","C":"300","D":"86658","F":"76.5"},{"Policy Line":"70116326","B":"NMDA Receptor Antibody, IgG","C":"300","D":"86255","F":"283.5"},{"Policy Line":"70116327","B":"GAD Antibody","C":"300","D":"86341","F":"283.5"},{"Policy Line":"70116328","B":"LGI1 Ab IgG Screen by IFA","C":"300","D":"86255","F":"204"},{"Policy Line":"70116329","B":"CASPR2 Ab IgG Screen by IFA","C":"300","D":"86255","F":"204"},{"Policy Line":"70116330","B":"LGI1 Ab IgG Titer by IFA","C":"300","D":"86256","F":"425.1"},{"Policy Line":"70116331","B":"CASPR2 Ab IgG Titer by IFA","C":"300","D":"86256","F":"382.5"},{"Policy Line":"70116332","B":"NMDA Receptor Ab, IgGTiter","C":"300","D":"86256","F":"255"},{"Policy Line":"70116333","B":"NMO/AQP4-IgG, Serum","C":"300","D":"86255","F":"300.9"},{"Policy Line":"70116334","B":"NMO/AQP4-IgG, Titer Serum","C":"300","D":"86256","F":"222.3"},{"Policy Line":"70116345","B":"Pneumo Serotype 3 IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116346","B":"Pneumo Serotype 10A IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116347","B":"Pneumo Serotype 11A IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116348","B":"Pneumo Serotype 15B IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116349","B":"Pneumo Serotype 17F IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116350","B":"Pneumo Serotype 19A IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116351","B":"Pneumo Serotype 20 IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116352","B":"Pneumo Serotype 22F IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116353","B":"Pneumo Serotype 33F IgG","C":"300","D":"86317","F":"10.2"},{"Policy Line":"70116354","B":"Brucella Ab by Agglutination","C":"300","D":"86622","F":"35.7"},{"Policy Line":"70116365","B":"Aspergillus fumigatus Ab IgG","C":"300","D":"86606","F":"127.5"},{"Policy Line":"70116373","B":"Typhus Fever Antibody, IgG","C":"300","D":"86757","F":"31.8"},{"Policy Line":"70116374","B":"Typhus Fever Antibody, IgM","C":"300","D":"86757","F":"31.8"},{"Policy Line":"70116379","B":"S. cerevisiae Ab, IgA","C":"300","D":"86671","F":"42"},{"Policy Line":"70116380","B":"S. cerevisiae Ab, IgG","C":"300","D":"86671","F":"42"},{"Policy Line":"70116381","B":"ANCA, IgG","C":"300","D":"86255","F":"42"},{"Policy Line":"70116397","B":"Peach IgE","C":"300","D":"86003","F":"9.6"},{"Policy Line":"70116398","B":"Tilapia IgE","C":"300","D":"86003","F":"9.6"},{"Policy Line":"70116400","B":"Mouse Epithelium IgE","C":"300","D":"86003","F":"9.6"},{"Policy Line":"70116401","B":"M. racemosus IgE","C":"300","D":"86003","F":"9.6"},{"Policy Line":"70116403","B":"Mackerel IgE","C":"300","D":"86003","F":"9.6"},{"Policy Line":"70116404","B":"Halibut IgE","C":"300","D":"86003","F":"9.6"},{"Policy Line":"70116405","B":"Salmon IgE","C":"300","D":"86003","F":"9.6"},{"Policy Line":"70116408","B":"EBV VCA, IgM","C":"300","D":"86665","F":"19.8"},{"Policy Line":"70116411","B":"Echinococcus Ab, IgG","C":"300","D":"86682","F":"38.7"},{"Policy Line":"70116414","B":"Complement Component 5","C":"300","D":"86160","F":"53.1"},{"Policy Line":"70116415","B":"Complement Component 7","C":"300","D":"86160","F":"166.2"},{"Policy Line":"70116416","B":"Complement Component 9","C":"300","D":"86160","F":"166.2"},{"Policy Line":"70116419","B":"C1q Binding Assay","C":"300","D":"86332","F":"34.2"},{"Policy Line":"70116452","B":"MOG IgG Antibody","C":"300","D":"86255","F":"242.1"},{"Policy Line":"70116453","B":"MOG IgG Antibody Titer","C":"300","D":"86256","F":"353.1"},{"Policy Line":"70116458","B":"Apple IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116472","B":"Babesia microti IgG","C":"300","D":"86753","F":"30"},{"Policy Line":"70116473","B":"Babesia microti IgM","C":"300","D":"86753","F":"30"},{"Policy Line":"70116474","B":"A. Phagocytophilum Ab, IgG","C":"300","D":"86666","F":"59.4"},{"Policy Line":"70116475","B":"A. Phagocytophilum Ab, IgM","C":"300","D":"86666","F":"59.4"},{"Policy Line":"70116476","B":"Cinnamon IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116477","B":"Trichinella Antibody, IgG","C":"300","D":"86784","F":"192"},{"Policy Line":"70116484","B":"Francisella tularensis Ab IgG","C":"300","D":"86668","F":"48.3"},{"Policy Line":"70116485","B":"Francisella tularensis Ab IgM","C":"300","D":"86668","F":"48.3"},{"Policy Line":"70116487","B":"Ehrlichia chaffeensis Ab, IgG","C":"300","D":"86666","F":"26.4"},{"Policy Line":"70116488","B":"Ehrlichia chaffeensis Ab, IgM","C":"300","D":"86666","F":"26.4"},{"Policy Line":"70116491","B":"Ovomucoid IgE","C":"300","D":"86008","F":"9.3"},{"Policy Line":"70116492","B":"Apricot IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116511","B":"Purk Cell/Neur Nuc IgG Scrn","C":"300","D":"86255","F":"26.7"},{"Policy Line":"70116512","B":"HSV 1 Glyco G-Specific, IgG","C":"300","D":"86695","F":"38.4"},{"Policy Line":"70116513","B":"HSV 2 Glyco G-Specific, IgG","C":"300","D":"86696","F":"38.4"},{"Policy Line":"70116516","B":"E. histolytica Ab, IgG","C":"300","D":"86753","F":"21.3"},{"Policy Line":"70116525","B":"Western Ragweed IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116526","B":"Sycamore Tree IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116527","B":"Russian Thistle IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116528","B":"Mugwort IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116529","B":"Goldenrod IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116530","B":"Kochia/Firebush IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116531","B":"Eucalyptus Tree IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116532","B":"White Ash Tree IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116538","B":"Fungi/Mold, C. albicans IgG","C":"300","D":"86001","F":"33"},{"Policy Line":"70116541","B":"Giardia lamblia IgG","C":"300","D":"86674","F":"56.1"},{"Policy Line":"70116542","B":"Giardia lamblia IgM","C":"300","D":"86674","F":"56.1"},{"Policy Line":"70116543","B":"Giardia lamblia IgA","C":"300","D":"86674","F":"56.1"},{"Policy Line":"70116544","B":"N.meningitidis Type A IgG","C":"300","D":"86741","F":"66.6"},{"Policy Line":"70116545","B":"N.meningitidis Type C IgG","C":"300","D":"86741","F":"66.6"},{"Policy Line":"70116546","B":"N.meningitidis Type Y IgG","C":"300","D":"86741","F":"66.6"},{"Policy Line":"70116547","B":"N.meningitidis Type W-135 IgG","C":"300","D":"86741","F":"66.6"},{"Policy Line":"70116554","B":"B cells, total count","C":"300","D":"86355","F":"40.2"},{"Policy Line":"70116555","B":"Natural killer cells,tot ct","C":"300","D":"86357","F":"40.2"},{"Policy Line":"70116556","B":"T cells; total count","C":"300","D":"86359","F":"40.2"},{"Policy Line":"70116557","B":"T cells;abs CD4&CD8 ct,inc rat","C":"300","D":"86360","F":"40.2"},{"Policy Line":"70116559","B":"NK cells Enumeration","C":"300","D":"86357","F":"149.4"},{"Policy Line":"70116561","B":"Mononuclear cell antigen 1","C":"300","D":"86356","F":"68.4"},{"Policy Line":"70116562","B":"Mononuclear cell antigen 2","C":"300","D":"86356","F":"68.4"},{"Policy Line":"70116563","B":"Mononuclear cell antigen 3","C":"300","D":"86356","F":"68.4"},{"Policy Line":"70116564","B":"Mononuclear cell antigen 4","C":"300","D":"86356","F":"68.4"},{"Policy Line":"70116565","B":"Mononuclear cell antigen 5","C":"300","D":"86356","F":"68.4"},{"Policy Line":"70116566","B":"Mononuclear cell antigen 6","C":"300","D":"86356","F":"68.4"},{"Policy Line":"70116567","B":"Mononuclear cell antigen 7","C":"300","D":"86356","F":"68.4"},{"Policy Line":"70116570","B":"Candida Antibody IgA","C":"300","D":"86628","F":"29.7"},{"Policy Line":"70116571","B":"Candida Antibody IgG","C":"300","D":"86628","F":"29.7"},{"Policy Line":"70116572","B":"Candida Antibody IgM","C":"300","D":"86628","F":"29.7"},{"Policy Line":"70116580","B":"Alpha Fetoprotein, Body Fluid","C":"300","D":"86316","F":"24.6"},{"Policy Line":"70116616","B":"Jo-1 Ab IgG-EMP","C":"300","D":"86235","F":"27.3"},{"Policy Line":"70116617","B":"Smith/RNP (ENA) Ab IgG-EMP","C":"300","D":"86235","F":"27.3"},{"Policy Line":"70116618","B":"PM/Scl 100 Ab IgG-EMP","C":"300","D":"86235","F":"27.3"},{"Policy Line":"70116619","B":"SSA-52 (Ro52) (ENA) Ab IgG-EMP","C":"300","D":"86235","F":"27.3"},{"Policy Line":"70116620","B":"SSA-60 (Ro60) (ENA) Ab IgG-EMP","C":"300","D":"86235","F":"27.3"},{"Policy Line":"70116621","B":"Fibrillarin Ab IgG-EMP","C":"300","D":"86235","F":"27.3"},{"Policy Line":"70116622","B":"Sunflower Seed IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116623","B":"Avocado IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116629","B":"NMP22, Urine","C":"300","D":"86316","F":"138.9"},{"Policy Line":"70116633","B":"HSV 1/2 Ab, IgG","C":"302","D":"86694","F":"27"},{"Policy Line":"70116634","B":"HSV 1, IgG","C":"302","D":"86695","F":"39.9"},{"Policy Line":"70116635","B":"HSV 2, IgG","C":"302","D":"86696","F":"37.2"},{"Policy Line":"70116637","B":"Antistreptolysin O Screen","C":"302","D":"86060","F":"20.7"},{"Policy Line":"70116642","B":"Hepatitis A Virus Abs,Total","C":"302","D":"86708","F":"23.4"},{"Policy Line":"70116643","B":"Thyroid Peroxidase (TPO) Ab","C":"302","D":"86376","F":"17.4"},{"Policy Line":"70116647","B":"Varicella-Zoster Virus Ab, IgG","C":"302","D":"86787","F":"21"},{"Policy Line":"70116650","B":"Timothy Grass IgE","C":"302","D":"86003","F":"9.3"},{"Policy Line":"70116658","B":"IFE","C":"300","D":"86334","F":"18"},{"Policy Line":"70116662","B":"CMV Antibody IgM","C":"300","D":"86645","F":"21.9"},{"Policy Line":"70116663","B":"HSV 1 and/or 2 Abs,IgM ELISA","C":"302","D":"86694","F":"21.9"},{"Policy Line":"70116664","B":"Rubella Antibody IgM","C":"302","D":"86762","F":"21.9"},{"Policy Line":"70116665","B":"Toxoplasma gondii Ab, IgM","C":"302","D":"86778","F":"21.9"},{"Policy Line":"70116666","B":"CMV Antibody IgG","C":"300","D":"86644","F":"22.5"},{"Policy Line":"70116667","B":"HSV Type 1/2 Combined Ab, IgG","C":"302","D":"86694","F":"22.5"},{"Policy Line":"70116668","B":"Rubella Antibody IgG","C":"302","D":"86762","F":"22.5"},{"Policy Line":"70116669","B":"Toxoplasma gondii Ab, IgG","C":"302","D":"86777","F":"22.5"},{"Policy Line":"70116670","B":"Blastomyces Ab","C":"302","D":"86612","F":"25.5"},{"Policy Line":"70116671","B":"Blastomyces Abs Immunodifsn","C":"302","D":"86612","F":"22.8"},{"Policy Line":"70116676","B":"p2PSA","C":"302","D":"86316","F":"186.3"},{"Policy Line":"70116679","B":"Lemon IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116680","B":"Cucumber IgE","C":"300","D":"86003","F":"9.3"},{"Policy Line":"70116682","B":"GBM Ab, IgG by IFA","C":"300","D":"86255","F":"112.2"},{"Policy Line":"70116722","B":"Urticaria-Inducing Activity","C":"302","D":"86352","F":"171.3"},{"Policy Line":"70116723","B":"T-Spot TB","C":"302","D":"86481","F":"117.6"},{"Policy Line":"70116724","B":"Chikungunya Antibodies, IgG","C":"302","D":"86790","F":"84.3"},{"Policy Line":"70116725","B":"Chikungunya Antibodies, IgM","C":"302","D":"86790","F":"84.3"},{"Policy Line":"70116726","B":"Dengue Fever Virus Ab, IgG","C":"302","D":"86790","F":"35.4"},{"Policy Line":"70116727","B":"Dengue Fever Virus Ab, IgM","C":"302","D":"86790","F":"35.4"},{"Policy Line":"70116728","B":"PLA2R Antibody","C":"300","D":"86255","F":"174"},{"Policy Line":"70116729","B":"PLA2R Antibody Titer","C":"300","D":"86256","F":"174"},{"Policy Line":"70116730","B":"Peanut Sev Ara h 6","C":"302","D":"86008","F":"42.9"},{"Policy Line":"70118484","B":"Phosphatidylserine Ab Igg","C":"300","D":"86148","F":"82.8"},{"Policy Line":"70118486","B":"Phosphatidylserine Ab Iga","C":"300","D":"86148","F":"82.8"},{"Policy Line":"70118488","B":"Phosphatidylserine Ab Igm","C":"300","D":"86148","F":"82.8"},{"Policy Line":"70202000","B":"HLA Ab Screening","C":"302","D":"86828","F":"472.2"},{"Policy Line":"70202001","B":"HLA Ab ID, Class I","C":"302","D":"86830","F":"295.5"},{"Policy Line":"70202002","B":"HLA Molecular Ab Typing","C":"302","D":"86832","F":"1416.6"},{"Policy Line":"70206177","B":"CMV Negative Blood Prod Test","C":"300","D":"86644","F":"69.3"},{"Policy Line":"70100010","B":"Culture Aerobic: Blood","C":"300","D":"87040","F":"77.4"},{"Policy Line":"70100011","B":"Culture: Urine Colony Count","C":"300","D":"87086","F":"17.7"},{"Policy Line":"70100088","B":"Culture Aerobic: Stool","C":"300","D":"87045","F":"30.9"},{"Policy Line":"70100089","B":"Ova & Parasites","C":"300","D":"87177","F":"30.9"},{"Policy Line":"70100090","B":"H.Pylori Interp-GastTiss-Scrn","C":"300","D":"87081","F":"37.2"},{"Policy Line":"70100105","B":"RSV Antigen -Respiratory Syncy","C":"300","D":"87807","F":"108"},{"Policy Line":"70100113","B":"Gram Stain","C":"300","D":"87205","F":"16.8"},{"Policy Line":"70100117","B":"Culture ID -AEROBIC ADDL","C":"300","D":"87077","F":"15.9"},{"Policy Line":"70100126","B":"Beta Strp Scrn-Grp A","C":"300","D":"87430","F":"43.5"},{"Policy Line":"70100141","B":"Concentration For Infect Agent","C":"300","D":"87015","F":"24.3"},{"Policy Line":"70100151","B":"Fungal Culture:Body Fluid","C":"300","D":"87102","F":"123"},{"Policy Line":"70100152","B":"Fungus Culture Blood","C":"300","D":"87103","F":"133.5"},{"Policy Line":"70100154","B":"Culture Fungi: Skin-Hair-Nails","C":"300","D":"87101","F":"219.3"},{"Policy Line":"70100156","B":"Beta Strp Scrn-Grp B","C":"300","D":"87802","F":"217.8"},{"Policy Line":"70100158","B":"Culture: Strep Grp B-Oth Src","C":"300","D":"87070","F":"30.9"},{"Policy Line":"70100164","B":"HepatitisB SurfAg EIA (HBSAG)","C":"300","D":"87340","F":"51"},{"Policy Line":"70100165","B":"India Ink","C":"300","D":"87210","F":"71.4"},{"Policy Line":"70100175","B":"GDH Antigen","C":"300","D":"87449","F":"28.5"},{"Policy Line":"70100181","B":"KOH Prep","C":"300","D":"87220","F":"51.9"},{"Policy Line":"70100182","B":"AFB Smear","C":"300","D":"87206","F":"51"},{"Policy Line":"70100183","B":"Culture ID: Anaerobic","C":"300","D":"87075","F":"150.3"},{"Policy Line":"70100185","B":"Catheter Tip Culture; Oth Src","C":"300","D":"87070","F":"95.4"},{"Policy Line":"70100186","B":"Culture, Other, Source","C":"300","D":"87070","F":"30.9"},{"Policy Line":"70100358","B":"Inf Agent Det By Na Amp Pr","C":"300","D":"87798","F":"556.8"},{"Policy Line":"70100359","B":"Inf Agent Det By Na Amp Pr2","C":"300","D":"87798","F":"556.8"},{"Policy Line":"70100405","B":"T Vaginalis Rna Quest","C":"300","D":"87661","F":"64.5"},{"Policy Line":"70100420","B":"HIV-1 Integrase Genotype Qst","C":"300","D":"87906","F":"974.7"},{"Policy Line":"70100423","B":"IA Det By Rna Amp Probe Flu A","C":"300","D":"87798","F":"374.7"},{"Policy Line":"70100424","B":"IA Det By Rna Amp Probe H1","C":"300","D":"87798","F":"375.3"},{"Policy Line":"70100437","B":"Cytomegalovirus by Qual PCR","C":"300","D":"87496","F":"178.8"},{"Policy Line":"70100440","B":"Chlamydiazyme (Chlamydia Ag)","C":"300","D":"87320","F":"88.5"},{"Policy Line":"70100508","B":"C.Pneumoniae DNA Qual Pcr Qst","C":"300","D":"87486","F":"170.1"},{"Policy Line":"70100510","B":"Influenza A Qst","C":"300","D":"87275","F":"26.7"},{"Policy Line":"70100511","B":"Influenza B Qst","C":"300","D":"87276","F":"26.7"},{"Policy Line":"70100516","B":"Bartonella DNA Qual Qst","C":"300","D":"87471","F":"251.7"},{"Policy Line":"70100519","B":"HIV-1 Dns Qual Pcr Qst","C":"300","D":"87535","F":"221.1"},{"Policy Line":"70100526","B":"C.Difficile Toxin PCR","C":"300","D":"87493","F":"73.5"},{"Policy Line":"70100529","B":"Lyme Disease DNA Qst","C":"300","D":"87801","F":"277.5"},{"Policy Line":"70100604","B":"Virus Isol Cent Enhanced By If","C":"300","D":"87254","F":"127.8"},{"Policy Line":"70100654","B":"Jc Polyoma Virus DNA Ql-Quest","C":"300","D":"87798","F":"170.1"},{"Policy Line":"70100655","B":"Parvovirus DNA Pcr -Quest","C":"300","D":"87798","F":"556.8"},{"Policy Line":"70100662","B":"Malaria Smear","C":"300","D":"87207","F":"91.5"},{"Policy Line":"70100668","B":"Influenza DNA Amp Probe","C":"300","D":"87502","F":"268.5"},{"Policy Line":"70100670","B":"Enterovirus Rna Qual Rt-Pcr","C":"300","D":"87498","F":"341.7"},{"Policy Line":"70100671","B":"Ebv DNA Pcr Qual -Quest","C":"300","D":"87798","F":"351.9"},{"Policy Line":"70100684","B":"CMV Culture - Quest #2627","C":"300","D":"87252","F":"58.2"},{"Policy Line":"70100685","B":"CMV Rapid - Quest #2627","C":"300","D":"87254","F":"69"},{"Policy Line":"70100813","B":"Hep B Surface Antigen -Quest","C":"300","D":"87340","F":"51"},{"Policy Line":"70100876","B":"MRSA PCR","C":"300","D":"87641","F":"80.7"},{"Policy Line":"70100880","B":"Cryptosporidum/Giardia","C":"300","D":"87300","F":"340.5"},{"Policy Line":"70100895","B":"Ova Parasite Aspirate","C":"300","D":"87177","F":"43.5"},{"Policy Line":"70100937","B":"Hep B DNA Qual By Pcr Qst","C":"300","D":"87516","F":"321"},{"Policy Line":"70100941","B":"Chlamydia Amp Probe Mpl","C":"300","D":"87491","F":"161.4"},{"Policy Line":"70100942","B":"Gonorrhoea Amp Probe Mpl","C":"300","D":"87591","F":"161.4"},{"Policy Line":"70101052","B":"MIC Susceptibility Ea Microbe","C":"300","D":"87186","F":"20.4"},{"Policy Line":"70101054","B":"Haemophilus Panel","C":"300","D":"87184","F":"56.7"},{"Policy Line":"70101056","B":"Sensitivity Kb Disk/Plate","C":"300","D":"87184","F":"56.7"},{"Policy Line":"70101060","B":"Strep Pneumo Panel-CSF/Bld MIC","C":"300","D":"87186","F":"105.3"},{"Policy Line":"70101080","B":"Strep (Bs) Panel-Kb","C":"300","D":"87186","F":"51"},{"Policy Line":"70101390","B":"Herpes Virus 6 DNA Qualitative","C":"300","D":"87532","F":"306.6"},{"Policy Line":"70101402","B":"Ifa Concentration Quest#10018","C":"300","D":"87015","F":"24.3"},{"Policy Line":"70101403","B":"Spec Stain Parasite Qst#10018","C":"300","D":"87207","F":"54.3"},{"Policy Line":"70101425","B":"HSV Type 1 Dna","C":"300","D":"87530","F":"224.1"},{"Policy Line":"70101426","B":"HSV Type 2 Dna","C":"300","D":"87530","F":"224.1"},{"Policy Line":"70101428","B":"C.Albicans Dna","C":"306","D":"87481","F":"64.5"},{"Policy Line":"70101429","B":"C.Glabrata Dna","C":"306","D":"87481","F":"64.5"},{"Policy Line":"70101430","B":"C.Tropicalis Dna","C":"306","D":"87481","F":"64.5"},{"Policy Line":"70101431","B":"C.Parapsilosis Dna","C":"306","D":"87481","F":"64.5"},{"Policy Line":"70101432","B":"C.Krusei Dna","C":"300","D":"87481","F":"157.2"},{"Policy Line":"70101435","B":"T.Vaginalis","C":"300","D":"87660","F":"58.8"},{"Policy Line":"70101436","B":"G.Vaginalis Dir Nuc Acid Probe","C":"300","D":"87510","F":"58.8"},{"Policy Line":"70101437","B":"Candida","C":"300","D":"87480","F":"58.8"},{"Policy Line":"70101623","B":"Phenotype Prediction","C":"300","D":"87900","F":"243.3"},{"Policy Line":"70101624","B":"Phenotype Analysis 1St 10 Drgs","C":"300","D":"87903","F":"1546.2"},{"Policy Line":"70101625","B":"Phenotype Analysis Drug #11","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101626","B":"Phenotype Analysis Drug 12","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101627","B":"Phenotype Analysis Drug #13","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101628","B":"Phenotype Analysis Drug #14","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101629","B":"Phenotype Analysis Drug #15","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101630","B":"Phenotype Analysis Drug #16","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101631","B":"Phenotype Analysis Drug #17","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101632","B":"Phenotype Analysis Drug #18","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101633","B":"Phenotype Analysis Drug #19","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101638","B":"Phenotype Analysis Drug #20","C":"300","D":"87904","F":"193.2"},{"Policy Line":"70101672","B":"Helicobacter Pylori- Stool","C":"300","D":"87338","F":"306.3"},{"Policy Line":"70101962","B":"10 Drug MIC Suscept Ea Microbe","C":"300","D":"87186","F":"222.6"},{"Policy Line":"70102042","B":"HIV-1 Rna Quant Pcr","C":"300","D":"87536","F":"175.2"},{"Policy Line":"70102043","B":"Hep C Rna","C":"300","D":"87522","F":"175.5"},{"Policy Line":"70103654","B":"IA By Na Multiple Orgs","C":"300","D":"87800","F":"423.9"},{"Policy Line":"70103812","B":"IA By Eia; Hepatistis, Delta","C":"300","D":"87380","F":"337.5"},{"Policy Line":"70104082","B":"Clostridium Difficile Toxin","C":"300","D":"87324","F":"73.2"},{"Policy Line":"70104100","B":"Chlamydia Culture","C":"300","D":"87110","F":"100.2"},{"Policy Line":"70104103","B":"Viral Culture","C":"300","D":"87252","F":"178.8"},{"Policy Line":"70104104","B":"Culture: Viral Herpes","C":"300","D":"87255","F":"93.3"},{"Policy Line":"70104107","B":"Chlamydia Trach Probe","C":"300","D":"87490","F":"41.1"},{"Policy Line":"70104111","B":"GC By DNA Probe(Quest)","C":"300","D":"87590","F":"144.6"},{"Policy Line":"70104128","B":"Viral Culture: Body Fluid","C":"300","D":"87252","F":"232.2"},{"Policy Line":"70104154","B":"Mycoplasma Culture","C":"300","D":"87109","F":"113.1"},{"Policy Line":"70104166","B":"Hepatitis Be Ag","C":"300","D":"87350","F":"74.7"},{"Policy Line":"70104199","B":"PathogenCulture-Presumptv Scrn","C":"300","D":"87081","F":"71.4"},{"Policy Line":"70104361","B":"Chlamydia By DNA Probe","C":"300","D":"87490","F":"217.8"},{"Policy Line":"70104401","B":"Mycobacteria Definitive Id","C":"300","D":"87118","F":"68.1"},{"Policy Line":"70104403","B":"AFB Sensitivity Ea Drug","C":"300","D":"87190","F":"160.8"},{"Policy Line":"70104404","B":"DNA Probe M Tb","C":"300","D":"87555","F":"559.8"},{"Policy Line":"70104405","B":"DNA Probe M Avium","C":"300","D":"87560","F":"556.2"},{"Policy Line":"70104452","B":"Fungus Id","C":"300","D":"87106","F":"86.4"},{"Policy Line":"70104454","B":"CultureBacterial-Anaerob ID ea","C":"300","D":"87076","F":"229.8"},{"Policy Line":"70104986","B":"Viral Culture: Tissue","C":"300","D":"87252","F":"479.4"},{"Policy Line":"70104987","B":"Viral Culture: Csf","C":"300","D":"87252","F":"127.2"},{"Policy Line":"70105993","B":"GI PATHOGEN 12-25 TARGETS","C":"306","D":"87507","F":"255.6"},{"Policy Line":"70106436","B":"CMV Ia By Dfa","C":"300","D":"87271","F":"265.8"},{"Policy Line":"70107613","B":"GC By DNA Probe","C":"300","D":"87591","F":"16.5"},{"Policy Line":"70107614","B":"Chlamydia By DNA Probe","C":"300","D":"87491","F":"16.5"},{"Policy Line":"70108503","B":"Culture Urine Id","C":"300","D":"87088","F":"13.2"},{"Policy Line":"70108562","B":"IA Tuberculosis Direct Probe","C":"300","D":"87556","F":"282"},{"Policy Line":"70109033","B":"Hepatitis C Viral Rna Genotype","C":"300","D":"87902","F":"259.2"},{"Policy Line":"70109110","B":"Bk Virus Dna, Qual Pcr -Quest","C":"300","D":"87798","F":"238.5"},{"Policy Line":"70109111","B":"Bk Virus Qnt Rt Pcr -Qst","C":"300","D":"87799","F":"591.3"},{"Policy Line":"70109203","B":"Inf Agent Det By Rna Amp Pr","C":"300","D":"87798","F":"556.8"},{"Policy Line":"70109220","B":"Limulus Amebocyte Lysate (Lal)","C":"300","D":"87999","F":"202.8"},{"Policy Line":"70109655","B":"Giardia Ia By Eia","C":"300","D":"87329","F":"60.9"},{"Policy Line":"70109713","B":"Hepatitis C Amp Probe","C":"300","D":"87521","F":"273.6"},{"Policy Line":"70109714","B":"Chlamydia Quant","C":"300","D":"87492","F":"202.8"},{"Policy Line":"70109716","B":"Chlamydia Trach Probe Amp","C":"300","D":"87491","F":"72"},{"Policy Line":"70109746","B":"AFB Cult W/Isolation & Pre Id","C":"300","D":"87116","F":"174.6"},{"Policy Line":"70109748","B":"Cryptosporidium Ia By Eia","C":"300","D":"87328","F":"54"},{"Policy Line":"70109920","B":"DNA Probe / M Gordonae","C":"300","D":"87797","F":"411"},{"Policy Line":"70109945","B":"Legionella Antigen","C":"300","D":"87899","F":"83.4"},{"Policy Line":"70109947","B":"Hepatitis B Viral: DNA Quant","C":"300","D":"87517","F":"175.5"},{"Policy Line":"70110100","B":"Susceptibility Beta Lactamase","C":"300","D":"87185","F":"32.1"},{"Policy Line":"70110105","B":"CultureAerobic:Qnt (Not Urine)","C":"300","D":"87071","F":"128.1"},{"Policy Line":"70110110","B":"Mold Id","C":"300","D":"87107","F":"102"},{"Policy Line":"70110120","B":"Antibiotic Chg Per Disk (Add)","C":"300","D":"87181","F":"75"},{"Policy Line":"70110159","B":"HSV 1 By Pcr -Quest","C":"300","D":"87529","F":"212.7"},{"Policy Line":"70110161","B":"HSV 2 By Pcr -Quest","C":"300","D":"87529","F":"212.7"},{"Policy Line":"70110165","B":"Herpes 1/2 Dna: Pcr Quest -D","C":"300","D":"87529","F":"0"},{"Policy Line":"70110170","B":"Cytomegalovirus Dna: Quant Pcr","C":"300","D":"87497","F":"208.2"},{"Policy Line":"70110175","B":"Inf Agent Detection By Na","C":"300","D":"87798","F":"556.8"},{"Policy Line":"70110215","B":"IA Antigen Detection By Eia","C":"306","D":"87449","F":"228"},{"Policy Line":"70110241","B":"ABC Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110242","B":"ABC Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110243","B":"Adv-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110244","B":"Adv-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110245","B":"Adv Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110246","B":"Ddl-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110247","B":"Ddl-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110248","B":"Ddl Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110249","B":"3TC=A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110250","B":"3TC=B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110251","B":"3TC Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110252","B":"D4T-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110253","B":"D4T-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110254","B":"Ddc-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110255","B":"Ddc-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110256","B":"Ddc Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110257","B":"ZDV-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110258","B":"ZDV-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110259","B":"ZDV Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110260","B":"Dlv-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110261","B":"Dlv-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110262","B":"Dlv Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110263","B":"Efv-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110264","B":"Efv-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110265","B":"Efv Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110266","B":"NVP-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110267","B":"NVP-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110268","B":"NVP Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110269","B":"Amp-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110270","B":"Amp-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110271","B":"Amp Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110272","B":"IDV-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110273","B":"IDV-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110274","B":"IDV Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110275","B":"NFV-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110276","B":"NFV-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110277","B":"NFV Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110278","B":"RTV-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110279","B":"RTV-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110280","B":"RTV Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110281","B":"SQV-A Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110282","B":"SQV-B Tissue Culture","C":"300","D":"87252","F":"528.9"},{"Policy Line":"70110283","B":"SQV Tissue Culture: Add'L","C":"300","D":"87253","F":"95.4"},{"Policy Line":"70110310","B":"Hepatitis C Quantification","C":"300","D":"87522","F":"611.4"},{"Policy Line":"70110315","B":"HCV Rna Pcr/Iu","C":"300","D":"87522","F":"1214.4"},{"Policy Line":"70110318","B":"HCV Tissue","C":"300","D":"87521","F":"556.8"},{"Policy Line":"70110320","B":"Influenza Immunoassay/Optic","C":"300","D":"87804","F":"55.5"},{"Policy Line":"70110335","B":"HIV Genotype","C":"300","D":"87901","F":"708.6"},{"Policy Line":"70110515","B":"Culture: Water","C":"300","D":"87086","F":"52.2"},{"Policy Line":"70113446","B":"CMV Ia By Dfa","C":"300","D":"87271","F":"265.8"},{"Policy Line":"70114999","B":"Borrelia Species by PCR","C":"300","D":"87476","F":"226.5"},{"Policy Line":"70115010","B":"Ia, Histoplasma Capsulatum","C":"300","D":"87385","F":"340.5"},{"Policy Line":"70115015","B":"IA If Bordetella Per/Paraper 1","C":"300","D":"87265","F":"169.2"},{"Policy Line":"70115016","B":"IA If Bordetella Per/Paraper 2","C":"300","D":"87265","F":"169.2"},{"Policy Line":"70115506","B":"Genotype DNA Hepatitis B QST","C":"300","D":"87912","F":"408.9"},{"Policy Line":"70115612","B":"E coli K1 - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115613","B":"H influenzae - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115614","B":"L monocytogenes - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115615","B":"N meningitidis - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115616","B":"Strep agalactiae - Biofire","C":"300","D":"87653","F":"53.4"},{"Policy Line":"70115617","B":"Strep pneumoniae - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115618","B":"Enterovirus - Biofire","C":"300","D":"87498","F":"53.4"},{"Policy Line":"70115619","B":"Human parechovirus - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115620","B":"Culture Aerobic-Blood Referred","C":"300","D":"87040","F":"234.6"},{"Policy Line":"70115621","B":"Culture, MRSA Surveilance","C":"300","D":"87070","F":"36.6"},{"Policy Line":"70115623","B":"VZV - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115624","B":"C neoformans/gattii - Biofire","C":"300","D":"87798","F":"53.4"},{"Policy Line":"70115635","B":"Enterococcus AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115636","B":"LMonocytogenes AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115637","B":"Staphylococcus AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115638","B":"Streptococcus AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115639","B":"ABaumannii AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115640","B":"Enterobacteria AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115641","B":"HInfluenzae AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115642","B":"NMeningitidis AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115643","B":"PAeruginosa AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115644","B":"CAlbicans AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115645","B":"CTropicalis AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115646","B":"Cparap,krus,galb AmpProbe DNA","C":"306","D":"87150","F":"19.8"},{"Policy Line":"70115647","B":"G vaginalis DNA - Quest","C":"300","D":"87512","F":"54.6"},{"Policy Line":"70115648","B":"Lactobacillus sp DNA - Quest","C":"300","D":"87799","F":"54.6"},{"Policy Line":"70115649","B":"A vaginae DNA - Quest","C":"300","D":"87799","F":"54.6"},{"Policy Line":"70115650","B":"Megasphaera sp DNA - Quest","C":"300","D":"87799","F":"54.6"},{"Policy Line":"70115673","B":"Macroscopic Exam Arthropod","C":"300","D":"87168","F":"57.6"},{"Policy Line":"70115761","B":"Cult, typing;ID by DNA/RNA seq","C":"300","D":"87153","F":"398.4"},{"Policy Line":"70115765","B":"Amplif NA Probe NOS Agent","C":"300","D":"87798","F":"224.7"},{"Policy Line":"70115766","B":"Amplif NA Probe NOS Agent","C":"300","D":"87798","F":"90.9"},{"Policy Line":"70115767","B":"Amplif NA Probe NOS Agent","C":"300","D":"87798","F":"90.9"},{"Policy Line":"70115768","B":"Amplif NA Probe NOS Agent","C":"300","D":"87798","F":"90.9"},{"Policy Line":"70115769","B":"Amplif NA Probe NOS Agent","C":"300","D":"87798","F":"90.9"},{"Policy Line":"70115770","B":"IKBKAP Gene","C":"300","D":"87798","F":"189"},{"Policy Line":"70115772","B":"T Vaginalis Rna","C":"300","D":"87661","F":"191.4"},{"Policy Line":"70115793","B":"1-3-beta-D-glucan","C":"306","D":"87449","F":"196.2"},{"Policy Line":"70115801","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115802","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115803","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115804","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115805","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115806","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115807","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115808","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115809","B":"AFB Sensitivity Mic Ea Agent","C":"300","D":"87188","F":"36.6"},{"Policy Line":"70115840","B":"Culture, Herpes Simplex Virus","C":"300","D":"87252","F":"76.5"},{"Policy Line":"70115841","B":"Culture, Cytomegalovirus Rapid","C":"300","D":"87254","F":"191.4"},{"Policy Line":"70115842","B":"Cult, Respiratory Virus Rapid","C":"300","D":"87254","F":"191.4"},{"Policy Line":"70115884","B":"Herpesvirus 6 Quant PCR","C":"300","D":"87533","F":"340.2"},{"Policy Line":"70115927","B":"Hep B Surface Antigen","C":"300","D":"87340","F":"20.4"},{"Policy Line":"70115928","B":"Hep B Surface Antigen, Confirm","C":"300","D":"87341","F":"102"},{"Policy Line":"70115949","B":"Varicella Zoster DFA","C":"300","D":"87290","F":"79.5"},{"Policy Line":"70115950","B":"Herpes Simplex 1 Ag","C":"300","D":"87274","F":"79.5"},{"Policy Line":"70115951","B":"Herpes Simplex 2 Ag","C":"300","D":"87273","F":"79.5"},{"Policy Line":"70115952","B":"Varicella Zoster Culture","C":"300","D":"87252","F":"95.7"},{"Policy Line":"70115953","B":"Varicella Zoster Isolation","C":"300","D":"87254","F":"95.7"},{"Policy Line":"70115954","B":"Herpes Simplex Culture","C":"300","D":"87252","F":"38.4"},{"Policy Line":"70115955","B":"Herpes Simplex Isolation","C":"300","D":"87253","F":"38.4"},{"Policy Line":"70116020","B":"Ref Aer Bacterial ID & Susc","C":"300","D":"87077","F":"103.5"},{"Policy Line":"70116078","B":"C. trachomatis by TMA","C":"300","D":"87491","F":"57.3"},{"Policy Line":"70116079","B":"N. gonorrheae by TMA","C":"300","D":"87591","F":"57.3"},{"Policy Line":"70116097","B":"B.pertussis/parapertussis PCR","C":"300","D":"87798","F":"153"},{"Policy Line":"70116106","B":"Norovirus, Groups 1 & 2 by PCR","C":"300","D":"87798","F":"340.2"},{"Policy Line":"70116173","B":"West Nile Virus RNA, CSF","C":"300","D":"87798","F":"248.1"},{"Policy Line":"70116203","B":"Chlamydia Culture","C":"300","D":"87110","F":"70.2"},{"Policy Line":"70116204","B":"Chlamydia Culture IF","C":"300","D":"87140","F":"70.2"},{"Policy Line":"70116219","B":"Hepatitis C Virus Quant","C":"300","D":"87522","F":"195.6"},{"Policy Line":"70116220","B":"Hepatitis C Virus Genotype","C":"300","D":"87902","F":"195.6"},{"Policy Line":"70116230","B":"Histo Galactomannan Ag,Qt,Ur","C":"300","D":"87385","F":"135.9"},{"Policy Line":"70116235","B":"Histoplasma Antigen, Serum","C":"300","D":"87385","F":"135.9"},{"Policy Line":"70116238","B":"Enterovirus, Amp Probe Tech","C":"300","D":"87498","F":"556.8"},{"Policy Line":"70116239","B":"Inf Ag Det By Eia","C":"300","D":"87305","F":"242.4"},{"Policy Line":"70116240","B":"Resp Virus PCR 12-25 Targets","C":"306","D":"87633","F":"296.7"},{"Policy Line":"70116246","B":"West Nile Virus by PCR","C":"300","D":"87798","F":"289.2"},{"Policy Line":"70116254","B":"Blastomyces dermatitidis Ag","C":"306","D":"87449","F":"166.2"},{"Policy Line":"70116264","B":"FLU/RSV by Nucleic Acid","C":"300","D":"87631","F":"124.8"},{"Policy Line":"70116265","B":"Strep A by Nucleic Acid","C":"300","D":"87651","F":"71.1"},{"Policy Line":"70116315","B":"Herpes Simplex Virus by PCR","C":"300","D":"87529","F":"153"},{"Policy Line":"70116340","B":"Parvovirus B19 by Quant PCR","C":"300","D":"87799","F":"261.6"},{"Policy Line":"70116356","B":"Microbe Susceptible MIC","C":"300","D":"87186","F":"99.6"},{"Policy Line":"70116363","B":"Vulvovag Candida spp by PCR","C":"300","D":"87481","F":"438.3"},{"Policy Line":"70116376","B":"Phenotype Infect Agent Drug","C":"300","D":"87900","F":"370.2"},{"Policy Line":"70116377","B":"Genotype DNA HIV Reverse T","C":"300","D":"87901","F":"370.2"},{"Policy Line":"70116378","B":"Genotype DNA HIV Other Region","C":"300","D":"87901","F":"370.2"},{"Policy Line":"70116384","B":"Pheno DNA HIV w/Cult;1-10 Drgs","C":"300","D":"87903","F":"740.4"},{"Policy Line":"70116385","B":"Pheno DNA HIV w/Clt Drug 11","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116386","B":"Pheno DNA HIV w/Clt Drug 12","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116387","B":"Pheno DNA HIV w/Clt Drug 13","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116388","B":"Pheno DNA HIV w/Clt Drug 14","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116389","B":"Pheno DNA HIV w/Clt Drug 15","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116390","B":"Pheno DNA HIV w/Clt Drug 16","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116391","B":"Pheno DNA HIV w/Clt Drug 17","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116392","B":"Pheno DNA HIV w/Clt Drug 18","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116393","B":"Pheno DNA HIV w/Clt Drug 19","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116394","B":"Pheno DNA HIV w/Clt Drug 20","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116395","B":"Pheno DNA HIV w/Clt Drug 21","C":"300","D":"87904","F":"70.5"},{"Policy Line":"70116412","B":"Toxoplasma gondii by PCR","C":"300","D":"87798","F":"171.3"},{"Policy Line":"70116413","B":"Varicella-Zoster Virus by PCR","C":"300","D":"87798","F":"166.5"},{"Policy Line":"70116422","B":"DNA Sequencing-Bacterial ID","C":"300","D":"87153","F":"178.2"},{"Policy Line":"70116423","B":"Susc-Broth dilution panel","C":"300","D":"87186","F":"137.1"},{"Policy Line":"70116424","B":"Bact ID-Cystic Pseudomonas","C":"300","D":"87077","F":"79.8"},{"Policy Line":"70116425","B":"Bacterial ID-Pseudomonas","C":"300","D":"87077","F":"79.8"},{"Policy Line":"70116426","B":"Bacterial ID","C":"300","D":"87077","F":"79.8"},{"Policy Line":"70116427","B":"Bact ID-Gram positive(Phoenix)","C":"300","D":"87077","F":"79.8"},{"Policy Line":"70116428","B":"Bact ID-Gram negative(Phoenix)","C":"300","D":"87077","F":"79.8"},{"Policy Line":"70116429","B":"Bacterial ID-Bacillus","C":"300","D":"87077","F":"79.8"},{"Policy Line":"70116430","B":"Gm Neg ID&MIC Panel(Phoenix)","C":"300","D":"87077","F":"79.8"},{"Policy Line":"70116431","B":"Susc-AFB/Nocard by broth dil","C":"300","D":"87186","F":"138.9"},{"Policy Line":"70116432","B":"Susc-Automated broth dilution","C":"300","D":"87186","F":"99.6"},{"Policy Line":"70116433","B":"Susc-Beta-lactamase","C":"300","D":"87185","F":"34.8"},{"Policy Line":"70116434","B":"Susc-Anaerobe by broth dil","C":"300","D":"87186","F":"137.1"},{"Policy Line":"70116435","B":"Processing fee","C":"300","D":"87015","F":"65.1"},{"Policy Line":"70116436","B":"Susc-Single drug by broth dil","C":"300","D":"87186","F":"137.1"},{"Policy Line":"70116437","B":"Susc-Disk diffusion","C":"300","D":"87184","F":"74.1"},{"Policy Line":"70116438","B":"Susc-Single drug by Etest","C":"300","D":"87181","F":"134.7"},{"Policy Line":"70116439","B":"Susc-Automated disk diffusion","C":"300","D":"87184","F":"74.1"},{"Policy Line":"70116440","B":"DNA Sequencing-AFB ID","C":"300","D":"87153","F":"147.3"},{"Policy Line":"70116441","B":"DNA Sequencing-Fungal ID","C":"300","D":"87153","F":"211.5"},{"Policy Line":"70116442","B":"Bacterial ID by MALDI-TOF MS","C":"300","D":"87077","F":"122.7"},{"Policy Line":"70116443","B":"Anaer org ID by MALDI-TOF MS","C":"300","D":"87076","F":"122.7"},{"Policy Line":"70116444","B":"Susc-Penicillin Bind Prot 2a","C":"300","D":"87147","F":"96.6"},{"Policy Line":"70116445","B":"Salmonella typing","C":"300","D":"87147","F":"108.9"},{"Policy Line":"70116446","B":"Shigella serotyping","C":"300","D":"87147","F":"152.7"},{"Policy Line":"70116447","B":"E.coli 0157 Lat Agglutination","C":"300","D":"87147","F":"44.7"},{"Policy Line":"70116448","B":"PBP2A Normal Flora use","C":"300","D":"87147","F":"96.6"},{"Policy Line":"70116449","B":"Susc-mecA/mecC Gene Det by PCR","C":"300","D":"87641","F":"174"},{"Policy Line":"70116450","B":"Susc-Mod Carbapenem Inact Mtd","C":"300","D":"87185","F":"74.1"},{"Policy Line":"70116478","B":"Cryptococcal Ag by EIA, Serum","C":"300","D":"87327","F":"41.1"},{"Policy Line":"70116480","B":"Legionella pneumophila Ag, Ur","C":"300","D":"87449","F":"32.4"},{"Policy Line":"70116481","B":"Rotavirus Antigen by EIA","C":"300","D":"87425","F":"24.6"},{"Policy Line":"70116482","B":"Cryptococcal Ag by EIA, CSF","C":"300","D":"87327","F":"46.5"},{"Policy Line":"70116483","B":"O&P Trichrome Stain","C":"300","D":"87209","F":"29.7"},{"Policy Line":"70116486","B":"Ehrlichia/Anaplasma Spp by PCR","C":"300","D":"87798","F":"230.4"},{"Policy Line":"70116500","B":"IA Legionella Pneumophila","C":"300","D":"87278","F":"102"},{"Policy Line":"70116537","B":"BK Virus, Quantitative by PCR","C":"300","D":"87799","F":"124.5"},{"Policy Line":"70116575","B":"Parasites Smear, Blood","C":"300","D":"87207","F":"154.2"},{"Policy Line":"70116585","B":"Pheno DNA HIV w/Clt;1-10 Drugs","C":"300","D":"87903","F":"848.1"},{"Policy Line":"70116586","B":"Pheno DNA HIV w/Clt;Ea Ad Drg1","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116587","B":"Pheno DNA HIV w/Clt;Ea Ad Drg2","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116588","B":"Pheno DNA HIV w/Clt;Ea Ad Drg3","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116589","B":"Pheno DNA HIV w/Clt;Ea Ad Drg4","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116590","B":"Pheno DNA HIV w/Clt;Ea Ad Drg5","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116591","B":"Pheno DNA HIV w/Clt;Ea Ad Drg6","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116592","B":"Pheno DNA HIV w/Clt;Ea Ad Drg7","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116593","B":"Pheno DNA HIV w/Clt;Ea Ad Drg8","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116594","B":"Pheno DNA HIV w/Clt;Ea Ad Drg9","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116595","B":"Pheno DNA HIV w/Clt;Ea Ad Dg10","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116596","B":"Pheno DNA HIV w/Clt;Ea Ad Dg11","C":"300","D":"87904","F":"52.2"},{"Policy Line":"70116625","B":"HCV NS5A Genotype/Resistance","C":"300","D":"87902","F":"535.8"},{"Policy Line":"70116628","B":"Babesia Species by PCR","C":"300","D":"87798","F":"165.3"},{"Policy Line":"70116672","B":"Aspergillus Galactomannan Bron","C":"306","D":"87305","F":"118.2"},{"Policy Line":"70116688","B":"Drg Resist Mrks of Various NTM","C":"300","D":"87798","F":"122.1"},{"Policy Line":"70116721","B":"Malaria Detect/Speciation PCR","C":"306","D":"87798","F":"342"},{"Policy Line":"70118000","B":"Stool Culture Other Pathogens","C":"300","D":"87046","F":"124.2"},{"Policy Line":"70118001","B":"Concentration Any Type","C":"300","D":"87015","F":"24.3"},{"Policy Line":"70118474","B":"Ebv DNA Ultraquant","C":"300","D":"87799","F":"497.7"},{"Policy Line":"70118479","B":"Zika Virus RNA Qual RT-PCR QST","C":"300","D":"87662","F":"533.1"},{"Policy Line":"70100048","B":"Rett Syndrome Mutation Anlys","C":"300","D":"81302","F":"1140"},{"Policy Line":"70100049","B":"Fish Prader Willi Qst","C":"310","D":"81331","F":"831.6"},{"Policy Line":"70100053","B":"AAT Mutation Analysis Qst","C":"300","D":"81331","F":"304.8"},{"Policy Line":"70100231","B":"Huntington S Disease Qst 10247","C":"300","D":"81401","F":"660"},{"Policy Line":"70100782","B":"Alpha-Globin Mutation Analysis","C":"300","D":"81269","F":"434.7"},{"Policy Line":"70100799","B":"K Ras Clarient","C":"300","D":"81275","F":"272.4"},{"Policy Line":"70100858","B":"Human Platelet Antigen 1 Geno","C":"300","D":"81105","F":"257.1"},{"Policy Line":"70100859","B":"HLA-B51 DNA Typing","C":"300","D":"81381","F":"158.4"},{"Policy Line":"70100871","B":"Tay-Sachs Mutation Analysis","C":"300","D":"81255","F":"263.4"},{"Policy Line":"70100893","B":"HLA-A Class I DNA Typing Qst","C":"300","D":"81373","F":"99"},{"Policy Line":"70100918","B":"Fragile X So Blot Reflex Qst","C":"300","D":"81243","F":"626.4"},{"Policy Line":"70101009","B":"SMA Diagnostic Athena #11","C":"300","D":"81401","F":"660"},{"Policy Line":"70101014","B":"Combimatrix Oligo 180K Array","C":"300","D":"81299","F":"1138.5"},{"Policy Line":"70101044","B":"Cah (21 Oh) Rare Mutations Qst","C":"300","D":"81405","F":"549.6"},{"Policy Line":"70101046","B":"HLA Class II Hi Res 1St Allele","C":"300","D":"81383","F":"90"},{"Policy Line":"70101047","B":"HLA Class II Hi Res 2Nd Allele","C":"300","D":"81383","F":"90"},{"Policy Line":"70101048","B":"HLA Class II Lo Res Ea Antigen","C":"300","D":"81377","F":"90"},{"Policy Line":"70101087","B":"Brac 1/2 Analysis Myriad","C":"310","D":"81162","F":"1216.5"},{"Policy Line":"70101088","B":"Brac 1 Analysis Myriad","C":"310","D":"81166","F":"180.9"},{"Policy Line":"70101089","B":"Brac 2 Analysis Myriad","C":"300","D":"81216","F":"86.4"},{"Policy Line":"70101097","B":"Cyp2C9 (Warf Geno)","C":"300","D":"81227","F":"673.8"},{"Policy Line":"70101098","B":"VKORC1","C":"300","D":"81355","F":"673.8"},{"Policy Line":"70101261","B":"HLA-B 5701 Typing Quest 22722","C":"300","D":"81241","F":"434.7"},{"Policy Line":"70101297","B":"SMNI Deletion Athena 215","C":"300","D":"81401","F":"660"},{"Policy Line":"70101298","B":"SMNI Resequencing Athena 215","C":"300","D":"81405","F":"549.6"},{"Policy Line":"70101299","B":"Smard & Xlsma Athena 215","C":"300","D":"81479","F":"512.4"},{"Policy Line":"70101308","B":"Jak2 Qst 16539","C":"300","D":"81270","F":"389.4"},{"Policy Line":"70101309","B":"Jak2 Reflex Qst 16622","C":"300","D":"81403","F":"389.4"},{"Policy Line":"70101340","B":"Accutype Clopidogrel Cyp2C19","C":"300","D":"81225","F":"253.8"},{"Policy Line":"70101394","B":"Achondroplasia Mutation Analys","C":"300","D":"81404","F":"245.4"},{"Policy Line":"70101396","B":"Melas Mtdna Eval","C":"300","D":"81401","F":"1237.5"},{"Policy Line":"70101397","B":"Merrf Mtdna Eval","C":"300","D":"81401","F":"1237.5"},{"Policy Line":"70101398","B":"Narp Mtdna Eval","C":"300","D":"81401","F":"1237.5"},{"Policy Line":"70101399","B":"Polg DNA Sequencing","C":"300","D":"81406","F":"1237.5"},{"Policy Line":"70101438","B":"Cystic Fibrosis Entire Gene Sq","C":"300","D":"81223","F":"2131.8"},{"Policy Line":"70101456","B":"Combisnp Prenatal/Pediatric","C":"300","D":"81229","F":"1138.5"},{"Policy Line":"70101458","B":"Cytogenomic SNP Microarray","C":"300","D":"81229","F":"1680"},{"Policy Line":"70101461","B":"Cytogen Microarray Bac","C":"300","D":"81228","F":"569.4"},{"Policy Line":"70101464","B":"Myotonic Dystrophy DNA Test","C":"300","D":"81401","F":"943.2"},{"Policy Line":"70101469","B":"HLA-B27 DNA Typing","C":"300","D":"81374","F":"144"},{"Policy Line":"70101482","B":"HLA MOLECULAR TYPING","C":"300","D":"81373","F":"487.8"},{"Policy Line":"70101671","B":"Admark Apoe Genotype","C":"300","D":"81401","F":"1039.5"},{"Policy Line":"70102031","B":"Factor V Leiden Mutation Qst","C":"300","D":"81241","F":"126.6"},{"Policy Line":"70102511","B":"Braf By Pcr Clarient","C":"300","D":"81210","F":"89.4"},{"Policy Line":"70104410","B":"Jak2 Mutation Qst 16539","C":"300","D":"81270","F":"1308.9"},{"Policy Line":"70105580","B":"Microdeletion Synd Analysis","C":"300","D":"81403","F":"439.5"},{"Policy Line":"70106470","B":"PCA3 Antigen","C":"300","D":"81313","F":"540"},{"Policy Line":"70109003","B":"Cystic Fibrosis Scrn Qst 10458","C":"300","D":"81220","F":"151.2"},{"Policy Line":"70109219","B":"TPMT Genetic Genotype Prom330","C":"300","D":"81335","F":"700.8"},{"Policy Line":"70109267","B":"Lacto Type Prometheus #6100","C":"300","D":"81400","F":"468.6"},{"Policy Line":"70109278","B":"ATG16L1 Snp (Rs2241880)","C":"300","D":"81479","F":"74.7"},{"Policy Line":"70109279","B":"Ecm1 Snp (Rs3737240)","C":"300","D":"81479","F":"74.7"},{"Policy Line":"70109280","B":"Nkx2-3 Snp (Rs10883365)","C":"300","D":"81479","F":"74.7"},{"Policy Line":"70109281","B":"Stat3 Snp (Rs744166)","C":"300","D":"81479","F":"74.7"},{"Policy Line":"70109285","B":"RHCE VARIANTS BY SNP ARRAY","C":"310","D":"81479","F":"388.2"},{"Policy Line":"70111030","B":"Hereditary Hemochromat Dna","C":"300","D":"81256","F":"393.3"},{"Policy Line":"70112505","B":"Bcr-Abl By Pcr (81206)","C":"300","D":"81206","F":"484.2"},{"Policy Line":"70112506","B":"Bcr/Abl Minor Pcr Qnt Clarient","C":"300","D":"81207","F":"93"},{"Policy Line":"70112507","B":"Jak2 Clarient","C":"300","D":"81270","F":"89.4"},{"Policy Line":"70112508","B":"Jak2(Ffpe) Clarient","C":"300","D":"81270","F":"89.4"},{"Policy Line":"70112509","B":"PML/RARa CLARIENT","C":"300","D":"81315","F":"79.2"},{"Policy Line":"70112510","B":"KRAS By PCR Clarient","C":"300","D":"81275","F":"272.4"},{"Policy Line":"70112511","B":"Braf By Pcr Clarient","C":"300","D":"81210","F":"89.4"},{"Policy Line":"70112512","B":"Braf V600 Melanoma Clarient","C":"300","D":"81210","F":"89.4"},{"Policy Line":"70112513","B":"Egfr Mutation By Pcr Clarient","C":"300","D":"81235","F":"1860.9"},{"Policy Line":"70112514","B":"MSI By PCR Clarient","C":"300","D":"81301","F":"432"},{"Policy Line":"70112515","B":"HER2 By Pcr Clarient","C":"300","D":"81479","F":"145.2"},{"Policy Line":"70112516","B":"Egfr Viii By Pcr Clarient","C":"300","D":"81401","F":"103.2"},{"Policy Line":"70112555","B":"HLA Tissue Typing Quest 15484","C":"300","D":"81372","F":"228"},{"Policy Line":"70114000","B":"Prothrombin Mutation Analysis","C":"300","D":"81240","F":"169.5"},{"Policy Line":"70114100","B":"MTH FR Mutation Detection","C":"300","D":"81291","F":"237.6"},{"Policy Line":"70115672","B":"MPL TRGgene rearrangement anal","C":"310","D":"81342","F":"513"},{"Policy Line":"70115688","B":"EGFR Mutation Analysis","C":"300","D":"81235","F":"797.4"},{"Policy Line":"70115689","B":"KRAS Mutation Analysis","C":"300","D":"81275","F":"797.4"},{"Policy Line":"70115704","B":"BRAF Mutation Analysis","C":"300","D":"81210","F":"360"},{"Policy Line":"70115705","B":"NRAS Mutation Analysis","C":"300","D":"81311","F":"612"},{"Policy Line":"70115715","B":"B-cell IGH gene rearrange PCR","C":"300","D":"81261","F":"514.8"},{"Policy Line":"70115716","B":"CECPA Mutation Analysis","C":"300","D":"81403","F":"706.8"},{"Policy Line":"70115721","B":"FLT3 Gene Anal- ITD","C":"300","D":"81245","F":"472.5"},{"Policy Line":"70115722","B":"FLT3 Gene Analysis - TKD","C":"300","D":"81246","F":"472.5"},{"Policy Line":"70115723","B":"NPM1 GENE","C":"300","D":"81310","F":"90"},{"Policy Line":"70115736","B":"M CEBPA Gene Full Sequence","C":"310","D":"81218","F":"796.8"},{"Policy Line":"70115737","B":"M Kit Gene Targeted Seq Analys","C":"310","D":"81272","F":"796.8"},{"Policy Line":"70115762","B":"MLH1 PROMOTER METHYLATION","C":"310","D":"81288","F":"432"},{"Policy Line":"70115777","B":"JAK 2 Exon 12 Mutation","C":"300","D":"81403","F":"396"},{"Policy Line":"70115878","B":"HLA-B*57:01","C":"300","D":"81381","F":"180"},{"Policy Line":"70116010","B":"Fragile X Detection","C":"300","D":"81243","F":"171"},{"Policy Line":"70116011","B":"Fragile X Characterization","C":"300","D":"81244","F":"564"},{"Policy Line":"70116012","B":"Fetal chromosomal aneuploidy","C":"300","D":"81420","F":"405"},{"Policy Line":"70116021","B":"Fetal chromosomal microdeltj","C":"300","D":"81422","F":"405"},{"Policy Line":"70116084","B":"HLA II Typing 1 Allele HR","C":"300","D":"81383","F":"100.2"},{"Policy Line":"70116085","B":"HLA II Typing 1 Locus LR DQ2","C":"300","D":"81376","F":"100.2"},{"Policy Line":"70116086","B":"HLA II Typing 1 Locus LR DQ8","C":"300","D":"81376","F":"100.2"},{"Policy Line":"70116091","B":"TPMT Genotyping, 4 Variants","C":"300","D":"81335","F":"432"},{"Policy Line":"70116304","B":"BRCA1 and BRCA2 Seq & Del/Dup","C":"300","D":"81162","F":"2436"},{"Policy Line":"70116309","B":"MGMT Gene Prmtr Mthyltn Alys","C":"310","D":"81287","F":"384"},{"Policy Line":"70116310","B":"IDH1 common variants","C":"310","D":"81120","F":"318"},{"Policy Line":"70116311","B":"IDH2 common variants","C":"310","D":"81121","F":"318"},{"Policy Line":"70116339","B":"PML-RARA Transloc, t(15;17) Qt","C":"300","D":"81315","F":"414"},{"Policy Line":"70116364","B":"Angelman & Prader-Willi Synd","C":"300","D":"81331","F":"390"},{"Policy Line":"70116370","B":"PDGFRA Gene Analysis","C":"310","D":"81314","F":"600"},{"Policy Line":"70116406","B":"NTRK NGS Fusion","C":"300","D":"81479","F":"960"},{"Policy Line":"70116417","B":"CAR ION CHNNLPATH INC 10 GNS","C":"300","D":"81413","F":"1462.5"},{"Policy Line":"70116418","B":"CAR ION CHNNLPATH INC 2 GNS","C":"300","D":"81414","F":"1462.5"},{"Policy Line":"70116454","B":"Dihydropyrimidine Dehydrogenas","C":"300","D":"81232","F":"313.5"},{"Policy Line":"70116460","B":"SMA Copy Number","C":"300","D":"81329","F":"261"},{"Policy Line":"70116461","B":"BCR-ABL1 Major, Qual","C":"300","D":"81206","F":"108.3"},{"Policy Line":"70116462","B":"BCR-ABL1 Minor, Qual","C":"300","D":"81207","F":"108.3"},{"Policy Line":"70116463","B":"BCR-ABL1 Major, Quant","C":"300","D":"81206","F":"296.4"},{"Policy Line":"70116464","B":"BCR-ABL1 Minor, Quant","C":"300","D":"81207","F":"296.4"},{"Policy Line":"70116514","B":"Alpha-1-antitrypsin; Genotype","C":"300","D":"81332","F":"160.2"},{"Policy Line":"70116535","B":"NUDT15 Gene Common Variants","C":"300","D":"81306","F":"210"},{"Policy Line":"70116578","B":"IGHV Mutation Analysis by Seq","C":"300","D":"81263","F":"513"},{"Policy Line":"70116579","B":"Hereditary Hemolyt Anemia Seq","C":"300","D":"81443","F":"1941"},{"Policy Line":"70116582","B":"CADASIL (NOTCH3) Full Gene Seq","C":"300","D":"81406","F":"1288.2"},{"Policy Line":"70116601","B":"Marfan Syndrome (FBN1) Sequenc","C":"300","D":"81408","F":"1542"},{"Policy Line":"70116624","B":"APOE Genotyping","C":"310","D":"81401","F":"162.6"},{"Policy Line":"70116626","B":"Neotype colorectal Tumor Prof","C":"310","D":"81445","F":"2061"},{"Policy Line":"70116677","B":"Alpha Thalassemia, 7 Deletions","C":"300","D":"81257","F":"387.3"},{"Policy Line":"70116685","B":"CYP2C19","C":"300","D":"81225","F":"156"},{"Policy Line":"70116689","B":"JAK2 Gene,V617F Mutation,Qual","C":"310","D":"81270","F":"186.6"},{"Policy Line":"70116690","B":"CALR Exon 9 Mutation Analysis","C":"310","D":"81219","F":"285"},{"Policy Line":"70116691","B":"MPL Mutation Detection","C":"310","D":"81402","F":"424.5"},{"Policy Line":"64101903","B":"Electrolyte Panel","C":"300","D":"80051","F":"33.9"},{"Policy Line":"70100002","B":"Comprehensive Metabolic Panel","C":"300","D":"80053","F":"19.2"},{"Policy Line":"70100003","B":"Basic Metabolic Panel","C":"300","D":"80048","F":"13.8"},{"Policy Line":"70100097","B":"Basic Metabolic Panel (Ion Ca)","C":"300","D":"80047","F":"71.4"},{"Policy Line":"70100150","B":"Hepatic Function Panel","C":"300","D":"80076","F":"16.5"},{"Policy Line":"70100225","B":"Coronary Risk Pro/Lipid Panel","C":"300","D":"80061","F":"19.8"},{"Policy Line":"70100323","B":"Electrolyte Panel","C":"300","D":"80051","F":"33.9"},{"Policy Line":"70101636","B":"OB Prenatal Profile","C":"300","D":"80055","F":"657.3"},{"Policy Line":"70109881","B":"Hepatitis Panel","C":"300","D":"80074","F":"222"},{"Policy Line":"70109888","B":"General Health Panel","C":"300","D":"80050","F":"69.6"},{"Policy Line":"70109946","B":"Renal Function Panel","C":"300","D":"80069","F":"42.6"},{"Policy Line":"73100109","B":"Electrolyte Panel","C":"300","D":"80051","F":"33.9"},{"Policy Line":"74221017","B":"Lipid Panel","C":"300","D":"80061","F":"26.4"},{"Policy Line":"75452024","B":"Go Strong Lipid Profile","C":"300","D":"80061","F":"5.4"},{"Policy Line":"70100044","B":"Tobramycin Assay","C":"300","D":"80200","F":"56.7"},{"Policy Line":"70100045","B":"Theophylline Assay","C":"300","D":"80198","F":"33.3"},{"Policy Line":"70100046","B":"Digoxin Assay","C":"300","D":"80162","F":"32.7"},{"Policy Line":"70100081","B":"Cell Count Fluid W/ Diff","C":"300","D":"89051","F":"222"},{"Policy Line":"70100091","B":"Cell Count Fluid","C":"300","D":"89050","F":"43.5"},{"Policy Line":"70100103","B":"Gentamycin Assay","C":"300","D":"80170","F":"47.1"},{"Policy Line":"70100114","B":"Ethosuximide","C":"300","D":"80168","F":"61.2"},{"Policy Line":"70100196","B":"Procainamide: Total","C":"300","D":"80190","F":"369.9"},{"Policy Line":"70100281","B":"Dilantin Assay","C":"300","D":"80185","F":"38.1"},{"Policy Line":"70100282","B":"Phenobarbital Assay","C":"300","D":"80184","F":"30"},{"Policy Line":"70100285","B":"MOL Cyto In Situ Hybrid 1","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100286","B":"MOL Cyto In Situ Hybrid 2","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100287","B":"MOL Cyto In Situ Hybrid 3","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100288","B":"MOL Cyto In Situ Hybrid 4","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100289","B":"MOL Cyto In Situ Hybrid 5","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100290","B":"MOL Cyto In Situ Hybrid 6","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100291","B":"MOL Cyto In Situ Hybrid 7","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100292","B":"MOL Cyto In Situ Hybrid 8","C":"310","D":"88272","F":"42.9"},{"Policy Line":"70100293","B":"MOL Cyto In Situ Hybrid 9","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100294","B":"MOL Cyto In Situ Hybrid 10","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100295","B":"MOL Cyto In Situ Hybrid 11","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100296","B":"MOL Cyto In Situ Hybrid 12","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100297","B":"MOL Cyto In Situ Hybrid 13","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100298","B":"MOL Cyto In Situ Hybrid 14","C":"310","D":"88272","F":"42.9"},{"Policy Line":"70100299","B":"MOL Cyto In Situ Hybrid 15","C":"310","D":"88272","F":"42.6"},{"Policy Line":"70100330","B":"Eosinophil: Smear","C":"300","D":"89190","F":"27.3"},{"Policy Line":"70100332","B":"Haloperidol Quest 564","C":"300","D":"80173","F":"135.6"},{"Policy Line":"70100377","B":"Quinidine Assay","C":"300","D":"80194","F":"323.1"},{"Policy Line":"70100412","B":"Carbamazepine/Tegretol","C":"300","D":"80156","F":"31.2"},{"Policy Line":"70100429","B":"Vancomycin Assay","C":"300","D":"80202","F":"40.8"},{"Policy Line":"70100433","B":"Isotretinoin Quest 26519","C":"300","D":"80299","F":"321.9"},{"Policy Line":"70100515","B":"5-Flucytosine Serum Qst","C":"300","D":"80299","F":"171.6"},{"Policy Line":"70100532","B":"Wet Prep (Bact:Fungi)","C":"300","D":"Q0111","F":"43.8"},{"Policy Line":"70100540","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100541","B":"MOL Cytogenetics: DNA Probe 4","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100542","B":"MOL Cytogenetics: DNA Probe 5","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100543","B":"MOL Cytogenetics: DNA Probe 6","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100544","B":"MOL Cytogenetics: DNA Probe 7","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100545","B":"MOL Cytogenetics: DNA Probe 8","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100546","B":"MOL Cytogenetics: DNA Probe 9","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100547","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100548","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100549","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100550","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100551","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100552","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100553","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100554","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100555","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100556","B":"MOL Cytogenetics: DNA Probe 1","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100557","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100558","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100559","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100560","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100561","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100562","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100563","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100564","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100565","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100566","B":"MOL Cytogenetics: DNA Probe 2","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100567","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100568","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100569","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100570","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100571","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100572","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100573","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100574","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100575","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100576","B":"MOL Cytogenetics: DNA Probe 3","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100577","B":"MOL Cytogenetics: DNA Probe 4","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100578","B":"MOL Cytogenetics: DNA Probe 4","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100579","B":"MOL Cytogenetics: DNA Probe 4","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100580","B":"MOL Cytogenetics: DNA Probe 4","C":"310","D":"88271","F":"45.3"},{"Policy Line":"70100581","B":"MOL Cytogenetics: DNA Probe 4","C":"310","D":"88271","F":"109.5"},{"Policy Line":"70100598","B":"MOL Cytogenetics: DNA Probe 6","C":"310","D":"88271","F":"109.5"},{"Policy Line":"70100691","B":"Tissue Culture Amniotic Fl","C":"310","D":"88235","F":"60.3"},{"Policy Line":"70100692","B":"Chromosome Analysis","C":"310","D":"88269","F":"68.1"},{"Policy Line":"70100693","B":"Chromosome Analysis Adl Karyo","C":"310","D":"88280","F":"55.5"},{"Policy Line":"70100802","B":"Lidocaine Level","C":"300","D":"80176","F":"64.8"},{"Policy Line":"70100811","B":"Crystal Identification","C":"300","D":"89060","F":"23.4"},{"Policy Line":"70100817","B":"Growth Hormone Supprsn Panel","C":"300","D":"80430","F":"63"},{"Policy Line":"70100820","B":"GH Stimulation Panel","C":"300","D":"80428","F":"63"},{"Policy Line":"70100828","B":"Fat (Stool/Urine/Sputum)","C":"300","D":"89125","F":"32.4"},{"Policy Line":"70100857","B":"Warfarin Ur","C":"300","D":"80299","F":"178.8"},{"Policy Line":"70100863","B":"Felbamate","C":"300","D":"80299","F":"87.3"},{"Policy Line":"70100896","B":"Dantrolene Sp","C":"300","D":"80299","F":"174.6"},{"Policy Line":"70100899","B":"Semen Analysis","C":"300","D":"89322","F":"99"},{"Policy Line":"70100916","B":"Drug Quantitation -Quest","C":"300","D":"80299","F":"321.6"},{"Policy Line":"70100944","B":"Tissue Cult Bn/Bld-Cyto Bm Mpl","C":"310","D":"88237","F":"864.9"},{"Policy Line":"70100945","B":"Chromosome Analys-Cyto Bm Mpl","C":"310","D":"88264","F":"864.9"},{"Policy Line":"70100946","B":"Chrom Anyls Addl 1-Cyto Bm Mpl","C":"310","D":"88280","F":"418.2"},{"Policy Line":"70100947","B":"Chrom Anyls Addl 2-Cyto Bm Mpl","C":"310","D":"88280","F":"513.6"},{"Policy Line":"70100950","B":"Tissue Culture - Cyto Poc Mpl","C":"310","D":"88233","F":"1450.8"},{"Policy Line":"70100951","B":"Chrom Anaylsis - Cyto Poc Mpl","C":"310","D":"88262","F":"1450.8"},{"Policy Line":"70100954","B":"Tissue Culture -Cyto St Mpl","C":"310","D":"88233","F":"1450.8"},{"Policy Line":"70100955","B":"Chrom Anyls - Cyto St Mpl","C":"310","D":"88262","F":"1450.8"},{"Policy Line":"70100959","B":"Tissue Culture-Cyto Upb Mpl","C":"310","D":"88237","F":"864.9"},{"Policy Line":"70100960","B":"Chromosome Analys-Cyto Upb Mpl","C":"310","D":"88264","F":"864.9"},{"Policy Line":"70100961","B":"Chrom Anlys Addl1-Cyto Upb Mpl","C":"310","D":"88280","F":"513.6"},{"Policy Line":"70100962","B":"Chrom Anlys Addl2-Cyto Upb Mpl","C":"310","D":"88280","F":"513.6"},{"Policy Line":"70101362","B":"DNA Probe Each Mayo Fish Subt","C":"311","D":"88271","F":"438.3"},{"Policy Line":"70101363","B":"Chrom Situ Hybrid 10-30 Mayo","C":"310","D":"88273","F":"30.6"},{"Policy Line":"70101364","B":"ChromSituHybrid10-30cells Mayo","C":"311","D":"88273","F":"30.6"},{"Policy Line":"70101388","B":"Panorama Prenatal Test Qst","C":"300","D":"81599","F":"1575.6"},{"Policy Line":"70101420","B":"Dextro/Levo Methorphan Ur Qst","C":"300","D":"80299","F":"190.8"},{"Policy Line":"70101463","B":"Ova1 Quest 16991","C":"300","D":"81503","F":"1585.5"},{"Policy Line":"70101608","B":"Chrmosome Analysis: Hi Res","C":"310","D":"88289","F":"424.8"},{"Policy Line":"70101634","B":"Sirolimus","C":"300","D":"80195","F":"171"},{"Policy Line":"70101655","B":"MOL Cyto Interphase In Situ H","C":"310","D":"88275","F":"204.6"},{"Policy Line":"70102568","B":"MOL Cyto Interphas In Situ Hy","C":"311","D":"88275","F":"432.3"},{"Policy Line":"70104113","B":"Valproic Acid-Depakene","C":"300","D":"80164","F":"25.2"},{"Policy Line":"70104133","B":"Flecainide Acetate","C":"300","D":"80299","F":"219"},{"Policy Line":"70104183","B":"Chromos Analysis Tissue","C":"310","D":"88233","F":"211.8"},{"Policy Line":"70104206","B":"Lithium","C":"300","D":"80178","F":"23.4"},{"Policy Line":"70104210","B":"Amidarone and Metabolite","C":"300","D":"80299","F":"46.8"},{"Policy Line":"70104235","B":"Mysoline Primidone Assay","C":"300","D":"80188","F":"42"},{"Policy Line":"70104362","B":"Cyclosporine Level","C":"300","D":"80158","F":"86.7"},{"Policy Line":"70105081","B":"Pap Smear Bethesda;Man Scrn","C":"311","D":"P3000","F":"69.6"},{"Policy Line":"70106483","B":"Dilantin: Free","C":"300","D":"80186","F":"55.2"},{"Policy Line":"70108872","B":"Stool Component Analysis","C":"300","D":"80299","F":"141.9"},{"Policy Line":"70109707","B":"Chromosome: Blood","C":"310","D":"88262","F":"556.8"},{"Policy Line":"70109709","B":"Chromosome: Bone Marrow","C":"310","D":"88262","F":"750"},{"Policy Line":"70109710","B":"Tissue Cult: Chromo Anal","C":"310","D":"88230","F":"429.6"},{"Policy Line":"70109722","B":"Digitoxin Assay","C":"300","D":"80299","F":"56.1"},{"Policy Line":"70109723","B":"Insulin Glucose Tolerance","C":"300","D":"80422","F":"78.3"},{"Policy Line":"70109725","B":"Tacrolimus (Fk 506)","C":"300","D":"80197","F":"83.1"},{"Policy Line":"70109726","B":"Procainamide And Napa","C":"300","D":"80192","F":"107.1"},{"Policy Line":"70109729","B":"Sperm Washing","C":"300","D":"89260","F":"127.8"},{"Policy Line":"70109876","B":"Amikacin","C":"300","D":"80150","F":"33.9"},{"Policy Line":"70109929","B":"ACTH Stimulation Panel","C":"300","D":"80400","F":"85.2"},{"Policy Line":"70109958","B":"LIQUID BASED PAP","C":"310","D":"G0123","F":"21.6"},{"Policy Line":"70110034","B":"Fibrosis,Liver,FibroTest-ActiP","C":"300","D":"81599","F":"640.5"},{"Policy Line":"70110040","B":"Tissue Culture: Bone Marrow","C":"310","D":"88237","F":"424.8"},{"Policy Line":"70110065","B":"Trazadone","C":"300","D":"80299","F":"321.6"},{"Policy Line":"70110074","B":"Hypo Osmotic Swelling","C":"300","D":"89398","F":"66.6"},{"Policy Line":"70110095","B":"Sperm Isolation: Complex Prep","C":"300","D":"89261","F":"133.8"},{"Policy Line":"70110125","B":"Methotrexate","C":"300","D":"80299","F":"150"},{"Policy Line":"70110140","B":"Topiramate","C":"300","D":"80201","F":"282.9"},{"Policy Line":"70110290","B":"MOL Cytogenetics; DNA Probe 1","C":"310","D":"88271","F":"27"},{"Policy Line":"70110291","B":"MOL Cytogenetics; DNA Probe 2","C":"310","D":"88271","F":"27"},{"Policy Line":"70110292","B":"MOL Cyto; Interphase (25-99)","C":"310","D":"88274","F":"244.2"},{"Policy Line":"70115050","B":"Presence And/Or Motility Sperm","C":"300","D":"89321","F":"42.3"},{"Policy Line":"70115051","B":"Chromosome Analysis: 20-25 Cel","C":"310","D":"88264","F":"185.4"},{"Policy Line":"70115052","B":"Chromosome Anal: Add Karyotype","C":"310","D":"88280","F":"62.4"},{"Policy Line":"70115706","B":"Voriconazole, LC/MS/MS -Quest","C":"300","D":"80299","F":"249.9"},{"Policy Line":"70115720","B":"Lacosamide,LC/MS/MS-Quest","C":"300","D":"80299","F":"146.1"},{"Policy Line":"70115738","B":"RBC DNA HEA 35 AG 11 BLD GRP","C":"300","D":"0001U","F":"330"},{"Policy Line":"70115893","B":"Maternal Serum Screen Quad","C":"300","D":"81511","F":"140.4"},{"Policy Line":"70115894","B":"MSS Sequential, Specimen 1","C":"300","D":"81508","F":"126"},{"Policy Line":"70115895","B":"MSS Sequential, Specimen 2","C":"300","D":"81511","F":"144"},{"Policy Line":"70115924","B":"Chrom Anal Periph Bld","C":"310","D":"88262","F":"225"},{"Policy Line":"70115925","B":"Chrom Anal Periph Bld Tis Cult","C":"310","D":"88230","F":"225"},{"Policy Line":"70116087","B":"Adalimumab Activity","C":"300","D":"80299","F":"288"},{"Policy Line":"70116089","B":"Thiopurine Metabolites","C":"300","D":"80299","F":"155.7"},{"Policy Line":"70116093","B":"Infliximab Activity","C":"300","D":"80299","F":"288"},{"Policy Line":"70116234","B":"Dexamethasone","C":"300","D":"80299","F":"156"},{"Policy Line":"70116252","B":"MCG; DNA Probe Ea","C":"310","D":"88271","F":"165"},{"Policy Line":"70116253","B":"MCG; Situ Hybrid 10-30 Cells","C":"310","D":"88273","F":"165"},{"Policy Line":"70116300","B":"Antimicrobial Lev-Azithromycin","C":"300","D":"80299","F":"136.8"},{"Policy Line":"70116303","B":"14-3-3 Protein Tau/Theta, CSF","C":"300","D":"0035U","F":"121.2"},{"Policy Line":"70116357","B":"Sperm antibodies, IgA","C":"300","D":"89325","F":"87"},{"Policy Line":"70116358","B":"Sperm antibodies, IgG","C":"300","D":"89325","F":"87"},{"Policy Line":"70116366","B":"Carbamazepine; free","C":"300","D":"80157","F":"31.2"},{"Policy Line":"70116517","B":"MCG; DNA probe, each","C":"310","D":"88271","F":"102.6"},{"Policy Line":"70116518","B":"MCG; DNA probe, each","C":"310","D":"88271","F":"102.6"},{"Policy Line":"70116519","B":"MCG; DNA probe, each","C":"310","D":"88271","F":"102.6"},{"Policy Line":"70116520","B":"MCG; DNA probe, each","C":"310","D":"88271","F":"102.6"},{"Policy Line":"70116521","B":"MCG; IP SITU 100-300 Cells","C":"310","D":"88275","F":"102.6"},{"Policy Line":"70116522","B":"MCG; IP SITU 100-300 Cells","C":"310","D":"88275","F":"102.6"},{"Policy Line":"70116523","B":"MCG; IP SITU 100-300 Cells","C":"310","D":"88275","F":"102.6"},{"Policy Line":"70116524","B":"MCG; IP SITU 100-300 Cells","C":"310","D":"88275","F":"102.6"},{"Policy Line":"70116558","B":"Topiramate","C":"300","D":"80201","F":"51.6"},{"Policy Line":"70116598","B":"Valproic acid; free","C":"300","D":"80165","F":"80.4"},{"Policy Line":"70116636","B":"Cyclosporine","C":"301","D":"80158","F":"45.6"},{"Policy Line":"70116645","B":"Tacrolimus","C":"301","D":"80197","F":"45.9"},{"Policy Line":"70100388","B":"Immunohistchem Ea Multiplex Ab","C":"312","D":"88344","F":"203.7"},{"Policy Line":"70100398","B":"IHC Each-Armed Forces Ins Pat","C":"310","D":"88342","F":"84.6"},{"Policy Line":"70100534","B":"Direct If Staining Igg Mayo","C":"310","D":"88346","F":"158.4"},{"Policy Line":"70100535","B":"Direct If Staining Igm Mayo","C":"310","D":"88350","F":"45.9"},{"Policy Line":"70100536","B":"Direct If Staining Iga Mayo","C":"310","D":"88350","F":"45.9"},{"Policy Line":"70100537","B":"Direct If Staining C3 Mayo","C":"310","D":"88350","F":"45.9"},{"Policy Line":"70100538","B":"Direct If Fibrinogen Dep Mayo","C":"310","D":"88350","F":"45.9"},{"Policy Line":"70100539","B":"Path Consult Mayo","C":"310","D":"88323","F":"46.8"},{"Policy Line":"70100687","B":"Consult & Rpt Ref Slides","C":"310","D":"88323","F":"199.2"},{"Policy Line":"70100784","B":"IHC Tumor Er Clarient","C":"310","D":"88361","F":"150"},{"Policy Line":"70100785","B":"IHC Tumor Pr Clarient","C":"310","D":"88361","F":"150"},{"Policy Line":"70100786","B":"IHC Her-2 Clarient","C":"310","D":"88361","F":"402.3"},{"Policy Line":"70100787","B":"IHC Ki67 Clarient","C":"310","D":"88361","F":"401.7"},{"Policy Line":"70100788","B":"Fish Manual 88368 Clarient","C":"310","D":"88368","F":"503.1"},{"Policy Line":"70100789","B":"Fish Cad 88367 Clarient","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100790","B":"IHC 88342 Clarient","C":"310","D":"88342","F":"482.7"},{"Policy Line":"70100791","B":"IHC Tumor Manl 88360 Calrient","C":"310","D":"88360","F":"503.1"},{"Policy Line":"70100792","B":"Fish 88365 Clarient","C":"310","D":"88365","F":"503.1"},{"Policy Line":"70100965","B":"F Alk Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100966","B":"F Alk Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100968","B":"F Bcl1 Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100969","B":"F Bcl1 Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100971","B":"F Bcl 2 Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100972","B":"F Bcl 2 Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100974","B":"F Egr1 Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100975","B":"F Egr1 Probe#2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100977","B":"F Her2 Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100978","B":"F Her2 Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100980","B":"F Pml Rara Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100981","B":"F Pml Rara Probe #2","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100983","B":"F Malt Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100984","B":"F Malt Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100986","B":"F Mm Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100987","B":"F Mm Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100989","B":"F Bcr Abl Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100990","B":"F Brc Abl Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100991","B":"F Bcr Abl Probe #3 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100993","B":"F Myc Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100994","B":"F Myc Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70100995","B":"F Myc Probe #3 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70101040","B":"F Gli Probe #1 Mpl","C":"310","D":"88368","F":"503.1"},{"Policy Line":"70101041","B":"F Gli Probe #2","C":"310","D":"88368","F":"503.1"},{"Policy Line":"70101042","B":"F Gli Probe #3 Mpl","C":"310","D":"88368","F":"503.1"},{"Policy Line":"70101043","B":"F Gli Probe #4","C":"310","D":"88368","F":"503.1"},{"Policy Line":"70101072","B":"F Cll Probe #1 Mpl","C":"310","D":"88367","F":"346.5"},{"Policy Line":"70101073","B":"F Cll Probe #2 Mpl","C":"310","D":"88367","F":"346.5"},{"Policy Line":"70101074","B":"F Cll Probe #3 Mpl","C":"310","D":"88367","F":"346.5"},{"Policy Line":"70101075","B":"F Cll Probe #4 Mpl","C":"310","D":"88367","F":"346.5"},{"Policy Line":"70101076","B":"F Cll Probe #5 Mpl","C":"310","D":"88367","F":"346.5"},{"Policy Line":"70101077","B":"F Cll Probe #6 Mpl","C":"310","D":"88367","F":"346.5"},{"Policy Line":"70101110","B":"DNA Ploidy /S-Phase Mpl","C":"310","D":"88182","F":"415.5"},{"Policy Line":"70101114","B":"F Mds Probe #1 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70101115","B":"F Mds Probe #2 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70101116","B":"F Mds Probe #3 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70101117","B":"F Mds Probe #4 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70101118","B":"F Mds Probe #5 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70101119","B":"F Mds Probe #6 Mpl","C":"310","D":"88367","F":"503.1"},{"Policy Line":"70101121","B":"Flow T Mpl","C":"310","D":"88185","F":"3692.4"},{"Policy Line":"70101123","B":"Flow Cytometry Marker #1 Mpl","C":"310","D":"88184","F":"168.9"},{"Policy Line":"70101124","B":"Flow Cytometry Marker #2 Mpl","C":"310","D":"88185","F":"168.9"},{"Policy Line":"70101125","B":"Flow Cytometry Marker#3 Mpl","C":"310","D":"88185","F":"89.7"},{"Policy Line":"70101126","B":"Flow Cytometry Marker#4 Mpl","C":"310","D":"88185","F":"89.7"},{"Policy Line":"70101127","B":"Flow Cytometry Marker#5 Mpl","C":"310","D":"88185","F":"89.7"},{"Policy Line":"70101240","B":"Immunofluoroescent Stdy Initl","C":"310","D":"88346","F":"158.4"},{"Policy Line":"70101389","B":"Fish Bladder Cancer","C":"310","D":"88120","F":"435.6"},{"Policy Line":"70101459","B":"Combisnp Microdisection Manual","C":"310","D":"88381","F":"569.4"},{"Policy Line":"70101462","B":"Combibac Microdisection Manual","C":"310","D":"88381","F":"569.4"},{"Policy Line":"70101501","B":"Imunoflor AB Adl Stn, per Spec","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70101601","B":"Flow Cyto: Cell Marker 15","C":"311","D":"88185","F":"45"},{"Policy Line":"70101970","B":"Therapath Surg Spec Level 4","C":"310","D":"88305","F":"138.6"},{"Policy Line":"70101971","B":"Therapath Spec Stains Grp Ii","C":"310","D":"88313","F":"138.6"},{"Policy Line":"70101972","B":"Therapath Histo-Stain Mscl Bx","C":"310","D":"88314","F":"293.4"},{"Policy Line":"70101973","B":"Therapath Spec Stains Grp III","C":"310","D":"88319","F":"293.4"},{"Policy Line":"70101974","B":"Therapath Histo-Stains Nrv Bx","C":"310","D":"88314","F":"242.7"},{"Policy Line":"70101975","B":"Therapath Microscopy","C":"310","D":"88348","F":"242.7"},{"Policy Line":"70101976","B":"Therapath Nerve Teasing Prep","C":"310","D":"88362","F":"242.7"},{"Policy Line":"70101978","B":"Therapath Surg Spec Lvl 4 Msbx","C":"310","D":"88305","F":"138.6"},{"Policy Line":"70101979","B":"Therapath Spec Stains Ii Msbx","C":"310","D":"88313","F":"138.6"},{"Policy Line":"70101981","B":"ImmunoHisto Ab Slide-Ea Addl","C":"310","D":"88341","F":"51.9"},{"Policy Line":"70102566","B":"Morphometric Analysis; Cad","C":"310","D":"88367","F":"150.3"},{"Policy Line":"70102567","B":"Morphometric Analysis; Manual","C":"310","D":"88368","F":"298.2"},{"Policy Line":"70104295","B":"Morphometric Anal Tumor By Ic","C":"310","D":"88360","F":"503.1"},{"Policy Line":"70105006","B":"Acid Phosphatase Stain","C":"310","D":"88313","F":"91.5"},{"Policy Line":"70105007","B":"Gram Pos & Neg Bacteria","C":"310","D":"88312","F":"55.2"},{"Policy Line":"70105008","B":"Jones' Kidney Stain","C":"310","D":"88313","F":"41.4"},{"Policy Line":"70105009","B":"Calcium Stain","C":"310","D":"88313","F":"82.2"},{"Policy Line":"70105018","B":"Cd 20 B Cell","C":"310","D":"88342","F":"70.2"},{"Policy Line":"70105019","B":"Cd 34 Endothelial","C":"310","D":"88342","F":"61.8"},{"Policy Line":"70105020","B":"Cd 43 T Cell","C":"310","D":"88342","F":"70.5"},{"Policy Line":"70105027","B":"Cd 43/45 R T&B Cell","C":"310","D":"88342","F":"191.7"},{"Policy Line":"70105028","B":"Common Leukocyte Antigen","C":"310","D":"88342","F":"73.8"},{"Policy Line":"70105029","B":"Desmin","C":"310","D":"88342","F":"73.5"},{"Policy Line":"70105030","B":"Epithelial Membrane Antigen","C":"310","D":"88342","F":"71.4"},{"Policy Line":"70105031","B":"HMB45","C":"310","D":"88342","F":"79.2"},{"Policy Line":"70105032","B":"Pankeratin Ae1/Ae3","C":"310","D":"88342","F":"76.2"},{"Policy Line":"70105034","B":"Prostate Specific Acid Phospha","C":"310","D":"88342","F":"66"},{"Policy Line":"70105035","B":"S100","C":"310","D":"88342","F":"69.9"},{"Policy Line":"70105036","B":"Vimentin","C":"310","D":"88342","F":"72.9"},{"Policy Line":"70105037","B":"Kappa Light Chain","C":"310","D":"88342","F":"151.2"},{"Policy Line":"70105038","B":"Lambda Light Chain","C":"310","D":"88342","F":"151.2"},{"Policy Line":"70105039","B":"Human Chorionic Gonadotropin","C":"310","D":"88342","F":"77.7"},{"Policy Line":"70105040","B":"Cytokeratin 7","C":"310","D":"88342","F":"76.2"},{"Policy Line":"70105041","B":"Cytokeratin 20","C":"310","D":"88342","F":"75.9"},{"Policy Line":"70105044","B":"Synaptophysin","C":"310","D":"88342","F":"78"},{"Policy Line":"70105046","B":"Cd3","C":"310","D":"88342","F":"71.4"},{"Policy Line":"70105048","B":"KI 67 MIB 1","C":"310","D":"88361","F":"503.1"},{"Policy Line":"70105049","B":"Cd 30","C":"310","D":"88342","F":"70.5"},{"Policy Line":"70105052","B":"Alcian Blue Stain Hyd Digestio","C":"310","D":"88313","F":"91.5"},{"Policy Line":"70105053","B":"Acid Fast","C":"310","D":"88312","F":"158.7"},{"Policy Line":"70105054","B":"Amyloid Stain","C":"310","D":"88313","F":"40.8"},{"Policy Line":"70105055","B":"Cea","C":"310","D":"88342","F":"82.2"},{"Policy Line":"70105056","B":"Chromogranin","C":"310","D":"88342","F":"77.4"},{"Policy Line":"70105057","B":"Consult","C":"310","D":"88321","F":"273.3"},{"Policy Line":"70105060","B":"Elastic Stain","C":"310","D":"88313","F":"39.6"},{"Policy Line":"70105061","B":"Histiology Stain Group 1","C":"310","D":"88312","F":"42.3"},{"Policy Line":"70105062","B":"Giemsa","C":"310","D":"88313","F":"44.1"},{"Policy Line":"70105063","B":"Gomori'S Methenamine Silver","C":"310","D":"88312","F":"61.2"},{"Policy Line":"70105065","B":"Melanin","C":"310","D":"88313","F":"52.5"},{"Policy Line":"70105066","B":"Mucicarmine","C":"310","D":"88313","F":"45"},{"Policy Line":"70105067","B":"Periodic Acid Schiff","C":"310","D":"88313","F":"30.6"},{"Policy Line":"70105068","B":"Perio Acid Schiff W/Dias Dige","C":"310","D":"88313","F":"36"},{"Policy Line":"70105069","B":"PSA Stain","C":"310","D":"88342","F":"66.9"},{"Policy Line":"70105071","B":"Trichrome","C":"310","D":"88313","F":"46.2"},{"Policy Line":"70105073","B":"Duke University(Muscle Bx'S)","C":"310","D":"88305","F":"72.6"},{"Policy Line":"70105074","B":"Renal Bx Sendout","C":"310","D":"88305","F":"82.8"},{"Policy Line":"70105076","B":"UFDRL Consult","C":"310","D":"88323","F":"503.1"},{"Policy Line":"70105080","B":"Tissue Level 2","C":"310","D":"88302","F":"67.2"},{"Policy Line":"70105082","B":"Cytopath Fluids: Wash Or Brush","C":"310","D":"88104","F":"105.6"},{"Policy Line":"70105087","B":"Bc 1-2","C":"310","D":"88342","F":"57.6"},{"Policy Line":"70105088","B":"Misc Consult - Sendout","C":"310","D":"88321","F":"273.3"},{"Policy Line":"70105090","B":"Surg Spec Level 4","C":"310","D":"88305","F":"63.3"},{"Policy Line":"70105097","B":"Tissue Level 3","C":"310","D":"88304","F":"59.7"},{"Policy Line":"70105098","B":"Surg Spec Level 5","C":"310","D":"88307","F":"88.8"},{"Policy Line":"70105099","B":"FNA Interp & Report","C":"310","D":"88173","F":"61.2"},{"Policy Line":"70105201","B":"Tissue Level 6","C":"310","D":"88309","F":"97.5"},{"Policy Line":"70105524","B":"Decalcification","C":"310","D":"88311","F":"18.6"},{"Policy Line":"70105531","B":"Surg Path- TB-Frozen Section","C":"310","D":"88331","F":"36.9"},{"Policy Line":"70105532","B":"Frozen Section-Additional TB","C":"310","D":"88332","F":"114"},{"Policy Line":"70106301","B":"Est Recept","C":"310","D":"88361","F":"503.1"},{"Policy Line":"70106302","B":"Progest Recept","C":"310","D":"88361","F":"503.1"},{"Policy Line":"70106303","B":"DNA Histo","C":"310","D":"88182","F":"415.5"},{"Policy Line":"70106311","B":"Est Recept (Blk)","C":"310","D":"88361","F":"503.1"},{"Policy Line":"70106312","B":"Progest Recept (Blk)","C":"310","D":"88361","F":"503.1"},{"Policy Line":"70106313","B":"DNA Histo Analysis (Blk)","C":"311","D":"88182","F":"415.5"},{"Policy Line":"70108030","B":"Flow Cyto: Cell Marker 1","C":"310","D":"88184","F":"60"},{"Policy Line":"70108501","B":"Flow Cyto Interp 2-8 Markers","C":"310","D":"88187","F":"49.8"},{"Policy Line":"70109701","B":"Histology Stain Group Ii","C":"310","D":"88313","F":"45"},{"Policy Line":"70109703","B":"Tissue Level I Gross Only","C":"310","D":"88300","F":"23.4"},{"Policy Line":"70109711","B":"Cytopathology Fluid","C":"310","D":"88108","F":"273.3"},{"Policy Line":"70109890","B":"HER-2 Oncoprotein","C":"310","D":"88361","F":"503.1"},{"Policy Line":"70109931","B":"Flow Cytometry: Molecular Pat","C":"310","D":"88321","F":"273.3"},{"Policy Line":"70110019","B":"Flow Cyto: Cell Marker 1","C":"311","D":"88184","F":"358.2"},{"Policy Line":"70110020","B":"Flow Cyto: Cell Marker 2","C":"311","D":"88185","F":"45"},{"Policy Line":"70110021","B":"Flow Cyto: Cell Marker 3","C":"311","D":"88185","F":"45"},{"Policy Line":"70110022","B":"Flow Cyto: Cell Marker 4","C":"311","D":"88185","F":"45"},{"Policy Line":"70110023","B":"Flow Cyto: Cell Marker 5","C":"311","D":"88185","F":"45"},{"Policy Line":"70110024","B":"Flow Cyto: Cell Marker 6","C":"311","D":"88185","F":"45"},{"Policy Line":"70110025","B":"Flow Cyto: Cell Marker 7","C":"311","D":"88185","F":"45"},{"Policy Line":"70110026","B":"Flow Cyto: Cell Marker 8","C":"311","D":"88185","F":"45"},{"Policy Line":"70110027","B":"Flow Cyto: Cell Marker 9","C":"311","D":"88185","F":"45"},{"Policy Line":"70110028","B":"Flow Cyto: Cell Marker 10","C":"311","D":"88185","F":"45"},{"Policy Line":"70110029","B":"Flow Cyto: Cell Marker 11","C":"311","D":"88185","F":"45"},{"Policy Line":"70110030","B":"Flow Cyto: Cell Marker 12","C":"311","D":"88185","F":"45"},{"Policy Line":"70110031","B":"Flow Cyto: Cell Marker 13","C":"311","D":"88185","F":"45"},{"Policy Line":"70110032","B":"Flow Cyto: Cell Marker 14","C":"311","D":"88185","F":"45"},{"Policy Line":"70110080","B":"Morphology Tumor Analysis","C":"310","D":"88358","F":"229.5"},{"Policy Line":"70110293","B":"Tissue In Situ Hybridization","C":"310","D":"88365","F":"164.4"},{"Policy Line":"70110300","B":"Electron Microscopy:Diagnostic","C":"310","D":"88348","F":"2049.9"},{"Policy Line":"70112093","B":"Morphometric Analysis: Cad2","C":"310","D":"88367","F":"150.3"},{"Policy Line":"70112518","B":"Alk By Fish Clarient","C":"310","D":"88368","F":"363.3"},{"Policy Line":"70112519","B":"Alk By Fish Clarient","C":"310","D":"88368","F":"363.3"},{"Policy Line":"70112520","B":"BCR/ABL by FISH Computerassist","C":"310","D":"88374","F":"667.8"},{"Policy Line":"70112521","B":"BCR/ABL by FISH Manual","C":"310","D":"88377","F":"667.8"},{"Policy Line":"70115033","B":"Flow Cytro: Cell Marker 16","C":"311","D":"88185","F":"45"},{"Policy Line":"70115034","B":"Flow Cytro: Cell Marker 17","C":"311","D":"88185","F":"45"},{"Policy Line":"70115035","B":"Flow Cytro: Cell Marker 18","C":"311","D":"88185","F":"45"},{"Policy Line":"70115036","B":"Flow Cytro: Cell Marker 19","C":"311","D":"88185","F":"303.3"},{"Policy Line":"70115037","B":"Flow Cytro: Cell Marker 20","C":"311","D":"88185","F":"303.3"},{"Policy Line":"70115038","B":"Flow Cytro: Cell Marker 21","C":"311","D":"88185","F":"303.3"},{"Policy Line":"70115039","B":"Flow Cytro: Cell Marker 22","C":"311","D":"88185","F":"303.3"},{"Policy Line":"70115654","B":"Therapath Spec Stains Grp II 1","C":"310","D":"88313","F":"45"},{"Policy Line":"70115655","B":"Therapath Histo-Stain Mscl Bx","C":"310","D":"88314","F":"173.4"},{"Policy Line":"70115656","B":"Therapath Spec Stains GrpIII 3","C":"310","D":"88319","F":"293.4"},{"Policy Line":"70115657","B":"Therapath Spec Stains GrpIII 1","C":"310","D":"88319","F":"293.4"},{"Policy Line":"70115658","B":"Therapath Spec Stains GrpIII 2","C":"310","D":"88319","F":"293.4"},{"Policy Line":"70115660","B":"Arkana Light Microscopy 1-1","C":"310","D":"88313","F":"45"},{"Policy Line":"70115661","B":"Arkana Light Microscopy 1-2","C":"310","D":"88313","F":"45"},{"Policy Line":"70115662","B":"Arkana Light Microscopy 1-3","C":"310","D":"88313","F":"45"},{"Policy Line":"70115663","B":"Arkana Electron Microscopy","C":"310","D":"88348","F":"242.7"},{"Policy Line":"70115664","B":"Arkana Immunofluor, Add 1","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115665","B":"Arkana Immunofluor, Add 2","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115666","B":"Arkana Immunofluor, Add 3","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115667","B":"Arkana Immunofluor, Add 4","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115668","B":"Arkana Immunofluor, Add 5","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115669","B":"Arkana Immunofluor, Add 6","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115670","B":"Arkana Immunofluor, Add 7","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115671","B":"Arkana Immunofluor, Add 8","C":"310","D":"88350","F":"25.2"},{"Policy Line":"70115674","B":"ER IHC Tumor","C":"310","D":"88361","F":"150"},{"Policy Line":"70115675","B":"HER2 IHC Tumor","C":"310","D":"88361","F":"150"},{"Policy Line":"70115676","B":"Ki67 IHC Tumor","C":"310","D":"88361","F":"156"},{"Policy Line":"70115677","B":"PgR IHC Tumor","C":"310","D":"88361","F":"156"},{"Policy Line":"70115678","B":"MLH1 IHC Tumor","C":"310","D":"88361","F":"153"},{"Policy Line":"70115679","B":"MSH2 IHC Tumor","C":"310","D":"88361","F":"153"},{"Policy Line":"70115680","B":"MSH6 IHC Tumor","C":"310","D":"88361","F":"153"},{"Policy Line":"70115681","B":"PMS2 IHC Tumor","C":"310","D":"88361","F":"153"},{"Policy Line":"70115682","B":"ALK Lung by FISH Computer-asst","C":"310","D":"88374","F":"795.6"},{"Policy Line":"70115683","B":"ROS1 by FISH Computer-asst","C":"310","D":"88374","F":"795.6"},{"Policy Line":"70115684","B":"HER2 by FISH Computer-asst","C":"310","D":"88374","F":"795.6"},{"Policy Line":"70115685","B":"MDM2 by FISH Computer-asst","C":"310","D":"88374","F":"795.6"},{"Policy Line":"70115686","B":"RET Mutation Analysis","C":"310","D":"88374","F":"795.6"},{"Policy Line":"70115687","B":"PD-L1 22C3 IHC Tumor","C":"310","D":"88360","F":"181.8"},{"Policy Line":"70115690","B":"GATA3 IHC","C":"310","D":"88342","F":"81"},{"Policy Line":"70115691","B":"p16 IHC","C":"310","D":"88342","F":"81"},{"Policy Line":"70115692","B":"NKX3.1 IHC","C":"310","D":"88342","F":"81"},{"Policy Line":"70115693","B":"PSA IHC","C":"310","D":"88341","F":"81"},{"Policy Line":"70115694","B":"PSAP/HPAP IHC","C":"310","D":"88341","F":"81"},{"Policy Line":"70115695","B":"PSMA IHC","C":"310","D":"88341","F":"81"},{"Policy Line":"70115696","B":"CD99 IHC","C":"310","D":"88342","F":"81"},{"Policy Line":"70115697","B":"MyoD1 IHC","C":"310","D":"88341","F":"81"},{"Policy Line":"70115698","B":"S100 IHC","C":"310","D":"88341","F":"81"},{"Policy Line":"70115699","B":"CK AE1/AE3 IHC","C":"310","D":"88342","F":"81"},{"Policy Line":"70115700","B":"CD117 cKIT IHC","C":"310","D":"88342","F":"81"},{"Policy Line":"70115701","B":"PDGFR Alpha IHC","C":"310","D":"88341","F":"81"},{"Policy Line":"70115702","B":"PDGFR Beta IHC","C":"310","D":"88341","F":"81"},{"Policy Line":"70115703","B":"HPylori IHC","C":"310","D":"88342","F":"81"},{"Policy Line":"70116022","B":"Flow Cytometry TC 1st Marker","C":"311","D":"88184","F":"60"},{"Policy Line":"70116023","B":"Flow Cytometry Ea Add Marker 1","C":"311","D":"88185","F":"45"},{"Policy Line":"70116024","B":"Flow Cytometry Ea Add Marker 2","C":"311","D":"88185","F":"45"},{"Policy Line":"70116025","B":"Flow Cytometry Ea Add Marker 3","C":"311","D":"88185","F":"45"},{"Policy Line":"70116026","B":"Flow Cytometry Ea Add Marker 4","C":"311","D":"88185","F":"45"},{"Policy Line":"70116027","B":"Flow Cytometry Ea Add Marker 5","C":"311","D":"88185","F":"45"},{"Policy Line":"70116028","B":"Flow Cytometry Ea Add Marker 6","C":"311","D":"88185","F":"45"},{"Policy Line":"70116029","B":"Flow Cytometry Ea Add Marker 7","C":"311","D":"88185","F":"45"},{"Policy Line":"70116030","B":"Flow Cytometry Ea Add Marker 8","C":"311","D":"88185","F":"45"},{"Policy Line":"70116031","B":"Flow Cytometry Ea Add Marker 9","C":"311","D":"88185","F":"45"},{"Policy Line":"70116032","B":"Flow Cytometry Ea Add Marker10","C":"311","D":"88185","F":"45"},{"Policy Line":"70116033","B":"Flow Cytometry Ea Add Marker11","C":"311","D":"88185","F":"45"},{"Policy Line":"70116034","B":"Flow Cytometry Ea Add Marker12","C":"311","D":"88185","F":"45"},{"Policy Line":"70116035","B":"Flow Cytometry Ea Add Marker13","C":"311","D":"88185","F":"45"},{"Policy Line":"70116036","B":"Flow Cytometry Ea Add Marker14","C":"311","D":"88185","F":"45"},{"Policy Line":"70116037","B":"Flow Cytometry Ea Add Marker15","C":"311","D":"88185","F":"45"},{"Policy Line":"70116038","B":"Flow Cytometry Ea Add Marker16","C":"311","D":"88185","F":"45"},{"Policy Line":"70116039","B":"Flow Cytometry Ea Add Marker17","C":"311","D":"88185","F":"45"},{"Policy Line":"70116040","B":"Flow Cytometry Ea Add Marker18","C":"311","D":"88185","F":"45"},{"Policy Line":"70116041","B":"Flow Cytometry Ea Add Marker19","C":"311","D":"88185","F":"45"},{"Policy Line":"70116042","B":"Flow Cytometry Ea Add Marker20","C":"311","D":"88185","F":"45"},{"Policy Line":"70116043","B":"Flow Cytometry Ea Add Marker21","C":"311","D":"88185","F":"45"},{"Policy Line":"70116044","B":"Flow Cytometry Ea Add Marker22","C":"311","D":"88185","F":"45"},{"Policy Line":"70116045","B":"Flow Cytometry Ea Add Marker23","C":"311","D":"88185","F":"45"},{"Policy Line":"70116046","B":"Flow Cytometry Ea Add Marker24","C":"311","D":"88185","F":"45"},{"Policy Line":"70116047","B":"Flow Cytometry Ea Add Marker25","C":"311","D":"88185","F":"45"},{"Policy Line":"70116048","B":"Flow Cytometry Ea Add Marker26","C":"311","D":"88185","F":"45"},{"Policy Line":"70116049","B":"Flow Cytometry Ea Add Marker27","C":"311","D":"88185","F":"45"},{"Policy Line":"70116050","B":"Flow Cytometry Ea Add Marker28","C":"311","D":"88185","F":"45"},{"Policy Line":"70116051","B":"Flow Cytometry Ea Add Marker29","C":"311","D":"88185","F":"45"},{"Policy Line":"70116308","B":"PgR IHC Tumor","C":"310","D":"88360","F":"99"},{"Policy Line":"70116451","B":"MDM2","C":"310","D":"88377","F":"594"},{"Policy Line":"70116489","B":"RBC Band 3 Protein Reduction","C":"311","D":"88184","F":"126"},{"Policy Line":"70116660","B":"Immunofluor Antb 1st Stain","C":"310","D":"88346","F":"169.2"},{"Policy Line":"70116661","B":"Immunofluor Antb Addl Stain","C":"310","D":"88350","F":"169.2"},{"Policy Line":"70116687","B":"Plasma Cell Neoplasms FISH","C":"312","D":"88377","F":"744"},{"Policy Line":"70116693","B":"T-Cell Clonality by V-Beta","C":"311","D":"88184","F":"15.9"},{"Policy Line":"70116694","B":"T-Cell Clonality by V-Beta 2","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116695","B":"T-Cell Clonality by V-Beta 3","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116696","B":"T-Cell Clonality by V-Beta 4","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116697","B":"T-Cell Clonality by V-Beta 5","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116698","B":"T-Cell Clonality by V-Beta 6","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116699","B":"T-Cell Clonality by V-Beta 7","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116700","B":"T-Cell Clonality by V-Beta 8","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116701","B":"T-Cell Clonality by V-Beta 9","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116702","B":"T-Cell Clonality by V-Beta 10","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116703","B":"T-Cell Clonality by V-Beta 11","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116704","B":"T-Cell Clonality by V-Beta 12","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116705","B":"T-Cell Clonality by V-Beta 13","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116706","B":"T-Cell Clonality by V-Beta 14","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116707","B":"T-Cell Clonality by V-Beta 15","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116708","B":"T-Cell Clonality by V-Beta 16","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116709","B":"T-Cell Clonality by V-Beta 17","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116710","B":"T-Cell Clonality by V-Beta 18","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116711","B":"T-Cell Clonality by V-Beta 19","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116712","B":"T-Cell Clonality by V-Beta 20","C":"310","D":"88185","F":"15.9"},{"Policy Line":"70116713","B":"T-Cell Clonality by V-Beta 21","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116715","B":"T-Cell Clonality by V-Beta 22","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116716","B":"T-Cell Clonality by V-Beta 23","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116717","B":"T-Cell Clonality by V-Beta 24","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116718","B":"T-Cell Clonality by V-Beta 25","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70116719","B":"T-Cell Clonality by V-Beta 26","C":"311","D":"88185","F":"15.9"},{"Policy Line":"70109601","B":"Venipuncture","C":"300","D":"36415","F":"6"},{"Policy Line":"70110000","B":"Specimen Collection","C":"300","D":"36415","F":"6.6"},{"Policy Line":"70116367","B":"Routine Venipuncture, Quest","C":"300","D":"36415","F":"7.2"},{"Policy Line":"70116368","B":"Routine Venipuncture, LabCorp","C":"300","D":"36415","F":"7.2"},{"Policy Line":"70116369","B":"Routine Venipuncture, Other","C":"300","D":"36415","F":"6.6"},{"Policy Line":"74202027","B":"Venipuncture","C":"300","D":"36415","F":"6.6"},{"Policy Line":"75452027","B":"Go Strong Venipuncture","C":"300","D":"36415","F":"1.8"},{"Policy Line":"64100864","B":"RBC'S Ea Unit (Cell Saver)","C":"390","D":"P9021","F":"573.3"},{"Policy Line":"68300180","B":"Irradiation Blood Product Each","C":"300","D":"86945","F":"41.4"},{"Policy Line":"70100061","B":"Compatibility Testing-Is","C":"300","D":"86920","F":"38.1"},{"Policy Line":"70100360","B":"Sucrose Hemolysis Test","C":"300","D":"86941","F":"68.1"},{"Policy Line":"70100611","B":"Coombs: Direct","C":"300","D":"86880","F":"27"},{"Policy Line":"70100612","B":"Coombs: Indirect Qual, Each","C":"300","D":"86885","F":"57.3"},{"Policy Line":"70100613","B":"COOMBS: IND TITER EA ANTIBODY","C":"300","D":"86886","F":"57.3"},{"Policy Line":"70100619","B":"RH Immune Glob Wkup","C":"300","D":"86885","F":"66.9"},{"Policy Line":"70100641","B":"Isohemagglutinin Titer A1 Qst","C":"300","D":"86886","F":"164.7"},{"Policy Line":"70100642","B":"Isohemagglutinin Titer A2 Qst","C":"300","D":"86886","F":"116.1"},{"Policy Line":"70100643","B":"Isohemagglutinin Titer B Qst","C":"300","D":"86886","F":"116.1"},{"Policy Line":"70101676","B":"SERUM PRETX, RC ABSORPT EA","C":"300","D":"86978","F":"237.6"},{"Policy Line":"70101677","B":"SERUM PRETX, DILUTION","C":"300","D":"86976","F":"54"},{"Policy Line":"70101678","B":"SERUMPRETX,INHIB INCUBAT EA AB","C":"300","D":"86977","F":"129.6"},{"Policy Line":"70105992","B":"ARC RETICS: RBC PRETMT BY SDG","C":"300","D":"86972","F":"198"},{"Policy Line":"70106000","B":"Antibody Id","C":"300","D":"86870","F":"100.2"},{"Policy Line":"70106010","B":"Antigen Screen 1 /Ext Pheno","C":"300","D":"86902","F":"114.3"},{"Policy Line":"70106011","B":"ARC Basic Pt Workup","C":"300","D":"86870","F":"61.8"},{"Policy Line":"70106012","B":"Antigen Screen 2 /Ext Pheno","C":"300","D":"86902","F":"114.3"},{"Policy Line":"70106013","B":"Antigen Screen 3 /Ext Pheno","C":"300","D":"86902","F":"114.3"},{"Policy Line":"70106037","B":"Antigen Screen","C":"300","D":"86902","F":"114.3"},{"Policy Line":"70106038","B":"Antigen Screen 4 /Ext Pheno","C":"300","D":"86902","F":"114.3"},{"Policy Line":"70106039","B":"Antigen Screen 5/Ext Pheno","C":"300","D":"86902","F":"114.3"},{"Policy Line":"70106100","B":"ABO Group","C":"300","D":"86900","F":"12"},{"Policy Line":"70106101","B":"Serologic Blood Type Rh","C":"300","D":"86901","F":"12.3"},{"Policy Line":"70106150","B":"Irradiation Of Blood Prod Ea","C":"300","D":"P9038","F":"67.2"},{"Policy Line":"70106154","B":"Adsorption","C":"300","D":"86940","F":"82.5"},{"Policy Line":"70106156","B":"Elution","C":"300","D":"86860","F":"191.7"},{"Policy Line":"70106158","B":"Pooling Of Blood Products","C":"300","D":"86965","F":"40.2"},{"Policy Line":"70106471","B":"AG SCREEN, SERUM PER UNIT","C":"300","D":"86904","F":"108"},{"Policy Line":"70109700","B":"Antibody Screen","C":"300","D":"86850","F":"41.4"},{"Policy Line":"70110004","B":"ARC Antigen Type High Inciden","C":"300","D":"86905","F":"93"},{"Policy Line":"70110005","B":"ARC Chemical Treatment","C":"300","D":"86970","F":"59.4"},{"Policy Line":"70110006","B":"ARC Phenotype","C":"300","D":"86905","F":"43.5"},{"Policy Line":"70110007","B":"ARC Rh Phenotype","C":"300","D":"86906","F":"52.5"},{"Policy Line":"70201000","B":"FFP Thawing Ea Unit","C":"300","D":"86927","F":"29.1"},{"Policy Line":"70205000","B":"Platelets Pher Leukoreduce","C":"390","D":"P9035","F":"791.1"},{"Policy Line":"70205010","B":"Red Bld Cells Leuko-Depleted","C":"390","D":"P9016","F":"396.3"},{"Policy Line":"70206009","B":"Pooled Cryoprecipitate Ea U","C":"390","D":"P9012","F":"85.8"},{"Policy Line":"70206010","B":"Pooled Cryoprecipitate Ea U","C":"390","D":"P9012","F":"85.8"},{"Policy Line":"70206011","B":"Pooled Cryoprecipitate Ea Unit","C":"390","D":"P9012","F":"85.8"},{"Policy Line":"70206012","B":"Pooled Cryoprecipitate Ea Unit","C":"390","D":"P9012","F":"85.8"},{"Policy Line":"70206013","B":"Pooled Cryoprecipitate Ea Unit","C":"390","D":"P9012","F":"85.8"},{"Policy Line":"70206019","B":"Cryoprecipitate Per Unit","C":"390","D":"P9012","F":"85.8"},{"Policy Line":"70206020","B":"FFP<8Hrs /Unit","C":"390","D":"P9017","F":"103.2"},{"Policy Line":"70206022","B":"Platelet Concentrates Ea Unit","C":"390","D":"P9019","F":"32.4"},{"Policy Line":"70206051","B":"Blood Split Unit","C":"390","D":"P9011","F":"138.3"},{"Policy Line":"70206052","B":"Splitting Of Blood Each Unit","C":"300","D":"86985","F":"16.8"},{"Policy Line":"70206053","B":"Irradiation Of Blood Prod Ea","C":"390","D":"P9038","F":"67.2"},{"Policy Line":"70206055","B":"RBC'S Lr Irr Each Unit","C":"390","D":"P9040","F":"219"},{"Policy Line":"70206056","B":"ARC Ab/Id Each Selected Cell","C":"300","D":"86885","F":"18"},{"Policy Line":"70206057","B":"ARC Pretreatment W/Enzymes","C":"300","D":"86971","F":"21.6"},{"Policy Line":"70206166","B":"Autologous Blood Proc Charge","C":"300","D":"86890","F":"114.3"},{"Policy Line":"70206174","B":"ARC Crossmatch 86922","C":"300","D":"86922","F":"226.8"},{"Policy Line":"70206176","B":"Directed Donation Proced Chg","C":"300","D":"86999","F":"147.3"},{"Policy Line":"70206178","B":"Deglycerized/Washed Blood Prod","C":"390","D":"P9039","F":"636"},{"Policy Line":"70206179","B":"Washed Red Bld Cells Ea Un","C":"390","D":"P9022","F":"122.7"},{"Policy Line":"70206180","B":"ARC Platelet Crossmatch Test","C":"300","D":"86922","F":"112.8"},{"Policy Line":"70206185","B":"HLA Matched Products","C":"390","D":"P9052","F":"791.1"},{"Policy Line":"70206186","B":"Platelets Lp Irr Pher","C":"390","D":"P9037","F":"423.9"},{"Policy Line":"70206187","B":"FFP W/In 8-24 Hrs Collection","C":"390","D":"P9059","F":"79.5"},{"Policy Line":"70206189","B":"FFP JUMBO600ML<=1Unitw/in 8Hrs","C":"390","D":"P9017","F":"309.6"},{"Policy Line":"70209739","B":"Hypotonic Wash RBC Separation","C":"300","D":"86999","F":"146.4"},{"Policy Line":"70100017","B":"Urinalysis","C":"300","D":"81001","F":"9.6"},{"Policy Line":"70100753","B":"Reducing Substances","C":"300","D":"81005","F":"21.3"},{"Policy Line":"70100769","B":"Pregnancy Test-Urine","C":"300","D":"81025","F":"15.6"},{"Policy Line":"70101045","B":"Urine Dipstick - Poc","C":"300","D":"81002","F":"42"},{"Policy Line":"70101702","B":"Urine Dipstick No Microscopic","C":"300","D":"81003","F":"14.4"},{"Policy Line":"70101735","B":"Ketone-Urine","C":"300","D":"81005","F":"21.3"},{"Policy Line":"70109740","B":"Urine Microscopic","C":"300","D":"81015","F":"5.7"},{"Policy Line":"70109741","B":"Volume Measurement Timed Coll","C":"300","D":"81050","F":"13.5"},{"Policy Line":"70109623","B":"Travel Allowance P9604","C":"300","D":"P9604","F":"25.2"},{"Policy Line":"70206036","B":"Apheresis Ea Un Granulocytes","C":"390","D":"P9050","F":"1281.9"},{"Policy Line":"74221029","B":"SMOKING CESS GROUP","C":"942","D":"S9453","F":"36.6"},{"Policy Line":"77200309","B":"Insulin Pump Start - 30 Min","C":"942","D":"G0108","F":"67.5"},{"Policy Line":"77200310","B":"O/P Indiv Diab Ed - 30 Min","C":"942","D":"G0108","F":"67.5"},{"Policy Line":"77200312","B":"O/P Group Diab Ed - 30 Min","C":"942","D":"G0109","F":"45"},{"Policy Line":"64500512","B":"Endo Mod Sed Ini 15Min >5yrs","C":"370","D":"G0500","F":"47.1"},{"Policy Line":"64500523","B":"Endo Mod Sed Addl 15Min","C":"370","D":"99153","F":"38.4"},{"Policy Line":"65100502","B":"Moderate Sed Ini 15Min <5yrs","C":"370","D":"99151","F":"90.6"},{"Policy Line":"65100512","B":"Moderate Sed Ini 15Min >=5yrs","C":"370","D":"99152","F":"47.1"},{"Policy Line":"65100523","B":"Mod Sed Ea Addl 15Min Any Age","C":"370","D":"99153","F":"38.4"},{"Policy Line":"65101094","B":"Cardiopulmonary Resuscitation","C":"450","D":"92950","F":"897.3"},{"Policy Line":"65103503","B":"Pericardiocentesis","C":"450","D":"33010","F":"2603.4"},{"Policy Line":"72106750","B":"Pericardiocentesis","C":"480","D":"33010","F":"2603.4"},{"Policy Line":"72205052","B":"Ablation: AF","C":"480","D":"93656","F":"4338.9"},{"Policy Line":"72205090","B":"Ablation: V Tach","C":"480","D":"93654","F":"24045"},{"Policy Line":"72205597","B":"Bundle Of His Recording","C":"480","D":"93600","F":"472.8"},{"Policy Line":"72205598","B":"Right Ventricular Recording","C":"480","D":"93603","F":"472.8"},{"Policy Line":"72206005","B":"Intra-Atrial Recording","C":"480","D":"93602","F":"6731.1"},{"Policy Line":"72206006","B":"Intra-Atrial Pacing","C":"480","D":"93610","F":"1283.1"},{"Policy Line":"73100107","B":"Arterial Line Insertion","C":"361","D":"36620","F":"113.1"},{"Policy Line":"6325","B":"Dialysis Shunt Evaluation","C":"921","D":"93990","F":"207.6"},{"Policy Line":"4781","B":"THYROGEN INJ SQ/IM NM","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61050253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61050254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61050255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61050256","B":"Concurrent Infusion","C":"260","D":"96368","F":"131.4"},{"Policy Line":"61050815","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61051008","B":"4N Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61051009","B":"4N Pneumococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61051027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61052622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61052645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61052996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61055001","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61055510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61100253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61100254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61100255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61100256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61100815","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61101008","B":"2N Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61101009","B":"2N Pneumococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61101027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61102622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61102645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61102996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61105001","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61105510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61150253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61150254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61150256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61150815","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61151008","B":"6N Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61151009","B":"6N Pneumococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61151027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61152622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61152645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61152996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61155001","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61155510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61200251","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61200254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61200255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61200256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61200815","B":"IV INFUSION INITIAL UP TO 1HR","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61201008","B":"5S Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61201009","B":"5S Pneumococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61201027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61202622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61202645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61202996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61205001","B":"IV Infusion Ea Add Hr Nonchem","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61205510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61300253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61300254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61300255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61300256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61300815","B":"IV Infusion Therapy 1St Hour","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61301008","B":"Flu Vaccination Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61301009","B":"SJH 5N Pneumococcal Vacc Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61301027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61302622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61302645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61302996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61305001","B":"IV Infusion Ea Add Hr Nonchem","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61305510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61350253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61350254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61350255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61350256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61350815","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61351008","B":"Flu Vaccination Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61351009","B":"Pneumococcal Vaccine Administr","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61351027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61352622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61352645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61352996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61355001","B":"IV Infusion Ea Add Hr Nonchem","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61355510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61400253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61400254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61400255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61400256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61400815","B":"IV INFUSION INITIAL UP TO 1HR","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61401008","B":"Flu Vaccination Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61401009","B":"SJH 7N Pneumococcal Vacc Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61401027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61402622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61402645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61402996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61405001","B":"IV Infusion Ea Add Hr Nonchem","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61405510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61450253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61450255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61450256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61450510","B":"Admin Flu Virus Vaccine","C":"771","D":"G0008","F":"10.2"},{"Policy Line":"61450815","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61451009","B":"SJH 7S Pneumococcal Vacc Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61451027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61452622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61452645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61452996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61455001","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61455510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61500253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61500254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61500255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61500256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61500815","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61501008","B":"Flu Vaccination Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61501009","B":"Pneumococcal Immuniz admin x1","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61501027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61502622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61502645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61502996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61505001","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61505510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61550253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61550255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61551001","B":"Hydration Infsn IV Ea Adl 1 Hr","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61551002","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61551003","B":"IV Infusion Ea Addl 1.0 Hr","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61551008","B":"Flu Immunizatn Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61552645","B":"Ea Adl Seqnl IV Push/New Drg","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61552952","B":"Rhogam Im Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61552996","B":"IM / Sq Injection","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61552997","B":"IV Inj/Push Initial","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61700253","B":"Hydration Infsn Ini 31-60Min","C":"260","D":"96360","F":"251.4"},{"Policy Line":"61700254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"61700255","B":"IV Inj Adl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61700256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"61700815","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"61701008","B":"PCU Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"61701009","B":"PCU Pneumococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"61701027","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"61702622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"61702645","B":"Ea Sequential IV Push/New Drug","C":"260","D":"96375","F":"106.2"},{"Policy Line":"61705001","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"61705510","B":"Non Chemo IV Push Injection","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61800251","B":"Injection IV Push Initial","C":"260","D":"96374","F":"119.7"},{"Policy Line":"61800252","B":"Injection: SQ/IM","C":"260","D":"96372","F":"102.6"},{"Policy Line":"61800255","B":"IV Inj Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"61851009","B":"Pneumococcal Vaccine Administr","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"64101839","B":"Pneumococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"64201008","B":"ODS Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"64505423","B":"IV Push","C":"260","D":"96374","F":"119.7"},{"Policy Line":"64550010","B":"HBIG IM Injection","C":"761","D":"96372","F":"102.6"},{"Policy Line":"64555423","B":"IV Push","C":"260","D":"96374","F":"119.7"},{"Policy Line":"65100251","B":"Injection: Iv Push Initl Drug","C":"260","D":"96374","F":"119.7"},{"Policy Line":"65100252","B":"Injection: Sq/Im","C":"260","D":"96372","F":"102.6"},{"Policy Line":"65100253","B":"Hydration First Hour","C":"260","D":"96360","F":"251.4"},{"Policy Line":"65100254","B":"Hydration Each Addl Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"65100255","B":"IV Inj Addl Seq Push Same Drug","C":"260","D":"96376","F":"42.6"},{"Policy Line":"65100256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"65100509","B":"PPV Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"65100510","B":"Admin Flu Virus Vaccine","C":"771","D":"G0008","F":"10.2"},{"Policy Line":"65101009","B":"Pneumococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"65102618","B":"IV Infusion Each Addit. Hr","C":"260","D":"96366","F":"201.9"},{"Policy Line":"65102622","B":"IV Infusion Seq Addl Drug","C":"260","D":"96367","F":"147.9"},{"Policy Line":"65102645","B":"Ea Sequential IV Push /New Dr","C":"260","D":"96375","F":"106.2"},{"Policy Line":"65103499","B":"Vaccine Admin Additional","C":"771","D":"90472","F":"27.9"},{"Policy Line":"65103500","B":"Injection: Immunization","C":"771","D":"90471","F":"14.7"},{"Policy Line":"65105001","B":"IV INFUSION EA ADD HR NONCHEMO","C":"260","D":"96366","F":"201.9"},{"Policy Line":"65106412","B":"IV Infusion Initial up to 1hr","C":"260","D":"96365","F":"276.6"},{"Policy Line":"68250253","B":"Vaccine Admin Initial","C":"771","D":"90471","F":"14.7"},{"Policy Line":"68250254","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"68250258","B":"Hepatitis B Vaccine Admin 1.0","C":"771","D":"G0010","F":"14.7"},{"Policy Line":"68250510","B":"Admin Flu Virus Vaccine","C":"771","D":"G0008","F":"10.2"},{"Policy Line":"68251000","B":"Hydration 1St Hour Hhi","C":"260","D":"96360","F":"251.4"},{"Policy Line":"68251001","B":"Hydration Ea Addl Hour Hhi","C":"260","D":"96361","F":"102.6"},{"Policy Line":"68251002","B":"Non-Chemo Infusion 1St Hr Hhi","C":"260","D":"96365","F":"276.6"},{"Policy Line":"68251003","B":"Non-Chemo Infusion Addl Hr Hhi","C":"260","D":"96366","F":"201.9"},{"Policy Line":"68251004","B":"Non-Chemo Infusion Seq Hhi","C":"260","D":"96367","F":"147.9"},{"Policy Line":"68251005","B":"Non-Chemo Infusion Concrnt Hhi","C":"260","D":"96368","F":"130.5"},{"Policy Line":"68251006","B":"SubQ Non-Chemo Infusion 1stHR","C":"260","D":"96369","F":"190.8"},{"Policy Line":"68251007","B":"Non-Chemo Inj Im Sq Hhi","C":"260","D":"96372","F":"102.6"},{"Policy Line":"68251008","B":"Non-Chemo IV Inj Intl Drug Hh","C":"260","D":"96374","F":"119.7"},{"Policy Line":"68251009","B":"Non-Chemo IV Inj Subsqt Hhi","C":"260","D":"96375","F":"106.2"},{"Policy Line":"68251037","B":"IV Inj Seq Push Same Drug Addl","C":"260","D":"96376","F":"42.6"},{"Policy Line":"68252291","B":"Appl On-BodyInjtr/Timed SC Inj","C":"260","D":"96377","F":"138.9"},{"Policy Line":"68256009","B":"ADMIN PNEUMOCOCCAL VACCINE","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"68260253","B":"Immunizatn Adm Initl Vaccine","C":"771","D":"90471","F":"14.7"},{"Policy Line":"68260254","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"68260257","B":"Hep B Vaccine Admin","C":"771","D":"G0010","F":"18.9"},{"Policy Line":"68260258","B":"Hepatitis B Vaccine Admin 1.0","C":"771","D":"G0010","F":"14.7"},{"Policy Line":"68260510","B":"Admin Flu Vaccine","C":"771","D":"G0008","F":"10.2"},{"Policy Line":"68261000","B":"Hydration IV Infsn 1St Hour","C":"260","D":"96360","F":"251.4"},{"Policy Line":"68261001","B":"Hydration Ea Addl Hour Okt","C":"260","D":"96361","F":"102.6"},{"Policy Line":"68261002","B":"Non-Chemo Infusion 1St Hr Okt","C":"260","D":"96365","F":"276.6"},{"Policy Line":"68261003","B":"Non-Chemo Infusion Addl Hr Okt","C":"260","D":"96366","F":"201.9"},{"Policy Line":"68261004","B":"Non-Chemo Infusion Seq Okt","C":"260","D":"96367","F":"147.9"},{"Policy Line":"68261005","B":"Non-Chemo Inf Concurrent Okt","C":"260","D":"96368","F":"130.5"},{"Policy Line":"68261006","B":"SubQ Non-Chemo Infusion 1stHR","C":"260","D":"96369","F":"190.8"},{"Policy Line":"68261007","B":"Non-Chemo Inj Im Sq Okt","C":"260","D":"96372","F":"102.6"},{"Policy Line":"68261008","B":"Non-Chemo IV Inj Intl Drug Ok","C":"260","D":"96374","F":"119.7"},{"Policy Line":"68261009","B":"Non-Chemo IV Inj Subsqt Ok","C":"260","D":"96375","F":"106.2"},{"Policy Line":"68261037","B":"IV Inj Seq Push Same Drug Addl","C":"260","D":"96376","F":"42.6"},{"Policy Line":"68262291","B":"Appl On-BodyInjtr/Timed SC Inj","C":"260","D":"96377","F":"138.9"},{"Policy Line":"68266109","B":"PPV Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"71701008","B":"Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"72050011","B":"IV Infusion Therapy 1St Hour","C":"260","D":"96365","F":"276.6"},{"Policy Line":"72050012","B":"IV Infusn Therapy Ea Addl 1Hr","C":"260","D":"96366","F":"201.9"},{"Policy Line":"72050251","B":"Injection: Iv Push Initl Drug","C":"260","D":"96374","F":"119.7"},{"Policy Line":"72052645","B":"Ea Sequential IV Push /New Dr","C":"260","D":"96375","F":"106.2"},{"Policy Line":"72151008","B":"ODS Flu Vaccination Admin","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"74200252","B":"Injection: SQ/IM","C":"260","D":"96372","F":"102.6"},{"Policy Line":"74201008","B":"Flu Vaccination Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"74201009","B":"Pnuemococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"74201011","B":"Vaccine Admin Initial","C":"771","D":"90471","F":"14.7"},{"Policy Line":"74221008","B":"Flu Vaccination Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"74221009","B":"Pnuemococcal Vaccine Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"74401000","B":"Hydration First Hour","C":"260","D":"96360","F":"251.4"},{"Policy Line":"74401001","B":"Hydration Each Additional Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"74401002","B":"Non-Chemo IV Infusion First H","C":"260","D":"96365","F":"276.6"},{"Policy Line":"74401003","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"74401004","B":"Sequential Infusion","C":"260","D":"96367","F":"147.9"},{"Policy Line":"74401005","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"74401006","B":"Non-Chemo Inj Sq/Im","C":"260","D":"96372","F":"102.6"},{"Policy Line":"74401007","B":"Non-Chemo IV Push Initial","C":"260","D":"96374","F":"119.7"},{"Policy Line":"74401008","B":"Ea Sequential IV Push /New Dr","C":"260","D":"96375","F":"106.2"},{"Policy Line":"74401020","B":"Flu Vaccine Administration","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"74401021","B":"PPV Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"74401026","B":"Vaccine Admin Initial","C":"771","D":"90471","F":"14.7"},{"Policy Line":"74401027","B":"Vaccine Admin Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"74401037","B":"IV Inj Seq Push Same Drug Addl","C":"260","D":"96376","F":"42.6"},{"Policy Line":"76970105","B":"Non-Chemo IV Infusin Ea Add H","C":"260","D":"96366","F":"201.9"},{"Policy Line":"76970110","B":"Non-Chemo IV Infusion First H","C":"260","D":"96365","F":"276.6"},{"Policy Line":"76970115","B":"Non-Chemo Inj Sq/Im","C":"260","D":"96372","F":"102.6"},{"Policy Line":"76970240","B":"Non-Chemo IV Push Initial","C":"260","D":"96374","F":"119.7"},{"Policy Line":"76970251","B":"Hydration First Hour","C":"260","D":"96360","F":"251.4"},{"Policy Line":"76970252","B":"Hydration Each Additional Hour","C":"260","D":"96361","F":"102.6"},{"Policy Line":"76970253","B":"Vaccine Admin Initial","C":"771","D":"90471","F":"14.7"},{"Policy Line":"76970254","B":"Vaccine Admin Ea Addl","C":"771","D":"90472","F":"27.9"},{"Policy Line":"76970255","B":"Sequential Infusion","C":"260","D":"96367","F":"147.9"},{"Policy Line":"76970256","B":"Concurrent Infusion","C":"260","D":"96368","F":"130.5"},{"Policy Line":"76970257","B":"Hep B Vaccine Admin","C":"771","D":"G0010","F":"18.9"},{"Policy Line":"76970258","B":"Hepatitis B Vaccine Admin 1.0","C":"771","D":"G0010","F":"14.7"},{"Policy Line":"76970510","B":"Admin Immuniz Flu Vaccine x1","C":"771","D":"G0008","F":"14.7"},{"Policy Line":"76971006","B":"SubQ Non-Chemo Infusion 1stHR","C":"260","D":"96369","F":"190.8"},{"Policy Line":"76971009","B":"PPV Admin","C":"771","D":"G0009","F":"14.7"},{"Policy Line":"76971037","B":"IV Inj Seq Push Same Drug Addl","C":"260","D":"96376","F":"42.6"},{"Policy Line":"76972291","B":"Appl On-BodyInjtr/Timed SC Inj","C":"260","D":"96377","F":"138.9"},{"Policy Line":"76972645","B":"Ea Sequential IV Push /New Dr","C":"260","D":"96375","F":"106.2"},{"Policy Line":"0119","B":"Breast BX US W/Clip Add Lesion","C":"361","D":"19084","F":"311.4"},{"Policy Line":"0121","B":"Breast Loc Devic 1stLsn Stereo","C":"361","D":"19081","F":"1534.8"},{"Policy Line":"0122","B":"Breast Bx W/Clip Stereo Addl","C":"361","D":"19082","F":"683.4"},{"Policy Line":"0123","B":"Brst Loc w/Mammo Guidance 1st","C":"361","D":"19281","F":"547.2"},{"Policy Line":"0125","B":"Brst Loc DeviceW/US Guidnc 1st","C":"361","D":"19285","F":"832.8"},{"Policy Line":"0126","B":"Brst Loc Devic W/US Addl Leson","C":"361","D":"19286","F":"832.8"},{"Policy Line":"0128","B":"LOCALIZATION BI MAMMO GUIDED","C":"361","D":"19281","F":"547.2"},{"Policy Line":"0154","B":"BX Breast 1st Lesn STRTCTC RT","C":"361","D":"19081","F":"1534.8"},{"Policy Line":"0156","B":"BX Breast 1st Lesn STRTCTC BI","C":"361","D":"19081","F":"1534.8"},{"Policy Line":"0187","B":"BX Breast 1st Lesn STRTCTC LT","C":"361","D":"19081","F":"1534.8"},{"Policy Line":"0224","B":"LOCALIZATION W/MAM ADDL LESION","C":"361","D":"19282","F":"547.2"},{"Policy Line":"0236","B":"Breast Bx US Guided LT","C":"361","D":"19083","F":"1157.1"},{"Policy Line":"0237","B":"Breast Bx US Guided RT","C":"361","D":"19083","F":"1157.1"},{"Policy Line":"0239","B":"Breast Bx US Guided BI","C":"361","D":"19083","F":"2313.9"},{"Policy Line":"1191","B":"MRI IMAG BX BREAST 1ST LESION","C":"361","D":"19085","F":"1289.1"},{"Policy Line":"1192","B":"MR IMAG BX BREAST ADD LESION","C":"361","D":"19086","F":"1092.9"},{"Policy Line":"4233","B":"ABLATION 1 OR MORE LIVERTUMORS","C":"361","D":"47382","F":"3753.6"},{"Policy Line":"4237","B":"MW ABLATION - LIVER TUMOR","C":"361","D":"47399","F":"480.3"},{"Policy Line":"4238","B":"MW ABLATION-LUNG/PLEURA TUMOR","C":"361","D":"32999","F":"609.3"},{"Policy Line":"4239","B":"MW ABLATION- KIDNEY TUMOR","C":"361","D":"53899","F":"204.6"},{"Policy Line":"61050515","B":"4N Exchange Transfusion","C":"391","D":"36455","F":"326.1"},{"Policy Line":"61150515","B":"Exchange Transfusion","C":"391","D":"36455","F":"326.1"},{"Policy Line":"61300516","B":"Exchange Transfusion","C":"391","D":"36455","F":"326.1"},{"Policy Line":"61552998","B":"External Version","C":"761","D":"59412","F":"1696.5"},{"Policy Line":"61600189","B":"Blood Exchng Transfusn-Newborn","C":"761","D":"36450","F":"1265.7"},{"Policy Line":"61600220","B":"Umbilical Artery Cath Newborn","C":"761","D":"36660","F":"537.3"},{"Policy Line":"61600221","B":"Umbilical Vein Catherization","C":"761","D":"36510","F":"537.3"},{"Policy Line":"65103505","B":"Intubation","C":"450","D":"31500","F":"155.1"},{"Policy Line":"68300257","B":"Fiducial Markr Placmnt-Prostat","C":"361","D":"55876","F":"936"},{"Policy Line":"71700014","B":"Para Abdomen w/o Imaging","C":"361","D":"49082","F":"390"},{"Policy Line":"71703505","B":"Intubation, Emergency Endotrac","C":"761","D":"31500","F":"155.1"},{"Policy Line":"7173","B":"EPIDRM AGRFT TAL 100CM2/1%%BA","C":"361","D":"15110","F":"858"},{"Policy Line":"7174","B":"EPIDRMAGRFT TAL100CM2/1%%BA AD","C":"361","D":"15111","F":"330"},{"Policy Line":"7175","B":"EPIDRMAGRFT FNHG 100CM2/1%%BA","C":"361","D":"15115","F":"858"},{"Policy Line":"7176","B":"EPIDRMAGRFT FNHG100CM2/1%%BAAD","C":"361","D":"15116","F":"330"},{"Policy Line":"7180","B":"SS APP T/A/L 1ST 25 SQCM (100)","C":"361","D":"15271","F":"1286.4"},{"Policy Line":"7181","B":"SS APP T/A/L EA ADD 25CM (100)","C":"361","D":"15272","F":"271.5"},{"Policy Line":"7182","B":"SS APP TAL 1ST 100SQCM >100CHL","C":"361","D":"15273","F":"1948.2"},{"Policy Line":"7183","B":"SS APP T/A/L ADD 100 CM >100","C":"361","D":"15274","F":"1120.5"},{"Policy Line":"7184","B":"SS APP H/N/H/F 1ST 25 CM (100)","C":"361","D":"15275","F":"1286.4"},{"Policy Line":"7185","B":"SS APP H/N/H/F EA ADD 25 CM","C":"361","D":"15276","F":"253.8"},{"Policy Line":"7186","B":"SS APP H/N/H/F 1ST 100 SQCM","C":"361","D":"15277","F":"948.3"},{"Policy Line":"7187","B":"SS APP H/N/H/F ADD 100 CM >100","C":"361","D":"15278","F":"135"},{"Policy Line":"7244","B":"Surg/Wound Prep trk/arm/leg","C":"361","D":"15002","F":"600"},{"Policy Line":"7245","B":"Addl Prep trk/arm/leg 100 cm","C":"361","D":"15003","F":"600"},{"Policy Line":"7246","B":"Surg/Wound Prep f/n/hf/g","C":"361","D":"15004","F":"450"},{"Policy Line":"7247","B":"Addl Prep f/n/hf/g 100 cm","C":"361","D":"15005","F":"450"},{"Policy Line":"73100313","B":"Intubation","C":"361","D":"31500","F":"155.1"},{"Policy Line":"0007","B":"PUNCTURE CYST ASPIRATION -ADDL","C":"361","D":"19001","F":"177"},{"Policy Line":"0149","B":"US Urine Bladder Vol Post Void","C":"361","D":"51798","F":"142.2"},{"Policy Line":"0157","B":"BX Lymph Node LT -Perc Ndl","C":"361","D":"38505","F":"1464.9"},{"Policy Line":"0158","B":"BX Lymph Node RT -Perc Ndl","C":"361","D":"38505","F":"1464.9"},{"Policy Line":"0159","B":"BX Lymph Node BI -Perc Ndl","C":"361","D":"38505","F":"2195.4"},{"Policy Line":"0253","B":"Complex Cystometrogram","C":"361","D":"51726","F":"636.3"},{"Policy Line":"0254","B":"Complex Cystometrogram W/VP","C":"920","D":"51728","F":"732.3"},{"Policy Line":"0255","B":"Complex Uroflowmetry","C":"920","D":"51741","F":"157.2"},{"Policy Line":"0257","B":"Intra-Abdominal Pressure","C":"920","D":"51797","F":"162.3"},{"Policy Line":"0259","B":"Breast Cyst Punct Asp Sgl Cyst","C":"361","D":"19000","F":"582.6"},{"Policy Line":"0261","B":"Breast FNA Inital Site","C":"361","D":"10011","F":"236.7"},{"Policy Line":"0263","B":"Breast FNA Addl Site","C":"361","D":"10010","F":"236.7"},{"Policy Line":"0268","B":"Dye Injection","C":"361","D":"19030","F":"72.9"},{"Policy Line":"2211","B":"Injection Hip","C":"361","D":"20610","F":"271.8"},{"Policy Line":"5043","B":"Percutaneous Sacroplasty Uni","C":"361","D":"0200T","F":"3996.3"},{"Policy Line":"5044","B":"Percutaneous Sacroplasty Bil","C":"361","D":"0201T","F":"3996.3"},{"Policy Line":"5046","B":"CT GUIDED FNA SURG COMPONENT","C":"361","D":"10009","F":"217.2"},{"Policy Line":"60950518","B":"Blood Admin 1 Unit - 1North","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61050508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61100508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61150157","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61200108","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61250508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61300508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61350508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61400508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61450100","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61500508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61500555","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61505890","B":"Circumcision Of Male Baby","C":"723","D":"54150","F":"987"},{"Policy Line":"61552950","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61555810","B":"Non-Stress Test","C":"920","D":"59025","F":"528"},{"Policy Line":"61555820","B":"Stress Test","C":"721","D":"59020","F":"225.3"},{"Policy Line":"61555890","B":"Circumcision Of Male Baby","C":"723","D":"54150","F":"987"},{"Policy Line":"61600006","B":"Circumcision Of Male Baby","C":"723","D":"54150","F":"987"},{"Policy Line":"61600190","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61700108","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61800508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61850508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"61900508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"62100508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"62200508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"6234","B":"Ablation 1 or More RenalTumors","C":"361","D":"50592","F":"5168.1"},{"Policy Line":"63100100","B":"Hemodialysis (OP Emergent)","C":"829","D":"G0257","F":"937.8"},{"Policy Line":"63100110","B":"Plasmapheresis","C":"940","D":"36514","F":"3947.4"},{"Policy Line":"63100111","B":"Cytopheresis","C":"940","D":"36511","F":"4751.7"},{"Policy Line":"63100112","B":"RBC Apheresis","C":"940","D":"36512","F":"2288.1"},{"Policy Line":"63100113","B":"Leukopheresis","C":"940","D":"36511","F":"4751.7"},{"Policy Line":"63100508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"63200025","B":"EMG Needle 2 Extrem","C":"922","D":"95861","F":"607.2"},{"Policy Line":"63200110","B":"Emg Needle 4 Extrem","C":"922","D":"95864","F":"788.4"},{"Policy Line":"63200111","B":"EMG Needle 1 Extrem","C":"922","D":"95860","F":"197.1"},{"Policy Line":"63200114","B":"EMG Needle 3 Extrem","C":"922","D":"95863","F":"697.8"},{"Policy Line":"63250006","B":"EMG Needle 1 Extrem","C":"922","D":"95860","F":"197.1"},{"Policy Line":"63250007","B":"EMG Needle 3 Extrem","C":"922","D":"95863","F":"697.8"},{"Policy Line":"63250008","B":"EMG Needle 2 Extrem","C":"922","D":"95861","F":"607.2"},{"Policy Line":"63600001","B":"ADVNCD CARE PLAN 1ST 30MIN","C":"510","D":"99497","F":"83.4"},{"Policy Line":"63600010","B":"ADVNCD CARE PLAN ADDL 30MIN","C":"510","D":"99498","F":"83.4"},{"Policy Line":"64100009","B":"ESWL","C":"790","D":"50590","F":"14662.8"},{"Policy Line":"64100785","B":"EMG Two Extremities","C":"922","D":"95861","F":"607.2"},{"Policy Line":"64100786","B":"Needle EMG Anal/Ureth Sphinctr","C":"361","D":"51785","F":"250.5"},{"Policy Line":"64100789","B":"EMG Cranial Nerve Unilat","C":"922","D":"95867","F":"66.3"},{"Policy Line":"64100791","B":"EMG Cranial Nerve BI","C":"922","D":"95868","F":"66.3"},{"Policy Line":"64100792","B":"EMG Four Extremities","C":"922","D":"95864","F":"788.4"},{"Policy Line":"64100865","B":"Cell Saver Transfusion","C":"391","D":"36430","F":"423.6"},{"Policy Line":"64150108","B":"Blood Admin","C":"391","D":"36430","F":"423.6"},{"Policy Line":"64200108","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"64300101","B":"Cardioversion, External, Elect","C":"480","D":"92960","F":"4080.6"},{"Policy Line":"64300108","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"64500186","B":"Emg","C":"761","D":"51784","F":"165.9"},{"Policy Line":"64502013","B":"Bravo Procedure","C":"761","D":"91035","F":"1723.5"},{"Policy Line":"64502016","B":"24 Hour Ph Probe Study","C":"761","D":"91034","F":"1723.5"},{"Policy Line":"64504170","B":"Blood Transfusion X 1","C":"391","D":"36430","F":"423.6"},{"Policy Line":"64606325","B":"Cardioversion","C":"361","D":"92960","F":"4080.6"},{"Policy Line":"65100094","B":"INJ ANESTH,OTHR PERIPH NRV/BRN","C":"450","D":"64450","F":"468.3"},{"Policy Line":"65100104","B":"Replacement Suprapubic Cath","C":"450","D":"51705","F":"165.6"},{"Policy Line":"65100260","B":"PICC Line/VAD Declot","C":"450","D":"36593","F":"228.9"},{"Policy Line":"65100508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"65102101","B":"Nebulizer Ther Initial Tx","C":"410","D":"94640","F":"82.5"},{"Policy Line":"65103501","B":"Chest Tube Insertion","C":"450","D":"32551","F":"585.6"},{"Policy Line":"65103502","B":"Intraosseous Infusion","C":"450","D":"36680","F":"303.9"},{"Policy Line":"65105380","B":"CL Placement >=5 Yrs","C":"450","D":"36556","F":"1869.6"},{"Policy Line":"65106305","B":"Rem Impct Ear Wax, Lavage, Uni","C":"450","D":"69209","F":"66"},{"Policy Line":"68251026","B":"Declot VAD/Picc Line","C":"361","D":"36593","F":"228.9"},{"Policy Line":"68251045","B":"Therapeutic Phlebotomy","C":"940","D":"99195","F":"135"},{"Policy Line":"68260260","B":"PICC Line Blood Draw","C":"361","D":"36592","F":"169.5"},{"Policy Line":"68261026","B":"Declot VAD/Picc Line","C":"361","D":"36593","F":"228.9"},{"Policy Line":"68261045","B":"Therapuetic Phlebotomy","C":"940","D":"99195","F":"135"},{"Policy Line":"68262351","B":"Vad Blood Draw","C":"761","D":"36591","F":"169.5"},{"Policy Line":"68266110","B":"INITIATION INFUSION >8HRS","C":"761","D":"C8957","F":"258.6"},{"Policy Line":"70100621","B":"Phlebotomy Therapeutic","C":"949","D":"99195","F":"135"},{"Policy Line":"70205005","B":"Therapeutic Apheresis","C":"940","D":"36514","F":"3947.4"},{"Policy Line":"70206030","B":"Apheresis W/Col Abs","C":"940","D":"36516","F":"3656.4"},{"Policy Line":"70206045","B":"Therapeutic Cytophresis","C":"940","D":"36511","F":"4751.7"},{"Policy Line":"7104","B":"AVULSION OF NAIL PLATE (EA ADD","C":"361","D":"11732","F":"309.9"},{"Policy Line":"7105","B":"AVULSION OF NAIL PLATE (FIRST)","C":"361","D":"11730","F":"386.7"},{"Policy Line":"7106","B":"BENIGN LESION PARING","C":"361","D":"11055","F":"142.8"},{"Policy Line":"7107","B":"BENIGN LESION PARING (2-4)","C":"361","D":"11056","F":"142.8"},{"Policy Line":"7108","B":"BENIGN LESION PARING (>4)","C":"361","D":"11057","F":"309.9"},{"Policy Line":"7109","B":"BIOPSY (ADDITIONAL)","C":"361","D":"11103","F":"38.7"},{"Policy Line":"7110","B":"BIOPSY COLLECTION","C":"361","D":"11102","F":"250.8"},{"Policy Line":"71100017","B":"PICC Line Insertion VAD","C":"361","D":"36561","F":"1536.9"},{"Policy Line":"71100850","B":"Injection Hip w/ US Guid","C":"361","D":"20611","F":"490.5"},{"Policy Line":"7111","B":"CALLUC ABRASION <=4 LESNS","C":"361","D":"15787","F":"386.7"},{"Policy Line":"7112","B":"CALLUC ABRASION (SINGLE)","C":"361","D":"15786","F":"386.7"},{"Policy Line":"7113","B":"CAUTERY OF WOUND (CHEMICAL)","C":"361","D":"17250","F":"142.8"},{"Policy Line":"7114","B":"CLEAN OUTER EAR CANAL","C":"361","D":"69200","F":"110.4"},{"Policy Line":"7115","B":"DEBRIDEMENT OF NAILS (1-5)","C":"361","D":"11720","F":"110.4"},{"Policy Line":"7116","B":"DEBRIDEMENT OF NAILS (6 or >6)","C":"361","D":"11721","F":"216.6"},{"Policy Line":"7117","B":"I & D COMPLEX","C":"361","D":"10061","F":"276.9"},{"Policy Line":"7118","B":"I & D SIMPLE","C":"361","D":"10060","F":"120.3"},{"Policy Line":"7119","B":"REMOVE IMPACTED CERUMEN","C":"361","D":"69210","F":"254.7"},{"Policy Line":"7120","B":"REMVL OF FOREIGN BODY FRM FOOT","C":"361","D":"28190","F":"1185.3"},{"Policy Line":"7121","B":"SHORT LEG SPLINT APPLICATION","C":"361","D":"29515","F":"395.1"},{"Policy Line":"7123","B":"TRIM NONDYSTROPHIC NAIL (ANY #","C":"361","D":"11719","F":"275.7"},{"Policy Line":"7126","B":"WOUND DEBRIDE SUBQ <20 CM SQ","C":"361","D":"11042","F":"378"},{"Policy Line":"7127","B":"WOUND DEBRIDE BONE <20 CM SQ","C":"361","D":"11044","F":"1142.1"},{"Policy Line":"7128","B":"WOUND DEBRIDE MUSCLE <20 CM SQ","C":"361","D":"11043","F":"519.6"},{"Policy Line":"71400508","B":"Blood Transfusion Admin","C":"391","D":"36430","F":"423.6"},{"Policy Line":"7141","B":"Punch Biopsy Single Lesion","C":"361","D":"11104","F":"250.8"},{"Policy Line":"7142","B":"WOUND REPAIR SIMPLE UPTO2.5CM","C":"361","D":"12002","F":"317.1"},{"Policy Line":"7143","B":"WOUND REPAIR SIMPLE 7.6-12.5","C":"361","D":"12004","F":"369"},{"Policy Line":"7144","B":"AMPUTATION TOE TIP","C":"361","D":"28825","F":"1852.8"},{"Policy Line":"7145","B":"BURN DRSG/DEBRIDEMENT SMALL","C":"361","D":"16020","F":"142.8"},{"Policy Line":"7146","B":"BURN DRSG/DEBRIDEMENT MED","C":"361","D":"16025","F":"273.3"},{"Policy Line":"7147","B":"BURN DRSG/DEBRIDEMENT LG","C":"361","D":"16030","F":"273.3"},{"Policy Line":"7148","B":"I&D PILONIDAL CYST SIMPLE","C":"361","D":"10080","F":"648.9"},{"Policy Line":"7149","B":"I&D PILONIDAL CYST COMPLEX","C":"361","D":"10081","F":"3239.7"},{"Policy Line":"7150","B":"I&D HEMATOMA / SEROMA","C":"361","D":"10140","F":"525.3"},{"Policy Line":"7151","B":"ASPIRATION CYST/ABCSS/HMTMA","C":"361","D":"10160","F":"497.7"},{"Policy Line":"7152","B":"BX BONE NEEDLE/TROCAR","C":"361","D":"20220","F":"1966.8"},{"Policy Line":"7153","B":"BX BONE OPEN","C":"361","D":"20240","F":"4600.5"},{"Policy Line":"7154","B":"EXCISION NAIL PART/COMPLETE","C":"361","D":"11750","F":"914.4"},{"Policy Line":"7155","B":"DEBRIDEMENT SKIN <10% SRFC","C":"361","D":"11000","F":"519.6"},{"Policy Line":"7156","B":"DEBRIDEMENT SKIN ADDL 10% SFC","C":"361","D":"11001","F":"486.9"},{"Policy Line":"7157","B":"DEBRIDEMENT SKIN FX","C":"361","D":"11010","F":"1142.1"},{"Policy Line":"7158","B":"DEBRIDE SKIN & MUSCLE (FX)","C":"361","D":"11011","F":"1163.1"},{"Policy Line":"7159","B":"DEBRIDE SKIN/MSCL/BONE (FX)","C":"361","D":"11012","F":"1365"},{"Policy Line":"7162","B":"REMOVE FB SUBCUTANEOUS","C":"361","D":"10120","F":"773.1"},{"Policy Line":"7163","B":"EXCISION BENIGN LESION .6-1 CM","C":"361","D":"11401","F":"1539.9"},{"Policy Line":"7164","B":"EXCISION SKIN/SQ HYDRADENITIS","C":"361","D":"11451","F":"1812.6"},{"Policy Line":"7165","B":"WOUND DEBRIDE SUBQ EA ADDL 20","C":"361","D":"11045","F":"453"},{"Policy Line":"7166","B":"WOUND DEBRIDE MUSCLE ADD 20 CM","C":"361","D":"11046","F":"453"},{"Policy Line":"7167","B":"WOUND DEBRIDE BONE ADDL 20 CM","C":"361","D":"11047","F":"614.1"},{"Policy Line":"7168","B":"WND RPR COMPLEX 2.3-7.5 CM","C":"360","D":"13132","F":"742.8"},{"Policy Line":"7169","B":"EXCIS BEN LESN T/A/L 1.1-2.0CM","C":"361","D":"11402","F":"2123.4"},{"Policy Line":"71704402","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"71706325","B":"Cardioversion","C":"361","D":"92960","F":"4080.6"},{"Policy Line":"7192","B":"APPLY RIGID LEG CAST","C":"761","D":"29445","F":"252.3"},{"Policy Line":"7193","B":"REMOVAL/REVISION OF FOOT CAST","C":"761","D":"29700","F":"252.3"},{"Policy Line":"7194","B":"NEG PRESS WOUND TX < 50 CM DT","C":"761","D":"97605","F":"119.7"},{"Policy Line":"7195","B":"NEG PRESS WOUND TX > 50 CM DT","C":"761","D":"97606","F":"563.1"},{"Policy Line":"7196","B":"NON-SELECTIVE DEBRIDEMENT","C":"761","D":"97602","F":"314.7"},{"Policy Line":"7197","B":"SELECTIVE DEBRIDEMENT <20 CM","C":"761","D":"97597","F":"277.8"},{"Policy Line":"7198","B":"SELECT DEBRIDEMNT EA ADD 20 CM","C":"761","D":"97598","F":"258.6"},{"Policy Line":"7199","B":"UNNA BOOT APPLICATION","C":"761","D":"29580","F":"276"},{"Policy Line":"7200","B":"COMPRESSION WRAP APP/BELOW KNE","C":"761","D":"29581","F":"376.5"},{"Policy Line":"7201","B":"UNNA BOOT APP BILATERAL","C":"761","D":"29580","F":"276"},{"Policy Line":"7202","B":"COMPRESSION WRAP BILATERAL","C":"761","D":"29581","F":"376.5"},{"Policy Line":"7203","B":"HBO THERAPY PER 30 MIN","C":"413","D":"G0277","F":"297.9"},{"Policy Line":"72102502","B":"Plcmnt Occulsive Device","C":"761","D":"G0269","F":"137.7"},{"Policy Line":"72106325","B":"Cardioversion","C":"480","D":"92960","F":"4080.6"},{"Policy Line":"7211","B":"Appl Low Cost SS T A L 1st25","C":"361","D":"C5271","F":"1402.2"},{"Policy Line":"7212","B":"Appl Low Cost SS T A L Addl25","C":"361","D":"C5272","F":"295.8"},{"Policy Line":"7213","B":"Appl Low Cost SS T A L 1st100","C":"361","D":"C5273","F":"2123.4"},{"Policy Line":"7214","B":"Appl Low Cost SS T A L Addl100","C":"361","D":"C5274","F":"1221.3"},{"Policy Line":"7215","B":"Appl Low Cost SS H G EX 1st25","C":"361","D":"C5275","F":"1402.2"},{"Policy Line":"72150508","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"72156325","B":"Cardioversion","C":"480","D":"92960","F":"4080.6"},{"Policy Line":"7216","B":"Appl Low Cost SS H G EX Addl25","C":"361","D":"C5276","F":"276.6"},{"Policy Line":"7217","B":"Appl Low cost SS H G EX 1st100","C":"361","D":"C5277","F":"1033.5"},{"Policy Line":"7218","B":"Apl Low Cost SS H G EX Addl100","C":"361","D":"C5278","F":"147"},{"Policy Line":"72205155","B":"Cardioversion: External","C":"480","D":"92960","F":"4080.6"},{"Policy Line":"7231","B":"APP MULTLY COMPRSN LWR LG - LT","C":"761","D":"29581","F":"376.5"},{"Policy Line":"7232","B":"APP MULTLY COMPRSN LWR LG - RT","C":"761","D":"29581","F":"376.5"},{"Policy Line":"7236","B":"TX SUPRFIC WND DEHISC,SIMPL","C":"361","D":"12020","F":"536.4"},{"Policy Line":"7237","B":"TX SUPFCL WND DEHIS; W/PACKNG","C":"361","D":"12021","F":"549"},{"Policy Line":"7238","B":"NEG PRES WND TX DISPO <=50SQCM","C":"761","D":"97607","F":"346.8"},{"Policy Line":"7239","B":"NEG PRESS WND TX DISPO >50SQCM","C":"761","D":"97608","F":"395.4"},{"Policy Line":"73100001","B":"IPPB Initial Tx","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73100002","B":"Nebulizer Therapy Initial Tx","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73100007","B":"Cpt Initial","C":"410","D":"94667","F":"82.5"},{"Policy Line":"73100305","B":"MDI Initial Tx","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73100306","B":"MDI Treatment Subsequent","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73100309","B":"Chest Physio Subseq","C":"410","D":"94668","F":"83.1"},{"Policy Line":"73100311","B":"Nebulizer Therapy Subseq","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73100314","B":"IPPB Subsequent","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73100400","B":"External Chest Vibration Initi","C":"410","D":"94667","F":"82.5"},{"Policy Line":"73100713","B":"Ez Pap Initial Tx","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73100714","B":"Ez Pap Subsequent Tx","C":"410","D":"94640","F":"82.5"},{"Policy Line":"73103070","B":"MIPS / MEPS","C":"410","D":"G0237","F":"232.5"},{"Policy Line":"73203070","B":"MIPS / MEPS","C":"410","D":"G0237","F":"232.5"},{"Policy Line":"73203079","B":"Nebulizer Subsequent","C":"410","D":"94640","F":"82.5"},{"Policy Line":"74400185","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"74401018","B":"INITIATION INFUSION >8HRS","C":"761","D":"C8957","F":"258.6"},{"Policy Line":"74401023","B":"PICC Line Blood Draw","C":"761","D":"36592","F":"169.5"},{"Policy Line":"74401024","B":"Port-A-Cath Blood Draw","C":"761","D":"36591","F":"169.5"},{"Policy Line":"74401025","B":"Therapuetic Phlebotomy","C":"761","D":"99195","F":"135"},{"Policy Line":"74401030","B":"Declot Picc Line/Vad","C":"361","D":"36593","F":"228.9"},{"Policy Line":"75100050","B":"Dry Needling 1-2 Muscles","C":"420","D":"20560","F":"47.1"},{"Policy Line":"75100051","B":"Dry Needling 3++ Muscles","C":"420","D":"20561","F":"61.5"},{"Policy Line":"75100108","B":"Unna Boot Application","C":"420","D":"29580","F":"276"},{"Policy Line":"75102102","B":"Electrical Stim","C":"420","D":"G0283","F":"66.3"},{"Policy Line":"75102117","B":"Compression Wrap App Uni","C":"420","D":"29581","F":"376.5"},{"Policy Line":"75102118","B":"Compression Wrap App Bilateral","C":"420","D":"29581","F":"376.5"},{"Policy Line":"75102665","B":"Wound Care Select <= 20 Sq Cm","C":"420","D":"97597","F":"277.8"},{"Policy Line":"75103004","B":"Wound Care Select Ea Add 20 Cm","C":"420","D":"97598","F":"258.6"},{"Policy Line":"75103030","B":"Wound Care - Non Select","C":"420","D":"97602","F":"314.7"},{"Policy Line":"75110050","B":"Dry Needling 1-2 Muscles","C":"420","D":"20560","F":"47.1"},{"Policy Line":"75110051","B":"Dry Needling 3++ Muscles","C":"420","D":"20561","F":"61.5"},{"Policy Line":"75110108","B":"Unna Boot Application","C":"420","D":"29580","F":"276"},{"Policy Line":"75112102","B":"Electrical Stim","C":"420","D":"G0283","F":"66.3"},{"Policy Line":"75112665","B":"Wound Care Select <=20 Sq Cm","C":"420","D":"97597","F":"277.8"},{"Policy Line":"75113004","B":"Wound Care Select Ea Add 20 Cm","C":"420","D":"97598","F":"258.6"},{"Policy Line":"75113030","B":"Wound Care - Non Select","C":"420","D":"97602","F":"314.7"},{"Policy Line":"75140108","B":"Unna Boot Application","C":"420","D":"29580","F":"276"},{"Policy Line":"75142102","B":"ELECTRIC STIM THERAPY 1++ AREA","C":"420","D":"G0283","F":"66.3"},{"Policy Line":"75142665","B":"Wound Care Select <=20 Sq Cm","C":"420","D":"97597","F":"277.8"},{"Policy Line":"75143004","B":"Wound Care Select Ea Add 20 Cm","C":"420","D":"97598","F":"258.6"},{"Policy Line":"75143030","B":"Wound Care Non Select","C":"420","D":"97602","F":"314.7"},{"Policy Line":"75150050","B":"Dry Needling 1-2 Muscles","C":"420","D":"20560","F":"47.1"},{"Policy Line":"75150051","B":"Dry Needling 3++ Muscles","C":"420","D":"20561","F":"61.5"},{"Policy Line":"75152102","B":"Electrical Stim","C":"420","D":"G0283","F":"66.3"},{"Policy Line":"75152665","B":"Wound Care Select <=20 Sq Cm","C":"420","D":"97597","F":"277.8"},{"Policy Line":"75153004","B":"Wound Care Select Ea Add 20 Cm","C":"420","D":"97598","F":"258.6"},{"Policy Line":"75160050","B":"Dry Needling 1-2 Muscles","C":"420","D":"20560","F":"47.1"},{"Policy Line":"75160051","B":"Dry Needling 3++ Muscles","C":"420","D":"20561","F":"61.5"},{"Policy Line":"75162102","B":"Electric Stim Unattended>1area","C":"420","D":"G0283","F":"66.3"},{"Policy Line":"75162665","B":"Wound Care Select <=20 Sq Cm","C":"420","D":"97597","F":"277.8"},{"Policy Line":"75163004","B":"Wound Care Select Ea Add 20 cm","C":"420","D":"97598","F":"258.6"},{"Policy Line":"75200050","B":"Dry Needling 1-2 Muscles","C":"430","D":"20560","F":"47.1"},{"Policy Line":"75200051","B":"Dry Needling 3++Muscles","C":"430","D":"20561","F":"61.5"},{"Policy Line":"75202102","B":"Electrical Stim","C":"430","D":"G0283","F":"66.3"},{"Policy Line":"75202117","B":"Comp Wrap Rt Lower Leg","C":"430","D":"29581","F":"376.5"},{"Policy Line":"75202118","B":"Comp Wrap Lt Lower Leg","C":"430","D":"29581","F":"376.5"},{"Policy Line":"75202123","B":"Comp Wrap Rt Arm/Hand/Fingers","C":"430","D":"29584","F":"239.4"},{"Policy Line":"75202124","B":"Comp Wrap Lt Arm/Hand/Fingers","C":"430","D":"29584","F":"239.4"},{"Policy Line":"75203004","B":"Wnd Care SelDeb Ea Add 20 Cm","C":"430","D":"97598","F":"258.6"},{"Policy Line":"75203030","B":"Wnd Care Non-Sel Debridement","C":"430","D":"97602","F":"314.7"},{"Policy Line":"75203665","B":"Wound Care Select <=20 Sq Cm","C":"430","D":"97597","F":"277.8"},{"Policy Line":"75370169","B":"Rpr Trnk Cmplx 2.6-7.5CM","C":"361","D":"13101","F":"1033.5"},{"Policy Line":"75375600","B":"Selective Debridement <20 Cm","C":"761","D":"97597","F":"277.8"},{"Policy Line":"75375602","B":"Select Debridemnt Ea Add 20 Cm","C":"761","D":"97598","F":"258.6"},{"Policy Line":"75375604","B":"Non-Selective Debridement","C":"761","D":"97602","F":"314.7"},{"Policy Line":"75375606","B":"Negative Pressure <50 Cm Sjc","C":"761","D":"97605","F":"119.7"},{"Policy Line":"75375608","B":"Negative Pressure >50 Cm Sjc","C":"761","D":"97606","F":"563.1"},{"Policy Line":"75375610","B":"Unna Boot Application","C":"761","D":"29580","F":"276"},{"Policy Line":"75390004","B":"Pavd Or Vad Declot/Repair (Iv)","C":"761","D":"36593","F":"228.9"},{"Policy Line":"75390006","B":"PICC Insertion (Iv)","C":"361","D":"36569","F":"1046.4"},{"Policy Line":"75390018","B":"PICC Replacement","C":"361","D":"36584","F":"1046.4"},{"Policy Line":"75395380","B":"CL Placement Non-Tun >=5 Yrs","C":"361","D":"36556","F":"1869.6"},{"Policy Line":"76970180","B":"Declot VAD/Picc Line","C":"361","D":"36593","F":"228.9"},{"Policy Line":"76970185","B":"Blood Administration - 1 Unit","C":"391","D":"36430","F":"423.6"},{"Policy Line":"76970260","B":"PICC Line Blood Draw","C":"361","D":"36592","F":"169.5"},{"Policy Line":"76971045","B":"Therapuetic Phlebotomy","C":"940","D":"99195","F":"135"},{"Policy Line":"76972351","B":"Vad Blood Draw","C":"761","D":"36591","F":"169.5"},{"Policy Line":"77200600","B":"MNT Individual Initial-15Min","C":"942","D":"97802","F":"48"},{"Policy Line":"77200601","B":"MNT Individual Subsqt - 15min","C":"942","D":"97803","F":"48"},{"Policy Line":"77200602","B":"MNT Group 30 MIN","C":"942","D":"97804","F":"16.2"},{"Policy Line":"0078","B":"CHEMO INTRATHECAL","C":"331","D":"96450","F":"409.2"},{"Policy Line":"61051013","B":"Chemo IV Push Add'L Drug","C":"331","D":"96411","F":"123.6"},{"Policy Line":"61051014","B":"Chemo IV Infusion 1StHr IniDrg","C":"335","D":"96413","F":"276.6"},{"Policy Line":"61051015","B":"Chemo IV Infusion Ea Addl Hr","C":"335","D":"96415","F":"221.7"},{"Policy Line":"61051016","B":"Chemo Infuse 8++Hrs - Pump","C":"335","D":"96416","F":"254.1"},{"Policy Line":"61051017","B":"Chemo IV Infus Addl Sequen/Hr","C":"335","D":"96417","F":"90.9"},{"Policy Line":"61051024","B":"VAD Irrigation","C":"260","D":"96523","F":"109.5"},{"Policy Line":"61052320","B":"Chemo: Sc/Im Non-Hormonal","C":"331","D":"96401","F":"171.9"},{"Policy Line":"61055011","B":"Chemo: IV Push Initial","C":"331","D":"96409","F":"234.6"},{"Policy Line":"64505003","B":"Remicade Infusion 1St Hour","C":"335","D":"96413","F":"276.6"},{"Policy Line":"64505004","B":"Remicade Infusion Ea Addl Hour","C":"335","D":"96415","F":"221.7"},{"Policy Line":"65101024","B":"VAD Irrigation","C":"260","D":"96523","F":"109.5"},{"Policy Line":"68251010","B":"Chemo Inj Im/Sq Non-Hormon Hhi","C":"331","D":"96401","F":"171.9"},{"Policy Line":"68251011","B":"Chemo Inj Im/Sq Hormonal Hhi","C":"331","D":"96402","F":"138.6"},{"Policy Line":"68251012","B":"Chemo IV Inj Initial Drug Hh","C":"331","D":"96409","F":"234.6"},{"Policy Line":"68251013","B":"Chemo IV Inj Subsqnt Drug Hh","C":"331","D":"96411","F":"123.6"},{"Policy Line":"68251014","B":"Chemo IV Infusion 1StHr IniDrg","C":"335","D":"96413","F":"276.6"},{"Policy Line":"68251015","B":"Chemo IV Infusn Ea Add Hr Hh","C":"335","D":"96415","F":"221.7"},{"Policy Line":"68251016","B":"Chemo Infuse 8+Hrs - Pump","C":"335","D":"96416","F":"254.1"},{"Policy Line":"68251017","B":"Chemo IV Inf Add'l Sequential","C":"335","D":"96417","F":"90.9"},{"Policy Line":"68251018","B":"Chemo Intra-Arterial Push","C":"331","D":"96420","F":"138.3"},{"Policy Line":"68251019","B":"Chemo Via Thoracentesis","C":"335","D":"96440","F":"141"},{"Policy Line":"68251020","B":"Chemo Into Peritoneal Cav","C":"335","D":"96446","F":"141"},{"Policy Line":"68251021","B":"Chemo Intrathecal W LP","C":"331","D":"96450","F":"409.2"},{"Policy Line":"68251022","B":"Portable Pump Refill/Maint Hhi","C":"335","D":"96521","F":"207.9"},{"Policy Line":"68251023","B":"Implanted Pump Refill/Main Hhi","C":"260","D":"96522","F":"191.1"},{"Policy Line":"68251024","B":"VAD Irrigation Hhi","C":"260","D":"96523","F":"109.5"},{"Policy Line":"68251025","B":"Chemo Inj Subarach/Intravent","C":"331","D":"96542","F":"128.1"},{"Policy Line":"68252264","B":"Chemo Admin:Intralesnl<=7Lesns","C":"331","D":"96405","F":"36"},{"Policy Line":"68261010","B":"Chemo Inj Im/Sq Non-Hormon Okt","C":"331","D":"96401","F":"171.9"},{"Policy Line":"68261011","B":"Chemo Inj Im/Sq Hormonal Okt","C":"331","D":"96402","F":"138.6"},{"Policy Line":"68261012","B":"Chemo IV Inj Initial Drug Ok","C":"331","D":"96409","F":"234.6"},{"Policy Line":"68261013","B":"Chemo IV Inj Subsequent Ok","C":"331","D":"96411","F":"123.6"},{"Policy Line":"68261014","B":"Chemo IV Infusion 1St Hr Ok","C":"335","D":"96413","F":"276.6"},{"Policy Line":"68261015","B":"Chemo IV Infusn Ea Addl Hr Ok","C":"335","D":"96415","F":"221.7"},{"Policy Line":"68261016","B":"Chemo Infuse 8+Hrs - Pump","C":"335","D":"96416","F":"254.1"},{"Policy Line":"68261017","B":"Chemo IV Inf Add'l Sequential","C":"335","D":"96417","F":"90.9"},{"Policy Line":"68261018","B":"Chemo Intra-Arterial Push Okt","C":"331","D":"96420","F":"138.3"},{"Policy Line":"68261019","B":"Chemo Via Thoracentesis Okt","C":"335","D":"96440","F":"141"},{"Policy Line":"68261020","B":"Chemo Into Peritoneal Cav Okt","C":"335","D":"96446","F":"141"},{"Policy Line":"68261021","B":"Chemo Intrathecal W LP","C":"331","D":"96450","F":"409.2"},{"Policy Line":"68261022","B":"Portable Pump Refill/Maint Okt","C":"260","D":"96521","F":"207.9"},{"Policy Line":"68261023","B":"Implanted Pump Refill/Main Okt","C":"260","D":"96522","F":"191.1"},{"Policy Line":"68261024","B":"Vad Irrigation Okt","C":"761","D":"96523","F":"109.5"},{"Policy Line":"68261025","B":"Chemo Inj Subarach/Intravent","C":"331","D":"96542","F":"128.1"},{"Policy Line":"68262264","B":"Chemo Admin:Intralesnl<=7Lesns","C":"331","D":"96405","F":"36"},{"Policy Line":"68262265","B":"Chemo Admin:Intralesnl>=7Lesns","C":"331","D":"96406","F":"144"},{"Policy Line":"68300259","B":"Fiducial Markr Placmnt-NonPros","C":"333","D":"49411","F":"850.8"},{"Policy Line":"71700181","B":"Port Flush","C":"761","D":"96523","F":"109.5"},{"Policy Line":"74401009","B":"MAB/BRN Subq/Im Non-Hormonal","C":"331","D":"96401","F":"171.9"},{"Policy Line":"74401011","B":"MAB/BRN IV Push Initial","C":"331","D":"96409","F":"234.6"},{"Policy Line":"74401012","B":"MAB/BRN IV Push Add'L Drug","C":"331","D":"96411","F":"123.6"},{"Policy Line":"74401013","B":"MAB/BRN IV Infusion First Hr","C":"335","D":"96413","F":"276.6"},{"Policy Line":"74401014","B":"MAB/BRN Infusion Ea Add 1Hr","C":"335","D":"96415","F":"221.7"},{"Policy Line":"74401016","B":"MAB/BRN IV Infus Add'l Sequen","C":"335","D":"96417","F":"90.9"},{"Policy Line":"74401017","B":"Cadd Pump Refill/Maintenance","C":"761","D":"96521","F":"207.9"},{"Policy Line":"74401022","B":"Vad Irrigation","C":"761","D":"96523","F":"109.5"},{"Policy Line":"76970130","B":"Chemo Intrathecal W LP","C":"331","D":"96450","F":"409.2"},{"Policy Line":"76970145","B":"Chemo: IV Push Initial","C":"331","D":"96409","F":"234.6"},{"Policy Line":"76970155","B":"Chemo Infuse 8+Hrs - Pump","C":"335","D":"96416","F":"254.1"},{"Policy Line":"76970160","B":"Chemo IV Infusion First Hr","C":"335","D":"96413","F":"276.6"},{"Policy Line":"76970170","B":"Chemo: Infusion Ea Add 1Hr","C":"335","D":"96415","F":"221.7"},{"Policy Line":"76971023","B":"Implanted Pump Refill/Main","C":"260","D":"96522","F":"191.1"},{"Policy Line":"76971024","B":"Vad Irrigation","C":"260","D":"96523","F":"109.5"},{"Policy Line":"76972264","B":"Chemo Admin:Intralesnl<=7Lesns","C":"331","D":"96405","F":"36"},{"Policy Line":"76972265","B":"Chemo Admin:Intralesnl>=7Lesns","C":"331","D":"96406","F":"144"},{"Policy Line":"76972300","B":"Chemo-Pump/Refill/Dc - Port","C":"335","D":"96521","F":"207.9"},{"Policy Line":"76972320","B":"Chemo: Sc/Im Non-Hormonal","C":"331","D":"96401","F":"171.9"},{"Policy Line":"76972321","B":"Chemo Inj: Sq/Im Hormonal","C":"331","D":"96402","F":"138.6"},{"Policy Line":"76972348","B":"Chemo IV Push Add'L Drug","C":"331","D":"96411","F":"123.6"},{"Policy Line":"76972349","B":"Chemo IV Infus Addl Sequen/Hr","C":"335","D":"96417","F":"90.9"},{"Policy Line":"0179","B":"Zevalin Therapuetic Admin","C":"340","D":"79403","F":"1201.8"},{"Policy Line":"2106","B":"Superv Hnd Load- Rad Source","C":"333","D":"77790","F":"189.9"},{"Policy Line":"5509","B":"Brachytherapy-Interstitial Com","C":"333","D":"77778","F":"1099.5"},{"Policy Line":"5514","B":"Brachyth-Intracav-Complex","C":"333","D":"77763","F":"1248.9"},{"Policy Line":"5515","B":"Basic Dosimetry Calculation","C":"333","D":"77300","F":"243.9"},{"Policy Line":"68300005","B":"Simulation Simple","C":"333","D":"77280","F":"409.5"},{"Policy Line":"68300010","B":"Simulation Intermediate","C":"333","D":"77285","F":"576.3"},{"Policy Line":"68300015","B":"Simulation Complex","C":"333","D":"77290","F":"787.2"},{"Policy Line":"68300017","B":"Special Treatment Proc (Srs)","C":"333","D":"77470","F":"1078.8"},{"Policy Line":"68300018","B":"Port Films Rad Image (SRS)","C":"333","D":"77417","F":"106.5"},{"Policy Line":"68300020","B":"Simulation 3D","C":"333","D":"77295","F":"2529.3"},{"Policy Line":"68300025","B":"Basic Dosimetry Calculation","C":"333","D":"77300","F":"243.9"},{"Policy Line":"68300030","B":"IMRT Planning","C":"333","D":"77301","F":"2635.2"},{"Policy Line":"68300041","B":"Telethx Isodose Plan, Simple","C":"333","D":"77306","F":"608.1"},{"Policy Line":"68300046","B":"Telethx Isodose Plan, Complex","C":"333","D":"77307","F":"821.1"},{"Policy Line":"68300050","B":"Special Teletherapy Port Plan","C":"333","D":"77321","F":"509.7"},{"Policy Line":"68300056","B":"Brachytx Isodose Plan Simple","C":"333","D":"77316","F":"583.8"},{"Policy Line":"68300061","B":"Brachytx Isodose Plan Interm w","C":"333","D":"77317","F":"736.5"},{"Policy Line":"68300066","B":"Brachytx Isodose Plan Complx w","C":"333","D":"77318","F":"921.3"},{"Policy Line":"68300070","B":"Special Dosimetry","C":"333","D":"77331","F":"184.8"},{"Policy Line":"68300075","B":"Treatment Devices Simple","C":"333","D":"77332","F":"224.1"},{"Policy Line":"68300080","B":"Treatment Devices Intermediate","C":"333","D":"77333","F":"357.6"},{"Policy Line":"68300085","B":"Treatment Devices Complex","C":"333","D":"77334","F":"518.7"},{"Policy Line":"68300090","B":"Continuing Med Phys Consult","C":"333","D":"77336","F":"291.9"},{"Policy Line":"68300095","B":"Treatment Devices Imrt","C":"333","D":"77338","F":"660.3"},{"Policy Line":"68300100","B":"Special Med Physics Consult","C":"333","D":"77370","F":"235.2"},{"Policy Line":"68300102","B":"Tx Delivery >1MeV, Simple","C":"333","D":"77402","F":"264.3"},{"Policy Line":"68300131","B":"TX Deliv w/Criteria;to 5MeV","C":"333","D":"77412","F":"369.6"},{"Policy Line":"68300150","B":"Port Films Rad Image","C":"333","D":"77417","F":"106.5"},{"Policy Line":"68300154","B":"IMRT Tx Deliv, Simple","C":"333","D":"77385","F":"545.4"},{"Policy Line":"68300156","B":"IMRT Tx Deliv, Complex","C":"333","D":"77386","F":"886.8"},{"Policy Line":"68300165","B":"SBRT MGMT 1+LSNS <=5 FRACTNS","C":"333","D":"77435","F":"230.4"},{"Policy Line":"68300170","B":"Special Treatment Procedure","C":"333","D":"77470","F":"1078.8"},{"Policy Line":"68300185","B":"Brachytherapy Handling/Ldg","C":"333","D":"77790","F":"189.9"},{"Policy Line":"68300200","B":"Brachy Intracav: Simple","C":"333","D":"77761","F":"962.7"},{"Policy Line":"68300205","B":"Brachy Intracav: Intermediate","C":"333","D":"77762","F":"998.4"},{"Policy Line":"68300210","B":"Brachy Intracav: Complex","C":"333","D":"77763","F":"1248.9"},{"Policy Line":"68300216","B":"HDRRDNCL NTRSTL/ICAVBRCHTX 1CH","C":"333","D":"77770","F":"656.7"},{"Policy Line":"68300217","B":"HDRRDNCL NTRSTL/ICAVBRCHTX2-12","C":"333","D":"77771","F":"927"},{"Policy Line":"68300218","B":"HDRRDNCL NTRSTL/ICAVBRCHTX >12","C":"333","D":"77772","F":"1222.2"},{"Policy Line":"68300225","B":"Brachy Interstitial: Complex","C":"333","D":"77778","F":"1099.5"},{"Policy Line":"68300245","B":"Infuse/Instill Radioelement","C":"333","D":"77750","F":"419.4"},{"Policy Line":"68300254","B":"INSERT CERVICAL CYLINDERS","C":"333","D":"57156","F":"1502.7"},{"Policy Line":"68300261","B":"SRS CRANIAL SGL SESSION","C":"333","D":"77372","F":"8391.9"},{"Policy Line":"68300263","B":"SBRT DELIVRY PER FRACTN >=1LSN","C":"333","D":"77373","F":"5323.8"},{"Policy Line":"68320001","B":"Treatment Devices Simple","C":"333","D":"77332","F":"224.1"},{"Policy Line":"68320002","B":"Treatment Devices Complex","C":"333","D":"77334","F":"518.7"},{"Policy Line":"68320003","B":"Special Treatment Proc (Srs)","C":"333","D":"77470","F":"1078.8"},{"Policy Line":"71820001","B":"Simulation Complex","C":"333","D":"77290","F":"787.2"},{"Policy Line":"63200012","B":"EEG","C":"740","D":"95816","F":"370.8"},{"Policy Line":"63200016","B":"EEG Sleep Deprived","C":"740","D":"95819","F":"442.5"},{"Policy Line":"63200023","B":"EEG (24 Hour Monitoring)","C":"740","D":"95953","F":"1417.5"},{"Policy Line":"63200084","B":"Video Eeg Monitoring (Ea 24Hr)","C":"740","D":"95951","F":"1903.8"},{"Policy Line":"63200086","B":"EEG Extended (41-60 Minutes)","C":"740","D":"95812","F":"573"},{"Policy Line":"63200120","B":"EEG 61-119 minutes","C":"740","D":"95813","F":"533.4"},{"Policy Line":"63200128","B":"EEG Coma","C":"740","D":"95822","F":"433.8"},{"Policy Line":"63200205","B":"Video Eeg Less Than 12 Hours","C":"740","D":"95951","F":"1903.8"},{"Policy Line":"63200251","B":"EEG Inital Set Up","C":"740","D":"95700","F":"573"},{"Policy Line":"63200252","B":"EEG 2-12 Hrs Unmonitored","C":"740","D":"95705","F":"1417.5"},{"Policy Line":"63200253","B":"EEG 2-12 Hrs Intermittent","C":"740","D":"95706","F":"1417.5"},{"Policy Line":"63200254","B":"EEG 2-12 Hrs Continuous","C":"740","D":"95707","F":"1417.5"},{"Policy Line":"63200255","B":"EEG 12-26 Hrs Unmonitored","C":"740","D":"95708","F":"1417.5"},{"Policy Line":"63200256","B":"EEG 12-26 Hrs Intermittent","C":"740","D":"95709","F":"1417.5"},{"Policy Line":"63200257","B":"EEG 12-26 Hrs Continuous","C":"740","D":"95710","F":"1417.5"},{"Policy Line":"63200258","B":"EEG Video 2-12 Hrs Unmonit","C":"740","D":"95711","F":"1417.5"},{"Policy Line":"63200259","B":"EEG Video 2-12 Hrs Intermitt","C":"740","D":"95712","F":"1417.5"},{"Policy Line":"63200260","B":"EEG Video 2-12 Hrs Continuous","C":"740","D":"95713","F":"1417.5"},{"Policy Line":"63200261","B":"EEG Video 12-26 Hrs Unmonit","C":"740","D":"95714","F":"1417.5"},{"Policy Line":"63200262","B":"EEG Video 12-26 Hrs Intermitt","C":"740","D":"95715","F":"1417.5"},{"Policy Line":"63200263","B":"EEG Video 12-26 Hrs Continuous","C":"740","D":"95716","F":"1417.5"},{"Policy Line":"64100793","B":"EEG Non-Intracranial Intraop","C":"740","D":"95955","F":"37.2"},{"Policy Line":"65103261","B":"Monitoring: Nibp","C":"921","D":"93770","F":"63.3"},{"Policy Line":"71705543","B":"Dft Testing","C":"361","D":"93641","F":"573.6"},{"Policy Line":"72205321","B":"EP Eval Lt:Vent W/Pacing/Rec","C":"480","D":"93622","F":"608.4"},{"Policy Line":"72205529","B":"Dft (Lead & Gnrtr Test)","C":"481","D":"93641","F":"573.6"},{"Policy Line":"72300038","B":"Treadmill Stress Testing","C":"482","D":"93017","F":"288.6"},{"Policy Line":"72300041","B":"Holter Monitor Scanning","C":"731","D":"93226","F":"563.4"},{"Policy Line":"72300050","B":"Holt Monitor Ext 3-14 Days","C":"731","D":"0296T","F":"39.3"},{"Policy Line":"72303001","B":"EKG, 12 LEAD, TRACING ONLY","C":"730","D":"93005","F":"73.5"},{"Policy Line":"72303005","B":"Rhythm Strip, Tracing Only","C":"730","D":"93041","F":"159.3"},{"Policy Line":"72303009","B":"Holter Monitor Use","C":"731","D":"93225","F":"58.5"},{"Policy Line":"72303064","B":"Cardio Stress Test","C":"482","D":"93017","F":"288.6"},{"Policy Line":"72303105","B":"Signal Averaged Ekg","C":"730","D":"93278","F":"162.6"},{"Policy Line":"72303176","B":"Event Monitor Hook-Up","C":"730","D":"93270","F":"323.7"},{"Policy Line":"75800068","B":"Chd Cardio Stress Test","C":"482","D":"93017","F":"262.2"},{"Policy Line":"5510","B":"ABI W/Wo Exercise-W/Toe Pressu","C":"921","D":"93923","F":"212.4"},{"Policy Line":"6105","B":"Art Abi W/Wave Forms & Toe Prs","C":"921","D":"93922","F":"274.8"},{"Policy Line":"61600100","B":"Hearing Screen","C":"470","D":"92586","F":"571.2"},{"Policy Line":"63200002","B":"Auditory Brainstem Rp Abr","C":"471","D":"92585","F":"1031.4"},{"Policy Line":"63200004","B":"Tympanometry","C":"471","D":"92567","F":"55.2"},{"Policy Line":"63200005","B":"Audiology Speech Discrim","C":"471","D":"92556","F":"62.7"},{"Policy Line":"63200006","B":"Audiology Sisi","C":"471","D":"92564","F":"62.1"},{"Policy Line":"63200007","B":"Audiology Tone Decay","C":"471","D":"92563","F":"60.6"},{"Policy Line":"63200008","B":"Audiology A B L B","C":"471","D":"92562","F":"56.7"},{"Policy Line":"63200010","B":"Speech Reception Threshol","C":"471","D":"92555","F":"62.1"},{"Policy Line":"63200014","B":"Visual Evoked Response","C":"922","D":"95930","F":"459.6"},{"Policy Line":"63200017","B":"Somatosensory Upper","C":"922","D":"95925","F":"387.3"},{"Policy Line":"63200040","B":"Conditioning Play Audiometry","C":"471","D":"92582","F":"421.2"},{"Policy Line":"63200050","B":"Audiology Air Bone Con","C":"471","D":"92553","F":"87.6"},{"Policy Line":"63200051","B":"Audiology Air Conduction","C":"471","D":"92552","F":"98.1"},{"Policy Line":"63200055","B":"Acoustic Reflex Testing","C":"471","D":"92568","F":"57"},{"Policy Line":"63200057","B":"Spontaneous/Gazes","C":"471","D":"92541","F":"107.4"},{"Policy Line":"63200058","B":"Positional Tests","C":"471","D":"92542","F":"107.4"},{"Policy Line":"63200060","B":"Optokinetic Tests","C":"471","D":"92544","F":"107.4"},{"Policy Line":"63200061","B":"Oscillating Tracking Test","C":"471","D":"92545","F":"107.4"},{"Policy Line":"63200062","B":"Vestibular Eval (Eng/Vng)","C":"471","D":"92540","F":"331.8"},{"Policy Line":"63200063","B":"Tymp-Reflex Threshold & Decay","C":"471","D":"92570","F":"117.9"},{"Policy Line":"63200064","B":"Typmanometry/Reflex Threshold","C":"471","D":"92550","F":"102.9"},{"Policy Line":"63200066","B":"Tympanom/Reflx Thresh- Red Svc","C":"471","D":"92550","F":"102.9"},{"Policy Line":"63200067","B":"Acoustic Reflex Testing-RedSvc","C":"471","D":"92568","F":"28.5"},{"Policy Line":"63200068","B":"EQUI-SOT","C":"471","D":"92548","F":"426.6"},{"Policy Line":"63200069","B":"Tymp-Refl Thrshld&Decay RedSvc","C":"471","D":"92570","F":"60"},{"Policy Line":"63200080","B":"Otoacoustic Emissions","C":"471","D":"92587","F":"113.7"},{"Policy Line":"63200087","B":"Hearing Screen Air Only","C":"471","D":"92551","F":"31.2"},{"Policy Line":"63200088","B":"Somatosensory Lower","C":"922","D":"95926","F":"344.7"},{"Policy Line":"63200091","B":"Somatosensory Upper & Lower","C":"922","D":"95938","F":"883.2"},{"Policy Line":"63200100","B":"Use Of Vertical Electrodes","C":"471","D":"92547","F":"104.4"},{"Policy Line":"63200124","B":"ABR With Medication","C":"471","D":"92585","F":"1031.4"},{"Policy Line":"63200125","B":"Visual Reinforcement Audiometr","C":"471","D":"92579","F":"308.1"},{"Policy Line":"63200126","B":"Comprensive Audiometry","C":"471","D":"92557","F":"380.4"},{"Policy Line":"63200127","B":"ABR Limited W/Med","C":"471","D":"92586","F":"891.6"},{"Policy Line":"63200202","B":"Somatosensory Trunk","C":"922","D":"95927","F":"274.2"},{"Policy Line":"63200203","B":"ABR Limited","C":"471","D":"92586","F":"571.2"},{"Policy Line":"63200207","B":"Stenger Test Pure Tone","C":"471","D":"92565","F":"80.7"},{"Policy Line":"63200250","B":"EQUI - Total","C":"471","D":"92549","F":"426.6"},{"Policy Line":"63250012","B":"Home Sleep Testing","C":"920","D":"G0400","F":"222"},{"Policy Line":"64100781","B":"SSEP Upper Extremities","C":"922","D":"95925","F":"387.3"},{"Policy Line":"64100782","B":"SSEP Lower Extremities","C":"922","D":"95926","F":"344.7"},{"Policy Line":"64100783","B":"Transcranial Motor Stim Upper","C":"922","D":"95928","F":"141"},{"Policy Line":"64100784","B":"Transcranial Motor Stim Lower","C":"922","D":"95929","F":"138.9"},{"Policy Line":"64100787","B":"Motor Nerve Test- 1-2 Studies","C":"922","D":"95907","F":"131.4"},{"Policy Line":"64100790","B":"Repetitive Stim Mep/Tof","C":"922","D":"95937","F":"216.9"},{"Policy Line":"64504500","B":"Hydrogen Breath Test","C":"759","D":"91065","F":"751.2"},{"Policy Line":"64504600","B":"Manometry: Anorectal","C":"759","D":"91122","F":"664.8"},{"Policy Line":"64505206","B":"Pudendal Nerve Conductn Study","C":"922","D":"95907","F":"131.4"},{"Policy Line":"65106306","B":"Pulse Ox Continuous","C":"410","D":"94762","F":"102.9"},{"Policy Line":"68261036","B":"Percut Allergy Skin test","C":"924","D":"95004","F":"42"},{"Policy Line":"68300260","B":"RESPIRATORY MOTION MGMT","C":"333","D":"77293","F":"334.5"},{"Policy Line":"7012","B":"Arterial Lower: W/O Exercise","C":"921","D":"93923","F":"212.4"},{"Policy Line":"7013","B":"Arterial Lower: W/Exercise","C":"921","D":"93924","F":"421.5"},{"Policy Line":"7031","B":"Ankle/Brachial Ind W-W/O Exer","C":"921","D":"93924","F":"421.5"},{"Policy Line":"7032","B":"ABI (W/O Exercise)","C":"921","D":"93922","F":"274.8"},{"Policy Line":"7082","B":"Arterial Upper Extr Digits -Bi","C":"921","D":"93923","F":"212.4"},{"Policy Line":"7206","B":"NONINV ART STUDY (MULT LEVELS)","C":"921","D":"93923","F":"212.4"},{"Policy Line":"7207","B":"NONINV ART STUDY-1,2 Lvls","C":"921","D":"93922","F":"274.8"},{"Policy Line":"7208","B":"NONINV ART STUDY (SGL LVL) UNI","C":"921","D":"93922","F":"274.8"},{"Policy Line":"72300021","B":"Pulse Oximetry Single","C":"460","D":"94760","F":"26.7"},{"Policy Line":"73100055","B":"Et Co2 Daily","C":"460","D":"94770","F":"134.4"},{"Policy Line":"73100064","B":"Pulse Oximetry Sngl","C":"460","D":"94760","F":"26.7"},{"Policy Line":"73100066","B":"Pulse Oximetry Max Exrc","C":"460","D":"94761","F":"80.1"},{"Policy Line":"73100067","B":"PFT Bedside","C":"460","D":"94010","F":"123.3"},{"Policy Line":"73100071","B":"Pulse Ox Daily","C":"460","D":"94762","F":"102.9"},{"Policy Line":"73100103","B":"Pulse Oximetry Overnight","C":"460","D":"94762","F":"102.9"},{"Policy Line":"73100301","B":"Spirometry","C":"460","D":"94010","F":"123.3"},{"Policy Line":"73103003","B":"DLCO","C":"460","D":"94729","F":"159.6"},{"Policy Line":"73103004","B":"Pft B/A Bronchodilator","C":"460","D":"94060","F":"145.5"},{"Policy Line":"73103006","B":"FV Loop","C":"460","D":"94375","F":"137.4"},{"Policy Line":"73103013","B":"PFT B/A Bronchodilator Bedsid","C":"460","D":"94060","F":"145.5"},{"Policy Line":"73103015","B":"Pulmonary Stress Test","C":"460","D":"94621","F":"388.2"},{"Policy Line":"73103017","B":"Indirect Calorimetry","C":"460","D":"94690","F":"287.7"},{"Policy Line":"73103020","B":"PFT Methacholine Chlng","C":"460","D":"94070","F":"84.3"},{"Policy Line":"73103068","B":"MVV - Maximal Vol Ventilation","C":"460","D":"94200","F":"160.8"},{"Policy Line":"73103069","B":"Plethsymography Lung Vol & Raw","C":"460","D":"94726","F":"421.8"},{"Policy Line":"73200301","B":"Spirometry","C":"460","D":"94010","F":"123.3"},{"Policy Line":"73203068","B":"MVV - Maximal Vol Ventilation","C":"460","D":"94200","F":"160.8"},{"Policy Line":"73203069","B":"Plethsymography Lung Vol & Raw","C":"460","D":"94726","F":"421.8"},{"Policy Line":"73203071","B":"PFT Bedside","C":"460","D":"94010","F":"123.3"},{"Policy Line":"73203072","B":"DLCO","C":"460","D":"94729","F":"159.6"},{"Policy Line":"73203073","B":"Pft B/A Bronchodilator","C":"460","D":"94060","F":"145.5"},{"Policy Line":"73203076","B":"PFT B/A Bronchodilator Bedsid","C":"460","D":"94060","F":"145.5"},{"Policy Line":"74221030","B":"HTC-Ambulatory BP Recording","C":"920","D":"93786","F":"29.7"},{"Policy Line":"74401036","B":"Perc Allergy SkinTest SPC NMBR","C":"924","D":"95004","F":"42"},{"Policy Line":"63250002","B":"Mult Sleep Latency Testing","C":"740","D":"95805","F":"1750.8"},{"Policy Line":"63250004","B":"PSG W/Cpap/Bi Pap","C":"740","D":"95811","F":"2077.8"},{"Policy Line":"63250010","B":"PSG W/3 Parameters","C":"740","D":"95808","F":"1052.1"},{"Policy Line":"63250011","B":"PSG W/4 Or More Parameters","C":"740","D":"95810","F":"2007.9"},{"Policy Line":"75100054","B":"Cogn Funct 1st 15 min","C":"420","D":"97129","F":"61.5"},{"Policy Line":"75100055","B":"Cogn Funct Add 15 min","C":"420","D":"97130","F":"37.5"},{"Policy Line":"75100162","B":"VR Exer Therapeutic 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75100163","B":"VR Gait Training 15 Min","C":"420","D":"97116","F":"47.4"},{"Policy Line":"75100307","B":"Home Management Tx - Ea 15 Min","C":"420","D":"97535","F":"40.2"},{"Policy Line":"75100309","B":"Selfcare Home Tx - Ea 15 Min","C":"420","D":"97535","F":"40.2"},{"Policy Line":"75100314","B":"Wheelchair Mgmt/Train 15 Min","C":"420","D":"97542","F":"33"},{"Policy Line":"75100315","B":"Community Reentry Ea 15 Min","C":"420","D":"97537","F":"174.3"},{"Policy Line":"75100316","B":"Group Treatment","C":"420","D":"97150","F":"110.1"},{"Policy Line":"75100337","B":"PT Rehab IP Eval Low 20Min","C":"424","D":"97161","F":"146.4"},{"Policy Line":"75100338","B":"PT Rehab IP Eval Mod 30Min","C":"424","D":"97162","F":"146.4"},{"Policy Line":"75100339","B":"PT Rehab IP Eval High 45Min","C":"424","D":"97163","F":"146.4"},{"Policy Line":"75100340","B":"PT Rehab IP Re-Eval EST20Min","C":"424","D":"97164","F":"96.9"},{"Policy Line":"75100502","B":"Pre-Op Eval 30 Min","C":"420","D":"97750","F":"71.4"},{"Policy Line":"75100503","B":"Therapeutic Activities 15 Min","C":"420","D":"97530","F":"44.1"},{"Policy Line":"75102006","B":"Physicial Perform Test 15 Min","C":"420","D":"97750","F":"71.4"},{"Policy Line":"75102010","B":"Sensory Integration - 15 Min","C":"420","D":"97533","F":"39.9"},{"Policy Line":"75102011","B":"PT Eval Low 20Min","C":"424","D":"97161","F":"146.4"},{"Policy Line":"75102012","B":"PT Eval Mod 30Min","C":"424","D":"97162","F":"146.4"},{"Policy Line":"75102013","B":"PT Eval High 45Min","C":"424","D":"97163","F":"146.4"},{"Policy Line":"75102014","B":"PT Re-Eval EST 20Min","C":"424","D":"97164","F":"96.9"},{"Policy Line":"75102101","B":"Traction Mechanical >=1 Area","C":"420","D":"97012","F":"85.2"},{"Policy Line":"75102104","B":"Paraffin Bath Applic >=1 Area","C":"420","D":"97018","F":"39.9"},{"Policy Line":"75102105","B":"Electric Stim Manual Ea 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75102106","B":"Iontophoresis Ea 15 Min","C":"420","D":"97033","F":"54.3"},{"Policy Line":"75102107","B":"Contrast Baths Each 15 Min","C":"420","D":"97034","F":"39.6"},{"Policy Line":"75102108","B":"Ultrasound Applic Ea 15 Min","C":"420","D":"97035","F":"54.3"},{"Policy Line":"75102109","B":"Whirlpool Applic >=1 Area","C":"420","D":"97022","F":"44.4"},{"Policy Line":"75102111","B":"Massage Ea 15 Min","C":"420","D":"97124","F":"42.3"},{"Policy Line":"75102113","B":"Fluidotherapy Applic,Whirlpool","C":"420","D":"97022","F":"44.4"},{"Policy Line":"75102201","B":"Therapeutic Exercise Ea 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75102202","B":"Neuromuscular Re-Ed 15 Min","C":"420","D":"97112","F":"46.8"},{"Policy Line":"75102203","B":"Gait Training 15 Min","C":"420","D":"97116","F":"47.4"},{"Policy Line":"75102206","B":"Adl Training Ea 15 Min","C":"420","D":"97535","F":"40.2"},{"Policy Line":"75102210","B":"VR Neuromuscular Re-Ed 15 Mi","C":"420","D":"97112","F":"46.8"},{"Policy Line":"75102301","B":"Orthotic 1st Visit 15 Min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75102304","B":"Orth-Pros Sub Visit 15 Min","C":"420","D":"97763","F":"39.6"},{"Policy Line":"75102305","B":"ProstheticTrain 1stVisit15 Min","C":"420","D":"97761","F":"46.8"},{"Policy Line":"75102307","B":"Aquatic Therapy 15 Min","C":"420","D":"97113","F":"43.8"},{"Policy Line":"75102605","B":"Cpm Exercise","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75102609","B":"Isokenetic Exercise 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75102632","B":"Work Condition First 2 Hrs","C":"420","D":"97545","F":"506.1"},{"Policy Line":"75102633","B":"Work Condition Additional Hr","C":"420","D":"97546","F":"213.6"},{"Policy Line":"75102666","B":"Tens Attended 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75102668","B":"Manual Therapy Each 15 Min","C":"420","D":"97140","F":"47.1"},{"Policy Line":"75102670","B":"VR Manual Therapy - 15 Min","C":"420","D":"97140","F":"47.1"},{"Policy Line":"75103001","B":"Orthotic Custom 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75103002","B":"Orthotic Insert 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75106025","B":"VR Group Therapy","C":"420","D":"97150","F":"110.1"},{"Policy Line":"75110054","B":"Cogn Funct 1st 15 min","C":"420","D":"97129","F":"61.5"},{"Policy Line":"75110055","B":"Cogn Funct Add 15 min","C":"420","D":"97130","F":"37.5"},{"Policy Line":"75110231","B":"PT Eval Low 20min","C":"424","D":"97161","F":"146.4"},{"Policy Line":"75110232","B":"PT Eval Mod 30min","C":"424","D":"97162","F":"146.4"},{"Policy Line":"75110233","B":"PT Eval High 45min","C":"424","D":"97163","F":"146.4"},{"Policy Line":"75110234","B":"PT Re-Eval Est 20Min","C":"424","D":"97164","F":"96.9"},{"Policy Line":"75112006","B":"Physical Perform Test 15 Min","C":"420","D":"97750","F":"71.4"},{"Policy Line":"75112101","B":"Traction Mechanical >=1 Area","C":"420","D":"97012","F":"85.2"},{"Policy Line":"75112104","B":"Paraffin Bath Applic >=1 Area","C":"420","D":"97018","F":"39.9"},{"Policy Line":"75112105","B":"Electric Stim Manual Ea 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75112106","B":"Iontophoresis Ea 15 Min","C":"420","D":"97033","F":"54.3"},{"Policy Line":"75112108","B":"Ultrasound Appl Ea 15 Min","C":"420","D":"97035","F":"54.3"},{"Policy Line":"75112109","B":"Whirlpool Applic >=1 Area","C":"420","D":"97022","F":"44.4"},{"Policy Line":"75112111","B":"Massage Ea 15 Min","C":"420","D":"97124","F":"42.3"},{"Policy Line":"75112113","B":"Fluidotherapy","C":"420","D":"97022","F":"44.4"},{"Policy Line":"75112116","B":"Vasopneumatic Therapy >=1 Area","C":"420","D":"97016","F":"42.9"},{"Policy Line":"75112201","B":"Therapeutic Exercise Ea 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75112202","B":"Neuromuscular Re-Ed 15 Min","C":"420","D":"97112","F":"46.8"},{"Policy Line":"75112203","B":"Gait Training 15 Min","C":"420","D":"97116","F":"47.4"},{"Policy Line":"75112302","B":"Orthotic 1st Visit 15 Min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75112304","B":"Orth-Pros Sub Visit 15 Min","C":"420","D":"97763","F":"39.6"},{"Policy Line":"75112305","B":"ProstheticTrain 1stVisit15 Min","C":"420","D":"97761","F":"46.8"},{"Policy Line":"75112618","B":"Therapeutic Activities 15 Min","C":"420","D":"97530","F":"44.1"},{"Policy Line":"75112620","B":"Group Treatment","C":"420","D":"97150","F":"110.1"},{"Policy Line":"75112625","B":"Isokenetic Exercise 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75112649","B":"Wheelchair Mgmt/Train 15 Min","C":"420","D":"97542","F":"33"},{"Policy Line":"75112650","B":"Work Condition First 2 Hours","C":"420","D":"97545","F":"506.1"},{"Policy Line":"75112651","B":"Work Condition Additional 1 Hr","C":"420","D":"97546","F":"213.6"},{"Policy Line":"75112666","B":"Tens Attended 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75112668","B":"Manual Therapy Each 15 Min","C":"420","D":"97140","F":"47.1"},{"Policy Line":"75113000","B":"Orthotic Custom 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75113002","B":"Orthotic Insert 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75140039","B":"Selfcare Home Tx - Ea 15 Min","C":"420","D":"97535","F":"40.2"},{"Policy Line":"75140231","B":"PT Eval Low 20min","C":"424","D":"97161","F":"146.4"},{"Policy Line":"75140232","B":"PT Eval Mod 30min","C":"424","D":"97162","F":"146.4"},{"Policy Line":"75140233","B":"PT Eval High 45min","C":"424","D":"97163","F":"146.4"},{"Policy Line":"75140234","B":"PT Re-Eval Est 20Min","C":"424","D":"97164","F":"96.9"},{"Policy Line":"75140314","B":"Wheelchair Mgmt/Train 15 Min","C":"420","D":"97542","F":"33"},{"Policy Line":"75140315","B":"Community Reentry Ea 15 Min","C":"420","D":"97537","F":"174.3"},{"Policy Line":"75140316","B":"Group Treatment","C":"420","D":"97150","F":"110.1"},{"Policy Line":"75140503","B":"Therapeutic Activities 15 Min","C":"420","D":"97530","F":"44.1"},{"Policy Line":"75142006","B":"Physical Perform Test 15 Min","C":"420","D":"97750","F":"71.4"},{"Policy Line":"75142010","B":"Sensory Integration - 15 Min","C":"420","D":"97533","F":"39.9"},{"Policy Line":"75142101","B":"Traction Mechanical >=1 Area","C":"420","D":"97012","F":"85.2"},{"Policy Line":"75142105","B":"Electric Stim Manual Ea 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75142106","B":"Iontophoresis Applic Ea 15 Min","C":"420","D":"97033","F":"54.3"},{"Policy Line":"75142107","B":"Contrast Baths Each 15 Min","C":"420","D":"97034","F":"39.6"},{"Policy Line":"75142108","B":"Ultrasound Appl Ea 15 Min","C":"420","D":"97035","F":"54.3"},{"Policy Line":"75142111","B":"Massage Ea 15 Min","C":"420","D":"97124","F":"42.3"},{"Policy Line":"75142113","B":"Fluidotherapy","C":"420","D":"97022","F":"44.4"},{"Policy Line":"75142201","B":"Therapeutic Exercise Ea 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75142202","B":"Neuromuscular Re-Ed 15 Min","C":"420","D":"97112","F":"46.8"},{"Policy Line":"75142203","B":"Gait Training 15 Min","C":"420","D":"97116","F":"47.4"},{"Policy Line":"75142206","B":"Adl Training Ea 15 Min","C":"420","D":"97535","F":"40.2"},{"Policy Line":"75142632","B":"Work Condition First 2 Hours","C":"420","D":"97545","F":"506.1"},{"Policy Line":"75142633","B":"Work Condition Additional 1 Hr","C":"420","D":"97546","F":"213.6"},{"Policy Line":"75142666","B":"Tens Attended - 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75142668","B":"Manual Therapy Each 15 Min","C":"420","D":"97140","F":"47.1"},{"Policy Line":"75150054","B":"Cogn Funct 1st 15 min","C":"420","D":"97129","F":"61.5"},{"Policy Line":"75150055","B":"Cogn Funct Add 15 min","C":"420","D":"97130","F":"37.5"},{"Policy Line":"75150231","B":"PT Eval Low 20Min","C":"424","D":"97161","F":"146.4"},{"Policy Line":"75150232","B":"PT Eval Med 30Min","C":"424","D":"97162","F":"146.4"},{"Policy Line":"75150233","B":"PT Eval High 45Min","C":"424","D":"97163","F":"146.4"},{"Policy Line":"75150234","B":"PT Re-Eval EST 20Min","C":"424","D":"97164","F":"96.9"},{"Policy Line":"75152006","B":"Physical Perform Test 15 Min","C":"420","D":"97750","F":"71.4"},{"Policy Line":"75152010","B":"Sensory Integration - 15 Min","C":"420","D":"97533","F":"39.9"},{"Policy Line":"75152101","B":"Traction Mechanical >=1 Area","C":"420","D":"97012","F":"85.2"},{"Policy Line":"75152105","B":"Electric Stim Manual Ea 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75152106","B":"Iontophoresis Ea 15 Min","C":"420","D":"97033","F":"54.3"},{"Policy Line":"75152107","B":"Contrast Baths Each 15 Min","C":"420","D":"97034","F":"39.6"},{"Policy Line":"75152108","B":"Ultrasound Appl Ea 15 Min","C":"420","D":"97035","F":"54.3"},{"Policy Line":"75152111","B":"Massage Ea 15 Min","C":"420","D":"97124","F":"42.3"},{"Policy Line":"75152113","B":"Fluidotherapy","C":"420","D":"97022","F":"44.4"},{"Policy Line":"75152201","B":"Therapeutic Exercise Ea 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75152202","B":"Neuromuscular Re-Ed 15 Min","C":"420","D":"97112","F":"46.8"},{"Policy Line":"75152203","B":"Gait Training 15 Min","C":"420","D":"97116","F":"47.4"},{"Policy Line":"75152206","B":"Adl Training Ea 15 Min","C":"420","D":"97535","F":"40.2"},{"Policy Line":"75152302","B":"Orthotic 1st Visit 15 Min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75152304","B":"Orth-Pros Sub Visit 15 Min","C":"420","D":"97763","F":"39.6"},{"Policy Line":"75152305","B":"ProstheticTrain 1stVisit15 Min","C":"420","D":"97761","F":"46.8"},{"Policy Line":"75152609","B":"Community Reentry Ea 15 Min","C":"420","D":"97537","F":"174.3"},{"Policy Line":"75152618","B":"Therapeutic Activities 15 Min","C":"420","D":"97530","F":"44.1"},{"Policy Line":"75152620","B":"Group Treatment","C":"420","D":"97150","F":"110.1"},{"Policy Line":"75152649","B":"Wheelchair Mgmt/Train 15 Min","C":"420","D":"97542","F":"33"},{"Policy Line":"75152666","B":"Tens Attended 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75152668","B":"Manual Therapy Each 15 Min","C":"420","D":"97140","F":"47.1"},{"Policy Line":"75153000","B":"Orthotic Insert 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75153002","B":"Orthotic Custom 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75160054","B":"Cogn Funct 1st 15 min","C":"420","D":"97129","F":"61.5"},{"Policy Line":"75160055","B":"Cogn Funct Add 15 min","C":"420","D":"97130","F":"37.5"},{"Policy Line":"75160231","B":"PT Eval Low 20min","C":"424","D":"97161","F":"146.4"},{"Policy Line":"75160232","B":"PT Eval Mod 30min","C":"424","D":"97162","F":"146.4"},{"Policy Line":"75160233","B":"PT Eval High 45min","C":"424","D":"97163","F":"146.4"},{"Policy Line":"75160234","B":"PT Re-Eval Est 20Min","C":"424","D":"97164","F":"96.9"},{"Policy Line":"75162006","B":"Physical Perform Test 15 Min","C":"420","D":"97750","F":"71.4"},{"Policy Line":"75162010","B":"Sensory Integration - 15 Min","C":"420","D":"97533","F":"39.9"},{"Policy Line":"75162101","B":"Traction Mechanical >=1 Area","C":"420","D":"97012","F":"85.2"},{"Policy Line":"75162105","B":"Electric Stim Manual Ea 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75162106","B":"Iontophoresis Ea 15 Min","C":"420","D":"97033","F":"54.3"},{"Policy Line":"75162107","B":"Contrast Baths Each 15 Min","C":"420","D":"97034","F":"39.6"},{"Policy Line":"75162108","B":"Ultrasound Appl Ea 15 Min","C":"420","D":"97035","F":"54.3"},{"Policy Line":"75162111","B":"Massage Ea 15 Min","C":"420","D":"97124","F":"42.3"},{"Policy Line":"75162113","B":"Fluidotherapy >= 1 area","C":"420","D":"97022","F":"44.4"},{"Policy Line":"75162201","B":"Therapeutic Exercise Ea 15 Min","C":"420","D":"97110","F":"47.7"},{"Policy Line":"75162202","B":"Neuromuscular Re-Ed 15 Min","C":"420","D":"97112","F":"46.8"},{"Policy Line":"75162203","B":"Gait Training 15 Min","C":"420","D":"97116","F":"47.4"},{"Policy Line":"75162206","B":"Adl Training Ea 15 Min","C":"420","D":"97535","F":"40.2"},{"Policy Line":"75162302","B":"Orthotic 1st Visit 15 Min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75162304","B":"Orth-Pros Sub Visit 15 Min","C":"420","D":"97763","F":"39.6"},{"Policy Line":"75162305","B":"ProstheticTrain 1stVisit15 Min","C":"420","D":"97761","F":"46.8"},{"Policy Line":"75162307","B":"Aquatic Therapy 15 Min","C":"420","D":"97113","F":"43.8"},{"Policy Line":"75162609","B":"Community Reentry Ea 15 Min","C":"420","D":"97537","F":"174.3"},{"Policy Line":"75162618","B":"Therapeutic Activities 15 Min","C":"420","D":"97530","F":"44.1"},{"Policy Line":"75162620","B":"Group Treatment","C":"420","D":"97150","F":"110.1"},{"Policy Line":"75162649","B":"Wheelchair Mgmt/Train 15 Min","C":"420","D":"97542","F":"33"},{"Policy Line":"75162666","B":"Tens Attended 15 Min","C":"420","D":"97032","F":"49.8"},{"Policy Line":"75162668","B":"Manual Therapy Each 15 Min","C":"420","D":"97140","F":"47.1"},{"Policy Line":"75163000","B":"Orthotic Custom 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75163002","B":"Orthotic Insert 1stVisit 15min","C":"420","D":"97760","F":"42.3"},{"Policy Line":"75200054","B":"Cogn Funct 1st 15 min","C":"430","D":"97129","F":"61.5"},{"Policy Line":"75200055","B":"Cogn Funct Add 15 min","C":"430","D":"97130","F":"37.5"},{"Policy Line":"75200325","B":"Community Reentry Ea 15 Min","C":"430","D":"97537","F":"174.3"},{"Policy Line":"75200335","B":"Home Mangmnt SelfTx - Ea 15Min","C":"430","D":"97535","F":"40.2"},{"Policy Line":"75200385","B":"OT REHAB Eval Low 30Min","C":"434","D":"97165","F":"117.3"},{"Policy Line":"75200386","B":"OT REHAB Eval Mod 45Min","C":"434","D":"97166","F":"117.3"},{"Policy Line":"75200387","B":"OT REHAB Eval High 60Min","C":"434","D":"97167","F":"117.3"},{"Policy Line":"75200388","B":"OT REHAB Re-Eval Est Plan Care","C":"434","D":"97168","F":"81.3"},{"Policy Line":"75202006","B":"Physical Perform Test 15 Min","C":"430","D":"97750","F":"71.4"},{"Policy Line":"75202010","B":"Sensory Integration - 15 Min","C":"430","D":"97533","F":"39.9"},{"Policy Line":"75202011","B":"OT Eval Low 30Min","C":"434","D":"97165","F":"117.3"},{"Policy Line":"75202012","B":"OT Eval Mod 45Min","C":"434","D":"97166","F":"117.3"},{"Policy Line":"75202013","B":"OT Eval High 60Min","C":"434","D":"97167","F":"117.3"},{"Policy Line":"75202014","B":"OT Re-Eval Est Plan Care","C":"434","D":"97168","F":"81.3"},{"Policy Line":"75202104","B":"Paraffin Bath Applic >=1 Area","C":"430","D":"97018","F":"39.9"},{"Policy Line":"75202105","B":"Electric Stim Manual Ea 15 Min","C":"430","D":"97032","F":"49.8"},{"Policy Line":"75202106","B":"Iontophoresis Ea 15 Min","C":"430","D":"97033","F":"54.3"},{"Policy Line":"75202107","B":"Contrast Baths Applic Ea 15Min","C":"430","D":"97034","F":"39.6"},{"Policy Line":"75202108","B":"Ultrasound Ea 15 Min","C":"430","D":"97035","F":"54.3"},{"Policy Line":"75202109","B":"Whirlpool","C":"430","D":"97022","F":"44.4"},{"Policy Line":"75202111","B":"Ther Massage Ea 15 Min","C":"430","D":"97124","F":"42.3"},{"Policy Line":"75202113","B":"Fluidotherapy","C":"430","D":"97022","F":"44.4"},{"Policy Line":"75202116","B":"Vasopneumatic Therapy","C":"430","D":"97016","F":"42.9"},{"Policy Line":"75202201","B":"Therapeutic Exercise Ea 15 Min","C":"430","D":"97110","F":"47.7"},{"Policy Line":"75202202","B":"Neuromuscular Re-Ed 15 Min","C":"430","D":"97112","F":"46.8"},{"Policy Line":"75202204","B":"Manual Therapy Each 15 Min","C":"430","D":"97140","F":"47.1"},{"Policy Line":"75202206","B":"Adl Training Ea 15 Min","C":"430","D":"97535","F":"40.2"},{"Policy Line":"75202302","B":"Orthotic 1st Visit 15 Min","C":"430","D":"97760","F":"42.3"},{"Policy Line":"75202304","B":"Orth-Pros Sub Visit 15 Min","C":"430","D":"97763","F":"39.6"},{"Policy Line":"75202550","B":"Dir Therapeutic Activs 15 Min","C":"430","D":"97530","F":"44.1"},{"Policy Line":"75202621","B":"Wheelchair Mgmt/Train 15 Min","C":"430","D":"97542","F":"33"},{"Policy Line":"75202636","B":"Selfcare Home Tx - Ea 15 Min","C":"430","D":"97535","F":"40.2"},{"Policy Line":"75202658","B":"Group Treatmt Proc Therapeutic","C":"430","D":"97150","F":"110.1"},{"Policy Line":"75203001","B":"Orthotic Custom 1stVisit 15min","C":"430","D":"97760","F":"42.3"},{"Policy Line":"75203002","B":"Orthotic Insert 1stVisit 15min","C":"430","D":"97760","F":"42.3"},{"Policy Line":"75203100","B":"Work Condition Additional 1 Hr","C":"430","D":"97546","F":"213.6"},{"Policy Line":"75203101","B":"Work Condition First 2 Hours","C":"430","D":"97545","F":"506.1"},{"Policy Line":"75203102","B":"ProstheticTrain 1stVisit15 Min","C":"430","D":"97761","F":"46.8"},{"Policy Line":"75203666","B":"Tens Attended","C":"430","D":"97032","F":"49.8"},{"Policy Line":"75300054","B":"Cogn Funct 1st 15 min","C":"430","D":"97129","F":"61.5"},{"Policy Line":"75300055","B":"Cogn Funct Add 15 min","C":"430","D":"97130","F":"37.5"},{"Policy Line":"63200208","B":"Tinnitus Assessment","C":"471","D":"92625","F":"109.5"},{"Policy Line":"63200209","B":"VEMP - Vest evoked myogenic pt","C":"470","D":"92700","F":"123.3"},{"Policy Line":"75301502","B":"EVAL SPEECH FLUENCY","C":"440","D":"92521","F":"189.9"},{"Policy Line":"75301503","B":"EVAL SPEECH SOUND PRODUCTION","C":"440","D":"92522","F":"189.9"},{"Policy Line":"75301504","B":"EVAL SPEECH SOUND/COMP/EXPRSS","C":"440","D":"92523","F":"189.9"},{"Policy Line":"75301505","B":"BHV/QUAL ANALYSIS VOICE/RESNC","C":"440","D":"92524","F":"189.9"},{"Policy Line":"75303000","B":"Eval Swall Oral Funct","C":"440","D":"92610","F":"140.4"},{"Policy Line":"75303003","B":"Tx Swall Oral Funct Feed","C":"440","D":"92526","F":"141.9"},{"Policy Line":"75303020","B":"Mod Barium Swall Evaluation","C":"440","D":"92611","F":"182.1"},{"Policy Line":"75303050","B":"Aug Communication Eval 1 HR","C":"440","D":"92607","F":"183"},{"Policy Line":"75303055","B":"Aug Communication Training","C":"440","D":"92609","F":"705.3"},{"Policy Line":"75303113","B":"ST Therapy Group","C":"440","D":"92508","F":"126.6"},{"Policy Line":"75303114","B":"ST Individual Thpy","C":"440","D":"92507","F":"143.7"},{"Policy Line":"73100023","B":"Vent Mgmt Initial IP 1st Day","C":"410","D":"94002","F":"668.7"},{"Policy Line":"73100025","B":"Cpap/Bipap Initial & Mgmt","C":"410","D":"94660","F":"186.6"},{"Policy Line":"73100027","B":"Infant Vent: Cpap Daily","C":"410","D":"94002","F":"668.7"},{"Policy Line":"73100300","B":"Ventiln Mgmt Ea Subseq IP Day","C":"410","D":"94003","F":"668.1"},{"Policy Line":"0120","B":"Breast Bx W/Clip Stereo Gd -D","C":"361","F":"0"},{"Policy Line":"0155","B":"Breast BxW/Clip Stereo Gd BI-D","C":"361","F":"0"},{"Policy Line":"0185","B":"Breast BxW/Clip Stereo Gd LT-D","C":"361","F":"0"},{"Policy Line":"0191","B":"Breast BxW/Clip Stereo Gd RT-D","C":"361","F":"0"},{"Policy Line":"0194","B":"CT GD FIDUCIAL MARKER W/O BX-D","C":"350","F":"0"},{"Policy Line":"0195","B":"Fiducial Marker Placemnt Ct Gd","C":"360","F":"975.3"},{"Policy Line":"0198","B":"Drain Seroma Us Guided","C":"360","F":"142.2"},{"Policy Line":"0244","B":"Biopsy Lymph Node(S)","C":"360","F":"632.1"},{"Policy Line":"0245","B":"Perc LYM ND BXw/ClipW/IMG-LT-D","C":"361","F":"0"},{"Policy Line":"0246","B":"Perc LY ND BXw/ClipW/IMG-RT -D","C":"361","F":"0"},{"Policy Line":"0247","B":"Perc L ND BXw/ClipW/IMG-BI -D","C":"361","F":"0"},{"Policy Line":"0251","B":"Uro Study-D","C":"920","F":"0"},{"Policy Line":"0252","B":"Uro StudyW/Voiding Pressure -D","C":"920","F":"0"},{"Policy Line":"0258","B":"Breast Punc/AspSglCyst USgui-D","C":"361","F":"0"},{"Policy Line":"1000","B":"MRI Brain WO, MRA Head/Neck-D","C":"611","F":"0"},{"Policy Line":"1018","B":"MRI Abd/Pelvis W&W/O Contr-D","C":"610","F":"0"},{"Policy Line":"2111","B":"FNA US GUIDED SURG COMPONENT","C":"360","F":"739.5"},{"Policy Line":"2130","B":"CT Neck/Chest W/Contrast- D","C":"350","F":"0"},{"Policy Line":"2131","B":"CT Neck/Chest W/Wo Contrast -D","C":"350","F":"0"},{"Policy Line":"2133","B":"CT Neck/Chest/Abd/Pel W/Con -D","C":"350","F":"0"},{"Policy Line":"2134","B":"CT Neck/Chest/Abd/Pel W/Wo -D","C":"350","F":"0"},{"Policy Line":"2135","B":"CT Chst/Adb/Pel W/Wo Conrast-D","C":"350","F":"0"},{"Policy Line":"2136","B":"CT Drainage: Extremity-D","C":"350","F":"0"},{"Policy Line":"2137","B":"CT Drainage: Extremity -Surg","C":"360","F":"3005.1"},{"Policy Line":"2138","B":"CT Chest w/ &CTabd&pelvis w/wo","C":"352","F":"0"},{"Policy Line":"2140","B":"CT Drainage Lung-D","C":"350","F":"0"},{"Policy Line":"2142","B":"CT Drainage: Neck-D","C":"350","F":"0"},{"Policy Line":"2143","B":"CT Drainage Neck- Surg Comp","C":"360","F":"1282.8"},{"Policy Line":"2144","B":"CT Drainage: Pelvic-D","C":"350","F":"0"},{"Policy Line":"2145","B":"CT Drainage Liver-D","C":"350","F":"0"},{"Policy Line":"2151","B":"CT Drainage Pancreas-D","C":"350","F":"0"},{"Policy Line":"2160","B":"CT Drainage: Retroperitoneal-D","C":"350","F":"0"},{"Policy Line":"2170","B":"CT Biopsy: Chest-D","C":"350","F":"0"},{"Policy Line":"2171","B":"CT Guided Block Celiac Plex -D","C":"350","F":"0"},{"Policy Line":"2172","B":"Inject Nerve Block Ct Guided","C":"360","F":"1935.9"},{"Policy Line":"2175","B":"CT Biopsy: Lung-D","C":"350","F":"0"},{"Policy Line":"2180","B":"CT Biopsy: Liver-D","C":"350","F":"0"},{"Policy Line":"2185","B":"CT Biopsy: Breast-D","C":"350","F":"0"},{"Policy Line":"2190","B":"CT Biopsy: Pancreas-D","C":"350","F":"0"},{"Policy Line":"2195","B":"CT Biopsy: Retroperitoneal-D","C":"350","F":"0"},{"Policy Line":"2196","B":"CT Biopsy: Renal-D","C":"350","F":"0"},{"Policy Line":"2217","B":"CT Drainage Kidney -D","C":"360","F":"0"},{"Policy Line":"2218","B":"CT Drain: Abdomen-D","C":"350","F":"0"},{"Policy Line":"2219","B":"Injec SI Joint Fluoro Guide","C":"360","F":"137.7"},{"Policy Line":"2220","B":"CT Biopsy: Femur-D","C":"359","F":"0"},{"Policy Line":"2221","B":"CT Biopsy: Vertebral Body-D","C":"352","F":"0"},{"Policy Line":"2222","B":"CT Biopsy: Bone Superficial-D","C":"352","F":"0"},{"Policy Line":"2223","B":"CT Biopsy:Soft Tissue - Body-D","C":"352","F":"0"},{"Policy Line":"2224","B":"CT Biop:Soft Tissue-Extremty-D","C":"359","F":"0"},{"Policy Line":"2226","B":"CT Biopsy:Vertebal Body - Surg","C":"360","F":"3798.6"},{"Policy Line":"2227","B":"CT Biopsy:Bone Superficial-Sur","C":"360","F":"3231.3"},{"Policy Line":"2228","B":"CT Biopsy: Soft Tissue","C":"360","F":"3133.8"},{"Policy Line":"2229","B":"CT Biopsy:Soft Tissue:Ext -Sur","C":"360","F":"2834.1"},{"Policy Line":"2230","B":"CT Biopsy: Femur - Surg Comp","C":"360","F":"1791.3"},{"Policy Line":"2240","B":"CT Guide: Tumor Loc - Lung-D","C":"352","F":"0"},{"Policy Line":"2241","B":"CT Biopsy - Neck-D","C":"352","F":"0"},{"Policy Line":"2242","B":"CT Biopsy: Neck Surg Comp","C":"360","F":"3034.5"},{"Policy Line":"2248","B":"CT Brain Perfusion -D","C":"351","F":"0"},{"Policy Line":"2252","B":"Sacroplasty Ct Guided","C":"360","F":"1544.4"},{"Policy Line":"2253","B":"CT Guided Sacroplasty -D","C":"350","F":"0"},{"Policy Line":"2254","B":"Remove Catheter Ct Guided-Surg","C":"360","F":"964.5"},{"Policy Line":"2501","B":"Endoven Saph Ablt Us Tech Time","C":"360","F":"469.5"},{"Policy Line":"2654","B":"MRI Guided Breast Biopsy -D","C":"610","F":"0"},{"Policy Line":"2656","B":"MRI Guided Breast Biopsy","C":"360","F":"1430.4"},{"Policy Line":"2657","B":"MRI Injection Proc","C":"360","F":"562.2"},{"Policy Line":"2658","B":"Fna By Mri","C":"360","F":"193.8"},{"Policy Line":"2900","B":"Gi Tube Insertion W/Fluoro Gd","C":"360","F":"257.7"},{"Policy Line":"3355","B":"Fistulagram Surg Comp","C":"360","F":"214.2"},{"Policy Line":"3452","B":"US Abcess Drainage Surg Comp","C":"360","F":"4264.2"},{"Policy Line":"3500","B":"Aspiration Surg Procedure","C":"360","F":"637.2"},{"Policy Line":"4235","B":"RF Ablation Lung Tumor","C":"360","F":"1777.5"},{"Policy Line":"4236","B":"CT Guided Rf Ablation Lung-D","C":"350","F":"0"},{"Policy Line":"5035","B":"CT Drainage Abdomen Surg Comp","C":"360","F":"3276"},{"Policy Line":"5042","B":"CT Biopsy: Breast Surg Comp","C":"360","F":"868.5"},{"Policy Line":"5045","B":"CT Biopsy: Surg Comp","C":"360","F":"3441.6"},{"Policy Line":"5053","B":"Injection Botox Ct Guided","C":"360","F":"337.5"},{"Policy Line":"5054","B":"CT Biopsy: Renal Surg Comp","C":"360","F":"3280.8"},{"Policy Line":"5055","B":"CT Biopsy: Lung Surg Comp","C":"360","F":"3024.6"},{"Policy Line":"5056","B":"CT Biopsy: Liver Surg Comp","C":"360","F":"3279"},{"Policy Line":"5058","B":"CT Biopsy: Pancreas Surg Comp","C":"360","F":"2955"},{"Policy Line":"5059","B":"CT Biopsy:Retroperitoneal Srg","C":"360","F":"3153"},{"Policy Line":"5090","B":"CT Guided Si Injection-D","C":"361","F":"0"},{"Policy Line":"5095","B":"Si Inject Ct Gd: Surgical Comp","C":"360","F":"1191.9"},{"Policy Line":"5171","B":"CTA ABD/PELVIS CT CHST W/O - D","C":"350","F":"0"},{"Policy Line":"5173","B":"CTA CHST ABD/PELV, CT ABD - D","C":"350","F":"0"},{"Policy Line":"5400","B":"LIVER: DRAIN/ASPIRATE SURG COM","C":"360","F":"3725.1"},{"Policy Line":"5405","B":"LUNG: DRAIN/ASPIRATE SURG COMP","C":"360","F":"3723.9"},{"Policy Line":"5406","B":"KIDNEY: DRAIN/ASPRIATE SURGERY","C":"360","F":"3239.4"},{"Policy Line":"5630","B":"CT Pancrease Drain/Aspir Surg","C":"360","F":"2712.9"},{"Policy Line":"5640","B":"CT Drainage Pelvic Surg","C":"360","F":"2181.3"},{"Policy Line":"5700","B":"CT Drainage Retroperit -Surg","C":"360","F":"3503.7"},{"Policy Line":"5771","B":"CT Guided NG Placement-Surg","C":"360","F":"229.2"},{"Policy Line":"6051","B":"US Amniocentesis Surgical Proc","C":"360","F":"159"},{"Policy Line":"61050021","B":"Bedside Procedure","C":"360","F":"129.6"},{"Policy Line":"61050650","B":"4N Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61100021","B":"2N Bedside Procedure","C":"360","F":"129.6"},{"Policy Line":"61150025","B":"6N Procedure","C":"360","F":"203.4"},{"Policy Line":"61150650","B":"6N Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61200015","B":"Observation: Admission","C":"510","F":"0"},{"Policy Line":"61200025","B":"Bedside Procedure 6120","C":"360","F":"56.4"},{"Policy Line":"61200650","B":"5S Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61250499","B":"2S Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61300021","B":"Bedside Procedure","C":"360","F":"123.6"},{"Policy Line":"61300650","B":"5N Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61350021","B":"Bedside Procedure","C":"360","F":"117.9"},{"Policy Line":"61350650","B":"6S Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61400650","B":"7N Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61405000","B":"Minor Procedure Charge","C":"360","F":"26.7"},{"Policy Line":"61450650","B":"7S Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61455000","B":"7S Bedside Procedure","C":"360","F":"129.6"},{"Policy Line":"61500021","B":"Bedside Procedure","C":"360","F":"123"},{"Policy Line":"61500650","B":"Peds Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61506152","B":"Adult Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61550203","B":"Childbirth Class Sessions","C":"942","F":"24"},{"Policy Line":"61550499","B":"3Rd Flr Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61552928","B":"Cerclage Placement","C":"360","F":"903.3"},{"Policy Line":"61552930","B":"Removal Cerclage Suture","C":"360","F":"1934.1"},{"Policy Line":"61552931","B":"Laminaria Insertion","C":"360","F":"366.3"},{"Policy Line":"61555645","B":"LDR Recovery: First Hour","C":"710","F":"273"},{"Policy Line":"61555656","B":"LDR Recovery: Each Addl Hour","C":"710","F":"322.8"},{"Policy Line":"61555860","B":"Anesthesia:Epidural Continuous","C":"370","F":"753"},{"Policy Line":"61555870","B":"Anesthesia: General 30 Min","C":"370","F":"183.9"},{"Policy Line":"61555880","B":"Anesthesia:Spinal/Saddle Block","C":"370","F":"266.7"},{"Policy Line":"61555935","B":"LDR Surg Time Per 30 Min","C":"360","F":"131.1"},{"Policy Line":"61557925","B":"Epidural Blood Patch","C":"360","F":"299.1"},{"Policy Line":"61567926","B":"Minor Proc","C":"360","F":"21.6"},{"Policy Line":"61700021","B":"Bedside Procedure","C":"360","F":"122.1"},{"Policy Line":"6177","B":"Breast Bx US Guided-LT - D","C":"361","F":"0"},{"Policy Line":"6178","B":"Breast BX US Guidew/Clip-RT -D","C":"361","F":"0"},{"Policy Line":"6179","B":"BreastBX US Guidew/Clip-BI -D","C":"361","F":"0"},{"Policy Line":"61800052","B":"Iabp Daily Charge","C":"360","F":"66.6"},{"Policy Line":"61800300","B":"CCU OPEN HRT RECOVERY 1ST HR","C":"710","F":"638.1"},{"Policy Line":"61800301","B":"CCU OPEN HRT RECOVERY ADDL HR","C":"710","F":"340.8"},{"Policy Line":"61800650","B":"Ccu Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61850650","B":"ICU Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"61900027","B":"ICP Pres Monit Daily","C":"360","F":"14.7"},{"Policy Line":"61900650","B":"NICU Recovery Hourly Charge","C":"719","F":"0"},{"Policy Line":"63101002","B":"Hemodialysis (Op)-D","C":"761","F":"0"},{"Policy Line":"63200076","B":"VES AUDIOMETRIC EVAL","C":"920","F":"47.7"},{"Policy Line":"64100096","B":"Surgery Time Per 30 Min","C":"360","F":"849"},{"Policy Line":"64101820","B":"Ecmo Daily Management","C":"360","F":"602.7"},{"Policy Line":"64102579","B":"Ds Ent Procedure","C":"360","F":"324.9"},{"Policy Line":"64102582","B":"Minor Procedure Room Charge","C":"360","F":"971.4"},{"Policy Line":"64102583","B":"Blood Patch Day Surgery","C":"360","F":"203.4"},{"Policy Line":"64102699","B":"Surg Time Major Proc 1st 30min","C":"360","F":"1377.6"},{"Policy Line":"64102700","B":"Surg Time Minor Proc 1st 30min","C":"360","F":"849"},{"Policy Line":"64102701","B":"Surg Time Additional 30 min","C":"360","F":"849"},{"Policy Line":"64102702","B":"SURG TIME MAJOR 2 PROC 1ST 30M","C":"360","F":"1913.4"},{"Policy Line":"64102703","B":"SURG TIME ADD'L 30MIN-MAJOR 2","C":"360","F":"956.7"},{"Policy Line":"64102704","B":"SURG TIME ADD'L 30MIN-MAJOR PR","C":"360","F":"849"},{"Policy Line":"64102705","B":"SURG TIME ADD'L 30MIN - MINOR","C":"360","F":"688.8"},{"Policy Line":"64102706","B":"CDD IN OR MAJ Proc 1st 30min","C":"750","F":"1377.6"},{"Policy Line":"64102707","B":"CDD IN OR ADD'L 30MIN-MAJOR PR","C":"750","F":"849"},{"Policy Line":"64102708","B":"Bronc in OR Maj Proc 1st 30min","C":"360","F":"1378.5"},{"Policy Line":"64102709","B":"Bronc in OR Add'l 30min-Major","C":"360","F":"849"},{"Policy Line":"64103003","B":"Perfusion: Open Heart Fee","C":"360","F":"5829"},{"Policy Line":"64104043","B":"Perfusion: Iabp Intra-Aortic","C":"360","F":"1050.9"},{"Policy Line":"64116467","B":"Perfusion: Beating Heart Lv Ii","C":"360","F":"2790.6"},{"Policy Line":"64117158","B":"Edwards Perf Open Heart Servic","C":"360","F":"8665.5"},{"Policy Line":"64138834","B":"OR Dental/PlasticClient 1st HR","C":"360","F":"382.5"},{"Policy Line":"64138835","B":"OR Dental/PlasticCli addl15min","C":"360","F":"95.7"},{"Policy Line":"64138899","B":"TAVR HEART FEE","C":"360","F":"1324.5"},{"Policy Line":"64140512","B":"Moderate Sed Ini 15Min >5yrs","C":"370","F":"49.5"},{"Policy Line":"64140523","B":"Moderat Sed Addl 15Min any age","C":"370","F":"40.5"},{"Policy Line":"64141382","B":"Anesthesia: General 30 Min","C":"370","F":"231"},{"Policy Line":"64141401","B":"Anesthesia Mac 30 Min","C":"370","F":"187.8"},{"Policy Line":"64142699","B":"Surg Time Major Proc 1st 30min","C":"360","F":"1324.5"},{"Policy Line":"64142700","B":"Surg Time Minor Proc 1st 30min","C":"360","F":"816.3"},{"Policy Line":"64142702","B":"SURG TIME MAJOR 2 PROC 1ST 30M","C":"360","F":"1839.9"},{"Policy Line":"64142703","B":"SURG TIME ADD'L 30MIN-MAJOR 2","C":"360","F":"919.8"},{"Policy Line":"64142704","B":"SURG TIME ADD'L 30MIN-MAJOR PR","C":"360","F":"816.3"},{"Policy Line":"64142705","B":"SURG TIME ADD'L 30MIN - MINOR","C":"360","F":"662.4"},{"Policy Line":"64145002","B":"Moderate Sed Ini 15Min <5yrs","C":"370","F":"95.7"},{"Policy Line":"64146300","B":"Surg Ctr Recovery 1st Hour","C":"710","F":"227.1"},{"Policy Line":"64146316","B":"Surg Ctr Recovery Ea Addl Hr","C":"710","F":"142.5"},{"Policy Line":"64300100","B":"Cardioversion, External, Ele-D","C":"361","F":"0"},{"Policy Line":"64306300","B":"Pacu Recovery: First Hour","C":"710","F":"638.1"},{"Policy Line":"64306316","B":"Pacu Recovery: Each Addl Hour","C":"710","F":"354"},{"Policy Line":"64400012","B":"Anesthesia Spinal/Epidural","C":"370","F":"213.9"},{"Policy Line":"64400500","B":"Anesthesia Regional Block","C":"370","F":"246.6"},{"Policy Line":"64400501","B":"Anesthesia: Bier Block","C":"370","F":"274.5"},{"Policy Line":"64400502","B":"Moderate Sed Ini 15Min <5yrs","C":"370","F":"99.6"},{"Policy Line":"64400512","B":"Moderate Sed Ini 15Min >5yrs","C":"370","F":"51.6"},{"Policy Line":"64400523","B":"Moderat Sed Addl 15Min any age","C":"370","F":"42"},{"Policy Line":"64401382","B":"Anesthesia: General 30 Min","C":"370","F":"240.3"},{"Policy Line":"64401401","B":"Anesthesia Mac 30 Min","C":"370","F":"195.3"},{"Policy Line":"64502055","B":"Solesta Injection Procedure","C":"360","F":"191.7"},{"Policy Line":"64504771","B":"EMG/RUS/PN/AM -D","C":"750","F":"0"},{"Policy Line":"64504772","B":"RUSs/ARMS -D","C":"750","F":"0"},{"Policy Line":"64505001","B":"Procedure Time Per 30 Min","C":"750","F":"591"},{"Policy Line":"64508206","B":"Pudendal Nerve Study-D","C":"750","F":"0"},{"Policy Line":"64515001","B":"Endo Procedure Time Per 30 Min","C":"750","F":"568.2"},{"Policy Line":"64600500","B":"Regional Block","C":"370","F":"216"},{"Policy Line":"64600501","B":"Retrobulbar Block","C":"370","F":"180.3"},{"Policy Line":"64601382","B":"Anesthesia General 30 Min","C":"370","F":"225"},{"Policy Line":"64601401","B":"Anesthesia Mac 30 Min","C":"370","F":"200.1"},{"Policy Line":"64602582","B":"Minor Procedure Room Charge","C":"360","F":"971.4"},{"Policy Line":"64605002","B":"Moderate Sed Ini 15Min <5yrs","C":"370","F":"99.6"},{"Policy Line":"64605012","B":"Moderate Sed Ini 15Min >5yrs","C":"370","F":"51.6"},{"Policy Line":"64605023","B":"Moderat Sed Addl 15Min any age","C":"370","F":"42"},{"Policy Line":"64606300","B":"Surg Ctr Recovery 1st Hour","C":"710","F":"236.1"},{"Policy Line":"64606316","B":"Surg Ctr Recovery Ea Addl Hr","C":"710","F":"148.2"},{"Policy Line":"64608834","B":"ASC Dental/PlasticClient 1stHR","C":"360","F":"382.5"},{"Policy Line":"64608835","B":"ASC Dental/PlasticCli adl15min","C":"360","F":"95.7"},{"Policy Line":"64608836","B":"ASC ENT Client 1st HR","C":"360","F":"287.1"},{"Policy Line":"64608837","B":"ASC ENT CLIENT EA addl15min","C":"360","F":"72"},{"Policy Line":"64609905","B":"Surg Time Per 30 Minutes","C":"360","F":"627"},{"Policy Line":"64609906","B":"Yag Laser Procedure","C":"360","F":"386.7"},{"Policy Line":"65103000","B":"Delivery Vaginal","C":"360","F":"1830"},{"Policy Line":"65103001","B":"ED Vaginal Delivery - D","C":"450","F":"0"},{"Policy Line":"65103504","B":"Paracentesis","C":"459","F":"2280.3"},{"Policy Line":"65106296","B":"Category 1 Procedure","C":"450","F":"89.4"},{"Policy Line":"65106297","B":"Category 2 Procedure","C":"450","F":"174.9"},{"Policy Line":"65106301","B":"Insert Bladder Cath Simple","C":"450","F":"298.8"},{"Policy Line":"65106302","B":"Insert Temp Bladder Cath","C":"450","F":"298.8"},{"Policy Line":"65106303","B":"Insert Bladder Cath Complex","C":"450","F":"533.7"},{"Policy Line":"65106304","B":"Temp External Pacing","C":"450","F":"419.4"},{"Policy Line":"65106416","B":"Category 3 Procedure","C":"450","F":"200.1"},{"Policy Line":"65106600","B":"Intraosseous Infusion Driver","C":"450","F":"0"},{"Policy Line":"65106610","B":"Paracentesis Driver","C":"450","F":"0"},{"Policy Line":"65106620","B":"Chest Tube Insertion Driver","C":"450","F":"0"},{"Policy Line":"65106630","B":"Intubation Driver","C":"450","F":"0"},{"Policy Line":"65106640","B":"Pericardiocentesis Driver","C":"450","F":"0"},{"Policy Line":"65106650","B":"Lumbar Punct: Pediatric Driver","C":"450","F":"0"},{"Policy Line":"65106660","B":"Lumbar Puncture: Adult Driver","C":"450","F":"0"},{"Policy Line":"65106670","B":"Central Line Placement Driver","C":"450","F":"0"},{"Policy Line":"65106680","B":"Precipitous Birth Driver","C":"450","F":"0"},{"Policy Line":"65106690","B":"Gastro Tube Replacement Driver","C":"450","F":"0"},{"Policy Line":"65106700","B":"Thoracentesis Driver","C":"450","F":"0"},{"Policy Line":"65106710","B":"Emergency Airway Insertion Dri","C":"450","F":"0"},{"Policy Line":"65106720","B":"Nasal Hem Packing Driver","C":"450","F":"0"},{"Policy Line":"6651","B":"Paracentesis Us Gd -Surg Comp","C":"360","F":"468"},{"Policy Line":"68260270","B":"Bone Marrow Biopsy","C":"360","F":"120.6"},{"Policy Line":"68300195","B":"Laryngoscopy","C":"360","F":"208.8"},{"Policy Line":"6861","B":"US-Surg Comp-Gall Bladr Drain","C":"360","F":"918.6"},{"Policy Line":"6886","B":"Thoracentesis Asp/Bx Us Guided","C":"360","F":"281.4"},{"Policy Line":"6901","B":"Thyroid Biopsy Us Guided -Surg","C":"360","F":"468"},{"Policy Line":"6906","B":"Thyroid Aspiration Us Gd -Surg","C":"360","F":"89.4"},{"Policy Line":"6998","B":"US Biopsy Surg Comp","C":"360","F":"540"},{"Policy Line":"7006","B":"US Biopsy: Liver Surg Comp","C":"360","F":"56.4"},{"Policy Line":"7008","B":"US Biopsy: Renal Surg Comp","C":"360","F":"1220.1"},{"Policy Line":"70101300","B":"FNA W/O Imaging","C":"360","F":"50.4"},{"Policy Line":"7100","B":"US Pseudoaneurysm INJ Surg Com","C":"360","F":"3121.8"},{"Policy Line":"71100015","B":"Injection Tx Psuedoaneurysm","C":"361","F":"624"},{"Policy Line":"71102213","B":"Small Joint Injection","C":"361","F":"247.2"},{"Policy Line":"71102214","B":"Sacroiliac Joint Injection","C":"361","F":"425.4"},{"Policy Line":"71106102","B":"Periocardiocentesis w/Img","C":"360","F":"906.3"},{"Policy Line":"71502171","B":"CT Guided Block Celiac Plex -D","C":"350","F":"0"},{"Policy Line":"71700004","B":"Lumbar/Sacral LESI w/ guidance","C":"361","F":"408.6"},{"Policy Line":"71705245","B":"Surg Time: Specials Per Min","C":"360","F":"46.8"},{"Policy Line":"71705515","B":"Insert Pm Single System","C":"360","F":"7105.8"},{"Policy Line":"71705541","B":"Loop Recorder Insertion","C":"360","F":"927"},{"Policy Line":"71708015","B":"Chest Tube Insertion","C":"360","F":"2025"},{"Policy Line":"72103003","B":"Perfusion: Open Heart Fee","C":"360","F":"5397"},{"Policy Line":"72104043","B":"Perfusion: Iabp Intra-Aortic","C":"360","F":"972.9"},{"Policy Line":"72106467","B":"Perfusion: Beating Heart Lv Ii","C":"360","F":"2583.9"},{"Policy Line":"72108899","B":"TAVR HEART FEE","C":"360","F":"1226.4"},{"Policy Line":"72158800","B":"CRU Recovery: First Hour","C":"710","F":"0"},{"Policy Line":"72158821","B":"CRU Recovery: Each Addl Hour","C":"710","F":"0"},{"Policy Line":"72158825","B":"CRU Nc Recovery - Each Hour","C":"719","F":"0"},{"Policy Line":"72203003","B":"Perfusion: Open Heart Fee","C":"360","F":"5397"},{"Policy Line":"72204043","B":"Perfusion: Iabp Intra-Aortic","C":"360","F":"972.9"},{"Policy Line":"72206473","B":"Perfusion: Beating Heart Lv Ii","C":"360","F":"2583.9"},{"Policy Line":"72208899","B":"TAVR HEART FEE","C":"360","F":"1226.4"},{"Policy Line":"72300051","B":"Tee Incomplete","C":"360","F":"183.6"},{"Policy Line":"73100013","B":"Eval Resp Thrpy 1/4 Hr","C":"410","F":"0"},{"Policy Line":"73100204","B":"Bronch Thoracentesis","C":"360","F":"576.6"},{"Policy Line":"73100310","B":"Extubation","C":"410","F":"0"},{"Policy Line":"73101206","B":"Endobronchial Ultrasound Ad-On","C":"360","F":"3191.7"},{"Policy Line":"73200206","B":"Injection Of Dye Lung Tissue","C":"360","F":"3006.6"},{"Policy Line":"73200740","B":"Bronch Proc Time Per 30 Min","C":"360","F":"498.6"},{"Policy Line":"73200742","B":"Laryngoscopy","C":"360","F":"193.2"},{"Policy Line":"73200743","B":"Chest Tube Placement","C":"360","F":"502.5"},{"Policy Line":"73200750","B":"Time Ebus/Superd Proc Ea 30 Mn","C":"360","F":"738"},{"Policy Line":"73201206","B":"Endobronchial Ultrasound Ad-On","C":"360","F":"1552.2"},{"Policy Line":"73206300","B":"Bronch Recovery: First Hour","C":"710","F":"638.1"},{"Policy Line":"73206316","B":"Bronch Recovery Each Addl Hour","C":"710","F":"354"},{"Policy Line":"74200120","B":"DM-Hypertension Prog Lvl One","C":"942","F":"115.566"},{"Policy Line":"74200125","B":"DM-Hypertension Prog Lvl Two","C":"942","F":"215.082"},{"Policy Line":"74200130","B":"DM-Hypertension Prog Lvl Three","C":"942","F":"308.175"},{"Policy Line":"74200140","B":"DM-Hyperlipidemia Prog Lvl 1","C":"942","F":"70.626"},{"Policy Line":"74200145","B":"DM-Hyperlipidemia Prog Lvl 2","C":"942","F":"141.246"},{"Policy Line":"74200150","B":"DM-Hyperlipidemia Prog Lvl 3","C":"942","F":"211.872"},{"Policy Line":"74220120","B":"Hypertension Prog Lvl One","C":"942","F":"111"},{"Policy Line":"74220125","B":"Hypertension Prog Lvl Two","C":"942","F":"206.7"},{"Policy Line":"74220130","B":"Hypertension Prog Lvl Three","C":"942","F":"296.1"},{"Policy Line":"74220140","B":"Hyperlipidemia Prog Lvl 1","C":"942","F":"67.8"},{"Policy Line":"74220145","B":"Hyperlipidemia Prog Lvl 2","C":"942","F":"135.9"},{"Policy Line":"74220150","B":"Hyperlipidemia Prog Lvl 3","C":"942","F":"203.7"},{"Policy Line":"75100115","B":"Fluidotherapy And Ultrasound-D","C":"420","F":"0"},{"Policy Line":"75108888","B":"PT FUNCTIONAL STATUS MAPPING#","C":"420","F":"0"},{"Policy Line":"75110015","B":"PPD - Permanent Impairment %","C":"420","F":"102.6"},{"Policy Line":"75110115","B":"Fluidotherapy And Ultrasound-D","C":"420","F":"0"},{"Policy Line":"75112020","B":"Physical Capacity Profile","C":"420","F":"73.5"},{"Policy Line":"75112021","B":"FCE First Hour","C":"420","F":"245.1"},{"Policy Line":"75112022","B":"FCE Each Addl Hour","C":"420","F":"245.1"},{"Policy Line":"75112023","B":"FCE Connect","C":"420","F":"276.6"},{"Policy Line":"75140115","B":"Fluidotherapy And Ultrasound-D","C":"420","F":"0"},{"Policy Line":"75200115","B":"Fluidotherapy And Ultrasound-D","C":"430","F":"0"},{"Policy Line":"75208888","B":"OT FUNCTIONAL STATUS MAPPING#","C":"430","F":"0"},{"Policy Line":"75230115","B":"Fluidotherapy And Ultrasound-D","C":"430","F":"0"},{"Policy Line":"75308888","B":"SP FUNCTIONAL STATUS MAPPING#","C":"440","F":"0"},{"Policy Line":"75451000","B":"Disease Mgt Wt Mgt Level 2","C":"942","F":"699.9"},{"Policy Line":"75451001","B":"Disease Mgt Wt Mgt Level 3","C":"942","F":"1399.8"},{"Policy Line":"75452000","B":"Disease Mgt Camp Fun","C":"942","F":"91.2"},{"Policy Line":"75452001","B":"Disease Mgt Wt Maintenance","C":"942","F":"412.2"},{"Policy Line":"75452002","B":"Disease Mgt DMC HYBRID","C":"942","F":"555.9"},{"Policy Line":"75452020","B":"Go Strong Level 1 Quarter","C":"940","F":"243.3"},{"Policy Line":"75452021","B":"Go Strong Level 2 Quarter","C":"940","F":"100.8"},{"Policy Line":"75452022","B":"Go Strong Rmr","C":"940","F":"35.1"},{"Policy Line":"75452023","B":"Go Strong Education Fee","C":"940","F":"10.8"},{"Policy Line":"75452028","B":"Coaching/Biometric 30 Min","C":"940","F":"8.7"},{"Policy Line":"75452029","B":"Personal Training 30 Min","C":"940","F":"6.3"},{"Policy Line":"75452030","B":"Lifestyle Lab","C":"940","F":"5.1"},{"Policy Line":"75452040","B":"Disease Wt Mgt Level 2 Qtr1","C":"942","F":"379.2"},{"Policy Line":"75452041","B":"Disease Wt Mgt Level 2 Qtr2","C":"942","F":"128.358"},{"Policy Line":"75452042","B":"Disease Wt Mgt Level 2 Qtr3","C":"942","F":"96.3"},{"Policy Line":"75452043","B":"Disease Wt Mgt Level 2 Qtr4","C":"942","F":"96.3"},{"Policy Line":"75452050","B":"Disease Wt Mgt Level 3 Qtr1","C":"942","F":"661.5"},{"Policy Line":"75452051","B":"Disease Wt Mgt Level 3 Qtr2","C":"942","F":"353.1"},{"Policy Line":"75452052","B":"Disease Wt Mgt Level 3 Qtr3","C":"942","F":"256.8"},{"Policy Line":"75452053","B":"Disease Wt Mgt Level 3 Qtr4","C":"942","F":"128.4"},{"Policy Line":"75452060","B":"Disease Wt Mgt Weigh To Go Q1","C":"942","F":"168.6"},{"Policy Line":"75452061","B":"Disease Wt Mgt Weigh To Go Q2","C":"942","F":"85.2"},{"Policy Line":"75452062","B":"Disease Wt Mgt Weigh To Go Q3","C":"942","F":"85.2"},{"Policy Line":"75452063","B":"Disease Wt Mgt Weigh To Go Q4","C":"942","F":"85.2"},{"Policy Line":"75458888","B":"Biometric Screen","C":"940","F":"0"},{"Policy Line":"76970270","B":"Bone Marrow Biopsy","C":"360","F":"120.6"},{"Policy Line":"77200050","B":"Inpatient Diabetic Ed - 30 Min","C":"942","F":"0"},{"Policy Line":"77200135","B":"Asthma Management Program","C":"942","F":"102"},{"Policy Line":"77200136","B":"Dietician Initial Consult","C":"942","F":"21.3"},{"Policy Line":"77200137","B":"Dietician Follow-Up","C":"942","F":"13.2"},{"Policy Line":"77200804","B":"SBG First Year","C":"942","F":"848.4"},{"Policy Line":"77200805","B":"SBG Annual Re-Enrollment","C":"942","F":"595.5"},{"Policy Line":"77200806","B":"SBG MAINTENANCE DIABETES","C":"942","F":"533.4"},{"Policy Line":"77200807","B":"SBG PREVENTT2","C":"942","F":"186.6"},{"Policy Line":"8001","B":"CT Cervicl Thoracic Lumbar W/O","C":"350","F":"0"},{"Policy Line":"8002","B":"CT cervical,lumbar wo con D","C":"350","F":"789"},{"Policy Line":"8003","B":"CT Head MaxiloFacl W/O Contra","C":"350","F":"0"},{"Policy Line":"8004","B":"CT Thorax W Abd W/Wo Contrast","C":"350","F":"0"},{"Policy Line":"8006","B":"CT ThoraxW Abd W/Wo PelW Contr","C":"350","F":"0"},{"Policy Line":"8007","B":"CTSft Tissuneck ThoraxW/OCon D","C":"350","F":"0"},{"Policy Line":"8008","B":"CT Thorax Abd W/O Contrast","C":"350","F":"0"},{"Policy Line":"8009","B":"CT Thorax Abd W/Contrast","C":"350","F":"0"},{"Policy Line":"8010","B":"CT Sft Tiss Neck Thx W/Contras","C":"350","F":"0"},{"Policy Line":"8011","B":"CT Abd Pelvis Wo/ Contrast-D","C":"350","F":"0"},{"Policy Line":"8013","B":"CT Abd Pelvis W/Contrast - D","C":"350","F":"0"},{"Policy Line":"8014","B":"CT Thorax Abd Pelvis W/O Contr","C":"350","F":"0"},{"Policy Line":"8015","B":"CT Thorax Abd Pelvis W/Contr-D","C":"350","F":"0"},{"Policy Line":"8016","B":"CTA Carotid CTA Cow- D","C":"350","F":"0"},{"Policy Line":"8017","B":"Head W/O Cta Carotid Cta Cow","C":"350","F":"0"},{"Policy Line":"8018","B":"CT Thoracic Lumbr W/O Contrast","C":"350","F":"0"},{"Policy Line":"8019","B":"CT Cervical Thoracic W/OContr","C":"350","F":"0"},{"Policy Line":"8020","B":"CTA Pulsatile Tinnitus Hd/Nk-D","C":"350","F":"0"},{"Policy Line":"8021","B":"CT Brain Perfusion For Reach-D","C":"350","F":"0"},{"Policy Line":"8022","B":"CTA Abd W/Wo &CTA Chest W/Wo-D","C":"350","F":"0"},{"Policy Line":"8023","B":"CTA Chest Pe & Ct Abd/Pel W","C":"350","F":"0"},{"Policy Line":"8024","B":"CT Thorax W/Abd Pel W/Wo -D","C":"350","F":"0"},{"Policy Line":"8025","B":"MRI Brain Mra Head Neck Wo","C":"610","F":"0"},{"Policy Line":"8026","B":"MRI Brain Mra Head W/Wo","C":"610","F":"0"},{"Policy Line":"8027","B":"MRI Brain Mra Head Neck W/Wo","C":"610","F":"0"},{"Policy Line":"8028","B":"MRI Lumbar Hip Lt Wo","C":"610","F":"0"},{"Policy Line":"8029","B":"MRI Lumbar Hip Rt Wo-D","C":"610","F":"0"},{"Policy Line":"8030","B":"MRI Lumbar Hip Bilat Wo - D","C":"610","F":"0"},{"Policy Line":"8031","B":"MRI Brain And Cervical Wo","C":"610","F":"0"},{"Policy Line":"8032","B":"MRI Brain/Orbits W/Wo -D","C":"611","F":"0"},{"Policy Line":"8034","B":"MRI Brain/Orbits W/O Cont -D","C":"610","F":"0"},{"Policy Line":"8035","B":"CT Tavr -D","C":"350","F":"0"},{"Policy Line":"8036","B":"MRI Brain Mra Head Wo","C":"610","F":"0"},{"Policy Line":"8037","B":"MRI Thoracic W/Wo Lumbar Wo","C":"610","F":"0"},{"Policy Line":"8038","B":"MRI Thoracic Lumbar W/Wo - D","C":"610","F":"0"},{"Policy Line":"8041","B":"MRI Brain Cerv Thorac Lumb Wo","C":"610","F":"0"},{"Policy Line":"8042","B":"MRI Brain Cerv Thor Lumb W/Wo","C":"610","F":"0"},{"Policy Line":"8043","B":"MRI Cervical Thoracic Wo - D","C":"610","F":"0"},{"Policy Line":"8045","B":"MRI Cervical Lumbar Wo","C":"610","F":"0"},{"Policy Line":"8046","B":"MRI Cervical Lumbar W/Wo","C":"610","F":"0"},{"Policy Line":"8047","B":"MRI Cervical Wo Lumbar W/Wo","C":"610","F":"0"},{"Policy Line":"8048","B":"MRI Thoracic Lumbar Wo","C":"610","F":"0"},{"Policy Line":"8050","B":"MRI Cervicalthorac Lumbar Wo","C":"610","F":"0"},{"Policy Line":"8051","B":"MRI Lumbar Hip Lt W/Wo","C":"610","F":"0"},{"Policy Line":"8052","B":"MRI Lumbar Hip Bilat W/Wo","C":"610","F":"0"},{"Policy Line":"8053","B":"MRI Lumbar W/Wo Hip Lt Wo-D","C":"610","F":"0"},{"Policy Line":"8054","B":"MRI Lumbar W/Wo Hip Rt Wo","C":"610","F":"0"},{"Policy Line":"8055","B":"MRI Brain/Cerv Sp W/WoCont - D","C":"610","F":"0"},{"Policy Line":"8056","B":"MRI Brain W/Wo Cervical Wo","C":"610","F":"0"},{"Policy Line":"8057","B":"MRI Brain Cervical Thoracic Wo","C":"610","F":"0"},{"Policy Line":"8058","B":"MRI Cervical Thor Lumb W/Wo","C":"610","F":"0"},{"Policy Line":"8060","B":"MRI Lumbar Hip Rt W/Wo","C":"610","F":"0"},{"Policy Line":"8061","B":"MRA Runoff-D","C":"610","F":"0"},{"Policy Line":"8063","B":"CT THX/ABD/PEL WWO - D","C":"350","F":"0"},{"Policy Line":"8064","B":"CT Brain and Cervical Spine wo","C":"350","F":"0"},{"Policy Line":"8065","B":"CT Brain/Maxillofacial/Cervica","C":"350","F":"0"},{"Policy Line":"8215","B":"Chest Tube Insertion Fluoro Gd","C":"360","F":"2025"},{"Policy Line":"8234","B":"CT RF Ablation Uni Liver-D","C":"350","F":"0"},{"Policy Line":"8235","B":"RF Ablat Unilat Renaltumors- D","C":"352","F":"0"},{"Policy Line":"8270","B":"Stent-Cervical Carotid","C":"360","F":"2470.5"},{"Policy Line":"8670","B":"Lumbar Spinal Puncture W/Floro","C":"360","F":"1989"},{"Policy Line":"8880","B":"CTA CHEST/ABD/PELVIS - D","C":"352","F":"0"},{"Policy Line":"8882","B":"CTA Thx/Ct Abd W/Contrast-D","C":"352","F":"0"},{"Policy Line":"8883","B":"CTA Thx/Ct Abd W/Wo Contrast-D","C":"352","F":"0"},{"Policy Line":"8884","B":"CTA Thx/Ct Abd&Pel W/Con -D","C":"351","F":"0"},{"Policy Line":"8885","B":"CTA Thx/Ct Ab W/Wo Pel W/Cn-D","C":"351","F":"0"},{"Policy Line":"8886","B":"CTA Thx/Ct Ab&Pel W/Wo Cn -D","C":"351","F":"0"},{"Policy Line":"8889","B":"CTA Thx/Ct Abd&Pel W/Con -D","C":"350","F":"0"},{"Policy Line":"8890","B":"CTA Thx/Ct Abd&Pel W/Wo -D","C":"350","F":"0"},{"Policy Line":"61551050","B":"Labor & Delivery Svcs","C":"720","F":"1491.6"},{"Policy Line":"61551051","B":"Labor & Delivery Svcs Ii","C":"720","F":"1491.6"},{"Policy Line":"61555050","B":"Amniocentesis","C":"721","F":"420.6"},{"Policy Line":"61600005","B":"Circumcision Of Male Baby-D","C":"723","F":"0"},{"Policy Line":"60950003","B":"CH 1 - Adm Room & Board","C":"121","F":"379.5"},{"Policy Line":"60958888","B":"CH 1 - Adm Outpatient Room","C":"121","F":"0"},{"Policy Line":"61050005","B":"CH 4N Room & Board","C":"121","F":"379.5"},{"Policy Line":"61050009","B":"CH 4N Stem Cell R&B Rad:Tram","C":"147","F":"341.4"},{"Policy Line":"61050022","B":"4 North Room & Board Monitored","C":"121","F":"379.5"},{"Policy Line":"61058888","B":"CH 4N Outpatient Room","C":"121","F":"0"},{"Policy Line":"61100003","B":"CH 2N Room & Board","C":"121","F":"379.5"},{"Policy Line":"61100009","B":"CH 2N Room & Board (Monitored)","C":"121","F":"379.5"},{"Policy Line":"61108888","B":"CH 2N Outpatient Room","C":"121","F":"0"},{"Policy Line":"61150001","B":"6 North Room And Board","C":"121","F":"379.5"},{"Policy Line":"61150002","B":"6 North Room And Board","C":"121","F":"379.5"},{"Policy Line":"61150015","B":"6 North Room & Board Monitored","C":"121","F":"379.5"},{"Policy Line":"61156666","B":"CH 1N Outpatient Room","C":"121","F":"0"},{"Policy Line":"61157777","B":"SJH 6Th Fl Outpatient Room","C":"121","F":"0"},{"Policy Line":"61158888","B":"CH 6N Outpatient Room","C":"121","F":"0"},{"Policy Line":"61200001","B":"5 South Room And Board","C":"121","F":"379.5"},{"Policy Line":"61200002","B":"5 South Room And Board","C":"121","F":"379.5"},{"Policy Line":"61200009","B":"5 South Room & Board- Monitore","C":"121","F":"379.5"},{"Policy Line":"61208888","B":"SJH 5S Outpatient Room","C":"121","F":"0"},{"Policy Line":"61250001","B":"2 South Room And Board","C":"121","F":"379.5"},{"Policy Line":"61258888","B":"SJH 2S Outpatient Room","C":"121","F":"0"},{"Policy Line":"61300001","B":"SJH 5 North Room And Board","C":"121","F":"379.5"},{"Policy Line":"61300002","B":"SJH 5 North Room And Board","C":"121","F":"379.5"},{"Policy Line":"61300006","B":"5 North Room & Board- Monitor","C":"121","F":"379.5"},{"Policy Line":"61300009","B":"SJH 5N Room & Board - Tram","C":"147","F":"341.4"},{"Policy Line":"61308888","B":"SJH 5N Outpatient Room","C":"121","F":"0"},{"Policy Line":"61350006","B":"CH 6S Room & Board","C":"121","F":"379.5"},{"Policy Line":"61350009","B":"6 South Room & Board Monitored","C":"121","F":"379.5"},{"Policy Line":"61358888","B":"CH 6S Outpatient Room","C":"121","F":"0"},{"Policy Line":"61400001","B":"7 North Room And Board","C":"121","F":"379.5"},{"Policy Line":"61400002","B":"7 North Room And Board","C":"121","F":"379.5"},{"Policy Line":"61400009","B":"SJH 7N Room & Board (Monitore","C":"121","F":"379.5"},{"Policy Line":"61400011","B":"SJH 7N Room & Board (Monitor-","C":"121","F":"0"},{"Policy Line":"61408888","B":"SJH 7N Outpatient Room","C":"121","F":"0"},{"Policy Line":"61450001","B":"SJH 7 South MED/SURG R&B","C":"121","F":"379.5"},{"Policy Line":"61458888","B":"SJH 7S Outpatient Room","C":"121","F":"0"},{"Policy Line":"61500016","B":"CH Pediatric Room And Board","C":"113","F":"379.5"},{"Policy Line":"61500068","B":"CH Peds Adult Overflow R&B","C":"111","F":"379.5"},{"Policy Line":"61500101","B":"Postpartum Rm Charge - Ped","C":"112","F":"379.5"},{"Policy Line":"61508888","B":"CH 5N Outpatient Room","C":"121","F":"0"},{"Policy Line":"61550005","B":"3Rd Floor Room & Board","C":"112","F":"379.5"},{"Policy Line":"61558888","B":"CH 3Rd Fl Outpatient Room","C":"121","F":"0"},{"Policy Line":"61560016","B":"CH PEDIATRIC RM & BD","C":"113","F":"379.5"},{"Policy Line":"61560100","B":"CH Postpartum Rm Charge","C":"112","F":"379.5"},{"Policy Line":"61700099","B":"Room And Board","C":"121","F":"379.5"},{"Policy Line":"61700100","B":"Room And Board","C":"121","F":"379.5"},{"Policy Line":"61707777","B":"SJH 3Rd Fl Outpatient Room","C":"121","F":"0"},{"Policy Line":"61708888","B":"CH Pcu Outpatient Room","C":"121","F":"0"},{"Policy Line":"61800100","B":"Room And Board","C":"121","F":"379.5"},{"Policy Line":"61850100","B":"Room And Board","C":"121","F":"379.5"},{"Policy Line":"61900002","B":"Private Room","C":"111","F":"379.5"},{"Policy Line":"61900013","B":"NICU Op Room","C":"121","F":"0"},{"Policy Line":"62100001","B":"Rehab Room And Board","C":"118","F":"445.2"},{"Policy Line":"62200001","B":"Sub-Acute Room And Board","C":"121","F":"354.3"},{"Policy Line":"64148888","B":"NO CHARGE POOLER","C":"110","F":"0"},{"Policy Line":"64150100","B":"Room And Board","C":"111","F":"379.5"},{"Policy Line":"64158888","B":"CH Post Surg Outpatient Room","C":"121","F":"0"},{"Policy Line":"64209002","B":"Day Surgery Room And Board","C":"121","F":"379.5"},{"Policy Line":"64309994","B":"Room And Board - Pacu","C":"121","F":"379.5"},{"Policy Line":"64518888","B":"NO CHARGE POOLER","C":"110","F":"0"},{"Policy Line":"65100098","B":"Ed Room And Board","C":"121","F":"379.5"},{"Policy Line":"72109900","B":"Card Cath: Room And Board","C":"121","F":"379.5"},{"Policy Line":"72150001","B":"CRU Room And Board - Monitored","C":"121","F":"379.5"},{"Policy Line":"72150002","B":"CRU Room And Board","C":"121","F":"379.5"},{"Policy Line":"72158888","B":"CRU Outpatient Room","C":"121","F":"0"},{"Policy Line":"73109900","B":"Resp Therapy: Room and Board","C":"121","F":"379.5"},{"Policy Line":"73209900","B":"Pulmonary Dx: Room and Board","C":"121","F":"379.5"},{"Policy Line":"61500200","B":"Newborn Room Charge - Ped","C":"171","F":"208.8"},{"Policy Line":"61558000","B":"3Rd Floor Newborn Nursery","C":"171","F":"208.8"},{"Policy Line":"61560200","B":"CH Newborn Room Charge","C":"171","F":"208.8"},{"Policy Line":"61600002","B":"Scn Level 2","C":"172","F":"600.9"},{"Policy Line":"61600009","B":"CH Newborn Nursery","C":"171","F":"208.8"},{"Policy Line":"61650001","B":"Newborn Nursery Charge","C":"171","F":"208.8"},{"Policy Line":"61450003","B":"SJH 7 SOUTH R&B MONITRD-PCU","C":"206","F":"495.6"},{"Policy Line":"61700001","B":"PCU Room And Board","C":"206","F":"495.6"},{"Policy Line":"61800001","B":"Ccu Room And Board","C":"210","F":"1236.9"},{"Policy Line":"61800101","B":"CCU Intermediate Care R&B","C":"214","F":"467.7"},{"Policy Line":"61850001","B":"Intensive Care Room & Board","C":"200","F":"1236.9"},{"Policy Line":"61900001","B":"NICU Room And Board","C":"202","F":"1236.9"},{"Policy Line":"60950004","B":"CH 1 - Adm Observation Hour","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61050003","B":"CH 4N Observ Hour","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61050020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61050111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61050150","B":"CH 4N Observation - Admission","C":"762","F":"0"},{"Policy Line":"61100004","B":"CH 2N Observ Hour","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61100020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61100111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61100150","B":"CH 2N Observation-Admission","C":"762","F":"0"},{"Policy Line":"61100505","B":"CH 2N OBS R & B (Monitored)","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61150005","B":"CH 6N Observ Hour","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61150020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61150111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61150150","B":"CH 6N Observation-Admission","C":"762","F":"0"},{"Policy Line":"61150200","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61150505","B":"6 North-Ortho Hr OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61200020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61200111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61200505","B":"5 South Hourly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61250015","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61250020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61250111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61250505","B":"2 South Hourly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61300015","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61300020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61300111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61300505","B":"5 North Hourly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61350003","B":"CH 6S Observ Hour","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61350020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61350111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61350150","B":"CH 6S Observation-Admission","C":"762","F":"0"},{"Policy Line":"61400015","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61400021","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61400111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61400505","B":"7 North Hourly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61400506","B":"SJH 7N OBS R & B (Monitored)","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61450015","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61450021","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61450111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61450505","B":"7 South Hourly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61450506","B":"OBS R & B (Monitored)","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61500004","B":"CH Peds Observ Hour","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61500020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61500111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61500150","B":"CH Pediatric Observation-Admis","C":"762","F":"0"},{"Policy Line":"61500510","B":"CH Adult OBS Hourly Chg","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61550021","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61550111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61550150","B":"3Rd Floor Observation-Adm","C":"762","F":"0"},{"Policy Line":"61550505","B":"LDRP Hourly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61560020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61560111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61560150","B":"OBS Admission - Postpartum","C":"762","F":"0"},{"Policy Line":"61560505","B":"CH Postpartum Hrly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61700020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61700106","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61700111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61700505","B":"PCU Monit Hourly OBS Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"61800015","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61800020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61800111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61800506","B":"Ccu OBS R & B","C":"762","D":"G0378","F":"51.3"},{"Policy Line":"61850015","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61850020","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61850105","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61850506","B":"Intensive Care OBS R & B","C":"762","D":"G0378","F":"51.3"},{"Policy Line":"61900014","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"61900021","B":"Observation Direct Admit","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"61900111","B":"Observation Per Hr Over 48 Hrs","C":"762","F":"0"},{"Policy Line":"61900506","B":"NICU OBS R & B","C":"762","D":"G0378","F":"51.3"},{"Policy Line":"64150001","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"64150002","B":"Observation: Hourly Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"64200505","B":"Observation: Hourly Charge","C":"762","D":"G0378","F":"14.7"},{"Policy Line":"65100103","B":"Observation: Admission","C":"762","F":"0"},{"Policy Line":"65101505","B":"Observation: Emergency Room","C":"762","D":"G0378","F":"17.7"},{"Policy Line":"72150020","B":"OBSERVATION DIRECT ADMIT","C":"762","D":"G0379","F":"117.9"},{"Policy Line":"72150505","B":"CRU OBS Hourly Chg - Monitored","C":"762","D":"G0378","F":"17.7"},{"Policy Line":"64100193","B":"Alloderm 6X12 Xthick","C":"636","D":"Q4116","F":"2645.658"},{"Policy Line":"64100237","B":"GraftJacket Xpress Inj 2cc","C":"636","D":"Q4113","F":"2546.16"},{"Policy Line":"64100424","B":"Integra Skin Sub Bmw2021 2X2In","C":"636","D":"C9363","F":"2032.911"},{"Policy Line":"64100851","B":"Integra Bilayer Meshed Mwm4101","C":"636","D":"C9363","F":"5469.40299999999","G":"**"},{"Policy Line":"64134399","B":"Integra WD Bilayer Matrx 4x10","C":"636","D":"Q4104","F":"4938.747"},{"Policy Line":"64134405","B":"Tissue Micronized Alloderm 2Cc","C":"636","D":"Q4112","F":"511.395"},{"Policy Line":"64134493","B":"Apligraf 7.5x7.5cm 40361","C":"636","D":"Q4101","F":"1689.921"},{"Policy Line":"64134650","B":"Alloderm Tissue 8X12 102096","C":"636","D":"Q4116","F":"2382.081"},{"Policy Line":"64134809","B":"Matrix Wound Flow 10cc Fwd301","C":"636","D":"Q4114","F":"3876.405","G":"**"},{"Policy Line":"64135569","B":"Allograft BiofixFlow 2.0cc BFA","C":"636","D":"Q4162","F":"6413.295"},{"Policy Line":"64135589","B":"Integra Matrix 5x5cm","C":"636","D":"Q4108","F":"2725.8435","G":"**"},{"Policy Line":"64135604","B":"Epifix Injectable 160mg","C":"636","D":"Q4145","F":"2973.62051020408","G":"**"},{"Policy Line":"64135696","B":"Epifix 5.0 X 5.5Cm ES-5500","C":"636","D":"Q4186","F":"2797.068"},{"Policy Line":"64135741","B":"PuraPlyAM-COM 2X4","C":"636","D":"Q4196","F":"1203.555","G":"**"},{"Policy Line":"64600173","B":"Integra MatrxWnd Flow Inj 10cc","C":"636","D":"Q4114","F":"4234.227"},{"Policy Line":"64600182","B":"Epifix 5.0 X 5.5Cm ES-550","C":"636","D":"Q4186","F":"2797.068"},{"Policy Line":"64600214","B":"Integra Mesh Mwm4051 10X12.5CM","C":"636","D":"C9363","F":"5060.184"},{"Policy Line":"64600916","B":"GraftJacket 2X4 8600-2X04","C":"636","D":"Q4107","F":"1680.651"},{"Policy Line":"64605727","B":"Alloderm Thick16x20cm 1519320","C":"636","D":"Q4116","F":"9350.649"},{"Policy Line":"68250425","B":"Meningococcal (A,C,Y&W-135)Pol","C":"636","D":"90733","F":"198.378"},{"Policy Line":"68250511","B":"Fluzone-High Dose 0.5Ml Syr","C":"636","D":"90662","F":"14.214"},{"Policy Line":"68251282","B":"Ascorbic Acid 500Mg/1Ml","C":"250","F":"17.922"},{"Policy Line":"68252020","B":"TUBERCULIN VL 5TU/0.1ML","C":"254","F":"17.922"},{"Policy Line":"68252039","B":"CALCIUM GLUCONATE 10ML INJ","C":"636","D":"J0610","F":"17.922"},{"Policy Line":"68252045","B":"Prevnar 13 Syringe","C":"636","D":"90670","F":"17.922"},{"Policy Line":"68252048","B":"NACL 0.45% 1000ML","C":"258","F":"17.922"},{"Policy Line":"68252049","B":"HYDROCORTISONE NA SUC 100MGINJ","C":"636","D":"J1720","F":"11.742"},{"Policy Line":"68252055","B":"ARSENIC TRIOX(6ML VL) 1 MG EA","C":"636","D":"J9017","F":"49.749","G":"**"},{"Policy Line":"68252059","B":"Triptorelin Depo 3.75MG Inj","C":"636","D":"J3315","F":"746.503475409837","G":"**"},{"Policy Line":"68252060","B":"GOSERELIN ACETATE EA 3.6 MG","C":"636","D":"J9202","F":"770.337","G":"**"},{"Policy Line":"68252065","B":"Hydromorphone HCL 1MG/ML Inj","C":"636","D":"J1170","F":"17.922"},{"Policy Line":"68252066","B":"Hydrocodon/Aceto10mg/325mg Tab","C":"637","F":"1.35"},{"Policy Line":"68252079","B":"CYTARABINE 100 MG","C":"636","D":"J9100","F":"16.995"},{"Policy Line":"68252083","B":"Hylenex Inj Ea 1.0 USP Unit","C":"636","D":"J3473","F":"0.618"},{"Policy Line":"68252084","B":"Pneumococcal 23 Vac Conj 0.5ml","C":"636","D":"90732","F":"113.403"},{"Policy Line":"68252087","B":"LEUPROLIDE ACETATE INJ 3.75MG","C":"636","D":"J1950","F":"1461.879","G":"**"},{"Policy Line":"68252089","B":"MORPHINE EA 10 MG INJ","C":"636","D":"J2270","F":"16.995"},{"Policy Line":"68252090","B":"ECULIZUMAB EA 10 MG","C":"636","D":"J1300","F":"149.9165","G":"**"},{"Policy Line":"68252091","B":"RANITIDINE/ZANTAC EA 25 MG","C":"636","D":"J2780","F":"8.652"},{"Policy Line":"68252099","B":"OLARATUMAB 500MG/50ML VIAL","C":"636","D":"J9999","F":"3100.506"},{"Policy Line":"68252100","B":"LIBATAYO 350 MG/7 ML VIAL","C":"636","F":"2896.257"},{"Policy Line":"68252105","B":"Heparin Sodium per 10 unit inj","C":"636","D":"J1642","F":"1.55411979166667","G":"**"},{"Policy Line":"68252106","B":"Normal Saline 1000 CC HHI","C":"636","D":"J7030","F":"6.12547058823528","G":"**"},{"Policy Line":"68252107","B":"Normal Saline 500Ml","C":"258","D":"J7040","F":"5.79444179104476","G":"**"},{"Policy Line":"68252108","B":"Normal Saline 250 Cc","C":"636","D":"J7050","F":"5.871","G":"**"},{"Policy Line":"68252109","B":"Lipidox Ea 10 Mg","C":"636","D":"Q2049","F":"436.617"},{"Policy Line":"68252111","B":"Interferon Alfa 2B 1M Unts Hhi","C":"636","D":"J9214","F":"37.698"},{"Policy Line":"68252112","B":"Gammagard Ea 500 Mg","C":"636","D":"J1569","F":"53.7360967741938","G":"**"},{"Policy Line":"68252113","B":"BAVENCIO 200 MG/10 ML VIAL","C":"636","D":"J9023","F":"493.164"},{"Policy Line":"68252116","B":"Ipilimumab Ea 1 Mg","C":"636","D":"J9228","F":"146.157","G":"**"},{"Policy Line":"68252117","B":"Solumedrol Up To 125 Mg","C":"636","D":"J2930","F":"17.7807428571428","G":"**"},{"Policy Line":"68252118","B":"Furosemide/Lasix Up To 20 Mg","C":"636","D":"J1940","F":"17.922","G":"**"},{"Policy Line":"68252119","B":"Iron Sucrose Ea 1 Mg Inj","C":"636","D":"J1756","F":"1.545"},{"Policy Line":"68252120","B":"Carfilzomib / Kyprolis 1Mg Inj","C":"636","F":"41.4087144948756","G":"**"},{"Policy Line":"68252121","B":"Decitabine/Dacogen Inj Ea 1 Mg","C":"636","D":"J0894","F":"18.0305675675676","G":"**"},{"Policy Line":"68252122","B":"Sipuleucel-T/Provenge Per Vial","C":"636","D":"Q2043","F":"23314.359"},{"Policy Line":"68252123","B":"Vincristine Ea 1 Mg","C":"636","D":"J9370","F":"17.9026875","G":"**"},{"Policy Line":"68252126","B":"Dexrazoxane/Zinecard 250 Mg","C":"636","D":"J1190","F":"166.242"},{"Policy Line":"68252127","B":"Vinblastine Ea 1 Mg","C":"636","D":"J9360","F":"4.017","G":"**"},{"Policy Line":"68252128","B":"Gamunex Ea 500 Mg Inj","C":"636","D":"J1561","F":"55.311"},{"Policy Line":"68252129","B":"Ondansetron/Zofran Ea 1 Mg","C":"636","D":"J2405","F":"2.163","G":"**"},{"Policy Line":"68252130","B":"Cladribine/Leustatin Ea 1 Mg","C":"636","D":"J9065","F":"23.175"},{"Policy Line":"68252131","B":"Erlotinib 100 Mg Tab","C":"637","F":"213.3"},{"Policy Line":"68252132","B":"ZOLEDRONIC ACID IV-ea 1 mg","C":"636","D":"J3489","F":"275.105329787234","G":"**"},{"Policy Line":"68252133","B":"D5W 1000Ml","C":"636","D":"J7070","F":"16.995","G":"**"},{"Policy Line":"68252134","B":"D5W 500Ml","C":"636","D":"J7060","F":"17.716","G":"**"},{"Policy Line":"68252135","B":"D5W 250 Ml","C":"258","F":"5.871"},{"Policy Line":"68252138","B":"Panitumumab Ea 10 Mg","C":"636","D":"J9303","F":"139.668"},{"Policy Line":"68252139","B":"Lorazepam Tab 0.5mg","C":"637","F":"1.125","G":"**"},{"Policy Line":"68252140","B":"Ondansetron Tablet Ea 1 Mg","C":"636","D":"Q0162","F":"0.927"},{"Policy Line":"68252141","B":"Kadcyla Ea 1 Mg","C":"636","D":"J9354","F":"30.591"},{"Policy Line":"68252142","B":"Doxorubicin/Doxil Ea 10 Mg","C":"636","D":"Q2050","F":"696.221142857145","G":"**"},{"Policy Line":"68252143","B":"Brentuximab/Adcetris Ea 1 Mg","C":"636","D":"J9042","F":"142.449","G":"**"},{"Policy Line":"68252144","B":"Clofarabine/Clolar Ea 1 Mg","C":"636","D":"J9027","F":"180.147"},{"Policy Line":"68252145","B":"Filgramstim(G-Csf) EaMcg INJ","C":"636","D":"J1442","F":"1.545","G":"**"},{"Policy Line":"68252146","B":"Pertuzumab/Perjeta Ea 1 Mg Hhi","C":"636","D":"J9306","F":"14.42","G":"**"},{"Policy Line":"68252147","B":"GRANIX/TBO-FILGRASTIM Inj 1Mcg","C":"636","D":"J1447","F":"5.871"},{"Policy Line":"68252148","B":"TOPOTECAN 0.1 MG","C":"636","D":"J9351","F":"4.017","G":"**"},{"Policy Line":"68252149","B":"LORAZEPAM EA 2 MG","C":"636","D":"J2060","F":"17.922","G":"**"},{"Policy Line":"68252150","B":"DEXTROSE 5%/0.45% NACL 500ml","C":"258","F":"4.017"},{"Policy Line":"68252151","B":"EPINEPHRINE 0.1 MG HHI","C":"636","D":"J0171","F":"1.854"},{"Policy Line":"68252152","B":"PACLITAXEL PROTEIN BND 1MG INJ","C":"636","D":"J9264","F":"15.0068086522462","G":"**"},{"Policy Line":"68252153","B":"FLUOROURACIL 500 MG HHI","C":"636","D":"J9190","F":"17.7294139534884","G":"**"},{"Policy Line":"68252154","B":"PEMETREXED/ALIMTA 10 MG INJ","C":"636","D":"J9305","F":"65.1816509863428","G":"**"},{"Policy Line":"68252155","B":"PALONOSETRON/ALOXI 25MCG HHI","C":"636","D":"J2469","F":"18.7635059288538","G":"**"},{"Policy Line":"68252156","B":"ATROPINE SULFATE 0.01 MG HHI","C":"636","D":"J0461","F":"1.545","G":"**"},{"Policy Line":"68252157","B":"BEVACIZUMAB 10 MG INJ HHI","C":"636","D":"J9035","F":"97.660570977918","G":"**"},{"Policy Line":"68252158","B":"BLEOMYCIN SULFATE 15U Inj HHI","C":"636","D":"J9040","F":"42.333"},{"Policy Line":"68252160","B":"IRINOTECAN Inj 20 MG HHI","C":"636","D":"J9206","F":"4.017","G":"**"},{"Policy Line":"68252161","B":"CARBOPLATIN EA 50 MG","C":"636","D":"J9045","F":"3.708","G":"**"},{"Policy Line":"68252162","B":"ALTEPLASE 1MG INJ HHI","C":"636","D":"J2997","F":"90.92325","G":"**"},{"Policy Line":"68252163","B":"CISPLATIN EA 10 MG Inj HHI","C":"636","D":"J9060","F":"3.708","G":"**"},{"Policy Line":"68252165","B":"B-12 INJ UP TO 1000 MCG HHI","C":"636","D":"J3420","F":"16.7705684210526","G":"**"},{"Policy Line":"68252166","B":"CYCLOPHOSPHAMIDE 100 MG HHI","C":"636","D":"J9070","F":"53.7666851441241","G":"**"},{"Policy Line":"68252167","B":"DACARBAZINE/DTIC 100 MG HHI","C":"636","F":"8.961","G":"**"},{"Policy Line":"68252169","B":"DEXAMETHASONE EA 1 MG HHI","C":"636","D":"J1100","F":"1.854","G":"**"},{"Policy Line":"68252170","B":"DIPHENHYDRAMINE HCL UP TO 50MG","C":"636","D":"J1200","F":"17.7125084745763","G":"**"},{"Policy Line":"68252171","B":"DOCETAXEL 1 MG INJ HHI","C":"636","F":"6.04900705026156","G":"**"},{"Policy Line":"68252172","B":"DOXORUBICIN HCL 10 MG HHI","C":"636","D":"J9000","F":"7.06551388888887","G":"**"},{"Policy Line":"68252173","B":"FOSAPREPITANT EA 1MG HHI","C":"636","D":"J1453","F":"2.781","G":"**"},{"Policy Line":"68252174","B":"EPIRUBICIN HCL 2 MG HHI","C":"636","D":"J9178","F":"4.326"},{"Policy Line":"68252175","B":"CETUXIMAB 10 MG INJ HHI","C":"636","D":"J9055","F":"73.542"},{"Policy Line":"68252176","B":"FAMOTIDINE ea 20mg","C":"250","F":"17.6796470588235","G":"**"},{"Policy Line":"68252177","B":"ERIBULIN MESYLATE 0.1 MG HHI","C":"636","D":"J9179","F":"138.432","G":"**"},{"Policy Line":"68252178","B":"ROMIPLOSTIM/NPLATE 10MCG","C":"636","D":"J2796","F":"72.1824","G":"**"},{"Policy Line":"68252179","B":"DENOSUMAB Inj EA 1 MG","C":"636","D":"J0897","F":"22.6671652173913","G":"**"},{"Policy Line":"68252180","B":"OCTREOTIDE DEPOT IM ING EA 1MG","C":"636","D":"J2353","F":"244.436166666667","G":"**"},{"Policy Line":"68252181","B":"BORTIZOMIB/VELCADE EA .1 MG","C":"636","D":"J9041","F":"57.8587924528302","G":"**"},{"Policy Line":"68252182","B":"AZACITIDINE EA 1 MG","C":"636","D":"J9025","F":"7.30503314917128","G":"**"},{"Policy Line":"68252183","B":"DARBEPOETIN ALFA EA 1 MCG HHI","C":"636","D":"J0881","F":"8.85100097073915","G":"**"},{"Policy Line":"68252184","B":"MESNA EA 200 MG HHI","C":"636","D":"J9209","F":"8.034"},{"Policy Line":"68252185","B":"IXABEPILONE 1 MG","C":"636","D":"J9207","F":"95.481"},{"Policy Line":"68252186","B":"CABAZITAXEL 1 MG","C":"636","D":"J9043","F":"167.169","G":"**"},{"Policy Line":"68252187","B":"METHOTREXATE EA 50 MG","C":"636","D":"J9260","F":"16.995"},{"Policy Line":"68252188","B":"EPO INJ Non-ESRD EA 1000 UNITS","C":"636","D":"J0885","F":"28.9411293984109","G":"**"},{"Policy Line":"68252192","B":"FLUDARBINE EA 50MG","C":"636","D":"J9185","F":"77.559"},{"Policy Line":"68252193","B":"GEMCITABINE Inj EA 200 MG","C":"636","D":"J9201","F":"52.4179003759398","G":"**"},{"Policy Line":"68252194","B":"InjectAFer EA 1 MG","C":"636","D":"J1439","F":"1.854","G":"**"},{"Policy Line":"68252195","B":"GRANISETRON HCL EA 100 MCG","C":"636","D":"J1626","F":"1.854","G":"**"},{"Policy Line":"68252196","B":"Neulasta/Pegfilgramsim 6MG Inj","C":"636","D":"J2505","F":"5100.07490322579","G":"**"},{"Policy Line":"68252197","B":"PAMIDRONATE INJ EA 30MG","C":"636","D":"J2430","F":"16.068"},{"Policy Line":"68252198","B":"RITUXAN EA 100 MG INJ","C":"636","D":"J9312","F":"1150.098"},{"Policy Line":"68252199","B":"VINORELBINE/NAVELBINE 10 MG","C":"636","D":"J9390","F":"17.922"},{"Policy Line":"68252200","B":"Copper, 0.4mg/ml, Inj","C":"636","D":"J3490","F":"46.35"},{"Policy Line":"68252201","B":"IFOSFAMIDE/IFEX 1 GM","C":"636","D":"J9208","F":"40.17"},{"Policy Line":"68252203","B":"NOVOLIN EA 5 UNITS INJ","C":"636","D":"J1815","F":"0.927"},{"Policy Line":"68252204","B":"MITOXANTRONE HCL 5 MG","C":"636","D":"J9293","F":"24.72"},{"Policy Line":"68252205","B":"MAGNESIUM CITRATE","C":"637","F":"1.35"},{"Policy Line":"68252206","B":"KCL 20 MEQ / 15ML ORAL","C":"637","F":"1.125"},{"Policy Line":"68252208","B":"DESMOPRESSIN ACETATE 1 MCG","C":"636","D":"J2597","F":"14.214"},{"Policy Line":"68252209","B":"FULVESTRANT/FASLODEX 25 MG","C":"636","D":"J9395","F":"113.495105769231","G":"**"},{"Policy Line":"68252210","B":"FERUMOXYTOL 1 MG","C":"636","D":"Q0138","F":"1.854","G":"**"},{"Policy Line":"68252211","B":"FERRIC NA GLUCONATE INJ 12.5MG","C":"636","D":"J2916","F":"3.399"},{"Policy Line":"68252212","B":"TRASTUZUMAB/HERCE MDV 10 MGINJ","C":"636","D":"J9355","F":"108.15","G":"**"},{"Policy Line":"68252213","B":"kcl 2 mEq","C":"636","D":"J3480","F":"5.84332835820894","G":"**"},{"Policy Line":"68252214","B":"Acetaminophen 10Mg","C":"636","D":"J0131","F":"0.618"},{"Policy Line":"68252216","B":"FLUZONE VACCINE V4","C":"636","D":"90686","F":"23.175"},{"Policy Line":"68252218","B":"CYRAMZA EA 5 MG","C":"636","D":"J9308","F":"70.761"},{"Policy Line":"68252220","B":"Meningococcal Vac IM 0.5ml Inj","C":"636","D":"90734","F":"140.904"},{"Policy Line":"68252223","B":"TRANSDERM-SCOP 1PATCH","C":"637","F":"20.925"},{"Policy Line":"68252224","B":"TEMSIROLIMUS/TORISEL 1 MG","C":"636","D":"J9330","F":"85.593"},{"Policy Line":"68252225","B":"BENDAMUSTINE/TREANDA EA 1 MG","C":"636","D":"J9033","F":"29.046"},{"Policy Line":"68252226","B":"Etoposide/Toposar 10 mg","C":"636","D":"J9181","F":"1.854","G":"**"},{"Policy Line":"68252227","B":"PRIVIGEN INJ EA 500 MG","C":"636","D":"J1459","F":"50.367","G":"**"},{"Policy Line":"68252228","B":"PACLITAXEL 1.0 MG","C":"636","D":"J9267","F":"6.36648127635471","G":"**"},{"Policy Line":"68252229","B":"PROCHLORPERAZINE <=10 MG INJ","C":"636","D":"J0780","F":"20.085"},{"Policy Line":"68252230","B":"OXALIPLATIN INJ 0.5 MG","C":"636","D":"J9263","F":"1.545","G":"**"},{"Policy Line":"68252232","B":"TESTOSTERONE CYPIONATE 1MG","C":"636","D":"J1071","F":"17.922"},{"Policy Line":"68252233","B":"BICNU 100 MG","C":"636","D":"J9050","F":"1199.538"},{"Policy Line":"68252234","B":"MITOMYCIN 5 MG","C":"636","D":"J9280","F":"166.86","G":"**"},{"Policy Line":"68252235","B":"MANNITOL 25%, 50ml VIAL","C":"636","D":"J2150","F":"5.82346153846152","G":"**"},{"Policy Line":"68252236","B":"MG Sulfate 500 MG","C":"636","D":"J3475","F":"5.85354237288138","G":"**"},{"Policy Line":"68252237","B":"LEUCOVORIN CALCIUM INJ EA 50MG","C":"636","D":"J0640","F":"8.55789208633092","G":"**"},{"Policy Line":"68252239","B":"HEPARIN PER 1000 U INJ","C":"636","D":"J1644","F":"17.922"},{"Policy Line":"68252240","B":"ZIV-AFLIBERCEPT/ZALTRAP EA 1MG","C":"636","D":"J9400","F":"27.81"},{"Policy Line":"68252241","B":"Neulasta Delivery Kit 6mg Inj","C":"636","D":"J2505","F":"5059.35999999999","G":"**"},{"Policy Line":"68252242","B":"Keytruda Inj 1mg","C":"636","D":"J9271","F":"57.6199166666667","G":"**"},{"Policy Line":"68252243","B":"Mycafungin - Micamine each 1MG","C":"636","D":"J2248","F":"0.927"},{"Policy Line":"68252244","B":"ZARXIO,FILGRSTM(G-CSF) BS 1MCG","C":"636","D":"Q5101","F":"1.854","G":"**"},{"Policy Line":"68252245","B":"Trabectedin/Yondelis 0.1MG INJ","C":"636","D":"J9352","F":"357.822"},{"Policy Line":"68252246","B":"Pentostatin/Nipent Inj 10MG","C":"636","D":"J9268","F":"2507.226"},{"Policy Line":"68252247","B":"Pegaspargase Inj SDV 3750IU5ml","C":"636","D":"J9266","F":"17154.753"},{"Policy Line":"68252248","B":"CIPROFLOXACIN 500MG ORAL TAB","C":"637","F":"1.575"},{"Policy Line":"68252250","B":"Gazyva / Obinutuzumab 10MG Inj","C":"636","D":"J9301","F":"64.1315454545457","G":"**"},{"Policy Line":"68252251","B":"Gammaplex Inj 500mg","C":"636","D":"J1557","F":"48.204"},{"Policy Line":"68252252","B":"Aminocaproic Acid 250mg/ml Inj","C":"636","D":"J3490","F":"1.854"},{"Policy Line":"68252253","B":"Albuterol-Nebulizer NonCom 1mg","C":"250","D":"J7611","F":"1.854"},{"Policy Line":"68252254","B":"Iron Sucrose Comp Inj 1mg","C":"636","D":"J1756","F":"1.854"},{"Policy Line":"68252255","B":"BENDAMUSTINE/BENDEKA 1MG MDV","C":"636","D":"J9034","F":"29.0273000834724","G":"**"},{"Policy Line":"68252256","B":"Ertapenem Na Inj 500 mg","C":"636","D":"J1335","F":"77.868"},{"Policy Line":"68252257","B":"ISTODAX/RomiDEPsin pwdr 1mg","C":"636","D":"J9315","F":"373.272"},{"Policy Line":"68252258","B":"DEXAMETHASONE ORAL EA 0.25MG","C":"636","D":"J8540","F":"0.927"},{"Policy Line":"68252259","B":"IMLYGIC/TalLah 1M PFU/ml Inj","C":"636","D":"J9325","F":"59.328"},{"Policy Line":"68252260","B":"IMLYGIC 100xM PFU Inj EA Vial","C":"636","D":"J9325","F":"29.046"},{"Policy Line":"68252261","B":"Engerix-B 10mcg/0.5 ml Ped SDV","C":"636","D":"90744","F":"28.428"},{"Policy Line":"68252262","B":"Amlodipine 5MG Oral Tab","C":"637","F":"0.45"},{"Policy Line":"68252263","B":"Darzalex 10mg Inj","C":"636","D":"J9145","F":"61.380450931677","G":"**"},{"Policy Line":"68252266","B":"CIPROFLOXACIN 200MG IV INJ","C":"636","D":"J0744","F":"3.09"},{"Policy Line":"68252267","B":"HEP A VACC PED/ADOL 2DSE IMINJ","C":"636","D":"90633","F":"37.698"},{"Policy Line":"68252268","B":"PREDNISONE IR/DR ORAL 1MG TAB","C":"636","D":"J7512","F":"1.545"},{"Policy Line":"68252269","B":"ARRANON INJ EA 50MG","C":"636","D":"J9261","F":"178.911"},{"Policy Line":"68252270","B":"CYCLOPHOSPHAMIDE CAP EA 25MG","C":"636","D":"J8530","F":"7.107"},{"Policy Line":"68252271","B":"EMEND CAP EA 5 MG","C":"636","D":"J8501","F":"12.978"},{"Policy Line":"68252272","B":"Rasburicase/Elitek 0.5mg Inj","C":"636","D":"J2783","F":"335.265"},{"Policy Line":"68252273","B":"Leuprolide Acet/Eligard 7.5Mg","C":"636","D":"J9217","F":"557.5905","G":"**"},{"Policy Line":"68252275","B":"GANCICLOVIR 500MG PWVL","C":"636","D":"J1570","F":"101.97"},{"Policy Line":"68252277","B":"ELOTUZUMAB/EMPLICITI INJ 1MG","C":"636","D":"J9176","F":"7.725","G":"**"},{"Policy Line":"68252278","B":"MENACWY VACCINE IM SDV","C":"636","D":"90734","F":"141.831"},{"Policy Line":"68252279","B":"CIPROFLOXACIN 250MG ORAL TAB","C":"637","F":"1.125"},{"Policy Line":"68252280","B":"Bleomycin 15 Un Inj (Imported)","C":"636","D":"J9040","F":"178.293"},{"Policy Line":"68252281","B":"PEGINTERFERON ALFA2A 180MCG/ML","C":"636","D":"J3490","F":"1237.545"},{"Policy Line":"68252282","B":"HYDROCORTISONE NONCHEMO10MGTAB","C":"636","D":"J8499","F":"1.854"},{"Policy Line":"68252283","B":"TECENTRIQ/ATEZOLIZUMAB INJ10MG","C":"636","D":"J9022","F":"75.396","G":"**"},{"Policy Line":"68252284","B":"Vancomycin HCL 500Mg Inj","C":"636","D":"J3370","F":"24.411"},{"Policy Line":"68252285","B":"Chlorpromazine HCL Inj to 50MG","C":"636","D":"J3230","F":"34.608"},{"Policy Line":"68252286","B":"SUSTOL INJ 10MG/0.4ML INJ","C":"636","F":"646.119"},{"Policy Line":"68252287","B":"Tranexamic Acid 10ml IV","C":"250","F":"65.508"},{"Policy Line":"68252288","B":"Infanrix DTAP Peds 0.5ml Syr","C":"636","D":"90700","F":"28.119"},{"Policy Line":"68252289","B":"Ofatumumab/Arzerra 10mg Inj","C":"636","D":"J9302","F":"64.272"},{"Policy Line":"68252290","B":"ALBUTEROL HFA MDI 200INH 18GM","C":"636","D":"J3535","F":"55.311"},{"Policy Line":"68252292","B":"Fentanyl Ptch-Xtd Rel 25mcg/hr","C":"637","F":"2.7"},{"Policy Line":"68252293","B":"HYQVIA IMMUNGLOBULIN INJ 100MG","C":"636","D":"J1575","F":"2775.438"},{"Policy Line":"68252294","B":"FLUCONAZOLE/DIFLUCAN INJ 200MG","C":"636","D":"J1450","F":"17.922"},{"Policy Line":"68252295","B":"Hydralazine 25Mg Tab","C":"637","F":"1.125"},{"Policy Line":"68252296","B":"ELOSULFASEALFA,VIMIZIM INJ 1MG","C":"636","D":"J1322","F":"292.005"},{"Policy Line":"68252297","B":"GALSULFASE/NAGLAZYM INJ 1MG","C":"636","D":"J1458","F":"466.281"},{"Policy Line":"68252298","B":"ImmuneGlobul-Octagam 500mg Inj","C":"636","D":"J1568","F":"66.126"},{"Policy Line":"68252299","B":"Varubi Inj 166.5mg/92.5ml Vial","C":"636","D":"J3490","F":"375.435"},{"Policy Line":"68252301","B":"Degarelix/Firmagon Inj 1MG","C":"636","D":"J9155","F":"4.635"},{"Policy Line":"68252322","B":"DEPO_MEDROL 40 MG INJ","C":"636","D":"J1030","F":"8.652"},{"Policy Line":"68252345","B":"Filgrastim-Neupogen Inj 1Mcg","C":"636","D":"J1442","F":"1.545","G":"**"},{"Policy Line":"68252346","B":"Montelukast Sod 10mg Tab","C":"637","F":"1.35"},{"Policy Line":"68252352","B":"ALLOPURINOL 300MG TAB","C":"637","F":"1.35"},{"Policy Line":"68252353","B":"ALLOPURINOL 100MG TAB","C":"637","F":"1.35"},{"Policy Line":"68252354","B":"NIVOLUMAB / OPDIVO, INJ 1MG","C":"636","D":"J9299","F":"32.3791196698761","G":"**"},{"Policy Line":"68252355","B":"Somatuline Depot ea 1mg, Inj","C":"636","D":"J1930","F":"85.7303333333331","G":"**"},{"Policy Line":"68252356","B":"ALEMTUZUMAB/CAMPATH Inj 1mg","C":"636","D":"J0202","F":"0"},{"Policy Line":"68252357","B":"Levoleucovorin Calcm Inj 0.5mg","C":"636","D":"J0641","F":"2.472"},{"Policy Line":"68252358","B":"CARPUJET,MORPH SULF 4MG/ML INJ","C":"250","F":"23.175"},{"Policy Line":"68252359","B":"OLARATUMAB INJ 10MG","C":"636","D":"J9285","F":"60.255"},{"Policy Line":"68252360","B":"Sustol Inj ea 0.1mg","C":"636","D":"J1627","F":"678.255"},{"Policy Line":"68252361","B":"TRASTUZUMAB/HER INJ SDV 10MG","C":"636","D":"J9355","F":"127.30971349353","G":"**"},{"Policy Line":"68252362","B":"IRINOTECAN LIP/ONIVYDE INJ 1MG","C":"636","D":"J9205","F":"50.0647173913044","G":"**"},{"Policy Line":"68252363","B":"FLEBOGAMMA IG 5%%DIF 500MG INJ","C":"636","D":"J1572","F":"50.058","G":"**"},{"Policy Line":"68252364","B":"Fentanyl 100mcg/2Ml Inj SDV","C":"636","D":"J3010","F":"17.922"},{"Policy Line":"68252365","B":"COPANLISIB/ALIQOPA 1mg Inj","C":"636","D":"J9057","F":"5346.936"},{"Policy Line":"68252366","B":"DURVALUMAB/IMFINZI INJ 10MG","C":"636","D":"J9173","F":"71.7124625000001","G":"**"},{"Policy Line":"68252367","B":"CARIMUNE NF,IG 500MG INJ","C":"636","D":"J1566","F":"36.771","G":"**"},{"Policy Line":"68252368","B":"Vedolizumab/Entyvio Inj, 1mg","C":"636","D":"J3380","F":"24.72"},{"Policy Line":"68252369","B":"GEMTUZUMAB OZOGAMICIN IN 0.1MG","C":"636","D":"J9203","F":"231.75"},{"Policy Line":"68252370","B":"AMLODIPENE BESYLATE 10MG TAB","C":"637","F":"1.125"},{"Policy Line":"68252371","B":"METOPROLOL TARTRATE 100MG TAB","C":"637","F":"1.125"},{"Policy Line":"68252372","B":"HAVRIX 1440U/ 1ML SYR INJ","C":"250","F":"80.649"},{"Policy Line":"68252373","B":"9VHPVGARDASIL VAC2-3D 0.5MLINJ","C":"636","D":"90651","F":"241.638"},{"Policy Line":"68252400","B":"RITUXAN EA 10 MG INJ","C":"636","D":"J9312","F":"111.6726","G":"**"},{"Policy Line":"68252425","B":"Emicizumab-KXWH 0.5 mg","C":"636","D":"J7170","F":"45.94212"},{"Policy Line":"68252450","B":"Cemiplimab-rwlc 1mg ea","C":"636","D":"J9119","F":"25.956","G":"**"},{"Policy Line":"68252451","B":"Fulphila 0.5mg inj HHI","C":"636","D":"Q5108","F":"335.574"},{"Policy Line":"68252453","B":"Romosozumab 105mg/1.17ml syr","C":"636","D":"J3590","F":"964.08","G":"**"},{"Policy Line":"68252454","B":"Mogamulizumab-kpkc 1mg EA","C":"636","D":"J9204","F":"190.344"},{"Policy Line":"68252455","B":"POLATUZUMAB 1MG VIAL","C":"636","D":"J9999","F":"15063.75","G":"**"},{"Policy Line":"68252456","B":"Pentamidine iset 300mg inh pwd","C":"250","D":"J2545","F":"125.454"},{"Policy Line":"68252458","B":"Ravulizumab-CWVZ EA 10 MG","C":"636","D":"J1303","F":"214.446"},{"Policy Line":"68252459","B":"Romosozumab-AQQG 1mg ea","C":"636","D":"J3111","F":"10.506","G":"**"},{"Policy Line":"68252460","B":"Bevacizumab-AWWB 10mg (MVASI)","C":"636","D":"Q5107","F":"80.649"},{"Policy Line":"68252461","B":"TRASTUZ-ANNS (KANJINTI) 10MG","C":"636","D":"Q5117","F":"85.284"},{"Policy Line":"68252464","B":"NaPhos 45mmol/15ml vial","C":"250","F":"39.552","G":"**"},{"Policy Line":"68252466","B":"Enfortumab Vedotin-ejfv 1mg","C":"636","D":"J3590","F":"105.987"},{"Policy Line":"68252468","B":"TRUXIMA 10 mg","C":"636","D":"Q5115","F":"79.413"},{"Policy Line":"68252469","B":"Reblozyl 1mg inj","C":"636","D":"J3590","F":"138.123"},{"Policy Line":"68252504","B":"Cerezyme (Imiglucerase) 10Unit","C":"636","D":"J1786","F":"50.676"},{"Policy Line":"68252505","B":"Methylprednisolone 40MG Inj","C":"636","D":"J2920","F":"17.922"},{"Policy Line":"68252506","B":"Leuprolide Depot Ea 7.5Mg","C":"636","D":"J9217","F":"1752.46447272727","G":"**"},{"Policy Line":"68252508","B":"Vitamin K / Mephyton ea 5mg","C":"250","F":"71.379"},{"Policy Line":"68252509","B":"Folic Acid ea 1mg","C":"250","F":"1.854"},{"Policy Line":"68252510","B":"Levofloxacin/Levaquin 250 mg","C":"636","D":"J1956","F":"5.871"},{"Policy Line":"68252511","B":"Magnesium Oxide 400mg Tab","C":"637","F":"1.35"},{"Policy Line":"68252512","B":"Pralatrexate / Folotyn ea 1 MG","C":"636","D":"J9307","F":"261.105"},{"Policy Line":"68252513","B":"Cefepime/Maxepine Inj ea 500MG","C":"636","D":"J0692","F":"4.635"},{"Policy Line":"68252514","B":"Nivolumab/Optivo 10mg/ml","C":"636","D":"C9399","F":"331.557"},{"Policy Line":"68252517","B":"ADDAMEL N INJ10ML AMP (TRA ME)","C":"250","F":"19.467"},{"Policy Line":"68252518","B":"Velaglucerase Alfa/VPRIV100UIn","C":"636","D":"J3385","F":"438.162"},{"Policy Line":"68252638","B":"Gammagard S/D 500 mg Powder","C":"636","D":"J1566","F":"88.3000191304347","G":"**"},{"Policy Line":"68252646","B":"EPOETIN ALFA -EBX 1000U","C":"636","D":"Q5106","F":"511.64838","G":"**"},{"Policy Line":"68256113","B":"INFLIXIMAB INJ 10 MG","C":"636","D":"J1745","F":"141.213"},{"Policy Line":"68257534","B":"Lidocaine 1%% 2Ml Amp","C":"636","D":"J2001","F":"15.45"},{"Policy Line":"68257537","B":"Lidocaine 1%% 30Ml Amp","C":"636","D":"J2001","F":"0.618"},{"Policy Line":"68257538","B":"Lidocaine 1%% 30Ml Amp","C":"636","D":"J2001","F":"0.618"},{"Policy Line":"68258888","B":"Nonchargable","C":"250","F":"0"},{"Policy Line":"68259017","B":"ARSENIC TRIOXIDE 10MG/10ML VL","C":"636","D":"J9017","F":"1758.519","G":"**"},{"Policy Line":"68259467","B":"RITUXIMAB/HYALURONIDASE","C":"636","D":"J9311","F":"2032.16322","G":"**"},{"Policy Line":"68259468","B":"RITUXIMAB/HYALURONIDASE","C":"636","D":"J9311","F":"203.21385","G":"**"},{"Policy Line":"68260425","B":"Meningococcal (A,C,Y&W-135)Pol","C":"636","D":"90733","F":"198.378"},{"Policy Line":"68260511","B":"Fluzone-High Dose 0.5Ml Syr","C":"636","D":"90662","F":"14.214"},{"Policy Line":"68261282","B":"Ascorbic Acid 500Mg/ 1Ml","C":"250","F":"17.922"},{"Policy Line":"68261492","B":"Prochlorperazine 10Mg2Ml Inj","C":"636","D":"J0780","F":"9.27","G":"**"},{"Policy Line":"68262018","B":"Hydrocodone 5MG/APAP 325MG TAB","C":"637","F":"1.35"},{"Policy Line":"68262019","B":"HYDRALAZINE 20 MG/ML","C":"636","D":"J0360","F":"17.922"},{"Policy Line":"68262020","B":"TUBERCULIN VL 5TU/0.1ML","C":"254","F":"17.922"},{"Policy Line":"68262021","B":"IPOL","C":"636","D":"90713","F":"46.041"},{"Policy Line":"68262022","B":"ISOVUE EA 1ML","C":"255","D":"Q9967","F":"1.854"},{"Policy Line":"68262023","B":"LABETALOL 20MG/4ML","C":"250","F":"17.922"},{"Policy Line":"68262024","B":"LOPERAMIDE 2 MG CAPSULE","C":"637","F":"1.35"},{"Policy Line":"68262026","B":"METOCLOPRPAMIDE 10MG/2ML INJ","C":"636","D":"J2765","F":"17.922"},{"Policy Line":"68262027","B":"METOCLOPRAMIDE 10MG 1TAB","C":"637","F":"1.35"},{"Policy Line":"68262028","B":"MEASLES-MUMPS-RUBELLA II","C":"636","D":"90707","F":"81.885"},{"Policy Line":"68262029","B":"OXYCODONE 5MG TAB","C":"637","F":"1.125"},{"Policy Line":"68262030","B":"OXYCODONE 5MG/APAP 325MG TAB","C":"637","F":"1.125"},{"Policy Line":"68262031","B":"PROBENECID 500MG TAB","C":"637","F":"1.35"},{"Policy Line":"68262032","B":"PROCHLORPERAZINE Oral EA 5MG","C":"636","D":"Q0164","F":"1.854"},{"Policy Line":"68262033","B":"PROMETHAZINE 25MG TAB","C":"637","F":"1.35"},{"Policy Line":"68262034","B":"BELIMUMAB/BENLYSTA INJ 10MG","C":"636","D":"J0490","F":"53.457"},{"Policy Line":"68262035","B":"SODIUM POLYSTYRENE SULF ORAL","C":"637","F":"0.45"},{"Policy Line":"68262036","B":"SOD. THIOSULFATE 25%% 50ML VIA","C":"250","F":"4.326"},{"Policy Line":"68262037","B":"ALBUTEROL INHALER PER USE 1INH","C":"637","F":"1.35"},{"Policy Line":"68262038","B":"LORATADINE 10MG TAB","C":"637","F":"1.35"},{"Policy Line":"68262039","B":"CALCIUM GLUCONATE 10ML INJ","C":"636","D":"J0610","F":"17.922"},{"Policy Line":"68262041","B":"DIPHENOXYLATE/ATROPIN 2.5MGTAB","C":"637","F":"1.35"},{"Policy Line":"68262043","B":"PREDNISONE 5 MG TAB","C":"637","F":"1.35"},{"Policy Line":"68262044","B":"PEDAXHIB VACCINE 7.5ug / 0.5mL","C":"636","D":"90647","F":"30.282"},{"Policy Line":"68262045","B":"PREVNAR 13 SYRINGE","C":"636","D":"90670","F":"17.922"},{"Policy Line":"68262046","B":"PROMETHAZINE UP TO 50 MG","C":"636","D":"J2550","F":"17.922"},{"Policy Line":"68262047","B":"SODIUM BICARB 8.4%% VIAL","C":"250","F":"17.922"},{"Policy Line":"68262048","B":"NACL 0.45%% 1000ML","C":"258","F":"17.922"},{"Policy Line":"68262049","B":"HYDROCORTISONE NA SUC 100MGINJ","C":"636","D":"J1720","F":"11.742"},{"Policy Line":"68262051","B":"WINRHO EACH 100 IU","C":"636","D":"J2792","F":"29.973"},{"Policy Line":"68262052","B":"PHYTONADIONE/VIT K EA 1MG","C":"636","D":"J3430","F":"1.854"},{"Policy Line":"68262053","B":"HepB Vac 20mcg/1ml","C":"636","D":"90747","F":"29.355"},{"Policy Line":"68262054","B":"TDAP VACCINE","C":"636","D":"90715","F":"51.912"},{"Policy Line":"68262055","B":"ARSENIC TRIOX(6ML VL) 1 MG EA","C":"636","D":"J9017","F":"49.749"},{"Policy Line":"68262057","B":"HYDROMORPHONE 4 MG","C":"636","D":"J1170","F":"8.961"},{"Policy Line":"68262058","B":"GLUCAGEN 1 MG","C":"636","D":"J1610","F":"215.373"},{"Policy Line":"68262059","B":"TRIPTORELIN DEPO 3.75 MG Inj","C":"636","D":"J3315","F":"747.78","G":"**"},{"Policy Line":"68262060","B":"GOSERELIN ACETATE EA 3.6 MG","C":"636","D":"J9202","F":"770.337"},{"Policy Line":"68262061","B":"ALBUTEROL HFA MDI 60INH 8GM","C":"636","D":"J3535","F":"24.411"},{"Policy Line":"68262062","B":"TEMOZOLOMIDE ORAL EA 5 MG","C":"636","D":"J8700","F":"4.017"},{"Policy Line":"68262063","B":"LACTATED RINGERS 500 ML","C":"258","D":"J7120","F":"17.922"},{"Policy Line":"68262064","B":"LACTATED RINGERS 1000 ML","C":"258","D":"J7120","F":"17.922"},{"Policy Line":"68262065","B":"Hydromorphone HCL 1MG/ML","C":"636","D":"J1170","F":"17.922"},{"Policy Line":"68262066","B":"Hydrocodon/Aceto10mg/325mg Tab","C":"637","F":"1.35"},{"Policy Line":"68262068","B":"GRANISETRON HCL 1 MG TAB","C":"636","D":"Q0166","F":"1.545"},{"Policy Line":"68262070","B":"FLUMAZENIL 0.1MG/ML 5ML INJ MD","C":"636","D":"J3490","F":"4.944"},{"Policy Line":"68262072","B":"ASPARAGINASE 10,000 UNITS","C":"636","D":"J9020","F":"126.381"},{"Policy Line":"68262073","B":"D5W 500 ML","C":"636","D":"J7060","F":"17.8154482758621","G":"**"},{"Policy Line":"68262074","B":"D5W 1000 ML","C":"636","D":"J7070","F":"16.995"},{"Policy Line":"68262075","B":"D5W/NACL 0.9%% 500ML","C":"636","D":"J7042","F":"16.995"},{"Policy Line":"68262076","B":"D5W/NACL 0.45%% 1000 ML","C":"258","F":"16.995"},{"Policy Line":"68262078","B":"DEFEROXAMINE INJ 500 MG","C":"636","D":"J0895","F":"16.995"},{"Policy Line":"68262079","B":"CYTARABINE 100 MG","C":"636","D":"J9100","F":"16.995"},{"Policy Line":"68262081","B":"MANVEO VACCINE","C":"636","D":"90734","F":"160.989"},{"Policy Line":"68262082","B":"ActHIB VACCIN 4DoseIM","C":"636","D":"90648","F":"45.732"},{"Policy Line":"68262083","B":"HYLENEX INJ EA 1 USP UNIT","C":"636","D":"J3473","F":"0.618"},{"Policy Line":"68262084","B":"Pneumococcal 23 Vac Conj 0.5ml","C":"636","D":"90732","F":"113.403"},{"Policy Line":"68262085","B":"NACL 0.45%%500 ML","C":"258","F":"16.995"},{"Policy Line":"68262086","B":"ENOXAPARIN EA 10 MG","C":"636","D":"J1650","F":"3.708"},{"Policy Line":"68262087","B":"LEUPROLIDE ACETATE INJ 3.75MG","C":"636","D":"J1950","F":"1470.19823076923","G":"**"},{"Policy Line":"68262088","B":"MEPERIDINE UP TO 100 MG","C":"636","D":"J2175","F":"16.995"},{"Policy Line":"68262089","B":"MORPHINE EA 10 MG INJ","C":"636","D":"J2270","F":"16.995"},{"Policy Line":"68262090","B":"ECULIZUMAB EA 10 MG","C":"636","D":"J1300","F":"151.719"},{"Policy Line":"68262091","B":"RANITIDINE/ZANTAC EA 25 MG","C":"636","D":"J2780","F":"8.652"},{"Policy Line":"68262092","B":"IDARUBICIN EA 5 MG","C":"636","D":"J9211","F":"55.929"},{"Policy Line":"68262094","B":"CEFTRIAXONE EA 250 MG","C":"636","D":"J0696","F":"10.197"},{"Policy Line":"68262095","B":"VISTIDE 375 MG","C":"636","D":"J0740","F":"863.346"},{"Policy Line":"68262097","B":"CORTROSYN 0.25 MG","C":"636","D":"J0834","F":"24.102"},{"Policy Line":"68262098","B":"DACTINOMYCIN 0.5 MG","C":"636","D":"J9120","F":"787.641"},{"Policy Line":"68262099","B":"OLARATUMAB 500MG/50ML VIAL","C":"636","D":"J9999","F":"3100.506"},{"Policy Line":"68262100","B":"LIBATAYO 350 MG/7 ML VIAL","C":"636","F":"2896.257"},{"Policy Line":"68262102","B":"ZIPRASIDONE MESYLATE EA 10 MG","C":"636","D":"J3486","F":"23.793"},{"Policy Line":"68262103","B":"KETOROLAC TROMETHAMINE 15MG LC","C":"636","D":"J1885","F":"3.09"},{"Policy Line":"68262105","B":"Heparin Sodium per 10 unit inj","C":"636","D":"J1642","F":"0.309","G":"**"},{"Policy Line":"68262106","B":"Normal Saline 1000 CC OKT","C":"636","D":"J7030","F":"6.0255","G":"**"},{"Policy Line":"68262107","B":"Normal Saline Sterile 500Ml","C":"258","D":"J7040","F":"5.79085590778098","G":"**"},{"Policy Line":"68262108","B":"Normal Saline 250 Cc","C":"636","D":"J7050","F":"1.854","G":"**"},{"Policy Line":"68262109","B":"Lipidox Ea 10 Mg","C":"636","D":"Q2049","F":"436.617"},{"Policy Line":"68262111","B":"Interferon Alfa 2B 1M Unts","C":"636","D":"J9214","F":"37.698"},{"Policy Line":"68262112","B":"Gammagard Inj Ea 500 Mg","C":"636","D":"J1569","F":"53.5531981132077","G":"**"},{"Policy Line":"68262113","B":"BAVENCIO 200 MG/10 ML VIAL","C":"636","D":"J9023","F":"493.164"},{"Policy Line":"68262116","B":"Ipilimumab Ea 1 Mg","C":"636","D":"J9228","F":"179.838"},{"Policy Line":"68262117","B":"Solumedrol Up To 125 Mg","C":"636","D":"J2930","F":"17.7753559322034","G":"**"},{"Policy Line":"68262118","B":"Furosemide/Lasix Up To 20 Mg","C":"636","D":"J1940","F":"17.922"},{"Policy Line":"68262119","B":"Iron Sucrose Each 1 Mg Inj","C":"636","D":"J1756","F":"1.545"},{"Policy Line":"68262120","B":"Carfilzomib / Kyprolis 1Mg Inj","C":"636","D":"J9047","F":"42.1515238095237","G":"**"},{"Policy Line":"68262121","B":"Decitabine/Dacogen Inj Ea 1 Mg","C":"636","D":"J0894","F":"17.8982307692308","G":"**"},{"Policy Line":"68262122","B":"Sipuleucel-T/Provenge Per Vial","C":"636","D":"Q2043","F":"23314.359"},{"Policy Line":"68262123","B":"Vincristine Ea 1 Mg","C":"636","D":"J9370","F":"17.5688571428572","G":"**"},{"Policy Line":"68262126","B":"Dexrazoxane/Zinecard 250 Mg","C":"636","D":"J1190","F":"166.242"},{"Policy Line":"68262127","B":"Vinblastine Ea 1 Mg","C":"636","D":"J9360","F":"4.017","G":"**"},{"Policy Line":"68262128","B":"Gamunex Inj Ea 500 Mg","C":"636","D":"J1561","F":"55.311","G":"**"},{"Policy Line":"68262129","B":"Ondansetron/Zofran Ea 1 Mg","C":"636","D":"J2405","F":"2.163","G":"**"},{"Policy Line":"68262130","B":"Cladribine/Leustatin Ea 1 Mg","C":"636","D":"J9065","F":"22.557","G":"**"},{"Policy Line":"68262132","B":"ZOLEDRONIC ACID IV-ea 1mg","C":"636","D":"J3489","F":"275.000190476191","G":"**"},{"Policy Line":"68262135","B":"D5W 250 Ml","C":"258","F":"5.871"},{"Policy Line":"68262138","B":"PANITUMUMAB EA 10 MG","C":"636","D":"J9303","F":"139.668","G":"**"},{"Policy Line":"68262139","B":"LORAZEPAM TABLET 0.5mg","C":"637","F":"1.125","G":"**"},{"Policy Line":"68262140","B":"ONDANSETRON TABLET EA 1 MG","C":"636","D":"Q0162","F":"1.545","G":"**"},{"Policy Line":"68262141","B":"KADCYLA EA 1 MG","C":"636","D":"J9354","F":"30.591"},{"Policy Line":"68262142","B":"DOXORUBICIN/DOXIL EA 10 MG","C":"636","D":"Q2050","F":"709.365904761906","G":"**"},{"Policy Line":"68262143","B":"BRENTUXIMAB/ADCETRIS EA 1 MG","C":"636","D":"J9042","F":"146.775"},{"Policy Line":"68262144","B":"CLOFARABINE/CLOLAR EA 1 MG","C":"636","D":"J9027","F":"180.147"},{"Policy Line":"68262145","B":"Filgramstim (G-Csf) Ea Mcg INJ","C":"636","D":"J1442","F":"1.545","G":"**"},{"Policy Line":"68262146","B":"Pertuzumab/Perjeta Ea 1 Mg Okt","C":"636","D":"J9306","F":"14.4162545454546","G":"**"},{"Policy Line":"68262147","B":"GRANIX/TBO-FILGRASTIM Inj 1Mcg","C":"636","D":"J1447","F":"5.871"},{"Policy Line":"68262148","B":"TOPOTECAN EA 0.1 MG","C":"636","D":"J9351","F":"4.017","G":"**"},{"Policy Line":"68262149","B":"Lorazepam Ea 2mg","C":"636","D":"J2060","F":"17.7675","G":"**"},{"Policy Line":"68262150","B":"DEXTROSE 5%/0.45% NACL 500ml","C":"258","F":"4.017"},{"Policy Line":"68262151","B":"EPINEPHRINE 0.1 MG OKT","C":"636","D":"J0171","F":"1.854"},{"Policy Line":"68262152","B":"PACLITAXEL PROTEIN BND 1MG INJ","C":"636","D":"J9264","F":"15.0464657534246","G":"**"},{"Policy Line":"68262153","B":"FLUOROURACIL 500 MG OKT","C":"636","D":"J9190","F":"17.7066641901932","G":"**"},{"Policy Line":"68262154","B":"PEMETREXED/ALIMTA 10 MG INJ","C":"636","D":"J9305","F":"65.292570422535","G":"**"},{"Policy Line":"68262155","B":"PALONOSETRON/ALOXI 25MCG OKT","C":"636","D":"J2469","F":"18.666481865285","G":"**"},{"Policy Line":"68262156","B":"ATROPINE SULFATE 0.01 MG OKT","C":"636","D":"J0461","F":"1.545","G":"**"},{"Policy Line":"68262157","B":"BEVACIZUMAB 10 MG Inj OKT","C":"636","D":"J9035","F":"98.4305454545457","G":"**"},{"Policy Line":"68262158","B":"BLEOMYCIN SULFATE 15U Inj","C":"636","D":"J9040","F":"42.333","G":"**"},{"Policy Line":"68262160","B":"IRINOTECAN Inj 20 MG OKT","C":"636","D":"J9206","F":"4.017","G":"**"},{"Policy Line":"68262161","B":"CARBOPLATIN EA 50 MG OKT","C":"636","D":"J9045","F":"3.708","G":"**"},{"Policy Line":"68262162","B":"ALTEPLASE 1MG INJ OKT","C":"636","D":"J2997","F":"92.4044347826088","G":"**"},{"Policy Line":"68262163","B":"CISPLATIN EA 10 MG Inj OKT","C":"636","D":"J9060","F":"3.708","G":"**"},{"Policy Line":"68262165","B":"B-12 INJ UP TO 1000 MCG OKT","C":"636","D":"J3420","F":"16.7661111111111","G":"**"},{"Policy Line":"68262166","B":"CYCLOPHOSPHAMIDE 100 MG OKT","C":"636","D":"J9070","F":"53.473641370869","G":"**"},{"Policy Line":"68262167","B":"DACARBAZINE/DTIC 100 MG OKT","C":"636","D":"J9130","F":"8.961","G":"**"},{"Policy Line":"68262169","B":"DEXAMETHASONE EA 1 MG","C":"636","D":"J1100","F":"1.854","G":"**"},{"Policy Line":"68262170","B":"DIPHENHYDRAMINE HCL UP TO 50MG","C":"636","D":"J1200","F":"17.7911963190184","G":"**"},{"Policy Line":"68262171","B":"DOCETAXEL INJ 1 MG OKT","C":"636","D":"J9171","F":"6.54908333333331","G":"**"},{"Policy Line":"68262172","B":"DOXORUBICIN HCL 10 MG OKT","C":"636","D":"J9000","F":"7.02291836734695","G":"**"},{"Policy Line":"68262173","B":"FOSAPREPITANT EA 1MG OKT","C":"636","D":"J1453","F":"2.781","G":"**"},{"Policy Line":"68262174","B":"EPIRUBICIN HCL 2 MG OKT","C":"636","D":"J9178","F":"4.326"},{"Policy Line":"68262175","B":"CETUXIMAB 10 MG Inj OKT","C":"636","D":"J9055","F":"72.6956086956522","G":"**"},{"Policy Line":"68262176","B":"FAMOTIDINE 10 MG/ML 2 ML VIAL","C":"250","F":"17.6958039215687","G":"**"},{"Policy Line":"68262177","B":"ERIBULIN MESYLATE INJ 0.1MG","C":"636","D":"J9179","F":"137.439564705883","G":"**"},{"Policy Line":"68262178","B":"ROMIPLOSTIM/NPLATE INJ 10MCG","C":"636","D":"J2796","F":"73.7627142857145","G":"**"},{"Policy Line":"68262179","B":"DENOSUMAB Inj EA 1 MG","C":"636","D":"J0897","F":"22.6692185886403","G":"**"},{"Policy Line":"68262180","B":"OCTREOTIDE DEPOT IM ING EA 1MG","C":"636","D":"J2353","F":"245.261727272727","G":"**"},{"Policy Line":"68262181","B":"BORTIZOMIB/VELCADE EA .1 MG","C":"636","D":"J9041","F":"57.5385671641791","G":"**"},{"Policy Line":"68262182","B":"AZACITIDINE EA 1 MG","C":"636","D":"J9025","F":"7.28108450704224","G":"**"},{"Policy Line":"68262183","B":"DARBEPOETIN ALFA INJ EA 1MCG","C":"636","D":"J0881","F":"8.87893915533285","G":"**"},{"Policy Line":"68262184","B":"Mesna ea 200 MG","C":"636","D":"J9209","F":"8.034"},{"Policy Line":"68262185","B":"IXABEPILONE 1 MG","C":"636","D":"J9207","F":"87.447"},{"Policy Line":"68262186","B":"Cabazitaxel 1 MG","C":"636","D":"J9043","F":"162.225","G":"**"},{"Policy Line":"68262187","B":"Methotrexate Ea 50 MG","C":"636","D":"J9260","F":"16.995"},{"Policy Line":"68262188","B":"EPO INJ NonESRD EA 1000 Units","C":"636","D":"J0885","F":"29.3013861940298","G":"**"},{"Policy Line":"68262192","B":"FLUDARBINE EA 50MG","C":"636","D":"J9185","F":"77.559"},{"Policy Line":"68262193","B":"GEMCITABINE Inj EA 200 MG","C":"636","D":"J9201","F":"52.0885052473764","G":"**"},{"Policy Line":"68262194","B":"InjectAFer EA 1 MG","C":"636","D":"J1439","F":"1.854","G":"**"},{"Policy Line":"68262195","B":"GRANISETRON HCL EA 100 MCG","C":"636","D":"J1626","F":"1.854","G":"**"},{"Policy Line":"68262196","B":"Neulasta/Pegfilgramsim Inj 6MG","C":"636","D":"J2505","F":"5115.69905660379","G":"**"},{"Policy Line":"68262197","B":"Pamidronate Inj 30 MG","C":"636","D":"J2430","F":"16.068"},{"Policy Line":"68262198","B":"RITUXAN INJ EA 100 MG","C":"636","D":"J9312","F":"1116.726","G":"**"},{"Policy Line":"68262199","B":"VINORELBINE/NAVELB 10MG","C":"636","D":"J9390","F":"17.6401052631579","G":"**"},{"Policy Line":"68262200","B":"Copper, 0.4mg/ml, Inj","C":"636","D":"J3490","F":"46.35"},{"Policy Line":"68262201","B":"IFOSFAMIDE/IFEX 1 GM","C":"636","D":"J9208","F":"40.17"},{"Policy Line":"68262204","B":"MITOXANTRONE HCL 5 MG","C":"636","D":"J9293","F":"24.72"},{"Policy Line":"68262205","B":"Magnesium Citrate","C":"637","F":"1.35"},{"Policy Line":"68262206","B":"KCL 20 MEQ /15 ML ORAL","C":"637","F":"1.125"},{"Policy Line":"68262208","B":"DESMOPRESSIN ACETATE 1 MCG","C":"636","D":"J2597","F":"5.562"},{"Policy Line":"68262209","B":"FULVESTRANT/FASLODEX INJ 25 MG","C":"636","D":"J9395","F":"113.600416666667","G":"**"},{"Policy Line":"68262210","B":"FERUMOXYTOL 1 MG","C":"636","D":"Q0138","F":"1.854","G":"**"},{"Policy Line":"68262211","B":"FERRIC NA GLUCONATE INJ 12.5MG","C":"636","D":"J2916","F":"3.399"},{"Policy Line":"68262212","B":"TRASTUZUMAB/HERCE MDV 10 MGINJ","C":"636","D":"J9355","F":"108.768","G":"**"},{"Policy Line":"68262213","B":"KCL 2 mEq","C":"636","D":"J3480","F":"5.76800000000001","G":"**"},{"Policy Line":"68262214","B":"Acetaminophen 10Mg Inj","C":"636","D":"J0131","F":"0.618"},{"Policy Line":"68262216","B":"FLUZONE VACCINE V4","C":"636","D":"90686","F":"23.175"},{"Policy Line":"68262218","B":"CYRAMZA EA 5 MG","C":"636","D":"J9308","F":"69.698698224852","G":"**"},{"Policy Line":"68262219","B":"ELELYSO EA 10 UNITS","C":"636","D":"J3060","F":"49.749"},{"Policy Line":"68262220","B":"Meningococcal Vac IM 0.5ml Inj","C":"636","D":"90734","F":"140.904"},{"Policy Line":"68262223","B":"TRANSDERM-SCOP 1PATCH","C":"637","F":"20.925"},{"Policy Line":"68262224","B":"TEMSIROLIMUS/TORISEL 1 MG","C":"636","D":"J9330","F":"85.593"},{"Policy Line":"68262225","B":"BENDAMUSTINE/TREANDA EA 1 MG","C":"636","D":"J9033","F":"29.046"},{"Policy Line":"68262226","B":"Etoposide/Toposar 10 MG","C":"636","D":"J9181","F":"1.854","G":"**"},{"Policy Line":"68262227","B":"PRIVIGEN INJ EA 500 MG","C":"636","D":"J1459","F":"50.367","G":"**"},{"Policy Line":"68262228","B":"PACLITAXEL 1.0 MG","C":"636","D":"J9267","F":"6.36492017295087","G":"**"},{"Policy Line":"68262229","B":"PROCHLORPERAZINE <=10 MG INJ","C":"636","D":"J0780","F":"19.776","G":"**"},{"Policy Line":"68262230","B":"OXALIPLATIN INJ 0.5 MG","C":"636","D":"J9263","F":"1.545","G":"**"},{"Policy Line":"68262231","B":"SARGRAMOSTIM INJ EA 50 MCG","C":"636","D":"J2820","F":"39.243"},{"Policy Line":"68262232","B":"TESTOSTERONE CYPIONATE 1MG","C":"636","D":"J1071","F":"17.922"},{"Policy Line":"68262233","B":"BICNU 100 MG","C":"636","D":"J9050","F":"218.463"},{"Policy Line":"68262234","B":"MITOMYCIN 5 MG","C":"636","D":"J9280","F":"166.86","G":"**"},{"Policy Line":"68262235","B":"MANNITOL 25%%, 50ml VIAL","C":"636","D":"J2150","F":"5.871","G":"**"},{"Policy Line":"68262236","B":"MG SULFATE 500 MG","C":"636","D":"J3475","F":"5.76703738317759","G":"**"},{"Policy Line":"68262237","B":"LEUCOVORIN CALCIUM INJ EA 50MG","C":"636","D":"J0640","F":"8.5442208","G":"**"},{"Policy Line":"68262238","B":"INFED/IRON DEXTRAN EA 50 MG","C":"636","D":"J1750","F":"24.411"},{"Policy Line":"68262239","B":"HEPARIN INJ PER 1000 UNITS","C":"636","D":"J1644","F":"17.922"},{"Policy Line":"68262240","B":"ZIV-AFLIBERCEPT/ZALTRAP EA 1MG","C":"636","D":"J9400","F":"27.81"},{"Policy Line":"68262241","B":"Neulasta Inj Delivery Kit 6mg","C":"636","D":"J2505","F":"5061.94496774193","G":"**"},{"Policy Line":"68262242","B":"Keytruda Inj 1mg","C":"636","D":"J9271","F":"57.8167897080654","G":"**"},{"Policy Line":"68262243","B":"Mycafungin - Micamine ea 1MG","C":"636","D":"J2248","F":"0.927"},{"Policy Line":"68262244","B":"ZARXIO,FILGRSTM(G-CSF) BS 1MCG","C":"636","D":"Q5101","F":"1.854","G":"**"},{"Policy Line":"68262245","B":"Trabectedin/Yondelis 0.1MG INJ","C":"636","D":"J9352","F":"354.820285714284","G":"**"},{"Policy Line":"68262246","B":"Pentostatin/Nipent Inj 10MG","C":"636","D":"J9268","F":"2507.226"},{"Policy Line":"68262247","B":"Pegaspargase Inj SDV 3750IU5ml","C":"636","D":"J9266","F":"17154.753"},{"Policy Line":"68262248","B":"CIPROFLOXACIN 500MG ORAL TAB","C":"637","F":"1.575"},{"Policy Line":"68262250","B":"Gazyva / Obinutuzumab 10MG Inj","C":"636","D":"J9301","F":"63.6883333333332","G":"**"},{"Policy Line":"68262251","B":"Gammaplex Inj 500mg","C":"636","D":"J1557","F":"48.204"},{"Policy Line":"68262252","B":"Aminocaproic Acid 250mg/ml Inj","C":"636","D":"J3490","F":"1.854"},{"Policy Line":"68262253","B":"Albuterol-Nebulizer NonCom 1mg","C":"250","D":"J7611","F":"1.854"},{"Policy Line":"68262254","B":"Iron Sucrose Comp Inj 1mg","C":"636","D":"J1756","F":"1.854"},{"Policy Line":"68262255","B":"BENDAMUSTINE/BENDEKA 1MG MDV","C":"636","D":"J9034","F":"29.1932938432836","G":"**"},{"Policy Line":"68262256","B":"Ertapenem Na Inj 500 mg","C":"636","D":"J1335","F":"77.868"},{"Policy Line":"68262257","B":"ISTODAX/RomiDEPsin pwdr 1mg","C":"636","D":"J9315","F":"373.272"},{"Policy Line":"68262258","B":"DEXAMETHASONE ORAL EA 0.25MG","C":"636","D":"J8540","F":"0.927"},{"Policy Line":"68262259","B":"IMLYGIC/TalLah 1M PFU/ml Inj","C":"636","D":"J9325","F":"59.328"},{"Policy Line":"68262260","B":"IMLYGIC 100X PFU Inj EA Vial","C":"636","D":"J9325","F":"29.046"},{"Policy Line":"68262261","B":"Engerix-B 10mcg/0.5 ml Ped SDV","C":"636","D":"90744","F":"28.428"},{"Policy Line":"68262262","B":"Amlodipine 5MG Oral Tab","C":"637","F":"0.45"},{"Policy Line":"68262263","B":"Darzalex 10mg Inj","C":"636","D":"J9145","F":"61.0825299877599","G":"**"},{"Policy Line":"68262266","B":"CIPROFLOXACIN 200MG IV INJ","C":"636","D":"J0744","F":"3.09"},{"Policy Line":"68262267","B":"HEP A VACC PED/ADOL 2DSE IMINJ","C":"636","D":"90633","F":"37.698"},{"Policy Line":"68262268","B":"PREDNISONE IR/DR ORAL 1MG TAB","C":"636","D":"J7512","F":"1.545"},{"Policy Line":"68262269","B":"ARRANON INJ EA 50MG","C":"636","D":"J9261","F":"178.911"},{"Policy Line":"68262270","B":"CYCLOPHOSPHAMIDE CAP EA 25MG","C":"636","D":"J8530","F":"7.107","G":"**"},{"Policy Line":"68262271","B":"EMEND CAP EA 5 MG","C":"636","D":"J8501","F":"12.978"},{"Policy Line":"68262272","B":"Rasburicase/Elitek 0.5mg Inj","C":"636","D":"J2783","F":"335.265"},{"Policy Line":"68262273","B":"Leuprolide Acet/Eligard 7.5Mg","C":"636","D":"J9217","F":"557.5905","G":"**"},{"Policy Line":"68262275","B":"GANCICLOVIR 500MG PWVL","C":"636","D":"J1570","F":"72.615"},{"Policy Line":"68262277","B":"ELOTUZUMAB/EMPLICITI INJ 1MG","C":"636","D":"J9176","F":"8.034"},{"Policy Line":"68262278","B":"MENACWY VACCINE IM SDV","C":"636","D":"90734","F":"141.831"},{"Policy Line":"68262279","B":"CIPROFLOXACIN 250MG ORAL TAB","C":"637","F":"1.125"},{"Policy Line":"68262280","B":"Bleomycin 15 Un Inj (Imported)","C":"636","D":"J9040","F":"183.855"},{"Policy Line":"68262281","B":"PEGINTERFERON ALFA2A 180MCG/ML","C":"636","D":"J3490","F":"1237.545"},{"Policy Line":"68262282","B":"HYDROCORTISONE NONCHEMO10MGTAB","C":"636","D":"J8499","F":"1.854"},{"Policy Line":"68262283","B":"TECENTRIQ/ATEZOLIZUMAB INJ10MG","C":"636","D":"J9022","F":"74.7350833333332","G":"**"},{"Policy Line":"68262284","B":"Vancomycin HCL 500Mg Inj","C":"636","D":"J3370","F":"24.411"},{"Policy Line":"68262285","B":"Chlorpromazine HCL Inj to 50MG","C":"636","D":"J3230","F":"34.608"},{"Policy Line":"68262286","B":"SUSTOL INJ 10MG/0.4ML INJ","C":"636","F":"646.119"},{"Policy Line":"68262287","B":"Tranexamic Acid 10ml IV","C":"250","F":"65.508"},{"Policy Line":"68262288","B":"Infanrix DTAP Peds 0.5ml Syr","C":"636","D":"90700","F":"28.119"},{"Policy Line":"68262289","B":"Ofatumumab/Arzerra 10mg Inj","C":"636","D":"J9302","F":"64.272"},{"Policy Line":"68262290","B":"ALBUTEROL HFA MDI 200INH 18GM","C":"636","D":"J3535","F":"55.311"},{"Policy Line":"68262292","B":"Fentanyl Ptch-Xtd Rel 25mcg/hr","C":"637","F":"2.7"},{"Policy Line":"68262293","B":"HYQVIA IMMUNGLOBULIN INJ 100MG","C":"636","D":"J1575","F":"2775.438"},{"Policy Line":"68262294","B":"FLUCONAZOLE/DIFLUCAN INJ 200MG","C":"636","D":"J1450","F":"17.922"},{"Policy Line":"68262295","B":"Hydralazine 25Mg Tab","C":"637","F":"1.125"},{"Policy Line":"68262296","B":"ELOSULFASEALFA,VIMIZIM INJ 1MG","C":"636","D":"J1322","F":"292.005"},{"Policy Line":"68262297","B":"GALSULFASE/NAGLAZYM INJ 1MG","C":"636","D":"J1458","F":"463.881705882354","G":"**"},{"Policy Line":"68262298","B":"ImmuneGlobul-Octagam 500mg Inj","C":"636","D":"J1568","F":"66.126"},{"Policy Line":"68262299","B":"Varubi Inj 166.5mg/92.5ml Vial","C":"636","D":"J3490","F":"375.435"},{"Policy Line":"68262301","B":"Degarelix/Firmagon Inj 1MG","C":"636","D":"J9155","F":"4.635"},{"Policy Line":"68262322","B":"DEPO_MEDROL 40 MG INJ","C":"636","D":"J1030","F":"8.652"},{"Policy Line":"68262345","B":"Filgrastim-Neupogen Inj 1Mcg","C":"636","D":"J1442","F":"1.545","G":"**"},{"Policy Line":"68262346","B":"Montelukast Sod 10mg Tab","C":"637","F":"1.35"},{"Policy Line":"68262352","B":"ALLOPURINOL 300MG TAB","C":"637","F":"1.35"},{"Policy Line":"68262353","B":"ALLOPURINOL 100MG TAB","C":"637","F":"1.35"},{"Policy Line":"68262354","B":"NIVOLUMAB / OPDIVO, INJ 1MG","C":"636","D":"J9299","F":"32.5285660377357","G":"**"},{"Policy Line":"68262355","B":"Somatuline Depot ea 1mg, Inj","C":"636","D":"J1930","F":"86.829","G":"**"},{"Policy Line":"68262356","B":"ALEMTUZUMAB/CAMPATH Inj 1mg","C":"636","D":"J0202","F":"0"},{"Policy Line":"68262357","B":"Levoleucovorin Calcm Inj 0.5mg","C":"636","D":"J0641","F":"2.472"},{"Policy Line":"68262358","B":"CARPUJET,MORPH SULF 4MG/ML INJ","C":"250","F":"23.175"},{"Policy Line":"68262359","B":"OLARATUMAB INJ 10MG","C":"636","D":"J9285","F":"60.255"},{"Policy Line":"68262360","B":"Sustol Inj ea 0.1mg","C":"636","D":"J1627","F":"678.255"},{"Policy Line":"68262361","B":"TRASTUZUMAB/HER INJ SDV 10MG","C":"636","D":"J9355","F":"126.46415282392","G":"**"},{"Policy Line":"68262362","B":"IRINOTECAN LIP/ONIVYDE INJ 1MG","C":"636","D":"J9205","F":"49.82625","G":"**"},{"Policy Line":"68262363","B":"FLEBOGAMMA IG 5%%DIF 500MG INJ","C":"636","D":"J1572","F":"50.058","G":"**"},{"Policy Line":"68262364","B":"Fentanyl 100mcg/2Ml Inj SDV","C":"636","D":"J3010","F":"17.922"},{"Policy Line":"68262365","B":"COPANLISIB/ALIQOPA 1mg Inj","C":"636","D":"J9057","F":"5346.936"},{"Policy Line":"68262366","B":"DURVALUMAB/IMFINZI INJ 10MG","C":"636","D":"J9173","F":"72.2633699472759","G":"**"},{"Policy Line":"68262367","B":"CARIMUNE NF,IG 500MG INJ","C":"636","D":"J1566","F":"36.771"},{"Policy Line":"68262368","B":"Vedolizumab/Entyvio Inj, 1mg","C":"636","D":"J3380","F":"24.5826666666667","G":"**"},{"Policy Line":"68262369","B":"GEMTUZUMAB OZOGAMICIN IN 0.1MG","C":"636","D":"J9203","F":"231.75"},{"Policy Line":"68262370","B":"AMLODIPENE BESYLATE 10MG TAB","C":"637","F":"1.125"},{"Policy Line":"68262371","B":"METOPROLOL TARTRATE 100MG TAB","C":"637","F":"1.125"},{"Policy Line":"68262372","B":"HAVRIX 1440U/ 1ML SYR INJ","C":"250","F":"80.649"},{"Policy Line":"68262373","B":"9VHPVGARDASIL VAC2-3D 0.5MLINJ","C":"636","D":"90651","F":"241.638"},{"Policy Line":"68262400","B":"RITUXAN EA 10 MG INJ","C":"636","D":"J9312","F":"111.6726","G":"**"},{"Policy Line":"68262425","B":"Emicizumab-KXWH 0.5 mg","C":"636","D":"J7170","F":"45.94212"},{"Policy Line":"68262450","B":"Cemiplimab-rwlc 1 mg ea","C":"636","D":"J9119","F":"25.956","G":"**"},{"Policy Line":"68262451","B":"Fulphila 0.5mg inj NR","C":"636","D":"Q5108","F":"335.574"},{"Policy Line":"68262453","B":"Romosozumab 105mg/1.17ml syr","C":"636","D":"J3590","F":"964.08","G":"**"},{"Policy Line":"68262454","B":"Mogamulizumab-kpkc 1mg EA","C":"636","D":"J9204","F":"190.344"},{"Policy Line":"68262455","B":"POLATUZUMAB 1MG VIAL","C":"636","D":"J9999","F":"107.532"},{"Policy Line":"68262456","B":"Pentamidine iset 300mg inh pwd","C":"250","D":"J2545","F":"125.454"},{"Policy Line":"68262458","B":"Ravulizumab-CWVZ EA 10 MG","C":"636","D":"J1303","F":"214.446"},{"Policy Line":"68262459","B":"Romosozumab-AQQG 1mg ea","C":"636","D":"J3111","F":"10.506","G":"**"},{"Policy Line":"68262460","B":"Bevacizumab-AWWB 10mg (MVASI)","C":"636","D":"Q5107","F":"80.649"},{"Policy Line":"68262461","B":"TRASTUZ-ANNS (KANJINTI) 10MG","C":"636","D":"Q5117","F":"85.284"},{"Policy Line":"68262464","B":"NaPhos 45mmol/15ml vial","C":"250","F":"39.552"},{"Policy Line":"68262466","B":"Enfortumab Vedotin-ejfv 1mg","C":"636","D":"J3590","F":"105.987","G":"**"},{"Policy Line":"68262468","B":"TRUXIMA 10 mg","C":"636","D":"Q5115","F":"79.413"},{"Policy Line":"68262500","B":"Abatacept Inj 10mg SDV","C":"636","D":"J0129","F":"47.895"},{"Policy Line":"68262501","B":"Amifostine 500mg","C":"636","D":"J0207","F":"448.359"},{"Policy Line":"68262502","B":"Amikacin Sulfate 100mg","C":"636","D":"J0278","F":"16.995"},{"Policy Line":"68262504","B":"Cerezyme (Imiglucerase) 10Unit","C":"636","D":"J1786","F":"50.676"},{"Policy Line":"68262505","B":"Methylprednisolone Inj <=40MG","C":"636","D":"J2920","F":"17.922"},{"Policy Line":"68262506","B":"Leuprolide Depot Ea 7.5Mg","C":"636","D":"J9217","F":"1747.01376623377","G":"**"},{"Policy Line":"68262508","B":"Vitamin K (Mephyton) ea 5mg","C":"250","F":"71.379"},{"Policy Line":"68262509","B":"Folic Acid ea 1mg","C":"250","F":"1.854"},{"Policy Line":"68262510","B":"Levofloxacin/Levaquin 250 mg","C":"636","D":"J1956","F":"5.871"},{"Policy Line":"68262511","B":"Magnesium Oxide 400mg Tab","C":"637","F":"1.35"},{"Policy Line":"68262512","B":"Praltrexate / Folotyn ea 1MG","C":"636","D":"J9307","F":"261.105"},{"Policy Line":"68262513","B":"Cefepime/Maxepine Inj ea 500MG","C":"636","D":"J0692","F":"4.635"},{"Policy Line":"68262516","B":"Tetanus-Diptheria (Tenivac)0.5","C":"636","D":"90714","F":"28.428"},{"Policy Line":"68262517","B":"ADDAMEL N INJ10ML AMP (TRA ME)","C":"250","F":"19.467"},{"Policy Line":"68262518","B":"Velaglucerase Alfa/VPRIV100UIn","C":"636","D":"J3385","F":"438.162"},{"Policy Line":"68262638","B":"Gammagard S/D 500 mg Powder","C":"636","D":"J1566","F":"76.323"},{"Policy Line":"68262646","B":"EPOETIN ALFA -EBX 1000U","C":"636","D":"Q5106","F":"11.124","G":"**"},{"Policy Line":"68265000","B":"Bevacizumab 10MG - Foundation","C":"636","D":"J9035","F":"0.00309","G":"**"},{"Policy Line":"68265001","B":"Keytruda Inj 1mg - Foundation","C":"636","D":"J9271","F":"0.00309","G":"**"},{"Policy Line":"68265002","B":"Nivol/Opdivo 1mg - Foundation","C":"636","D":"J9299","F":"0.00309","G":"**"},{"Policy Line":"68265003","B":"EMEND CAP EA 5 MG - Foundation","C":"636","D":"J8501","F":"0.00309"},{"Policy Line":"68265004","B":"Rituximab/Hyal - Foundation","C":"636","D":"J9311","F":"0.00309"},{"Policy Line":"68265005","B":"TRAST/HER I10MG - Foundation","C":"636","D":"J9355","F":"0.00309","G":"**"},{"Policy Line":"68265006","B":"OCTREO INJ 1MG - Foundation","C":"636","D":"J2353","F":"0.00309"},{"Policy Line":"68265007","B":"Dalbavancin 500mg - Foundation","C":"636","D":"J0875","F":"0.00309"},{"Policy Line":"68265008","B":"INFLIXIMAB 10 MG - Foundation","C":"636","D":"J1745","F":"0.00309"},{"Policy Line":"68265009","B":"NATALIZUMAB 1MG - Foundation","C":"636","D":"J2323","F":"0.00309"},{"Policy Line":"68265010","B":"BRENT/ADCETRIS 1Mg- Foundation","C":"636","D":"J9042","F":"0.00309"},{"Policy Line":"68265011","B":"TECENTRIQ 10MG - Foundation","C":"636","D":"J9022","F":"0.00309"},{"Policy Line":"68265012","B":"Velcade Ea 0.1MG - Foundation","C":"636","D":"J9041","F":"0.00309","G":"**"},{"Policy Line":"68265013","B":"Perjeta Ea 1 Mg - Foundation","C":"636","D":"J9306","F":"0.00309"},{"Policy Line":"68265014","B":"DENOSUMAB EA 1 MG - Foundation","C":"636","D":"J0897","F":"0.00309","G":"**"},{"Policy Line":"68265015","B":"Ocrevus 300mg/10ml Foundation","C":"636","D":"J2350","F":"0.00309"},{"Policy Line":"68265016","B":"Erbitux 10MG Inj - Foundation","C":"636","D":"J9055","F":"0.00309"},{"Policy Line":"68265017","B":"Neulasta Inj 6mg - Foundation","C":"636","D":"J2505","F":"0.00309","G":"**"},{"Policy Line":"68265018","B":"BENDAMUSTINE/BENDEKA 1MG MDV","C":"636","D":"J9034","F":"0.00309"},{"Policy Line":"68265019","B":"Neulasta Onpro - Foundation","C":"636","D":"J2505","F":"0.00309","G":"**"},{"Policy Line":"68265020","B":"ALTEPLASE 1MG INJ - Foundation","C":"636","D":"J2997","F":"0.00309"},{"Policy Line":"68265021","B":"Abatacept Inj 10mg SDV","C":"636","D":"J0129","F":"0.00309"},{"Policy Line":"68265024","B":"EMPLICITI INJ 1MG - Foundation","C":"636","D":"J9176","F":"0.00309"},{"Policy Line":"68265025","B":"Entyvio Inj 1mg - Foundation","C":"636","D":"J3380","F":"0.00309"},{"Policy Line":"68265026","B":"IMFINZI INJ 10MG - Foundation","C":"636","D":"J9173","F":"0.00309"},{"Policy Line":"68265027","B":"Nuyzra 100mg vial","C":"636","D":"J3490","F":"0.00309"},{"Policy Line":"68265028","B":"Neupogen Inj 1Mcg - Foundation","C":"636","D":"J1442","F":"0.00309"},{"Policy Line":"68265029","B":"InjectAFer 1 MG - Foundation","C":"636","D":"J1439","F":"0.00309"},{"Policy Line":"68265030","B":"ALIMTA 10 MG - Foundation","C":"636","D":"J9305","F":"0.00309"},{"Policy Line":"68265031","B":"Leuprolide Depot - Foundation","C":"636","D":"J1950","F":"0.00309","G":"**"},{"Policy Line":"68265032","B":"Azacitidine 1 Mg - Foundation","C":"636","D":"J9025","F":"0.00309","G":"**"},{"Policy Line":"68266111","B":"DEHYDROERGOTAMINE INJ TO 1 MG","C":"636","D":"J1110","F":"81.885"},{"Policy Line":"68266112","B":"Alpha1-ProtnaseInhibitrInj10mg","C":"636","D":"J0256","F":"17.922"},{"Policy Line":"68266113","B":"INFLIXIMAB INJ 10 MG","C":"636","D":"J1745","F":"139.809209677419","G":"**"},{"Policy Line":"68266114","B":"PANTOPRAZOL SODIM INJ PER VIAL","C":"636","D":"C9113","F":"17.922"},{"Policy Line":"68266115","B":"NATALIZUMAB INJECTION 1 MG","C":"636","D":"J2323","F":"24.102"},{"Policy Line":"68266116","B":"IBANDRONATE SODIUM INJ 1 MG","C":"636","D":"J1740","F":"207.648"},{"Policy Line":"68266117","B":"TOCILIZUMAB INJECTION 1 MG","C":"636","D":"J3262","F":"5.562"},{"Policy Line":"68266120","B":"Fingolimod Hydrochloride 0.5Mg","C":"637","F":"1.8"},{"Policy Line":"68266121","B":"Inj, belatacept, 1 mg","C":"636","D":"J0485","F":"19.158"},{"Policy Line":"68266123","B":"Prepen 1ml Inj","C":"250","F":"6331.41"},{"Policy Line":"68266124","B":"Histamine Positive Control 1ml","C":"250","F":"533.334"},{"Policy Line":"68266125","B":"Penicillin 10,000 Units, Inj","C":"250","F":"159.135"},{"Policy Line":"68266126","B":"Saline Negative control 1ml S","C":"250","F":"7.416"},{"Policy Line":"68266127","B":"GOLIMUMAB FOR IV USE 1MG","C":"636","D":"J1602","F":"146.775"},{"Policy Line":"68267534","B":"Lidocaine 1%% 2Ml Amp","C":"636","D":"J2001","F":"15.45"},{"Policy Line":"68267537","B":"Lidocaine 1%% 30Ml Vial","C":"636","D":"J2001","F":"0.618"},{"Policy Line":"68267538","B":"Lidocaine 1%% 30Ml Vial","C":"636","D":"J2001","F":"0.618"},{"Policy Line":"68269017","B":"ARSENIC TRIOXIDE 10MG/10ML VL","C":"636","D":"J9017","F":"1758.519","G":"**"},{"Policy Line":"68269467","B":"RITUXIMAB/HYALURONIDASE","C":"636","D":"J9311","F":"2093.166"},{"Policy Line":"68269468","B":"RITUXIMAB/HYALURONIDASE","C":"636","D":"J9311","F":"203.21385"},{"Policy Line":"70206023","B":"RH Immune Globulin/Unit","C":"636","D":"J2790","F":"78.9796102236423","G":"**"},{"Policy Line":"70206028","B":"Micro Rhogam","C":"636","D":"J2790","F":"46.968"},{"Policy Line":"71103000","B":"Syringe: .9% Sodium Chloride","C":"250","F":"3.708"},{"Policy Line":"7129","B":"EPIFIX PER SQ CM","C":"636","D":"Q4186","F":"292.005","G":"**"},{"Policy Line":"7131","B":"APLIGRAF PER SQ CM","C":"636","D":"Q4101","F":"66.5589548810502","G":"**"},{"Policy Line":"7132","B":"Dermagraft Per Sq Cm","C":"636","D":"Q4106","F":"53.5045384615383","G":"**"},{"Policy Line":"7133","B":"Theraskin Per Sq Cm","C":"636","D":"Q4121","F":"105.369","G":"**"},{"Policy Line":"7134","B":"OASIS WOUND DRESSING PER SQ CM","C":"636","D":"Q4102","F":"25.647","G":"**"},{"Policy Line":"7135","B":"EPICORD PER SQ CM","C":"636","D":"Q4187","F":"292.005","G":"**"},{"Policy Line":"71402303","B":"DIPYRIDAMOLE 10MG INJ","C":"636","D":"J1245","F":"2.472"},{"Policy Line":"71405305","B":"Kinevac Per 2Mcg","C":"636","D":"J2805","F":"256.153813953488","G":"**"},{"Policy Line":"7178","B":"PuraPly per sq cm","C":"636","D":"Q4195","F":"165.933","G":"**"},{"Policy Line":"7179","B":"PuraPly AM per sq cm","C":"636","D":"Q4196","F":"180.147","G":"**"},{"Policy Line":"7191","B":"Primatrix per Sq Cm","C":"636","D":"Q4110","F":"50.985"},{"Policy Line":"7233","B":"HYALOMATRIX PER SQ CM","C":"636","D":"Q4117","F":"17.304","G":"**"},{"Policy Line":"7234","B":"Waste PuraPly AM per sq cm","C":"636","F":"180.147"},{"Policy Line":"7235","B":"Waste PuraPly per sq cm","C":"636","D":"Q4195","F":"165.933"},{"Policy Line":"7240","B":"Grafix Prime Per Sq Cm","C":"636","D":"Q4133","F":"80.031","G":"**"},{"Policy Line":"7241","B":"Affinity Per Sq Cm","C":"636","D":"Q4159","F":"304.674"},{"Policy Line":"7242","B":"Nushield Per Sq Cm","C":"636","D":"Q4160","F":"233.295","G":"**"},{"Policy Line":"74100004","B":"Hydrocortisone Na Suc 1000Mg","C":"636","D":"J1720","F":"115.566"},{"Policy Line":"74100007","B":"Hydrocortisone Na Suc 500Mginj","C":"636","D":"J1720","F":"17.922"},{"Policy Line":"74100009","B":"Novantrone 25Mg/Vial","C":"636","D":"J9293","F":"124.218"},{"Policy Line":"74100010","B":"Hydrocortisone Na Suc 100Mginj","C":"636","D":"J1720","F":"17.6960049680789","G":"**"},{"Policy Line":"74100011","B":"Dextrose 25% 10Ml","C":"258","F":"17.922","G":"**"},{"Policy Line":"74100013","B":"Methylprednisolone 500Mg Inj","C":"636","D":"J2930","F":"17.7396781609195","G":"**"},{"Policy Line":"74100014","B":"Ifex (Ifosfamide) 1Gm Vial","C":"636","D":"J9208","F":"39.7277058823527","G":"**"},{"Policy Line":"74100015","B":"Mesna 1000Mg Inj","C":"636","D":"J9209","F":"39.7324275862068","G":"**"},{"Policy Line":"74100016","B":"Methylprednisolone 1000Mg Inj","C":"636","D":"J2930","F":"26.5907292993631","G":"**"},{"Policy Line":"74100019","B":"Methylprednisolone 125Mg Inj","C":"636","D":"J2930","F":"17.633042669028","G":"**"},{"Policy Line":"74100022","B":"Methylprednisolone 40Mg Inj","C":"636","D":"J2920","F":"17.6660359460668","G":"**"},{"Policy Line":"74100031","B":"Acetaminophen Liq 160Mg/5Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100033","B":"Apap-Butabarbital/1 Tab","C":"637","F":"1.35"},{"Policy Line":"74100034","B":"Acetaminophen 650Mg/20Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100036","B":"Oxycodone Hcl 10Mg Cr Tab","C":"637","F":"3.15","G":"**"},{"Policy Line":"74100037","B":"Acetaminophen 325Mg Supp","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100040","B":"Acetaminophen 650 Mg Supp","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100044","B":"Nimodipine 30 Mg Cap","C":"637","F":"6.975","G":"**"},{"Policy Line":"74100049","B":"Acetic Acid Irr 0.25% 250Ml","C":"250","F":"18.54"},{"Policy Line":"74100053","B":"Loratadine 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100067","B":"Act Charcoal/Sorbitol 25Gm 120","C":"250","F":"17.72424","G":"**"},{"Policy Line":"74100071","B":"Bio Glucose Tab/ Bx/6","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100073","B":"Alteplase: Recom 50Mg Inj","C":"636","D":"J2997","F":"4359.32971578945","G":"**"},{"Policy Line":"74100075","B":"Tuberculin Ppd 1Unit 1St Str","C":"250","F":"17.922"},{"Policy Line":"74100078","B":"Mutamycin 5Mg Vial","C":"636","D":"J9280","F":"165.47568","G":"**"},{"Policy Line":"74100079","B":"Nifedipine Extended Release 30","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100081","B":"Benzocaine 20% Aerosol 60Gm","C":"637","F":"3.15","G":"**"},{"Policy Line":"74100084","B":"Lidocaine 2% 20Ml Vial","C":"636","D":"J2001","F":"17.6413141715728","G":"**"},{"Policy Line":"74100086","B":"Lidocaine 2% W Epi 20Ml Vial","C":"250","F":"17.6785454545454","G":"**"},{"Policy Line":"74100092","B":"Bicitra 15Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100094","B":"Epinephrine 1:1000 Inj 1Ml","C":"636","D":"J0171","F":"17.6820682671434","G":"**"},{"Policy Line":"74100100","B":"Epinephine 1:1000 Inj 30Ml","C":"636","D":"J0171","F":"73.1403","G":"**"},{"Policy Line":"74100103","B":"Doxorubicin-Pfs 10Mg Vial","C":"636","D":"J9000","F":"6.9988865248227","G":"**"},{"Policy Line":"74100115","B":"Ibuprofen 200 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100116","B":"Beclomethasone Aq Nas Spy 25Gm","C":"637","F":"251.55"},{"Policy Line":"74100117","B":"Capsaicin 0.025% Cr 45Gm","C":"637","F":"6.3","G":"**"},{"Policy Line":"74100119","B":"Preparation-H Oint 30Gm","C":"637","F":"9.225","G":"**"},{"Policy Line":"74100120","B":"Acetaminophen 120Mg Supp","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100121","B":"Polymixin B 500Ku Powder Vial","C":"250","F":"17.922"},{"Policy Line":"74100122","B":"Lidocaine 1% With Epi 20Ml","C":"250","F":"17.4844825307716","G":"**"},{"Policy Line":"74100130","B":"Oxymetazoline Nasal Drops 20Ml","C":"637","F":"4.05"},{"Policy Line":"74100133","B":"Leuprolide 7.5Mg/Ml Depot (Im)","C":"636","D":"J9217","F":"1756.73121428572","G":"**"},{"Policy Line":"74100135","B":"Cetaphil Lotion 16 Oz","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100143","B":"Lansoprazole 15Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74100146","B":"Ional T Shampoo 120Ml Bot","C":"637","F":"6.75"},{"Policy Line":"74100148","B":"Spironolactone/Hct 25/25 Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100156","B":"Ziac 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100158","B":"Lorazepam 2Mg/Ml 10Ml","C":"636","D":"J2060","F":"17.613","G":"**"},{"Policy Line":"74100161","B":"Neostigmine 1-1000 10Ml Inj","C":"636","D":"J2710","F":"129.771428305085","G":"**"},{"Policy Line":"74100163","B":"Spironolactone 50 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100166","B":"Spironolactone 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100178","B":"Methyldopa 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100183","B":"Demadex Amp 20 Mg","C":"636","D":"J3265","F":"17.922"},{"Policy Line":"74100185","B":"Morphine 30Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100187","B":"Methyldopa 50Mg/Ml 5Ml Inj","C":"636","D":"J0210","F":"50.985"},{"Policy Line":"74100191","B":"Solution Z Nose Drops","C":"637","F":"5.625","G":"**"},{"Policy Line":"74100200","B":"Acetaminophen 325Mg Tab","C":"637","F":"0"},{"Policy Line":"74100201","B":"Calcium Chloride 1Gm Syringe","C":"250","F":"17.6595342364017","G":"**"},{"Policy Line":"74100204","B":"Aspirin Enteric 325Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100208","B":"Melphalan 2Mg Tab","C":"636","D":"J8600","F":"17.922"},{"Policy Line":"74100211","B":"Allopurinol 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100219","B":"Candida Skin Test 1:100","C":"250","F":"17.922"},{"Policy Line":"74100227","B":"Goserelin Acetate 3.6Mg Syr","C":"636","D":"J9202","F":"448.05"},{"Policy Line":"74100235","B":"Alum Hydroxide Susp 30 Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100239","B":"Sterile Water 1000Ml Irrigatio","C":"250","F":"17.922"},{"Policy Line":"74100248","B":"Hetastarch 500Ml","C":"258","F":"17.7984","G":"**"},{"Policy Line":"74100251","B":"Isosorbide Dinitrate 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100254","B":"Zosyn 2.25 Gm Vial","C":"636","D":"J2543","F":"17.6547567567568","G":"**"},{"Policy Line":"74100256","B":"Benzocaine Ointment 30 Gm Tube","C":"250","F":"17.922"},{"Policy Line":"74100257","B":"Acetazolamide 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100258","B":"Readicat 450Ml","C":"255","F":"17.5544754550312","G":"**"},{"Policy Line":"74100260","B":"Piperacillian/Tazobactam 3.375","C":"636","D":"J2543","F":"17.6876926077008","G":"**"},{"Policy Line":"74100261","B":"Zosyn 4.5 Gm Vial","C":"636","D":"J2543","F":"17.6589763969932","G":"**"},{"Policy Line":"74100262","B":"Aminocaproic Acid 500Mg Tab","C":"637","F":"17.55","G":"**"},{"Policy Line":"74100264","B":"Lidocaine 2% Jelly 30Gm","C":"250","F":"17.7675","G":"**"},{"Policy Line":"74100265","B":"Amikacin 500Mg/2Ml Inj","C":"636","D":"J0278","F":"17.69681625","G":"**"},{"Policy Line":"74100266","B":"Lidocaine 5% Ointment 36Gm","C":"250","F":"38.6653043478261","G":"**"},{"Policy Line":"74100270","B":"Isoproterenol 1:5000 Inj 5Ml","C":"250","F":"2237.353125","G":"**"},{"Policy Line":"74100273","B":"Bupivacaine 0.25% Inj 30Ml Vl","C":"250","F":"17.5356831891892","G":"**"},{"Policy Line":"74100274","B":"Aminocaproic Acid Inj 5Gm/20Ml","C":"250","F":"17.643277852349","G":"**"},{"Policy Line":"74100278","B":"Phenylephrine 1% 10Mg/1Ml Inj","C":"636","D":"J2370","F":"17.6867617888055","G":"**"},{"Policy Line":"74100285","B":"Hydrocortisone Na Suc 250Mg In","C":"636","D":"J1720","F":"17.6015555555556","G":"**"},{"Policy Line":"74100289","B":"Aminophylline 250Mg Inj","C":"636","D":"J0280","F":"17.7396393442623","G":"**"},{"Policy Line":"74100290","B":"Tetracaine 0.5% 2Ml Opth Sol","C":"250","F":"15.90616125","G":"**"},{"Policy Line":"74100291","B":"Atracurium Besyl 10Mg/Ml 10Ml","C":"250","F":"17.5544562780269","G":"**"},{"Policy Line":"74100292","B":"Aminophylline 500Mg Inj","C":"636","D":"J0280","F":"17.922","G":"**"},{"Policy Line":"74100296","B":"Rabies Vaccine 1 Dose","C":"636","D":"90675","F":"401.868845090907","G":"**"},{"Policy Line":"74100305","B":"Imdur 60Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100321","B":"Amiodarone 150Mg/3Ml Inj","C":"636","D":"J0282","F":"17.6874769230769","G":"**"},{"Policy Line":"74100322","B":"Amitriptyline 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100323","B":"Granisetron Hcl 1Mg Tab","C":"636","D":"Q0166","F":"1.545"},{"Policy Line":"74100324","B":"Dorzolamide Hcl 2% 0Pth Sol5Ml","C":"637","F":"6.75","G":"**"},{"Policy Line":"74100325","B":"Amitriptyline 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100329","B":"Mesalamine 250Mg Cap","C":"637","F":"2.475","G":"**"},{"Policy Line":"74100330","B":"Stavudine 40Mg Cap","C":"637","F":"6.975"},{"Policy Line":"74100331","B":"Amitriptyline 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100332","B":"Terbinafine Hcl 1% 15Gm Cr","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100335","B":"Lotrel Capsule 5/10 Cap","C":"637","F":"7.65","G":"**"},{"Policy Line":"74100338","B":"Metfromin Hcl 850Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100339","B":"Alendronate 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74100342","B":"Nifedipine Extended Release 60","C":"637","F":"1.8","G":"**"},{"Policy Line":"74100344","B":"Estradiol Oral 0.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100347","B":"Midazolam 5Mg/Ml 5Ml","C":"250","F":"17.922"},{"Policy Line":"74100350","B":"Na Polystyren So4 Enema 30Gm","C":"637","F":"36.45","G":"**"},{"Policy Line":"74100354","B":"Dinoprostone 10Mg Vaginal Inse","C":"637","F":"321.3","G":"**"},{"Policy Line":"74100355","B":"Amoxicillin 250Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100356","B":"Botulinum Toxin Type A 100Unit","C":"636","D":"J0585","F":"745.986194805195","G":"**"},{"Policy Line":"74100358","B":"Amoxicillin 500Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100360","B":"Risperidone 2Mg Tab","C":"637","F":"1.335","G":"**"},{"Policy Line":"74100368","B":"Oxycodone Hcl 20Mg Cr Tab","C":"637","F":"5.826","G":"**"},{"Policy Line":"74100375","B":"Cephalexin 250Mg/5Ml 100Ml Sus","C":"637","F":"1.347","G":"**"},{"Policy Line":"74100379","B":"Verapamil Sr 120Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100386","B":"Flunisolide Menthol Inh 7Gm","C":"637","F":"6.75"},{"Policy Line":"74100392","B":"Timolol Xe 0.5 Ophth Sol 5Ml","C":"637","F":"102.6","G":"**"},{"Policy Line":"74100393","B":"Cisatracurium 2Mg/Ml 20 Ml Inj","C":"250","F":"17.7253636363637","G":"**"},{"Policy Line":"74100396","B":"Ipratropium Nasal 0.03% 30Ml","C":"637","F":"16.2","G":"**"},{"Policy Line":"74100398","B":"Ipratropium Nasal 0.06% 15Ml","C":"637","F":"15.525","G":"**"},{"Policy Line":"74100401","B":"Sandimmune 250Mg/5 Ml Amp","C":"636","D":"J7516","F":"67.671","G":"**"},{"Policy Line":"74100402","B":"Immuran 100 Mg Vial","C":"636","D":"J7501","F":"108.15"},{"Policy Line":"74100404","B":"Glimerpiride 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100405","B":"Acarbose 50Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74100406","B":"Flucytosine 250Mg Cap","C":"637","F":"59.175"},{"Policy Line":"74100409","B":"Flucytosine 500Mg Cap","C":"637","F":"114.3","G":"**"},{"Policy Line":"74100412","B":"Succinylcholine Cl 20Mg/Ml 10M","C":"636","D":"J0330","F":"17.5957086530173","G":"**"},{"Policy Line":"74100417","B":"Augmentin 875Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100420","B":"Naproxen 500Mg Tab Ec","C":"637","F":"1.35"},{"Policy Line":"74100422","B":"Octreotide Acetate 0.5Mg/Ml","C":"636","D":"J2354","F":"47.7873099824868","G":"**"},{"Policy Line":"74100423","B":"Haemophilus 8 Vaccine","C":"636","D":"90648","F":"17.716","G":"**"},{"Policy Line":"74100427","B":"Antabuse/250Mg/1Tab","C":"637","F":"1.35"},{"Policy Line":"74100428","B":"Vitamin E Cr 60Ml","C":"637","F":"0"},{"Policy Line":"74100429","B":"Nisoldipine 20Mg Tab","C":"637","F":"12.6"},{"Policy Line":"74100430","B":"Physostigmine 1Mg/Ml 2Ml Amp","C":"250","F":"17.922"},{"Policy Line":"74100435","B":"Ziac 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100436","B":"Antivenin Micrurus Fulviu Vial","C":"250","F":"6301.746"},{"Policy Line":"74100441","B":"Muro-128 Ophth Oint 3.5Gm","C":"250","F":"17.58725","G":"**"},{"Policy Line":"74100442","B":"Meclizine Hcl 12.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100443","B":"Meclizine 25Mg/1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100444","B":"Valium 5 Mg Tab-Brand Nec","C":"637","F":"4.725"},{"Policy Line":"74100451","B":"Anusol Oint 30Ml","C":"637","F":"6.75"},{"Policy Line":"74100452","B":"Terbinafine 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100454","B":"Anusol Supp","C":"637","F":"1.35"},{"Policy Line":"74100455","B":"Timolol 5 Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74100457","B":"Anusol: Hc 2.5% Cr 30Gm","C":"637","F":"14.625","G":"**"},{"Policy Line":"74100458","B":"Zerit 30 Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74100459","B":"Lamivudine 150Mg Tablet","C":"637","F":"6.3","G":"**"},{"Policy Line":"74100460","B":"Hydrocortisone Supp 25Mg","C":"637","F":"5.85","G":"**"},{"Policy Line":"74100464","B":"Insulin Humalog 100U 10Ml Inj","C":"637","D":"J1815","F":"72.225"},{"Policy Line":"74100465","B":"Bicalutamide 50Mg Tab","C":"636","D":"J8999","F":"1.854","G":"**"},{"Policy Line":"74100472","B":"Hydralazine 20Mg/Ml Inj","C":"636","D":"J0360","F":"17.6844582293692","G":"**"},{"Policy Line":"74100473","B":"Estradiol 0.05 Mg Top Patch","C":"637","F":"16.65"},{"Policy Line":"74100475","B":"Hydralazine 25Mg Tab","C":"637","F":"1.125","G":"**"},{"Policy Line":"74100478","B":"Hydralazine 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100484","B":"Phytonadione 10Mg/Ml Inj","C":"636","D":"J3430","F":"18.9378904109589","G":"**"},{"Policy Line":"74100487","B":"Phytonadione 1Mg/0.5Ml Inj","C":"636","D":"J3430","F":"17.7294772881356","G":"**"},{"Policy Line":"74100535","B":"Ammonia Aspiroles: Aromatic Ea","C":"250","F":"17.7756315789474","G":"**"},{"Policy Line":"74100547","B":"Ascorbic Acid Tab 250Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100550","B":"Ascriptin Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100568","B":"Aspirin/300Mg/1Ea/Supp","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100580","B":"Aspirin 600Mg Supp","C":"637","F":"1.35"},{"Policy Line":"74100583","B":"Aspirin 325Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100586","B":"Hydroxyzine 2Mg/Ml Syrup 60Ml","C":"637","F":"2.925"},{"Policy Line":"74100589","B":"Hydroxyzine Hcl 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100592","B":"Hydroxyzine Hcl 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100598","B":"Lorazepam 2Mg/Ml Inj","C":"636","D":"J2060","F":"17.6266204079804","G":"**"},{"Policy Line":"74100604","B":"Lorazepam 1Mg Tablet","C":"637","F":"1.347","G":"**"},{"Policy Line":"74100610","B":"Lorazepam 0.5Mg Tablet","C":"637","F":"1.125","G":"**"},{"Policy Line":"74100628","B":"Atropine O.4Mg/Ml 1Ml","C":"636","D":"J0461","F":"13.9403391549296","G":"**"},{"Policy Line":"74100631","B":"Atropine 1% Opth Soln 1Ml","C":"250","F":"17.8269230769231","G":"**"},{"Policy Line":"74100637","B":"Ipratropium Bromide 14Gm Inh","C":"637","F":"299.475","G":"**"},{"Policy Line":"74100643","B":"Augmentin 250Mg/5Ml 75Ml","C":"637","F":"46.575"},{"Policy Line":"74100646","B":"Augmentin 250/250Mg/1Tab","C":"637","F":"4.275"},{"Policy Line":"74100649","B":"Augmentin 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100652","B":"Benzocaine/Antipyrine 10Ml","C":"637","F":"0"},{"Policy Line":"74100670","B":"Nortriptyline 10Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100671","B":"Cefepime 1 Gm Vial","C":"636","D":"J0692","F":"9.26052419741256","G":"**"},{"Policy Line":"74100688","B":"Norethindrone Acetate 5Mg Tab","C":"637","F":"8.1"},{"Policy Line":"74100691","B":"Aztreonam 1Gm Inj","C":"250","F":"34.2039106395348","G":"**"},{"Policy Line":"74100694","B":"Azactam 2Gm Inj","C":"250","F":"68.598","G":"**"},{"Policy Line":"74100700","B":"Gabapentin 300Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100703","B":"Gabapentin 100Mg Cap","C":"637","F":"7.539","G":"**"},{"Policy Line":"74100715","B":"Sulfasalazine 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100727","B":"Bacitracin Opth Oint 3.5Gm","C":"250","F":"139.567367462686","G":"**"},{"Policy Line":"74100730","B":"Bacitracin Oint 15Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100736","B":"Famciclovir 500Mg Tab","C":"637","F":"2.496","G":"**"},{"Policy Line":"74100739","B":"Bacitracin 50:000 Units","C":"250","F":"16.8684492547864","G":"**"},{"Policy Line":"74100751","B":"Mupirocin 2% Oint 22Gm","C":"637","F":"8.04","G":"**"},{"Policy Line":"74100763","B":"Aspirin Chewable 81Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74100769","B":"Penicillin 250Mg/5Ml 100Ml Bot","C":"637","F":"1.35"},{"Policy Line":"74100775","B":"Diphenhydramine 25Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100787","B":"Diphenhydramine 50Mg/Ml Syring","C":"250","D":"J1200","F":"17.218927881142","G":"**"},{"Policy Line":"74100793","B":"Dicyclomine 10Mg.Ml 2Ml Inj","C":"636","D":"J0500","F":"59.3504756842104","G":"**"},{"Policy Line":"74100796","B":"Dyclomine 10Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100799","B":"Dicyclomine 10Mg/5Ml Syr 60Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100803","B":"Diltiazem 125 Mg Vial","C":"250","F":"17.129645106383","G":"**"},{"Policy Line":"74100850","B":"Levobunolol 0.5Ml Op Sol","C":"637","F":"12.375"},{"Policy Line":"74100856","B":"Betamethasone Val 0.1% Cr 15Gm","C":"637","F":"10.35","G":"**"},{"Policy Line":"74100874","B":"Bethanechol 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100877","B":"Milrinone 20Mg/20Ml Inj","C":"636","D":"J2260","F":"17.922"},{"Policy Line":"74100880","B":"Bethamechol 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100898","B":"Bicillin L-A/600Ku/1Ml/Sy","C":"636","D":"J0561","F":"34.299","G":"**"},{"Policy Line":"74100901","B":"Bicillin La 1:200:000 Units","C":"636","D":"J0561","F":"107.852035714285","G":"**"},{"Policy Line":"74100910","B":"Bisacodyl 10Mg Supp","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100913","B":"Bisacodyl 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100919","B":"Bleomycin 15 Units Vial","C":"636","D":"J9040","F":"41.097","G":"**"},{"Policy Line":"74100928","B":"Blephamide Opth Sol 5Cc","C":"637","F":"114.075"},{"Policy Line":"74100940","B":"Terbutaline 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100948","B":"Enoxaparin 40 Mg/0.4 Ml Syrd","C":"636","D":"J1650","F":"17.6928528521539","G":"**"},{"Policy Line":"74100949","B":"Esmolol Hcl 100Mg/10Ml Vl","C":"250","F":"17.7357373455378","G":"**"},{"Policy Line":"74100952","B":"Mexthohexital Na 500Mg Inj","C":"250","F":"0"},{"Policy Line":"74100955","B":"Terbutaline 1Mg/1Ml Inj","C":"636","D":"J3105","F":"17.5405694164456","G":"**"},{"Policy Line":"74100973","B":"Bss Plus Ophth Irrig 500Ml","C":"250","F":"85.284"},{"Policy Line":"74100979","B":"Bumetanide 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100982","B":"Bumetanide 0.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100985","B":"Bumetanide 1Mg/4Ml Inj","C":"250","F":"17.7416812437752","G":"**"},{"Policy Line":"74100991","B":"Buspirone 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100995","B":"Verapamil Sr 180Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74100999","B":"Magnesium Lact Sr 84Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101001","B":"Propafenone Hcl 150Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101004","B":"Retrovir 200Mg Vial","C":"636","D":"J3485","F":"37.389","G":"**"},{"Policy Line":"74101007","B":"Oramorph (Morphine) 100Mg","C":"637","F":"1.35"},{"Policy Line":"74101010","B":"Divalproex Na Er 250 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101015","B":"Ergotami Tarira Caffe 1Ta","C":"637","F":"1.35"},{"Policy Line":"74101027","B":"Pramoxine-Calamine 6 Oz Bot","C":"637","F":"1.35"},{"Policy Line":"74101030","B":"Calamine Lotion 120Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101033","B":"Ampicillin 500 Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101036","B":"Verapamil 80Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101039","B":"Verapamil 120Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101048","B":"Verapamil Sr 240Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101057","B":"Calciton-Salmon200IU/Ml2Ml Inj","C":"636","D":"J0630","F":"2882.56342105263","G":"**"},{"Policy Line":"74101072","B":"Calcium Gluconate 10Ml Inj","C":"636","D":"J0610","F":"17.720911913836","G":"**"},{"Policy Line":"74101081","B":"Tramdol Hcl 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101090","B":"Captopril 12.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101093","B":"Captropil 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101096","B":"Captopril 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101117","B":"Sucralfate 1 Gram Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101123","B":"Mepivacaine Hcl 1% 30Ml Inj","C":"636","D":"J0670","F":"17.922"},{"Policy Line":"74101126","B":"Mepivacaine Hcl 2% 20Ml Inj","C":"636","D":"J0670","F":"17.922","G":"**"},{"Policy Line":"74101133","B":"Nicardine 20Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101135","B":"Diltiazem 60Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101137","B":"Diltiazem Sr 120Mg Cap","C":"637","F":"4.5","G":"**"},{"Policy Line":"74101156","B":"Caster Oil Flavored 30Cc","C":"637","F":"2.7","G":"**"},{"Policy Line":"74101168","B":"Clonidine Hcl 0.1Mg Tab","C":"637","F":"1.125","G":"**"},{"Policy Line":"74101171","B":"Clonidine Hcl 0.2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101174","B":"Clonidine Hcl 0.3Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101177","B":"Clonidine Tts 1 Patch","C":"637","F":"23.85","G":"**"},{"Policy Line":"74101180","B":"Clonidine Tts 2 Patch","C":"637","F":"39.816","G":"**"},{"Policy Line":"74101183","B":"Clonidine Tts 3 Patch","C":"637","F":"55.8","G":"**"},{"Policy Line":"74101228","B":"Cefotetan 1Gram Inj","C":"250","F":"17.922","G":"**"},{"Policy Line":"74101231","B":"Cefuroxime 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101234","B":"Cefuroxime 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101243","B":"Betameth Na Phos/Acet 6Mg/1Ml","C":"636","D":"J0702","F":"17.6199525","G":"**"},{"Policy Line":"74101252","B":"Losartan 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101255","B":"Cepacol Loz 9 Tab","C":"637","F":"1.35"},{"Policy Line":"74101273","B":"Lactulose Syrup 20G/30Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101279","B":"Abciximab 10mg Vial","C":"636","D":"J0130","F":"1576.209"},{"Policy Line":"74101282","B":"Ascorbic Acid 500Mg/1Ml","C":"250","F":"17.7690927835052","G":"**"},{"Policy Line":"74101294","B":"Cherry Syrup Charge","C":"250","F":"17.922"},{"Policy Line":"74101297","B":"Glipizide Xl 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101303","B":"Chlordiazepoxide 5Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101306","B":"Chlordiazepexide 10Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101309","B":"Chlordiazepoxide 25Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101318","B":"Chloramphenicol 1Gm Inj","C":"636","D":"J0720","F":"49.749"},{"Policy Line":"74101339","B":"Chlorpromazine 25Mg Tab","C":"637","F":"4.5","G":"**"},{"Policy Line":"74101348","B":"Chlorthalidone 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101366","B":"Chromagen Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101381","B":"Ciprofloxacin 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101384","B":"Ciprofloxacin 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101387","B":"Ciprofloxacin 750Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101390","B":"Citrate Magnesia 345 Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101396","B":"Cefotaxime 1Gm Inj","C":"636","D":"J0698","F":"17.922"},{"Policy Line":"74101402","B":"Clindamycin 150Mg Cap","C":"637","F":"1.347","G":"**"},{"Policy Line":"74101405","B":"Clindamycin 300Mg/2Ml Inj","C":"250","F":"17.613","G":"**"},{"Policy Line":"74101420","B":"Clindamycin 600Mg/4Ml Inj","C":"250","F":"17.304","G":"**"},{"Policy Line":"74101426","B":"Sulindac 150Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101429","B":"Sulindac 200Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74101447","B":"Cocaine Hcl 10% Top Soln 4Ml","C":"250","F":"228.969"},{"Policy Line":"74101450","B":"Codeine Oral Soln 15Mg/5Ml","C":"637","F":"4.5"},{"Policy Line":"74101459","B":"Codeine 30Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101465","B":"Benztropine Mesyl 2Mg/2Ml Inj","C":"636","D":"J0515","F":"76.323","G":"**"},{"Policy Line":"74101468","B":"Benztropine Mesylate 1Mg Tab","C":"637","F":"1.344","G":"**"},{"Policy Line":"74101471","B":"Probenecid+Colchicine 500Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101492","B":"Prochlorperazine 10Mg2Ml Inj","C":"636","D":"J0780","F":"11.5717168773234","G":"**"},{"Policy Line":"74101501","B":"Prochlorperazine 25Mg Supp","C":"637","F":"8.775","G":"**"},{"Policy Line":"74101507","B":"Prochlorperazine 5Mg Tab","C":"636","D":"Q0164","F":"1.854"},{"Policy Line":"74101510","B":"Prochlorperazine 10Mg Tab","C":"636","D":"Q0164","F":"1.854","G":"**"},{"Policy Line":"74101516","B":"Amiodarone 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101537","B":"Nadolol 40Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101547","B":"Hydrocortisone Enema 100Mg 60M","C":"637","F":"15.075","G":"**"},{"Policy Line":"74101558","B":"Cortisporin Opth Susp 7.5Ml","C":"250","F":"70.268454","G":"**"},{"Policy Line":"74101564","B":"Cortisporin Otic Solution 10Ml","C":"637","F":"70.866","G":"**"},{"Policy Line":"74101567","B":"Cortisporin Otic Suspension 10","C":"637","F":"61.2","G":"**"},{"Policy Line":"74101573","B":"Cortrosyn 0.25Mg/1Ml Inj","C":"636","D":"J0834","F":"23.9006292134831","G":"**"},{"Policy Line":"74101582","B":"Dactinomycin 0.5Mg Inj Vial","C":"636","D":"J9120","F":"1720.512"},{"Policy Line":"74101588","B":"Warfarin 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101591","B":"Warfarin Sodium 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101612","B":"Cyanocobalamin 1000Mcg/Ml 1Ml","C":"636","D":"J3420","F":"16.8229680851064","G":"**"},{"Policy Line":"74101642","B":"Cyproheptadine Hci 4Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101654","B":"Cytomel/5Mcg/1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101660","B":"Cytarabine 100 Mg Inj","C":"636","D":"J9100","F":"8.034"},{"Policy Line":"74101663","B":"Cytarabine 1000 Mg Vial","C":"636","D":"J9100","F":"79.722"},{"Policy Line":"74101667","B":"Cyclophosphamide 25Mg Tab","C":"636","D":"J8530","F":"17.4688","G":"**"},{"Policy Line":"74101668","B":"Cytoxan 50Mg 1Tab","C":"636","D":"J8530","F":"17.829","G":"**"},{"Policy Line":"74101669","B":"Cyclophosphamide 500Mg Inj","C":"636","D":"J9070","F":"268.045094890511","G":"**"},{"Policy Line":"74101672","B":"D.H.E.45/1Mg/1Ml/Amp","C":"636","D":"J1110","F":"156.670186046512","G":"**"},{"Policy Line":"74101687","B":"Danocrine/100Mg/1Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101690","B":"Danocrine/50Mg/1Cap","C":"637","F":"1.35"},{"Policy Line":"74101720","B":"Desmopressin Acet 4Mcg/Ml 1Ml","C":"636","D":"J2597","F":"56.3093221680879","G":"**"},{"Policy Line":"74101723","B":"Desmopressin 0.01% Nasal Spray","C":"637","F":"128.925","G":"**"},{"Policy Line":"74101729","B":"Carbamide Perox 6.5% Otic 15Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101735","B":"Dexamethasone Oral Sol 60Ml","C":"637","F":"1.35"},{"Policy Line":"74101738","B":"Dexamethasone 0.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101741","B":"Decadron Ocumeter 5Ml Opt","C":"250","F":"17.6816666666667","G":"**"},{"Policy Line":"74101756","B":"Demeclocycline 150Mg Cap","C":"637","F":"5.625","G":"**"},{"Policy Line":"74101771","B":"Estradiol Valerate 20Mg Syr","C":"636","D":"J1380","F":"17.6175715068493","G":"**"},{"Policy Line":"74101780","B":"Meperidine 25Mg Inj","C":"636","D":"J2175","F":"17.5696765493969","G":"**"},{"Policy Line":"74101783","B":"Meperidine 100Mg Inj","C":"636","D":"J2175","F":"17.7675","G":"**"},{"Policy Line":"74101789","B":"Meperidine 75Mg Inj","C":"636","D":"J2175","F":"17.922"},{"Policy Line":"74101793","B":"Meperidine 10Mg/Ml 30Ml PCA","C":"250","F":"17.922"},{"Policy Line":"74101794","B":"Meperidine 50Mg Inj","C":"636","D":"J2175","F":"17.7012604295943","G":"**"},{"Policy Line":"74101801","B":"Meperidine 50Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74101807","B":"Depakene/250Mg/1Cap","C":"637","F":"4.275","G":"**"},{"Policy Line":"74101816","B":"Divalproex Sodium 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101819","B":"Divalproex Sodium 500Mg Tab","C":"637","F":"5.361","G":"**"},{"Policy Line":"74101822","B":"Depo-Estradiol 5mg/1Ml Vial","C":"636","D":"J1000","F":"17.922"},{"Policy Line":"74101825","B":"Methylprednisolone Ace 40Mg/Ml","C":"636","D":"J1030","F":"17.7080769230769","G":"**"},{"Policy Line":"74101828","B":"Medroxyprogesterone 400Mg/Ml 2","C":"250","F":"250.908"},{"Policy Line":"74101846","B":"Deferoxamine 500Mg Inj","C":"636","D":"J0895","F":"16.995","G":"**"},{"Policy Line":"74101849","B":"Trazodone 50Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74101852","B":"Venlafazine Hcl 37.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101855","B":"Dexamethasone 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74101861","B":"Dexamethasone 0.75Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74101870","B":"Dexamethasone 4Mg Tab","C":"636","D":"J8540","F":"1.8500573776908","G":"**"},{"Policy Line":"74101873","B":"Dexamethasone 4Mg/Ml 5Ml Inj","C":"636","D":"J1100","F":"17.6036234019145","G":"**"},{"Policy Line":"74101876","B":"Dexamethasone 4Mg/Ml Inj","C":"636","D":"J1100","F":"17.4660201775724","G":"**"},{"Policy Line":"74101882","B":"D10W 250Ml","C":"258","F":"17.922"},{"Policy Line":"74101888","B":"D10W 1000Ml","C":"258","F":"17.7468664495114","G":"**"},{"Policy Line":"74101894","B":"D10W/Nacl 0.9% 1000Ml","C":"258","F":"17.7539723502304","G":"**"},{"Policy Line":"74101900","B":"D2.5W/Nacl 0.45% 1000Ml","C":"258","F":"17.922"},{"Policy Line":"74101912","B":"D5W 50Ml","C":"258","F":"17.6232540764331","G":"**"},{"Policy Line":"74101915","B":"D5W 100Ml","C":"258","F":"0"},{"Policy Line":"74101921","B":"D5W 150Ml","C":"258","F":"17.304","G":"**"},{"Policy Line":"74101924","B":"D5W 250Ml","C":"258","F":"0"},{"Policy Line":"74101927","B":"D5W 500Ml","C":"258","D":"J7060","F":"17.5443208659218","G":"**"},{"Policy Line":"74101930","B":"D5W 1000Ml","C":"636","D":"J7070","F":"17.6938415405777","G":"**"},{"Policy Line":"74101933","B":"D5W/Kcl 20Meq 1000Ml","C":"258","F":"17.6175777777778","G":"**"},{"Policy Line":"74101939","B":"D5W/Rl 500Ml","C":"258","D":"J7121","F":"17.304","G":"**"},{"Policy Line":"74101942","B":"D5W/Rl 1000Ml","C":"258","D":"J7121","F":"17.6433361928105","G":"**"},{"Policy Line":"74101948","B":"D5W/Nacl 0.9% Ns 500Ml","C":"636","D":"J7042","F":"16.995"},{"Policy Line":"74101951","B":"D5W/Nacl 0.9% 1000Ml","C":"636","D":"J7042","F":"17.6968890153671","G":"**"},{"Policy Line":"74101963","B":"D5W/Nacl 0.45% 500Ml","C":"258","F":"17.407","G":"**"},{"Policy Line":"74101966","B":"D5W/Nacl 0.45% 1000Ml","C":"258","F":"17.6199059265851","G":"**"},{"Policy Line":"74101969","B":"D5W/Nacl 0.45%% /Kcl 20Meq 100","C":"636","D":"J3480","F":"17.6947457411117","G":"**"},{"Policy Line":"74101972","B":"D5W/Nacl 0.45% /Kcl 30Meq 1000","C":"258","F":"17.6691818181818","G":"**"},{"Policy Line":"74101975","B":"D5W/Nacl 0.45% /Kcl 40Meq 1000","C":"258","F":"17.819","G":"**"},{"Policy Line":"74101978","B":"D5W/Nacl 0.2% 250Ml","C":"258","F":"17.922"},{"Policy Line":"74101981","B":"D5W/Nacl 0.2% 1000Ml","C":"258","F":"17.8153401015229","G":"**"},{"Policy Line":"74101984","B":"D5W/Nacl 0.2% 500Ml","C":"258","F":"17.922"},{"Policy Line":"74101987","B":"D5W/Nacl 0.2%% /Kcl 20Meq 1000","C":"636","D":"J3480","F":"17.6571428571428","G":"**"},{"Policy Line":"74101990","B":"Dextrose 50% 50Cc Syringe","C":"250","F":"17.6744245391061","G":"**"},{"Policy Line":"74101999","B":"Nitroglycerin 2% Oint 1Gm","C":"637","F":"1.797","G":"**"},{"Policy Line":"74102002","B":"Glyburide 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102005","B":"Glyburide 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102017","B":"Acetazolamide 500Mg Injection","C":"636","D":"J1120","F":"27.0937821428572","G":"**"},{"Policy Line":"74102020","B":"Acetazolamide 500Mg Sequel","C":"637","F":"8.325","G":"**"},{"Policy Line":"74102026","B":"Diazepam Soln 5Mg/Ml 1Ml Inj","C":"636","D":"J3360","F":"17.922","G":"**"},{"Policy Line":"74102035","B":"Diazepam 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102053","B":"Dibenzyline 10Mg 1Cap","C":"637","F":"56.7"},{"Policy Line":"74102077","B":"Digoxin Immune (Digibind) 40Mg","C":"636","D":"J1162","F":"3215.2068","G":"**"},{"Policy Line":"74102089","B":"Phenytoin 250Mg Inj","C":"636","D":"J1165","F":"17.7503333333333","G":"**"},{"Policy Line":"74102092","B":"Phenytoin 100Mg Inj","C":"636","D":"J1165","F":"17.6506829268293","G":"**"},{"Policy Line":"74102095","B":"Phenytoin 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102098","B":"Phenytoin 100Mg Cap","C":"637","F":"1.344","G":"**"},{"Policy Line":"74102101","B":"Flu Vac 4Val Fluzone 0.5ml","C":"636","D":"90686","F":"17.8635914634146","G":"**"},{"Policy Line":"74102104","B":"Phenytoin 100Mg/4Ml Susp Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102116","B":"Hydromorphone 2Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74102128","B":"Dimenhydrinate 50Mg/Ml Inj","C":"250","F":"17.922"},{"Policy Line":"74102164","B":"Diphenoxylate/Atropin 2.5Mgtab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74102176","B":"Diprolene 0.05% 45Gm Cr","C":"637","F":"58.275","G":"**"},{"Policy Line":"74102182","B":"Diprolene 0.05% Af 15Gm Cr","C":"637","F":"3.6","G":"**"},{"Policy Line":"74102206","B":"Triacinalone .5% 15Gm Cr","C":"250","F":"17.8533333333333","G":"**"},{"Policy Line":"74102209","B":"Salsalate 750Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74102212","B":"Salsalate 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102218","B":"Oxybutynin Cl 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102239","B":"Dobutamine Inj 250Mg/20Ml","C":"636","D":"J1250","F":"17.922"},{"Policy Line":"74102242","B":"Docusate Na 100Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102248","B":"Docusate Na 100Mg/10Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102281","B":"Domeboro Packet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102290","B":"Donnatal Elix 5Ml Ud","C":"637","F":"1.35"},{"Policy Line":"74102302","B":"Dopamine 800Mg In D5W 250Ml","C":"636","D":"J1265","F":"17.6191977077364","G":"**"},{"Policy Line":"74102311","B":"Doxapram 20Mg/Ml 20Ml Inj","C":"250","F":"53.457"},{"Policy Line":"74102317","B":"Doxycycline 100Mg Inj","C":"250","F":"17.624014644936","G":"**"},{"Policy Line":"74102323","B":"Doxycycline 100Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102335","B":"Nefazodone 100Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74102344","B":"Dtic-Dome 200Mg/Vial","C":"636","D":"J9130","F":"16.5535714285714","G":"**"},{"Policy Line":"74102359","B":"Cefadroxyl/500Mg/1 Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102383","B":"Triamterene Cap 50Mg","C":"637","F":"8.55","G":"**"},{"Policy Line":"74102434","B":"Phosphorated Carbohydr 120Ml","C":"637","F":"1.35"},{"Policy Line":"74102461","B":"Methyclothiazi/2.5Mg/1Tab","C":"637","F":"1.35"},{"Policy Line":"74102518","B":"Ephedrine 50Mg/Ml Inj","C":"250","F":"17.6666500044583","G":"**"},{"Policy Line":"74102527","B":"Epifoam 1%/10Gm","C":"637","F":"66.825"},{"Policy Line":"74102536","B":"Magneium Sulfate Cryst 454Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102548","B":"Erythromycin 500Mg Iv","C":"636","D":"J1364","F":"43.569","G":"**"},{"Policy Line":"74102551","B":"Erythromycin Stearate 250Mg Ta","C":"637","F":"9","G":"**"},{"Policy Line":"74102554","B":"Erythromycin Base 250Mg Tab","C":"637","F":"9.45","G":"**"},{"Policy Line":"74102557","B":"Erythromycin 1Gm Iv","C":"636","D":"J1364","F":"47.895"},{"Policy Line":"74102572","B":"Eskalith Cr 450Mg/1Tab Tb","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102581","B":"Estradiol Oral 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102584","B":"Estradiol 0.05Mg Top Patch","C":"637","F":"11.7","G":"**"},{"Policy Line":"74102587","B":"Estradiol 0.1Mg Top Patch","C":"637","F":"13.725","G":"**"},{"Policy Line":"74102602","B":"Estratest Tab","C":"637","F":"1.35"},{"Policy Line":"74102641","B":"Piroxicam 20Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74102644","B":"Fentanyl 0.1MG/2Ml Inj","C":"636","D":"J3010","F":"17.5939825408463","G":"**"},{"Policy Line":"74102674","B":"Ferrous Gluconate 320Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102677","B":"Ferrous Sulfate 300Mg/5Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102683","B":"Ferrous Sulfate Tab 325Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102684","B":"Fioricet Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74102689","B":"Fiorinal Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102695","B":"Metronidazole 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102701","B":"Fleet Enema Disp 133Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102713","B":"Cyclobenzaprine 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102719","B":"Fludrocortisone Acet 0.1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102728","B":"Fluor-1-Strip Each","C":"250","F":"17.4264640329218","G":"**"},{"Policy Line":"74102731","B":"Fluorescein 10% 5Ml","C":"250","F":"17.7212990353698","G":"**"},{"Policy Line":"74102737","B":"Fluorouracil 500Mg/10Ml","C":"636","D":"J9190","F":"16.5244440944882","G":"**"},{"Policy Line":"74102743","B":"Fluorometholone 0.1% Op Sol5Ml","C":"637","F":"58.725","G":"**"},{"Policy Line":"74102752","B":"Folic Acid 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102755","B":"Estratest Hs Tab","C":"637","F":"1.35"},{"Policy Line":"74102758","B":"Folic Acid 5Mg/Ml 10Ml Inj","C":"250","F":"17.7652309746328","G":"**"},{"Policy Line":"74102761","B":"Isoflurane 100Ml","C":"250","F":"17.922"},{"Policy Line":"74102779","B":"Amphotericin B 50Mg Inj","C":"636","D":"J0285","F":"42.0858","G":"**"},{"Policy Line":"74102782","B":"Nitrofurantoin25Mg/5Ml Liq60Ml","C":"637","F":"2.475"},{"Policy Line":"74102788","B":"Furodemide 40Mg/5Ml Liq Ud","C":"637","F":"1.35"},{"Policy Line":"74102833","B":"Gentamicin 0.3% Opth Soln 1Ml","C":"250","F":"17.613","G":"**"},{"Policy Line":"74102836","B":"Gentamycin Opt Oint 3.5Gm","C":"250","F":"17.716","G":"**"},{"Policy Line":"74102839","B":"HOCM: Gastrografin 120Ml /Soln","C":"255","D":"Q9963","F":"17.5733385257143","G":"**"},{"Policy Line":"74102842","B":"Gaviscon Liquid 360Ml","C":"637","F":"5.4"},{"Policy Line":"74102845","B":"Gaviscon Foamtab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102857","B":"Gelfoam Size 100 Cm Pad","C":"250","F":"51.7295626576953","G":"**"},{"Policy Line":"74102875","B":"Gentamicin Inj 80Mg/2Ml","C":"636","D":"J1580","F":"17.6980367501009","G":"**"},{"Policy Line":"74102878","B":"Gentamicin Inj 20Mg/2Ml Inj","C":"636","D":"J1580","F":"1.854","G":"**"},{"Policy Line":"74102884","B":"Gentamicin Oint 0.1% 15Gm","C":"637","F":"26.55","G":"**"},{"Policy Line":"74102887","B":"Gentamycin 80Mg Iv","C":"636","D":"J1580","F":"17.4867227436823","G":"**"},{"Policy Line":"74102890","B":"Gentian Violet 1%/60Ml/So","C":"637","F":"6.3","G":"**"},{"Policy Line":"74102896","B":"Gevrabon 60Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102905","B":"Glucagon 1Mg Inj","C":"636","D":"J1610","F":"100.982738964844","G":"**"},{"Policy Line":"74102908","B":"Glucagon Kit","C":"636","D":"J1610","F":"357.513","G":"**"},{"Policy Line":"74102911","B":"Glipizide 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102914","B":"Glipizide 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102920","B":"Glycerin Supp Adult","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102923","B":"Glycerin 60Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102926","B":"Golytely 4000Ml","C":"637","F":"12.573","G":"**"},{"Policy Line":"74102929","B":"Goniosol 2.5% Opth Drops 15Ml","C":"250","F":"17.5625510204082","G":"**"},{"Policy Line":"74102938","B":"Gris-Peg 250Mg 1Tab","C":"637","F":"4.5"},{"Policy Line":"74102956","B":"Hepatitis B Immune Globulin5Ml","C":"636","D":"90371","F":"1024.335"},{"Policy Line":"74102962","B":"Triazolam 0.125Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74102968","B":"Haloperidol 5Mg/Ml Inj","C":"636","D":"J1630","F":"17.4061269015544","G":"**"},{"Policy Line":"74102974","B":"Haloperidol 0.5Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74102977","B":"Haloperidol 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102980","B":"Haloperidol 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74102983","B":"Haloperidol 5Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74103004","B":"Heparin 100 Units/Ml Inj","C":"636","D":"J1642","F":"17.6336","G":"**"},{"Policy Line":"74103007","B":"Heparin Lock Flush 10U/Ml Inj","C":"636","D":"J1642","F":"0.927"},{"Policy Line":"74103010","B":"Heparin 1000U Inj Tubex 1Ea","C":"636","D":"J1644","F":"17.6354796547472","G":"**"},{"Policy Line":"74103016","B":"Heparin 5000 Units/Ml 1Ml Inj","C":"636","D":"J1644","F":"17.696681904078","G":"**"},{"Policy Line":"74103019","B":"Heparin 1000 U/Ml 10Ml Vial","C":"636","D":"J1644","F":"17.7127085937282","G":"**"},{"Policy Line":"74103022","B":"Omeprazole 20Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103028","B":"Heparin 25:000 Units/D5W 500Ml","C":"636","D":"J1644","F":"17.690925093633","G":"**"},{"Policy Line":"74103034","B":"Heparin 1000 U/Nacl 0.9%% 500M","C":"636","D":"J1644","F":"17.7032189673524","G":"**"},{"Policy Line":"74103040","B":"Risperidone 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103058","B":"Hiprex 1Gm 1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103070","B":"Homatropine 5% 2Ml Opgtts","C":"250","F":"17.922"},{"Policy Line":"74103073","B":"Tetanus Immune Globulin 250Uni","C":"636","D":"J1670","F":"634.068"},{"Policy Line":"74103079","B":"Humulin Nph 100U 10Ml Inj","C":"637","D":"J1815","F":"12.15"},{"Policy Line":"74103082","B":"Humulin Reg 100U 10Ml Inj","C":"637","D":"J1815","F":"12.15"},{"Policy Line":"74103088","B":"Hurricaine 20% Spray 60Ml","C":"250","F":"17.6748","G":"**"},{"Policy Line":"74103118","B":"Hydralazine 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103130","B":"Hydroxyurea 500Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103133","B":"Hydrocortisone 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103142","B":"Hydrocortisone 1% 30Gm Cr","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103145","B":"Hydrocortisone 2.5% 20Gm Cr","C":"637","F":"9.9","G":"**"},{"Policy Line":"74103163","B":"Hydroxyzine/25Mg/1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103169","B":"Hydroxyzine Hcl 50Mg/Ml Inj","C":"250","F":"17.9006896551724","G":"**"},{"Policy Line":"74103172","B":"Hydroxyzine Pamoate 50Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103175","B":"Hydroxyzine Pamoate 25Mg Cap","C":"636","D":"Q0177","F":"1.854","G":"**"},{"Policy Line":"74103181","B":"Isovue-M-300 15 Ml Vial","C":"250","F":"107.841","G":"**"},{"Policy Line":"74103190","B":"Hydrocortisone 0.5% Cream 30Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103196","B":"Terazosin 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103197","B":"Terazosin 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103198","B":"Terazosin 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103265","B":"Loperamide 2Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103271","B":"Azathioprine 50Mg Tablet","C":"636","D":"J7500","F":"1.854","G":"**"},{"Policy Line":"74103274","B":"Droperidol 2.5Mg/Ml 2Ml Inj","C":"636","D":"J1790","F":"17.922"},{"Policy Line":"74103277","B":"Propranolol 1Mg/Ml Inj","C":"636","D":"J1800","F":"17.304","G":"**"},{"Policy Line":"74103280","B":"Propranolol 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103283","B":"Fluticasone Propio.16Gm Nasinh","C":"637","F":"19.746","G":"**"},{"Policy Line":"74103286","B":"Propranalol 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103289","B":"Propranolol 80Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103295","B":"Propranolol La 60Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103298","B":"Propranolol La 80Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103301","B":"Propranolol La 120Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103325","B":"Indigotindisulfonate 8Mg/Ml5Ml","C":"250","F":"196.438373493976","G":"**"},{"Policy Line":"74103328","B":"Indomethacin 25Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103331","B":"Indomethacin 50Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103343","B":"Indomethacin Cap Sr 75Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103346","B":"Venlafaxine Hcl 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103382","B":"Cromolyn Sodium Inh 8.1Gm","C":"637","F":"52.875"},{"Policy Line":"74103388","B":"Cromolyn Sodium Neb Soln","C":"250","F":"17.304","G":"**"},{"Policy Line":"74103394","B":"Dopamine 400Mg/5Ml Inj","C":"636","D":"J1265","F":"17.922"},{"Policy Line":"74103424","B":"Isoniazid 300Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103445","B":"Tobrex Ophth Oint 3.5Gm","C":"250","F":"257.397","G":"**"},{"Policy Line":"74103451","B":"D10W 500Ml","C":"258","F":"17.6946384129847","G":"**"},{"Policy Line":"74103454","B":"Diltiazem Sr 90Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103457","B":"Cefotetan 2Gram Inj","C":"250","F":"48.4479060090024","G":"**"},{"Policy Line":"74103463","B":"Clarithromycin 250Mg/5Ml Oral","C":"637","F":"6.525"},{"Policy Line":"74103493","B":"Pilocarpine 4% Ophth Soln 15Ml","C":"250","F":"107.532"},{"Policy Line":"74103499","B":"Pilocarpine 6% Ophth Soln.15Ml","C":"250","F":"17.922"},{"Policy Line":"74103511","B":"Isopto Hyoscine 0.25%/5Ml","C":"250","F":"44.187"},{"Policy Line":"74103526","B":"Isosorbide Dinitrate 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103529","B":"Isosorbide 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103532","B":"Sorbitrate Dinitrate 40Mg Sa T","C":"637","F":"1.35"},{"Policy Line":"74103538","B":"Isuprel 0.2Mg 1Ml Amp","C":"250","F":"1853.61223529412","G":"**"},{"Policy Line":"74103553","B":"Potassium Chloride Tab 20Meq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103556","B":"K Chloride 20Meq Pack","C":"637","F":"1.35"},{"Policy Line":"74103568","B":"K Bicarbonate 25Meq Eff Tab","C":"637","F":"1.35"},{"Policy Line":"74103577","B":"K Phosphate 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103583","B":"K Phosphate 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103604","B":"Kanamycin 1Gm/3Ml Inj","C":"250","F":"17.922"},{"Policy Line":"74103610","B":"Bismuth Subsalicylate Liq 30Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103628","B":"Cephalexin 250Mg Cap","C":"637","F":"1.347","G":"**"},{"Policy Line":"74103631","B":"Cephalexin 500Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103654","B":"Cefuroxime 1.5Gm Adv","C":"636","D":"J0697","F":"17.922","G":"**"},{"Policy Line":"74103656","B":"Cefuroxime 750Mg Adv","C":"636","D":"J0697","F":"17.1893890909091","G":"**"},{"Policy Line":"74103658","B":"Fentanyl .05Mg/Ml 20Ml Inj","C":"636","D":"J3010","F":"17.6172040816327","G":"**"},{"Policy Line":"74103673","B":"Cefazolin 1Gm Inj","C":"636","D":"J0690","F":"17.665774234999","G":"**"},{"Policy Line":"74103679","B":"Triamcinolone Dental Paste 5Gm","C":"637","F":"31.725","G":"**"},{"Policy Line":"74103682","B":"Triamcinalone Acet .025% Cr 15","C":"637","F":"3.375","G":"**"},{"Policy Line":"74103709","B":"Triamcinolone Acet 0.1% Cr 15G","C":"637","F":"3.15","G":"**"},{"Policy Line":"74103718","B":"Triamcinolone Lotion 0.1% 60","C":"637","F":"29.475","G":"**"},{"Policy Line":"74103721","B":"Triaminalone Acet 0.1% Cr 15G","C":"637","F":"3.825","G":"**"},{"Policy Line":"74103751","B":"Ketamine 50Mg/Ml 10Ml Inj","C":"250","F":"17.922"},{"Policy Line":"74103754","B":"Ketamine 100Mg/Ml 1Ml Charge","C":"250","F":"16.9887076363637","G":"**"},{"Policy Line":"74103763","B":"Sincalide 5Mcg Inj","C":"636","D":"J2805","F":"106.296"},{"Policy Line":"74103766","B":"Clonazepam 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103769","B":"Clonazepam 0.5 Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74103787","B":"Lacri-Lube Oph Ointment 3.5Gm","C":"250","F":"0"},{"Policy Line":"74103796","B":"Lactated Ringers: 500Ml","C":"258","D":"J7120","F":"17.7623154362416","G":"**"},{"Policy Line":"74103799","B":"Lactated Ringers: 1000Ml Bag","C":"258","D":"J7120","F":"17.6195070605419","G":"**"},{"Policy Line":"74103808","B":"Lactrase 250Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74103829","B":"Lanoxin 0.5Mg/2Ml Inj","C":"636","D":"J1160","F":"17.6871845238095","G":"**"},{"Policy Line":"74103832","B":"Lanoxin Tab 0.125Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103835","B":"Lanoxin Tab 0.25Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103862","B":"Furosemide 40Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103868","B":"Furosemide 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103871","B":"Furosemide 20Mg/2Ml Inj","C":"636","D":"J1940","F":"17.6821547107438","G":"**"},{"Policy Line":"74103874","B":"Furosemide 40Mg/4Ml Inj","C":"636","D":"J1940","F":"17.6548287624252","G":"**"},{"Policy Line":"74103877","B":"Furosemide 100Mg/10Ml Inj","C":"250","F":"17.7222306238185","G":"**"},{"Policy Line":"74103889","B":"Leucovorin Calcium 100Mg Inj","C":"636","D":"J0640","F":"17.7952307692308","G":"**"},{"Policy Line":"74103901","B":"Chlorambucil 2Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74103907","B":"Norepinephrine 1Mg/1Ml Inj 4Ml","C":"250","F":"17.7058560606061","G":"**"},{"Policy Line":"74103913","B":"Levothyroxine Sod 175Mcg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103916","B":"Hyoscyamine 0.125Mg/Ml 15Ml","C":"637","F":"12.6","G":"**"},{"Policy Line":"74103919","B":"Hysocyamine Sulfate 0.125Mg Ta","C":"637","F":"1.344","G":"**"},{"Policy Line":"74103928","B":"Chlordiazepoxide/Clidinum Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103937","B":"Fluocinonide 0.5%% Oint 15Gm","C":"637","F":"3.375"},{"Policy Line":"74103943","B":"Lidex .05% 60Mg Oint","C":"637","F":"65.25"},{"Policy Line":"74103946","B":"Fluocinonide-E Cream 0.05% 15G","C":"637","F":"18","G":"**"},{"Policy Line":"74103967","B":"Lidocaine 100Mg Syringe","C":"636","D":"J2001","F":"17.6603752860412","G":"**"},{"Policy Line":"74103970","B":"Lidocaine 2Grams In D5W 500Ml","C":"636","D":"J2001","F":"17.73","G":"**"},{"Policy Line":"74103985","B":"Baclofen 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74103997","B":"Fat Emulsion 10% 500Ml","C":"258","F":"17.922"},{"Policy Line":"74104000","B":"Fat Emulsion 20% 500Ml","C":"258","F":"17.922"},{"Policy Line":"74104006","B":"Lithium Carbonate 300Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104012","B":"Minoxidil 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104015","B":"Minoxidil 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104021","B":"Gemfibrozil 600Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104024","B":"Metoprolol Tart.5Mg/5Ml 5Mlin","C":"250","F":"17.7305018543046","G":"**"},{"Policy Line":"74104027","B":"Metoprolol Tartrate 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104030","B":"Metorprolol Tartrate 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104051","B":"Clotrimazole 1% Cr 15Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104057","B":"Clotrimazole/Betameth 15Gm Cr","C":"637","F":"15.075","G":"**"},{"Policy Line":"74104069","B":"Indapamide 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104072","B":"Flanders Oint 60Gm","C":"637","F":"5.175","G":"**"},{"Policy Line":"74104120","B":"Maalox Plus/1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104126","B":"Nitrofurantoin Macro 100Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74104129","B":"Nitrofurantoin (Macro)50Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104138","B":"Magnesium Sulfate 4.06Meq/Ml","C":"636","D":"J3475","F":"17.6265175600739","G":"**"},{"Policy Line":"74104144","B":"Mandelamine Equiv. 1000Mg","C":"637","F":"1.35"},{"Policy Line":"74104156","B":"Mannitol 12.5Gm/50Ml Inj","C":"636","D":"J2150","F":"17.645136","G":"**"},{"Policy Line":"74104162","B":"Bupivacaine 0.25% 10Ml","C":"250","F":"17.6215834843819","G":"**"},{"Policy Line":"74104165","B":"Bupivaca 0.25% W/Epi 10Ml P","C":"250","F":"17.6767387005076","G":"**"},{"Policy Line":"74104168","B":"Bupivacaine 0.5% 10Ml Vl","C":"250","F":"17.6843076923077","G":"**"},{"Policy Line":"74104174","B":"Bupivacain 0.5% W Epi 10Ml Pf","C":"250","F":"17.5186904970179","G":"**"},{"Policy Line":"74104177","B":"Bupivacaine 0.75% 10Ml Vl","C":"250","F":"17.5179122727273","G":"**"},{"Policy Line":"74104183","B":"Dronabinol 2.5Mg Oral Cap","C":"636","D":"Q0167","F":"17.7318367588933","G":"**"},{"Policy Line":"74104186","B":"Marinol/5Mg/1Cap","C":"637","F":"8.775"},{"Policy Line":"74104204","B":"Maxitrol Ophth Sol 5Ml","C":"250","F":"17.6748","G":"**"},{"Policy Line":"74104207","B":"Neo Decadron Op Oint 3.5Gm","C":"250","F":"17.2630481927711","G":"**"},{"Policy Line":"74104210","B":"Triamterene 75Mg/Hctz 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104213","B":"Triamterene37.5Mg/Hctz 25Mgtab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104216","B":"MCT Oil/ Med Chain Tricl","C":"259","F":"17.922"},{"Policy Line":"74104219","B":"Ferro Sequels Cap","C":"637","F":"1.35"},{"Policy Line":"74104234","B":"Methylprednisolone 4Mg Tablet","C":"636","D":"J7509","F":"1.854","G":"**"},{"Policy Line":"74104258","B":"Mefoxin 1Gm Advant Vial","C":"636","D":"J0694","F":"17.922","G":"**"},{"Policy Line":"74104264","B":"Mefoxin 2Mg Addvant Vial","C":"636","D":"J0694","F":"17.407","G":"**"},{"Policy Line":"74104273","B":"Megestrol Acetate 40Mg Tab","C":"636","D":"J8999","F":"1.854","G":"**"},{"Policy Line":"74104279","B":"Thioridazine 25Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74104282","B":"Thioridazine 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74104318","B":"Meprobamate 400Mg Tab","C":"637","F":"1.575"},{"Policy Line":"74104336","B":"Pyridostigmine Br Sr 180Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104339","B":"Pyridostigmine Br 10Mg/2Ml Inj","C":"250","F":"17.922","G":"**"},{"Policy Line":"74104348","B":"Metamucil Pkts","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104360","B":"Methylergonovine 0.2Mg/Ml Inj","C":"636","D":"J2210","F":"17.7287554179567","G":"**"},{"Policy Line":"74104363","B":"Methylergonovine 0.2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104369","B":"Methocarbamol 750Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104372","B":"Methotrexate 2.5Mg Tab","C":"636","D":"J8610","F":"1.854","G":"**"},{"Policy Line":"74104387","B":"Methotrexate 50Mg Inj","C":"636","D":"J9260","F":"3.09","G":"**"},{"Policy Line":"74104399","B":"Methylene Blue INJ 1%% 10Ml","C":"636","D":"Q9968","F":"243.918935","G":"**"},{"Policy Line":"74104420","B":"Cardene 25 Mg/10Ml Amp","C":"250","F":"17.922"},{"Policy Line":"74104426","B":"Metronidazole 500Mg Iv","C":"250","F":"17.6842239024962","G":"**"},{"Policy Line":"74104435","B":"Lovastatin 20Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74104438","B":"Mexitiletine Hcl 150Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104441","B":"Mexitil/200Mg/1Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104471","B":"Amiloride 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104477","B":"Milk Of Magnesia 30Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104483","B":"Mineral Oil 30Cc","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104486","B":"Prazosin 5Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104489","B":"Prazosin 2Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104492","B":"Prazosin 1Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104504","B":"Minocycline 100Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104513","B":"Miochol 1%/2Ml Opth Inj","C":"250","F":"59.019","G":"**"},{"Policy Line":"74104519","B":"Ca Polycarbophil 625 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104543","B":"Amiloride+Hctz 5/50 Tab","C":"637","F":"1.35"},{"Policy Line":"74104552","B":"Miconazole Nitrate-3 Vag Supp","C":"637","F":"13.5","G":"**"},{"Policy Line":"74104555","B":"Miconazole Nitrate-7 Vag Supp","C":"637","F":"2.25","G":"**"},{"Policy Line":"74104558","B":"Miconazole Nitrate 2% Cr 45Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104567","B":"Morphine Inj 10Mg/Ml","C":"636","D":"J2270","F":"17.6480412371134","G":"**"},{"Policy Line":"74104573","B":"Morphine 8Mg Inj","C":"636","D":"J2270","F":"17.613","G":"**"},{"Policy Line":"74104576","B":"Morphine 2Mg Inj","C":"636","D":"J2270","F":"17.6569598498996","G":"**"},{"Policy Line":"74104579","B":"Morphine 4Mg/Ml Inj","C":"636","D":"J2270","F":"17.5830276785038","G":"**"},{"Policy Line":"74104585","B":"Morphine 1Mg/Ml 30Ml Pca Inj","C":"636","D":"J2270","F":"17.6175825678733","G":"**"},{"Policy Line":"74104591","B":"Ibuprofen 400Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104594","B":"Ibuprofen 600Mg Tablet","C":"637","F":"1.347","G":"**"},{"Policy Line":"74104597","B":"Ibuprofen 800Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104603","B":"Morphine Sr 30Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104606","B":"Acetylcysteine 10% 4Ml","C":"637","F":"7.2","G":"**"},{"Policy Line":"74104609","B":"Acetylcysteine 20% 4Ml","C":"637","F":"10.8","G":"**"},{"Policy Line":"74104612","B":"Acetylcysteine 20% 30Ml","C":"637","F":"18.675","G":"**"},{"Policy Line":"74104615","B":"Vitamin Multi Liq 5Ml Ud","C":"637","F":"1.8"},{"Policy Line":"74104618","B":"Muri-Lube Mineral Oil/2Ml","C":"637","F":"9.9"},{"Policy Line":"74104627","B":"Mutamycin/20Mg/Vial","C":"636","D":"J9280","F":"660.333","G":"**"},{"Policy Line":"74104630","B":"Myambutol/100Mg/1Tab","C":"637","F":"1.35"},{"Policy Line":"74104633","B":"Myambutol 400Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104636","B":"Clotrimazole 10Mg Troche","C":"637","F":"2.475","G":"**"},{"Policy Line":"74104648","B":"Nystatin 15Gm Cream","C":"637","F":"12.6","G":"**"},{"Policy Line":"74104660","B":"Nystatin 15Gm Oint","C":"637","F":"4.668","G":"**"},{"Policy Line":"74104663","B":"Mycostatin Oral/ 1 Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104666","B":"Nystatin Topical Powder 15Gm","C":"637","F":"19.539","G":"**"},{"Policy Line":"74104690","B":"Simethicone Drops 40Mg/0.6Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104693","B":"Simethicone 80Mg Tab Chew","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104702","B":"Primidone 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104705","B":"Primidone 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104714","B":"Imipenem-Cilastati500Mg Advvia","C":"636","D":"J0743","F":"23.4317426470588","G":"**"},{"Policy Line":"74104723","B":"Nafcillin 2Gm Adv","C":"250","F":"17.6906305418719","G":"**"},{"Policy Line":"74104726","B":"Naphazoline 0.1% Op Sol 15Ml","C":"637","F":"2.475"},{"Policy Line":"74104729","B":"Naprosyn 375Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104732","B":"Naprosyn 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104735","B":"Naprosyn 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104744","B":"Naloxone 0.4Mg/Ml Inj","C":"636","D":"J2310","F":"18.0940378378378","G":"**"},{"Policy Line":"74104750","B":"Naloxone 1Mg/Ml Inj","C":"636","D":"J2310","F":"45.984144","G":"**"},{"Policy Line":"74104759","B":"Nasalcrom Nas Spy 13Ml","C":"637","F":"6.75","G":"**"},{"Policy Line":"74104768","B":"Oxycodone 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104774","B":"Carteolol Hcl 1% Opth Soln 5Ml","C":"637","F":"17.775"},{"Policy Line":"74104777","B":"Thiothixene 5Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74104783","B":"Thiothixene 1Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74104795","B":"Tobramycin 80Mg Inj","C":"636","D":"J3260","F":"17.6686904942966","G":"**"},{"Policy Line":"74104813","B":"Neo Calglucon Syr 60Ml","C":"637","F":"1.35"},{"Policy Line":"74104822","B":"Phenylephrine 1/4% 15Ml Spray","C":"637","F":"2.925","G":"**"},{"Policy Line":"74104831","B":"Phenylephrine 1/2% 15 Ml Spray","C":"637","F":"2.925","G":"**"},{"Policy Line":"74104837","B":"Phenylephrine 10% 5Ml Op Bot","C":"250","F":"17.587945945946","G":"**"},{"Policy Line":"74104840","B":"Oxymetazoline Nas Spray 15Ml","C":"637","F":"1.347","G":"**"},{"Policy Line":"74104852","B":"Neomycin Sulfate 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104864","B":"Neomycin-Bac-Poly Op Sol 10Ml","C":"250","F":"17.4585","G":"**"},{"Policy Line":"74104873","B":"Neomycin-Bac-Polymyx Oint Pkt","C":"250","F":"9.57872706624606","G":"**"},{"Policy Line":"74104876","B":"Neomycin/Polymyxin B 40Mg Gu","C":"250","F":"17.4239104477612","G":"**"},{"Policy Line":"74104879","B":"Methazolamide 50Mg Tab","C":"637","F":"5.625"},{"Policy Line":"74104882","B":"Methazolamide 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104888","B":"Chloroprocaine 2%% Mpf 20Ml In","C":"636","D":"J2400","F":"32.3214","G":"**"},{"Policy Line":"74104891","B":"Chloroprocaine 3%% 20Ml Inj","C":"636","D":"J2400","F":"33.063","G":"**"},{"Policy Line":"74104894","B":"Ciprofloxacin 0.3% Op Sol 5Ml","C":"250","F":"17.7675","G":"**"},{"Policy Line":"74104897","B":"K + Na Phosphates 1.25Gm Pkt","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104909","B":"Niacin 100Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74104918","B":"Mineral Oil Lt Steri 10Ml","C":"250","F":"17.6562373626373","G":"**"},{"Policy Line":"74104927","B":"Niacin 500Mg Sr Cap","C":"637","F":"1.35"},{"Policy Line":"74104930","B":"Niacin 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104933","B":"Nicotine Polacrilex 2Mg Gum","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104945","B":"Nitroglycerin Patch 0.3Mg/Hr","C":"637","F":"4.95","G":"**"},{"Policy Line":"74104951","B":"Nitroglycerin 0.6Mg Patch","C":"637","F":"1.35","G":"**"},{"Policy Line":"74104966","B":"Nitroglycerin Cap Sr 2.5Mg","C":"637","F":"1.35"},{"Policy Line":"74104972","B":"Nitrogly 50Mg Vial + Set","C":"250","F":"17.922"},{"Policy Line":"74104981","B":"Nitrolingual Spray 13.8Gm","C":"250","F":"48.3805714285716","G":"**"},{"Policy Line":"74104987","B":"Nitroprusside 50Mg Inj","C":"250","F":"17.4494117647059","G":"**"},{"Policy Line":"74104990","B":"Ipratropium 0.02% Inh Soln 2.5","C":"250","F":"17.5838552868392","G":"**"},{"Policy Line":"74105002","B":"Ketoconazole 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105005","B":"Ketoconazole 2% Cr 15Gm","C":"637","F":"16.65","G":"**"},{"Policy Line":"74105006","B":"Ofloxacin 0.3% Opth Sol 5Ml","C":"250","F":"17.1063605635838","G":"**"},{"Policy Line":"74105007","B":"Thyroid 60Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105008","B":"Chloral Hydrate Cap 500Mg","C":"637","F":"1.35"},{"Policy Line":"74105009","B":"Benazepril Hcl 20Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105010","B":"Nacl 0.9% Aluer 10Ml Vial","C":"250","F":"0"},{"Policy Line":"74105013","B":"Morphine 2Mg/Ml Soln Chg","C":"637","F":"3.375"},{"Policy Line":"74105015","B":"Flecainide 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105019","B":"Ketoprofen 200Mg Cap","C":"637","F":"2.475"},{"Policy Line":"74105020","B":"Tamoxifen 10Mg Tab","C":"250","D":"J9999","F":"17.3121843243243","G":"**"},{"Policy Line":"74105021","B":"Morphine Pf 500Mg/20Ml Inj","C":"636","D":"J2274","F":"379.143","G":"**"},{"Policy Line":"74105022","B":"Bss Soln 15Ml","C":"250","F":"17.6106947619048","G":"**"},{"Policy Line":"74105023","B":"Vecuronium Bromide 10Mg Inj","C":"250","F":"17.6386418234536","G":"**"},{"Policy Line":"74105025","B":"Lidocaine 0.5% With Epi 50Ml","C":"250","F":"17.7318461538462","G":"**"},{"Policy Line":"74105026","B":"Orphenadrine Cit 30Mg/Ml2Mlinj","C":"636","D":"J2360","F":"17.922"},{"Policy Line":"74105029","B":"Orphenadrine Citrate 100Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74105041","B":"Nacl 0.9% 100Ml Adv","C":"258","F":"17.922","G":"**"},{"Policy Line":"74105044","B":"Labetalol 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105047","B":"Labetalol 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105050","B":"Labetalol 20mg/4ml Syringe","C":"250","F":"17.6583142595542","G":"**"},{"Policy Line":"74105059","B":"Disopyramid P04 Cap 150Mg","C":"637","F":"1.35"},{"Policy Line":"74105062","B":"Disopyramide Po4 Cr 100Mg Cap","C":"637","F":"3.375"},{"Policy Line":"74105065","B":"Disopyramide Po4 Cr 150Mg Cap","C":"637","F":"3.825"},{"Policy Line":"74105068","B":"Desipramine 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74105071","B":"Desipramine 25Mg 1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105095","B":"Novolin-N 10Ml INJ","C":"637","D":"J1815","F":"12.15","G":"**"},{"Policy Line":"74105098","B":"Novolin-R 100U 10Ml Inj","C":"637","D":"J1815","F":"12.15","G":"**"},{"Policy Line":"74105101","B":"Novolin 70/30 100U/Ml 10Ml Inj","C":"637","D":"J1815","F":"12.15","G":"**"},{"Policy Line":"74105104","B":"Nalbuphine 10Mg/Ml Inj","C":"636","D":"J2300","F":"17.6348292679738","G":"**"},{"Policy Line":"74105122","B":"Nystatin Oral Susp 60Ml","C":"637","F":"12.6","G":"**"},{"Policy Line":"74105125","B":"Nystatin-Triamcinolone Cr 15Gm","C":"637","F":"14.85","G":"**"},{"Policy Line":"74105128","B":"Nystatin-Triamcinolone Oint 15","C":"637","F":"7.425","G":"**"},{"Policy Line":"74105131","B":"Nacl 0.65% Nas Spray 45Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105152","B":"Ampicillin 500Mg Inj","C":"636","D":"J0290","F":"17.812450867052","G":"**"},{"Policy Line":"74105164","B":"Ampicillin 250Mg Vial","C":"636","D":"J0290","F":"17.7640883280757","G":"**"},{"Policy Line":"74105167","B":"Nitroglycerin 0.3Mg Pp100","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105170","B":"Vincristine 1 Mg Inj","C":"636","D":"J9370","F":"17.670488372093","G":"**"},{"Policy Line":"74105194","B":"Orabase With Benzocaine 5Gm","C":"637","F":"5.625"},{"Policy Line":"74105203","B":"Hydrochlorothiazide 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105239","B":"OS Cal Tab","C":"637","F":"1.35"},{"Policy Line":"74105248","B":"Cal Oyster Shell 500Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74105254","B":"Omnipaque 300 10Ml","C":"255","D":"Q9967","F":"51.294"},{"Policy Line":"74105266","B":"Pancrease Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105278","B":"Papaverine HCL Inj 2Ml Amp","C":"636","D":"J2440","F":"17.6697551020408","G":"**"},{"Policy Line":"74105287","B":"Chlorzoxazone 500Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74105290","B":"Paregoric/5Ml/Liqu","C":"637","F":"1.35"},{"Policy Line":"74105299","B":"Bromocriptine Mesyl 2.5Mg Tab","C":"637","F":"4.5","G":"**"},{"Policy Line":"74105317","B":"Pancuronium Br 2Mg/Ml 5Ml","C":"250","F":"17.922"},{"Policy Line":"74105353","B":"Pentamidine 300Mg Inj","C":"250","F":"60.255"},{"Policy Line":"74105362","B":"Thiopental 500Mg Syr","C":"250","F":"17.922"},{"Policy Line":"74105368","B":"Famotidine 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105374","B":"Famotidine 20Mg/2Ml Inj","C":"250","F":"17.6235782380258","G":"**"},{"Policy Line":"74105380","B":"Bismuth Subsalicylate 120Ml","C":"637","F":"2.25"},{"Policy Line":"74105382","B":"Platinol Aq 50mg/50Ml Vial","C":"636","D":"J9060","F":"27.7505769230769","G":"**"},{"Policy Line":"74105383","B":"Percocet-5 Tab","C":"637","F":"1.35"},{"Policy Line":"74105398","B":"Peridex Oral Rinse 473Ml","C":"637","F":"3.6"},{"Policy Line":"74105407","B":"Cimetidine 300Mg Iv","C":"250","F":"17.922"},{"Policy Line":"74105413","B":"Dipyridamole 50Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74105416","B":"Dipyridamole 75Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105419","B":"Dipyridamole 25Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74105428","B":"Penicillin G Potassl2.5Mu Inj","C":"636","D":"J2540","F":"70.0623913043478","G":"**"},{"Policy Line":"74105431","B":"Penicillin G Potassium 1Mu Inj","C":"250","F":"17.4668119800333","G":"**"},{"Policy Line":"74105434","B":"Phenazopyridine 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105437","B":"Phenazopyridine 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105446","B":"Promethazine 12.5Mg Supp","C":"637","F":"8.775","G":"**"},{"Policy Line":"74105449","B":"Phenergan/50Mg/1Ea/Supp","C":"637","F":"24.075"},{"Policy Line":"74105452","B":"Promethazine 25Mg Supp","C":"637","F":"8.775","G":"**"},{"Policy Line":"74105461","B":"Promethazine 25Mg Tab","C":"637","F":"1.344","G":"**"},{"Policy Line":"74105470","B":"Promethazine 6.25Mg/5Ml 30Ml","C":"636","D":"Q0169","F":"1.854","G":"**"},{"Policy Line":"74105488","B":"Phenobarbital Tab 15Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105491","B":"Phenobarbital Tab 30 Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105494","B":"Phenobarbital/65Mg/1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105497","B":"Phenobarbital 130Mg Inj","C":"250","F":"17.922"},{"Policy Line":"74105509","B":"Phisohex 150Ml","C":"250","F":"17.922"},{"Policy Line":"74105533","B":"Pilocarpine 2% Op Sol 2Ml","C":"250","F":"17.922"},{"Policy Line":"74105551","B":"Diltiazem Sr 60Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105554","B":"Oxytocin 10Units/Ml Inj","C":"636","D":"J2590","F":"17.713191108742","G":"**"},{"Policy Line":"74105563","B":"Vasopressin 20 Units/Ml 1Ml In","C":"250","F":"191.833461444903","G":"**"},{"Policy Line":"74105572","B":"Hydroxychloroquine 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105581","B":"Pneumococcal Vaccine Polyvalen","C":"636","D":"90732","F":"109.718769230769","G":"**"},{"Policy Line":"74105587","B":"Poly Vi Sol C Iron 50Ml","C":"637","F":"7.2","G":"**"},{"Policy Line":"74105596","B":"Amoxicillin Susp 250Mg/5Ml Ud","C":"637","F":"1.35"},{"Policy Line":"74105599","B":"Ondansetron Hcl 4Mg/2Ml Inj","C":"636","D":"J2405","F":"17.5500593661835","G":"**"},{"Policy Line":"74105614","B":"Pontocaine 0.5%/15Mg/Soln","C":"250","F":"17.7215675675676","G":"**"},{"Policy Line":"74105626","B":"Calcium Phos 600Mg+Vit D Tab","C":"637","F":"1.35"},{"Policy Line":"74105629","B":"Potassium Acetate 40Meq Inj.","C":"250","F":"17.7721818181818","G":"**"},{"Policy Line":"74105632","B":"Potassium Chloride 20Meq Inj","C":"636","D":"J3480","F":"17.7662189054726","G":"**"},{"Policy Line":"74105635","B":"Potassium Chloride 40Meq Inj","C":"636","D":"J3480","F":"17.6462446206115","G":"**"},{"Policy Line":"74105644","B":"Potassium Chl.20Meq/15Ml Liq","C":"637","F":"4.047","G":"**"},{"Policy Line":"74105647","B":"Potassium Po4 45Mm/15Ml Vial","C":"250","F":"17.7793846153846","G":"**"},{"Policy Line":"74105653","B":"Prednisolone Acetate 1% 5Ml","C":"250","F":"17.728875","G":"**"},{"Policy Line":"74105662","B":"Prednisone 1Mg Tab","C":"636","D":"J7512","F":"1.854","G":"**"},{"Policy Line":"74105666","B":"Prednisone 10Mg Tab","C":"636","D":"J7512","F":"1.85328390014131","G":"**"},{"Policy Line":"74105668","B":"Prednisone IR/DR 5Mg Tab","C":"636","D":"J7512","F":"1.854","G":"**"},{"Policy Line":"74105671","B":"Prednisone IR/DR 20Mg Tab","C":"636","D":"J7512","F":"1.84907994137257","G":"**"},{"Policy Line":"74105677","B":"Estrogen Conjug 5Mg/Ml 5Ml Inj","C":"636","D":"J1410","F":"364.7745","G":"**"},{"Policy Line":"74105683","B":"Estrogen Conjugated 0.625Mgtab","C":"637","F":"4.725","G":"**"},{"Policy Line":"74105686","B":"Estrogen Conjugated 0.3Mgtab","C":"637","F":"4.725","G":"**"},{"Policy Line":"74105689","B":"Estrogen Conjug Vag Cr 42.5Gm","C":"250","F":"491.627679264705","G":"**"},{"Policy Line":"74105695","B":"Primatene Inh. Areo. 15Ml","C":"637","F":"16.875"},{"Policy Line":"74105698","B":"Imipenem-Cilastatin 250Mg Inj","C":"636","D":"J0743","F":"17.922","G":"**"},{"Policy Line":"74105713","B":"Lisinopril 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105716","B":"Lisinopril 10Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74105719","B":"Propantheline 15Mg 1Tab","C":"637","F":"1.35"},{"Policy Line":"74105725","B":"Procalamine With Elect. 1000Ml","C":"258","F":"17.922"},{"Policy Line":"74105737","B":"Nifedipine 10Mg Cap","C":"637","F":"1.347","G":"**"},{"Policy Line":"74105743","B":"Proctofoam 1% 15Gm Foam","C":"637","F":"33.75","G":"**"},{"Policy Line":"74105746","B":"Proctofoam Hc 10Gm Foam","C":"637","F":"51.3"},{"Policy Line":"74105749","B":"Progesterone 10Ml Vial","C":"636","D":"J2675","F":"17.922"},{"Policy Line":"74105752","B":"Fluphenazine 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105785","B":"Promethazine 25Mg/Ml Inj","C":"636","D":"J2550","F":"17.4030682126396","G":"**"},{"Policy Line":"74105791","B":"Promethazine+Codeine 120Ml","C":"637","F":"1.35"},{"Policy Line":"74105800","B":"Procainamide 1Gm/10Ml Inj","C":"636","D":"J2690","F":"100.425"},{"Policy Line":"74105809","B":"Chlorpromazine 50Mg/2Ml Inj","C":"636","D":"J3230","F":"17.8254375","G":"**"},{"Policy Line":"74105812","B":"Hydromorphone 2Mg/Ml 1Ml Inj","C":"636","D":"J1170","F":"14.981542671655","G":"**"},{"Policy Line":"74105818","B":"Propylthiourrail Tab 50Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105824","B":"Oxacillin 1Gm Inj","C":"250","F":"17.922"},{"Policy Line":"74105830","B":"Protamine Sul 50Mg/5Ml","C":"636","D":"J2720","F":"17.7138762886598","G":"**"},{"Policy Line":"74105833","B":"Protamine 250Mg/25Ml Inj","C":"636","D":"J2720","F":"17.638054054054","G":"**"},{"Policy Line":"74105836","B":"Protopam Chl. 1Gm Vial","C":"636","D":"J2730","F":"110.313"},{"Policy Line":"74105839","B":"Albuterol 0.5% Inh Soln 20Ml","C":"250","F":"17.922"},{"Policy Line":"74105848","B":"Albuterol 2Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74105851","B":"Albuterol 4Mg Tab","C":"637","F":"3.825","G":"**"},{"Policy Line":"74105854","B":"Albuterol 4Mg Repetab","C":"637","F":"1.35"},{"Policy Line":"74105860","B":"Medroxyprogerstone 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105866","B":"Fluoxetine 20Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105869","B":"Pseudoephedrine 30Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105878","B":"Pyrazinamide 500Mg Tab","C":"637","F":"4.725","G":"**"},{"Policy Line":"74105884","B":"Pyridoxine 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105896","B":"Quinidine Gluconate 324Mg Tab","C":"637","F":"6.525"},{"Policy Line":"74105902","B":"Quinidine Sul Tab 200Mg","C":"637","F":"1.35"},{"Policy Line":"74105905","B":"Quinidine 300Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74105920","B":"Retrovir Syrup 60 Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105938","B":"Phentolamine 5Mg Inj","C":"636","D":"J2760","F":"44.496","G":"**"},{"Policy Line":"74105944","B":"Metoclopropamide Syr 10Mg/10Ml","C":"636","D":"J8597","F":"1.854","G":"**"},{"Policy Line":"74105947","B":"Metoclopramide 10Mg 1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105956","B":"Metocloprpamide 10Mg/2Ml Inj","C":"636","D":"J2765","F":"17.6016727440058","G":"**"},{"Policy Line":"74105980","B":"Temazepam 15Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105983","B":"Zidovudine 100Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105989","B":"Rifampin 300Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74105998","B":"Zinecard 500Mg Vial","C":"636","D":"J1190","F":"332.484"},{"Policy Line":"74106002","B":"Loratadine 1Mg/Ml Syrup 60Ml","C":"637","F":"1.515","G":"**"},{"Policy Line":"74106010","B":"Methylphenidate 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106013","B":"Miconazole Nitrate 2% 3O Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106016","B":"Methocarbanol 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106022","B":"Methocarbamol 100Mg/Ml Inj 10M","C":"636","D":"J2800","F":"82.6673392105263","G":"**"},{"Policy Line":"74106034","B":"Glycopyrrolate 0.2Mg/Ml 1Mlinj","C":"250","F":"17.6020123122677","G":"**"},{"Policy Line":"74106040","B":"Guaifenesin 100Mg/5Ml 10Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106051","B":"Robitussin-Dm 5Ml/Syrp","C":"637","F":"1.35"},{"Policy Line":"74106061","B":"Calcitriol 0.25Mcg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106067","B":"Ceftriaxone 250Mg Inj","C":"636","D":"J0696","F":"17.455424118799","G":"**"},{"Policy Line":"74106091","B":"Mesalamine 4Gm/60Ml Enema","C":"637","F":"12.6","G":"**"},{"Policy Line":"74106094","B":"Azatadine-Pseudoephedrine Tab","C":"637","F":"1.35"},{"Policy Line":"74106136","B":"Acebutolol Hcl 200Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106139","B":"Tobramycin 1.2Gm Vial","C":"636","D":"J3260","F":"210.239220472441","G":"**"},{"Policy Line":"74106148","B":"Selenium 40Mcg/Ml 1Ml","C":"250","F":"17.922"},{"Policy Line":"74106157","B":"Senna Concentrate 187Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106160","B":"Senna Conc 187Mg/Docusatena5Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106166","B":"Co-Trimoxazole Liquid 20Ml Ud","C":"637","F":"2.475","G":"**"},{"Policy Line":"74106169","B":"Co-Trimoxazole Ds Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106232","B":"Carbidopa 10Mg+Levo 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106235","B":"Carbidopa 25Mg+Levo 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106238","B":"Carbidopa 25Mg+Levo 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106241","B":"Doxepin 10Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106244","B":"Doxepin 25Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106247","B":"Doxepin 50Mg/1Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106271","B":"Theophylline 80Mg/15mlOral syr","C":"637","F":"9","G":"**"},{"Policy Line":"74106274","B":"Ferrous Sulfate Sr Tab 160Mg","C":"637","F":"1.35"},{"Policy Line":"74106277","B":"Sodium Acetate 40Meq/20Ml","C":"250","F":"17.4651531100479","G":"**"},{"Policy Line":"74106280","B":"Sodium Bicarb 650Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106286","B":"Sodium Bicarb 5Meq Infant Syr","C":"250","F":"17.5718","G":"**"},{"Policy Line":"74106295","B":"Sodium Bicarb 10Meq Ped Syr","C":"250","F":"17.922"},{"Policy Line":"74106301","B":"Nacl 1Gm Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106308","B":"NS 5% 500Ml+Adapter","C":"250","F":"19.467"},{"Policy Line":"74106310","B":"Nacl Conc 4Meq Per Ml Chg","C":"250","F":"17.7998372093023","G":"**"},{"Policy Line":"74106313","B":"Nacl 0.45% 500Ml","C":"258","F":"17.7290508345979","G":"**"},{"Policy Line":"74106316","B":"Nacl 0.45% 1000Ml","C":"258","F":"17.6931992317999","G":"**"},{"Policy Line":"74106325","B":"Nacl 0.9% 100Ml Bag Inj","C":"258","F":"0"},{"Policy Line":"74106328","B":"Nacl 0.9% 150Ml","C":"258","F":"0"},{"Policy Line":"74106331","B":"Nacl 0.9% 250Ml","C":"636","D":"J7050","F":"0"},{"Policy Line":"74106334","B":"Nacl 0.9%% 500Ml Bag","C":"258","D":"J7040","F":"17.4857120495104","G":"**"},{"Policy Line":"74106337","B":"Nacl 250Ml For For Irrigation","C":"250","F":"17.922"},{"Policy Line":"74106340","B":"Nacl 1000Ml For Irrigation","C":"250","F":"17.7404075829384","G":"**"},{"Policy Line":"74106343","B":"Nacl 3000Ml Irrigation Bag","C":"250","F":"17.922"},{"Policy Line":"74106346","B":"Nacl 3%% 500Ml","C":"258","D":"J7131","F":"17.5052093023256","G":"**"},{"Policy Line":"74106349","B":"Chlorothiazide 500Mg Inj","C":"636","D":"J1205","F":"374.119258064517","G":"**"},{"Policy Line":"74106358","B":"Na Phosphates 60 Meq/15 Ml Inj","C":"250","F":"17.7698327526132","G":"**"},{"Policy Line":"74106361","B":"SOD . Polystyren Sul 15Gm/60Ml","C":"637","F":"8.094","G":"**"},{"Policy Line":"74106391","B":"Carisoprodol 350Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106397","B":"Sorbitol 70% 60Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106398","B":"Sorbitol 70% 30 Ml Bot","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106425","B":"Spectazole Cream 15Mg","C":"637","F":"70.2"},{"Policy Line":"74106433","B":"SSKI/30Ml/Soln","C":"637","F":"9.45"},{"Policy Line":"74106436","B":"Butorphanol 1Mg/Ml Inj","C":"636","D":"J0595","F":"17.922"},{"Policy Line":"74106439","B":"Butorphanol 2Mg/Ml Inj","C":"636","D":"J0595","F":"17.922"},{"Policy Line":"74106448","B":"Trifluoperazine 5Mg/1 Tab","C":"637","F":"1.35"},{"Policy Line":"74106451","B":"Trifluoperazine 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74106454","B":"Trifluoperazine 1Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74106457","B":"Sterile Water 10Ml Vial","C":"250","D":"A4216","F":"0"},{"Policy Line":"74106481","B":"Streptomycin Sulf.1Gm/Via","C":"636","D":"J3000","F":"23.175"},{"Policy Line":"74106484","B":"Stuartnatal 1 + 1 Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106487","B":"Sufenta/100Mcg/2Ml/Amp","C":"250","F":"0"},{"Policy Line":"74106490","B":"Sufenta/50Mcg/5Ml/Amp","C":"250","F":"0"},{"Policy Line":"74106505","B":"Tetracyline 250Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74106529","B":"Amantadine 100Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106532","B":"Symmetrel Syrup 100Mg/10Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106559","B":"Levothyroxin Sod 0.075Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106562","B":"Levothyroxine Sod 0.05Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106565","B":"Levothyroxine Sod 0.1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106574","B":"Levothyroxine 0.15Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106577","B":"Levothyroxine Sod 0.025Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106580","B":"Levothyroxine Sod 200Mcg Inj","C":"250","F":"267.8","G":"**"},{"Policy Line":"74106607","B":"Tagamet 400Mg/1Tab","C":"637","F":"0"},{"Policy Line":"74106610","B":"Cimetidine 300Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74106631","B":"Flecainide 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106637","B":"Methimazole 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106646","B":"Clemastine Fumarate 2.68Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74106655","B":"Ceftazidime 2 Gram Vial","C":"636","D":"J0713","F":"32.2109554455447","G":"**"},{"Policy Line":"74106658","B":"Ceftazidime 1 Gram Vial","C":"636","D":"J0713","F":"17.7268421052632","G":"**"},{"Policy Line":"74106664","B":"Artifical Tears Op Sol 15Ml","C":"637","F":"23.175","G":"**"},{"Policy Line":"74106670","B":"Carbamazepine 200Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106673","B":"Carbamazepine 100Mg Chewable","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106682","B":"Guafacine 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106691","B":"Atenolol 100Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74106694","B":"Atenolol 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106700","B":"Terconazole 80Mg Vag Sup 3'S","C":"637","F":"24.525"},{"Policy Line":"74106718","B":"Benzonatate 100Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106724","B":"Tetanus-Diptheria Tox 0.5Ml","C":"636","D":"90714","F":"38.4189999999999","G":"**"},{"Policy Line":"74106730","B":"Tetracycline Susp 125Mg/5Ml 60","C":"637","F":"15.975"},{"Policy Line":"74106739","B":"Theophylline Sa 100Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74106742","B":"Theophylline Sa 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106745","B":"Theophylline Sa 300Mg Tab","C":"637","F":"2.25","G":"**"},{"Policy Line":"74106766","B":"Theo-24 200Mg Cap","C":"637","F":"2.025"},{"Policy Line":"74106769","B":"Theo-24 300Mg Cap","C":"637","F":"2.925"},{"Policy Line":"74106781","B":"Vitamin Multi+Mineral Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106787","B":"Thiamine 100Mg/Ml 2Ml Inj","C":"636","D":"J3411","F":"17.7491413992762","G":"**"},{"Policy Line":"74106790","B":"Thiamine 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106796","B":"Thiamine 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106820","B":"Chlorpromazine 25Mg/Ml Inj","C":"636","D":"J3230","F":"30.9817941176472","G":"**"},{"Policy Line":"74106868","B":"Trimethobenzamide 200Mg/2Ml In","C":"636","D":"J3250","F":"17.922"},{"Policy Line":"74106880","B":"Timentin 3.1Gm Addvantage","C":"250","F":"17.922"},{"Policy Line":"74106889","B":"Timolol Opth Soln 0.5% 2.5Ml","C":"250","F":"17.6972727272727","G":"**"},{"Policy Line":"74106892","B":"Benaoin Tincture 120Ml Top","C":"637","F":"3.825"},{"Policy Line":"74106898","B":"Tolnaftate 1% 15Gm Cream","C":"637","F":"2.7","G":"**"},{"Policy Line":"74106913","B":"Tobrex 0.3% Ophth Sol 5Ml","C":"250","F":"17.6675294117647","G":"**"},{"Policy Line":"74106919","B":"Imipramine Hcl 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106922","B":"Imipramine 10Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74106961","B":"Topicort 15Gm Top Cream","C":"637","F":"23.175"},{"Policy Line":"74106976","B":"Trace Metals Inj 5Ml","C":"250","F":"17.6874455445545","G":"**"},{"Policy Line":"74106994","B":"Transderm-Scop 1Patch","C":"250","F":"25.439130952381","G":"**"},{"Policy Line":"74106997","B":"Clorazepate Dipotass 3.75Mg Ta","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107015","B":"Trazodone Hcl/100Mg/1Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107018","B":"Pentoxifylline 400Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107045","B":"Amitrip/Perphenazine 2-10 Tab","C":"637","F":"1.35"},{"Policy Line":"74107048","B":"Amitrip/Perphenazine 2-25 Tab","C":"637","F":"1.35"},{"Policy Line":"74107054","B":"Amitrip/Perphenazine 4-25 Tab","C":"637","F":"1.35"},{"Policy Line":"74107058","B":"Paroxetine 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107060","B":"Tridesilon 15Gm/Top Cream","C":"637","F":"18.9"},{"Policy Line":"74107069","B":"D5W 250Ml Adv","C":"258","F":"0"},{"Policy Line":"74107072","B":"Propofol Inj 10Mg/Ml 20Ml Amp","C":"636","D":"J2704","F":"17.5588960469494","G":"**"},{"Policy Line":"74107075","B":"Erythromycin 500 MG Adv","C":"636","D":"J1364","F":"44.496","G":"**"},{"Policy Line":"74107087","B":"Choline Mg Salicylate 750Mgtab","C":"637","F":"1.35"},{"Policy Line":"74107108","B":"Tuberculin Ppd 5 Unit Int Str","C":"250","F":"17.6914029850746","G":"**"},{"Policy Line":"74107118","B":"Levothyroxine Sod 0.125Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107120","B":"Tums 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107153","B":"Acetaminophen100Mg/Ml 15Mlsoln","C":"637","F":"4.275"},{"Policy Line":"74107159","B":"Dibucaine Ointmetn 28 Gm","C":"637","F":"4.275"},{"Policy Line":"74107162","B":"Acetaminophen/Codeine Elix 5Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107171","B":"Acetaminophen/Codeine 30Mg Tab","C":"637","F":"1.344","G":"**"},{"Policy Line":"74107177","B":"Oxycodone 5Mg/Apap 325Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107180","B":"Tympagesic Otic Sol 15Ml","C":"637","F":"11.925"},{"Policy Line":"74107207","B":"Flavoxate Hcl 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107225","B":"Betamethasone .1% 45Gm Cr","C":"637","F":"32.85","G":"**"},{"Policy Line":"74107243","B":"Betamethasone .1% Ung 15G","C":"250","F":"17.6972727272727","G":"**"},{"Policy Line":"74107246","B":"Betamethasone .1% 45Gm Oint","C":"637","F":"22.95","G":"**"},{"Policy Line":"74107249","B":"Diazepam 10Mg Inj Syr","C":"636","D":"J3360","F":"17.5253837426901","G":"**"},{"Policy Line":"74107255","B":"Diazepam 5Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74107273","B":"Beclomethasone 40Mcg Oral Inh","C":"637","F":"69.75"},{"Policy Line":"74107276","B":"Vancomycin 250Mg Cap","C":"637","F":"48.15"},{"Policy Line":"74107282","B":"Vancomycin 500Mg Inj","C":"636","D":"J3370","F":"17.6913003708282","G":"**"},{"Policy Line":"74107324","B":"Enalapril 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107327","B":"Enalapril 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107333","B":"Enalaprilat 1.25Gm/Ml 2Ml Iv","C":"250","F":"17.6386243902439","G":"**"},{"Policy Line":"74107342","B":"Penicillin Vk 250Mg Tab","C":"637","F":"1.344","G":"**"},{"Policy Line":"74107348","B":"Velban 10Mg/Vial","C":"636","D":"J9360","F":"4.017","G":"**"},{"Policy Line":"74107372","B":"Etoposide 50Mg","C":"636","D":"J8560","F":"95.79"},{"Policy Line":"74107373","B":"Etoposide (Vp-16) 100Mg Inj","C":"636","D":"J9181","F":"6.34102816901409","G":"**"},{"Policy Line":"74107375","B":"Verapamil 5Mg/2Ml Inj","C":"250","F":"17.7555255198487","G":"**"},{"Policy Line":"74107378","B":"Verapamil 2.5Mg/Ml 4Ml Inj","C":"250","F":"17.922"},{"Policy Line":"74107390","B":"Midazolam 10Mg/2Ml Inj","C":"250","F":"17.304","G":"**"},{"Policy Line":"74107393","B":"Midazolam 1Mg/Ml 2Ml Inj","C":"636","D":"J2250","F":"17.6197809549766","G":"**"},{"Policy Line":"74107396","B":"Hydrocodone 5Mg/Apap 500Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74107414","B":"Trifluridine 1% Ophth Sol7.5Ml","C":"637","F":"116.325","G":"**"},{"Policy Line":"74107417","B":"Visine 0.05%/15Ml/Drops","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107420","B":"Pindolol 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74107423","B":"Pindolol 5 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107432","B":"Vitamin E 200 Unit Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107435","B":"Vitamin E 400 Unit Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107438","B":"Protriptyline 5Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74107441","B":"Vivactil/10Mg/1Tab","C":"637","F":"1.35"},{"Policy Line":"74107456","B":"Diclofenac Sodium 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107459","B":"Diclofenac Sodium 75Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107471","B":"Leucovorin/5Mg/1 Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107477","B":"Hydrocortisone Val 0.2% 15Gm C","C":"637","F":"43.65"},{"Policy Line":"74107513","B":"Alprazolam 0.25Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107516","B":"Alprazolam 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107519","B":"Alprazolam 0.5Mg Tablet","C":"637","F":"1.347","G":"**"},{"Policy Line":"74107525","B":"Lidocaine Viscous 2% 20Ml Cup","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107528","B":"Lidocaine 0.5% 50Ml Sdv","C":"636","D":"J2001","F":"17.716","G":"**"},{"Policy Line":"74107534","B":"Lidocaine 1% 2Ml Amp","C":"636","D":"J2001","F":"17.728875","G":"**"},{"Policy Line":"74107537","B":"Lidocaine 1% 30Ml Vial","C":"636","D":"J2001","F":"17.6172544404239","G":"**"},{"Policy Line":"74107540","B":"Lidocaine 1% With Epi 30Ml Sdv","C":"250","F":"17.6682112537019","G":"**"},{"Policy Line":"74107546","B":"Lidocaine 2% 2Ml Sda","C":"636","D":"J2001","F":"17.749471196455","G":"**"},{"Policy Line":"74107552","B":"Lidocaine 2% W Epi 20Ml Vial","C":"250","F":"17.6815911550633","G":"**"},{"Policy Line":"74107555","B":"Lidocaine 4% 5Ml Amp","C":"636","D":"J2001","F":"17.819","G":"**"},{"Policy Line":"74107558","B":"Lidocaine 5%+Glucose 2Ml","C":"250","F":"17.922"},{"Policy Line":"74107567","B":"Zanosar/1Gm/Vial","C":"636","D":"J9320","F":"444.651"},{"Policy Line":"74107582","B":"Metolazone 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107585","B":"Metolazone 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107588","B":"Metolazone 10Mg Tab","C":"637","F":"2.25"},{"Policy Line":"74107606","B":"Acyclovir 200Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107609","B":"Acyclovir 500Mg Injection","C":"636","D":"J0133","F":"17.787152016546","G":"**"},{"Policy Line":"74107612","B":"Acyclovir 5% Oint 15Gm","C":"637","F":"287.1","G":"**"},{"Policy Line":"74107615","B":"Carbamazepine Liq 100Mg/5Ml","C":"637","F":"2.7","G":"**"},{"Policy Line":"74107616","B":"Camptosar 100Mg/5Ml Vial","C":"636","D":"J9206","F":"20.703","G":"**"},{"Policy Line":"74107621","B":"Humulin Inj 70/30 Insulin 10Ml","C":"637","D":"J1815","F":"12.15"},{"Policy Line":"74107626","B":"Levothyroxine Sod 112Mcg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107630","B":"Clindamycin 900Mg/6Ml Inj","C":"250","F":"17.716","G":"**"},{"Policy Line":"74107631","B":"Estratab 0.625Mg Tab","C":"637","F":"2.025"},{"Policy Line":"74107633","B":"Nephro-Vite Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107634","B":"Urocit-K/Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107637","B":"Fluconazole 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74107638","B":"Fluconazole 200Mg/100Ml Iv","C":"636","D":"J1450","F":"17.7228468208093","G":"**"},{"Policy Line":"74107640","B":"Nifedipine Extended Release 90","C":"637","F":"1.8","G":"**"},{"Policy Line":"74107641","B":"Bupropion Hcl 100Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74107644","B":"Selegiline Hcl 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108023","B":"Uniphyl 400Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108347","B":"Ceftriaxone 1Gm Inj","C":"636","D":"J0696","F":"17.6208358711149","G":"**"},{"Policy Line":"74108348","B":"Allopurinol 300Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108350","B":"Alcohol Ethly Injection 5Ml","C":"250","F":"46.968"},{"Policy Line":"74108353","B":"Dextran 40/Nacl 0.9% 500Ml","C":"636","D":"J7100","F":"34.608"},{"Policy Line":"74108354","B":"Sterile Water 250Ml","C":"258","F":"17.69025","G":"**"},{"Policy Line":"74108356","B":"Torsemide 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108364","B":"Indapamide 1.25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108365","B":"Rifampin 600Mg Vial","C":"250","F":"224.992592493298","G":"**"},{"Policy Line":"74108368","B":"Ben Gay Ointment","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108369","B":"Probenecid 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108372","B":"Temovate .05% Oint 15 Gm","C":"637","F":"77.625","G":"**"},{"Policy Line":"74108376","B":"Propofol Inj 10Mg/Ml 100Ml","C":"636","D":"J2704","F":"17.6952150604617","G":"**"},{"Policy Line":"74108381","B":"Terbutaline 2.5Mg Tab","C":"637","F":"3.825"},{"Policy Line":"74108385","B":"Metformin Hcl 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108386","B":"Guaifenesin 600Mg+Dm 30Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108398","B":"Insta-Glucose Tube","C":"637","F":"2.25","G":"**"},{"Policy Line":"74108401","B":"Phenylephrine 1/4% 30Ml Drop","C":"637","F":"3.6"},{"Policy Line":"74108405","B":"Lidocaine 4% Topical 50Ml","C":"250","F":"17.7984","G":"**"},{"Policy Line":"74108415","B":"Magnesium Oxide 400Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108427","B":"Disopyramide Po4 Cap 100Mg","C":"637","F":"1.35"},{"Policy Line":"74108434","B":"Guaifenesin Dm Syrip 10Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108437","B":"Magnesium Cl Tab 64Mg Sr","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108440","B":"Paraplatin 450Mg Vial","C":"636","D":"J9045","F":"33.7236206896551","G":"**"},{"Policy Line":"74108441","B":"Ursodiol 300Mg Cap","C":"637","F":"6.975","G":"**"},{"Policy Line":"74108442","B":"Imipramine Hcl 50Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74108443","B":"Niacin 250Mg Sr Cap","C":"637","F":"1.35"},{"Policy Line":"74108445","B":"Medroxyprogerstone 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108446","B":"Nortriptyline 25Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108447","B":"Donnatal Tab","C":"637","F":"8.55","G":"**"},{"Policy Line":"74108452","B":"Dicloxacillin 250Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108464","B":"Daunorubicin Hcl 20Mg Vial","C":"636","D":"J9150","F":"150.174"},{"Policy Line":"74108468","B":"Chlorpheniramine 4Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108480","B":"Colchicine 0.6Mg Tab","C":"637","F":"6.06","G":"**"},{"Policy Line":"74108490","B":"Cortisporin Ophth Oint 3.5Gm","C":"250","F":"17.922","G":"**"},{"Policy Line":"74108491","B":"Cortone Acetate 25Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74108493","B":"Dantrolene 25Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108504","B":"Efudex 5% 25Gm Cream","C":"250","F":"289.533","G":"**"},{"Policy Line":"74108505","B":"Mometasone Fur Cr 0.1% 15Gm","C":"637","F":"3.825"},{"Policy Line":"74108511","B":"Fleet Bisacodyl Enema","C":"637","F":"3.825","G":"**"},{"Policy Line":"74108514","B":"Glycerin Supp Infant","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108523","B":"Calcijex 1Mcg/Ml Inj","C":"636","D":"J0636","F":"17.8546538461538","G":"**"},{"Policy Line":"74108526","B":"Leucovorin Calcium 350Mg Inj","C":"636","D":"J0640","F":"31.827","G":"**"},{"Policy Line":"74108529","B":"Non-Formulary Nebulizer Med","C":"250","F":"17.922"},{"Policy Line":"74108540","B":"Nacl 0.9% 1000Ml Bag","C":"636","D":"J7030","F":"17.5475870552473","G":"**"},{"Policy Line":"74108544","B":"Tobra-Dex Ophth Oint 3.5Gm","C":"250","F":"267.414169749216","G":"**"},{"Policy Line":"74108545","B":"Tobra-Dex Opth Susp5Ml","C":"250","F":"58.8794516129031","G":"**"},{"Policy Line":"74108546","B":"Clotrimazole 1% Vag Cr 45Gm","C":"637","F":"3.6","G":"**"},{"Policy Line":"74108549","B":"Myoflex Creme 60Gm","C":"637","F":"2.25","G":"**"},{"Policy Line":"74108551","B":"Dextran 40/D5W 5Ooml","C":"636","D":"J7100","F":"33.681"},{"Policy Line":"74108555","B":"Primaquine 26.3 Tab","C":"637","F":"1.35"},{"Policy Line":"74108557","B":"Senna-Psyllium 100Gm","C":"637","F":"1.35"},{"Policy Line":"74108559","B":"Diclofenac Potassium 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108562","B":"Perphenazine 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108565","B":"Glycerin Sterile Inj 5ml vial","C":"250","F":"17.922"},{"Policy Line":"74108567","B":"Octreotide Aceta 0.05Mg/Ml INJ","C":"636","D":"J2354","F":"17.5931559633028","G":"**"},{"Policy Line":"74108568","B":"Zarontin 250Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74108575","B":"EpoetinNon-ESRD4000U/Ml Vl Inj","C":"636","D":"J0885","F":"114.511625954198","G":"**"},{"Policy Line":"74108576","B":"Muro-128 5% Ophth Soln 15Ml","C":"250","F":"17.304","G":"**"},{"Policy Line":"74108585","B":"Bismuth Subsalicylate 262Mg Ta","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108594","B":"Fluid Non Pyxis","C":"258","F":"0"},{"Policy Line":"74108597","B":"Carboprost Trometh 250Mcg/Ml 1","C":"250","F":"409.99255102041","G":"**"},{"Policy Line":"74108602","B":"Enalapril 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108609","B":"Toradol 60Mg Syringe","C":"250","F":"17.922"},{"Policy Line":"74108610","B":"KetorolacTromethaminInj30Mg/Ml","C":"636","D":"J1885","F":"17.5423090294924","G":"**"},{"Policy Line":"74108611","B":"Colestid Pack","C":"637","F":"5.625","G":"**"},{"Policy Line":"74108613","B":"Triamcinolone Acet 40Mg/1Ml In","C":"636","D":"J3301","F":"17.5807823933975","G":"**"},{"Policy Line":"74108616","B":"Dapsone 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108617","B":"Fluvastatin 20Mg Cap","C":"637","F":"3.6"},{"Policy Line":"74108618","B":"Monistat Dual Pack","C":"637","F":"11.25"},{"Policy Line":"74108632","B":"Sodium Bicarb 50Cc Syringe","C":"250","F":"17.7291496381032","G":"**"},{"Policy Line":"74108636","B":"Adenosine 6Mg/2Ml Syringe Inj","C":"636","D":"J0153","F":"17.7157154354354","G":"**"},{"Policy Line":"74108641","B":"Thyroid 30Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108644","B":"Zovirax Susp 60Ml Bottle","C":"637","F":"11.025"},{"Policy Line":"74108646","B":"Ziac 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108647","B":"Trihexyphenidyl 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108652","B":"Lidocaine 1% 5Ml Sdv","C":"636","D":"J2001","F":"17.6763932059283","G":"**"},{"Policy Line":"74108655","B":"Methacholine Challenge","C":"250","F":"67.362"},{"Policy Line":"74108658","B":"Ocuvite Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108664","B":"Morphine PF 200Mg/20Ml","C":"636","D":"J2274","F":"225.364","G":"**"},{"Policy Line":"74108665","B":"Kerlone 10Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74108666","B":"Estradiol Vag Cr 0.01% 42.5Gm","C":"250","F":"100.151978613861","G":"**"},{"Policy Line":"74108668","B":"Cefuroxime 125Mg/5Ml 50Ml","C":"637","F":"1.35"},{"Policy Line":"74108673","B":"Clomipramine Hcl 25Mg Cap","C":"637","F":"6.075","G":"**"},{"Policy Line":"74108675","B":"Temovate .05% 15Gm Cream","C":"637","F":"31.5","G":"**"},{"Policy Line":"74108679","B":"Capsaicin 0.075% Cr 30Gm","C":"637","F":"9.9","G":"**"},{"Policy Line":"74108683","B":"Nacl 0.65% Nas Drop 50Ml","C":"637","F":"1.8"},{"Policy Line":"74108684","B":"Lithium Carbonate 300Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108686","B":"Temovate .05% 50Ml Ssc.Ap","C":"250","F":"17.922","G":"**"},{"Policy Line":"74108687","B":"Belladon 16.2Mg/Opium 30Mg Sup","C":"637","F":"16.632","G":"**"},{"Policy Line":"74108692","B":"Ferrous Sul 44Mg/5Ml 60Cc","C":"637","F":"1.35"},{"Policy Line":"74108695","B":"Levothyroxine Sod 0.2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108701","B":"Diazepam 5Mg Vial","C":"636","D":"J3360","F":"17.922"},{"Policy Line":"74108702","B":"Cyclopentolate 1% Op Sol 2Ml","C":"250","F":"16.9229","G":"**"},{"Policy Line":"74108707","B":"Polytrim Opth Soln 10Ml","C":"637","F":"9.006","G":"**"},{"Policy Line":"74108709","B":"Nonform Cream/Oint","C":"637","F":"5.625"},{"Policy Line":"74108711","B":"Non-Form Drug Tab/Cap","C":"637","F":"3.375","G":"**"},{"Policy Line":"74108712","B":"Nonform Charge","C":"637","F":"0"},{"Policy Line":"74108713","B":"OTC Nonform Misc Charge","C":"250","F":"17.922"},{"Policy Line":"74108718","B":"Nitroglycerin 25Mg/D5W 250Ml","C":"250","F":"17.6950316368638","G":"**"},{"Policy Line":"74108722","B":"Dimenhydrinate 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108723","B":"Dextrose 70% Hyperal 2000Mlchg","C":"258","F":"17.922"},{"Policy Line":"74108725","B":"MVI-Pediatrics 1Ml","C":"250","F":"17.922"},{"Policy Line":"74108727","B":"Lisinopril 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108734","B":"Ketoconazole 2% Shampoo 120Ml","C":"637","F":"8.55","G":"**"},{"Policy Line":"74108736","B":"Warfarin Sodium 1Mg Tab","C":"637","F":"1.344","G":"**"},{"Policy Line":"74108740","B":"Mometasone Fur 0.1% Lot 30Ml","C":"637","F":"14.625"},{"Policy Line":"74108741","B":"Emcyt 140Mg Capsule","C":"259","F":"17.922"},{"Policy Line":"74108745","B":"Epinephrine 1:10000 Syr","C":"250","F":"17.6471337209302","G":"**"},{"Policy Line":"74108746","B":"Nitroglycerin 0.4Mg Pp25","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108749","B":"Divalproex 125Mg/1 Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108751","B":"Doxycycline 5Mg/Ml Liq 60Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108753","B":"Ocufen Opth Sol 2.5Ml","C":"637","F":"0"},{"Policy Line":"74108756","B":"Doryx 100Mg Capsule","C":"637","F":"9.45"},{"Policy Line":"74108770","B":"Chlorpromazine 10Mg Tab","C":"637","F":"4.05","G":"**"},{"Policy Line":"74108772","B":"Vitamin A 10:000U Softgel","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108773","B":"Bupropion Hcl 75Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108774","B":"Zinc Gluconate 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108775","B":"Labetalol 100Mg/20Ml Inj","C":"250","F":"17.559724137931","G":"**"},{"Policy Line":"74108777","B":"Demeclocycline 300Mg Tab","C":"637","F":"11.25","G":"**"},{"Policy Line":"74108779","B":"Olsalazine 250Mg Cap","C":"637","F":"11.25"},{"Policy Line":"74108784","B":"Proparacaine 0.5%Opth Soln15Ml","C":"250","F":"17.5197635174746","G":"**"},{"Policy Line":"74108788","B":"Measles-Mumps-Rubella Ii","C":"636","D":"90707","F":"81.0404000000001","G":"**"},{"Policy Line":"74108795","B":"Isosorbide Mononitrate 20Mg Ta","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108799","B":"Ca Oyster Shell 500Mg+D 200Iu","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108806","B":"Azithromycin 250Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108807","B":"Tussionex 1Ml Chg","C":"250","F":"17.922"},{"Policy Line":"74108808","B":"Nicaredipine Sr 30Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74108810","B":"Empty Container 3000 Ml","C":"250","F":"17.922"},{"Policy Line":"74108813","B":"Mesalamine 400Mg Tab","C":"637","F":"2.925","G":"**"},{"Policy Line":"74108814","B":"Glyburide 1.5Mg Pres Tab","C":"637","F":"1.35"},{"Policy Line":"74108825","B":"Prostin Vr Pediatri 500Mcg Inj","C":"250","F":"137.814"},{"Policy Line":"74108828","B":"Nacl 0.9% 50Ml Adv","C":"258","F":"17.922","G":"**"},{"Policy Line":"74108829","B":"Diltiazem Cd 120Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108831","B":"Amlodipine 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108832","B":"Ampicillin/Sulbactam 1.5 Adv","C":"636","D":"J0295","F":"17.738410041841","G":"**"},{"Policy Line":"74108837","B":"Cyanide Antidote Package","C":"250","F":"1045.656","G":"**"},{"Policy Line":"74108838","B":"Iron Dextran 50Mg/Ml 2Ml Inj","C":"636","D":"J1750","F":"31.8541805555556","G":"**"},{"Policy Line":"74108839","B":"Bupivacaine 0.5% Pf 30Ml Vl","C":"250","F":"17.6441971153846","G":"**"},{"Policy Line":"74108847","B":"Sterile Water 50Ml","C":"250","F":"17.7967297297297","G":"**"},{"Policy Line":"74108849","B":"Nacl 50Ml Vial","C":"258","F":"17.6801407407407","G":"**"},{"Policy Line":"74108850","B":"C0-Trimoxazole 10Ml Inj","C":"250","F":"17.7481703637977","G":"**"},{"Policy Line":"74108852","B":"Aspirin 81Mg Tab Enteric","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108853","B":"Itraconazole 100Mg Cap","C":"637","F":"22.05"},{"Policy Line":"74108854","B":"Cytovene 500Mg Vial","C":"636","D":"J1570","F":"144.612","G":"**"},{"Policy Line":"74108855","B":"Fludarabine 50Mg Inj","C":"636","D":"J9185","F":"77.559","G":"**"},{"Policy Line":"74108858","B":"Paclitaxel 30Mg/5Ml Vial","C":"636","D":"J9267","F":"17.7701186440678","G":"**"},{"Policy Line":"74108859","B":"Nitroglycerin 2% Oint 30Gm","C":"637","F":"26.55","G":"**"},{"Policy Line":"74108861","B":"Pamidronate Disodium 30Mg Inj","C":"636","D":"J2430","F":"15.7442857142857","G":"**"},{"Policy Line":"74108862","B":"Atropine 1Mg/Ml 1Ml Vial","C":"636","D":"J0461","F":"17.613","G":"**"},{"Policy Line":"74108863","B":"Testosterone Cyp Inj 200Mg/Ml","C":"636","D":"J1071","F":"34.0541484","G":"**"},{"Policy Line":"74108869","B":"Diphenoxylate/Atropine 5Ml Liq","C":"637","F":"1.35"},{"Policy Line":"74108871","B":"Sotalol 80Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108872","B":"Vancomycin 500Mg Adv Inj","C":"636","D":"J3370","F":"17.922"},{"Policy Line":"74108873","B":"Midazolam 5Mg/Ml 10Ml Inj","C":"636","D":"J2250","F":"17.922","G":"**"},{"Policy Line":"74108876","B":"Cyanocobalamin 500Mcg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108881","B":"Povidin-Iodin 5% 50Ml Opth Sol","C":"250","F":"17.4273767680608","G":"**"},{"Policy Line":"74108885","B":"Ondansetron Hcl 4Mg Tab","C":"636","D":"Q0162","F":"17.4760705882353","G":"**"},{"Policy Line":"74108887","B":"Morphine Oral Sol 10Mg/5Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108895","B":"Diphenhydramine 1% Cr 30 Gm","C":"637","F":"1.8","G":"**"},{"Policy Line":"74108896","B":"Timolol Opth Soln. 0.25% 2.5Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74108897","B":"Refresh Pm Eye Lub 0.4Ml Appli","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109000","B":"Metronidazole Vag Gel0.75%70Gm","C":"637","F":"110.025","G":"**"},{"Policy Line":"74109001","B":"Mesalamine 1000Mg Supp","C":"637","F":"27.675","G":"**"},{"Policy Line":"74109002","B":"Nacl 0.9% 250Ml","C":"636","D":"J7050","F":"0"},{"Policy Line":"74109004","B":"Papaverine 30Mg/Ml 10Ml Inj","C":"636","D":"J2440","F":"17.922"},{"Policy Line":"74109008","B":"Propofol 10Mg/Ml 50Ml Vl","C":"636","D":"J2704","F":"17.5482025677603","G":"**"},{"Policy Line":"74109010","B":"Dextrose 5% 50Ml Mb-Plus","C":"258","F":"17.922","G":"**"},{"Policy Line":"74109011","B":"Nacl 0.9% 50Ml","C":"258","F":"0"},{"Policy Line":"74109012","B":"Sumatriptan 6Mg/0.5Ml Inj","C":"637","D":"J3030","F":"12.462","G":"**"},{"Policy Line":"74109014","B":"Phenobarbital 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109015","B":"Fluoxetine 10Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109018","B":"Hepatitis B Vaccine 10Mcg/0.5M","C":"636","D":"90744","F":"28.1462427536232","G":"**"},{"Policy Line":"74109020","B":"Sulfacetamide Na 10% Opth 2Ml","C":"637","F":"5.4"},{"Policy Line":"74109023","B":"Atenolol 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109024","B":"Filgrastim-Neupogen 480Mcg Inj","C":"636","D":"J1442","F":"519.197559","G":"**"},{"Policy Line":"74109025","B":"Cledcin 2% Vag Crm 40Gm","C":"637","F":"74.7","G":"**"},{"Policy Line":"74109026","B":"Alteplase: Recom 100Mg Inj","C":"636","D":"J2997","F":"8811.9693","G":"**"},{"Policy Line":"74109028","B":"Finasteride 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109029","B":"Dextrose 100Ml Minibag Pl","C":"258","F":"0"},{"Policy Line":"74109030","B":"Nacl 0.9% Minibag Plus 100 Ml","C":"258","F":"0"},{"Policy Line":"74109033","B":"Cardene Sr 45Mg Capsule","C":"637","F":"2.25"},{"Policy Line":"74109035","B":"Macrobid 100Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109040","B":"Act Charcoal/Water 25Gm 120Ml","C":"250","F":"17.7887058823529","G":"**"},{"Policy Line":"74109042","B":"Etomidate 2Mg/Ml 10Ml Inj","C":"250","F":"17.6347444444444","G":"**"},{"Policy Line":"74109043","B":"Hycrocortisone 1% 1.5Gm Pkt","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109045","B":"Atropine 1Mg Syringe","C":"636","D":"J0461","F":"17.6530555555556","G":"**"},{"Policy Line":"74109047","B":"Enoxaparin 30Mg/0.3Ml Syr","C":"636","D":"J1650","F":"17.6964267606976","G":"**"},{"Policy Line":"74109048","B":"Flumazenil 0.1Mg/Ml Inj 5Ml","C":"250","F":"17.4753122580645","G":"**"},{"Policy Line":"74109049","B":"Felbatol 400Mg","C":"637","F":"3.825"},{"Policy Line":"74109056","B":"Diprosone 0.05% 15 Gm Cr","C":"637","F":"38.025"},{"Policy Line":"74109057","B":"Zolpidem 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109058","B":"Diprolene(Betamet Dip).05% Oin","C":"637","F":"44.325"},{"Policy Line":"74109062","B":"Rifabutin 150Mg Cap","C":"637","F":"26.1"},{"Policy Line":"74109065","B":"Ultravate Oint 50 Gm","C":"637","F":"99.675"},{"Policy Line":"74109570","B":"Sterile Water 1000Ml","C":"258","F":"17.7513142857143","G":"**"},{"Policy Line":"74109572","B":"Viscoat Ophth O.5Ml","C":"250","F":"232.368","G":"**"},{"Policy Line":"74109580","B":"Dextrose 5% 100 Ml Add","C":"258","F":"17.304","G":"**"},{"Policy Line":"74109581","B":"Chloral Hydrate 500 Mg/5Ml Cup","C":"637","F":"1.35"},{"Policy Line":"74109586","B":"Read Skin Test Misc","C":"637","F":"0"},{"Policy Line":"74109597","B":"Ketorolac Trometh 0.5% Op Sol","C":"250","F":"4.3006002","G":"**"},{"Policy Line":"74109685","B":"Doxazosin Mesylate 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109686","B":"Niferex-150 Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109687","B":"Dipyridamole 5 Mg/Ml 10Ml Inj","C":"636","D":"J1245","F":"17.922"},{"Policy Line":"74109690","B":"Carbocaine 1.5% 30Ml Vial","C":"636","D":"J0670","F":"17.922"},{"Policy Line":"74109692","B":"Cyclopentolate 2% Op Sol 2Ml","C":"250","F":"17.613","G":"**"},{"Policy Line":"74109693","B":"Erythromycin 5Mg/Gm Oint 3.5Gm","C":"250","F":"17.69542575","G":"**"},{"Policy Line":"74109698","B":"Edrophonium Cl 10Mg/Ml 1Ml","C":"250","F":"17.922"},{"Policy Line":"74109699","B":"Edrophonium Cl 10Mg/Ml 15Ml","C":"250","F":"101.97"},{"Policy Line":"74109702","B":"Lidocaine 1.5% With Epi 5Mlsdv","C":"250","F":"17.7793846153846","G":"**"},{"Policy Line":"74109714","B":"Sterile Water Irrig 1500Ml","C":"250","F":"17.922"},{"Policy Line":"74109715","B":"Normosol-R 1L","C":"258","F":"17.922"},{"Policy Line":"74109716","B":"Cardioplegic Soln 1000Ml","C":"258","F":"66.4215652173912","G":"**"},{"Policy Line":"74109718","B":"Cefotaxime 500Mg Inj","C":"250","F":"17.922","G":"**"},{"Policy Line":"74109719","B":"Filgrastim-Neupogen 300Mcg Inj","C":"636","D":"J1442","F":"363.693","G":"**"},{"Policy Line":"74109734","B":"Novulin-R Insulin Pen 3Ml Inj","C":"637","D":"J1815","F":"44.55"},{"Policy Line":"74109737","B":"Estazolam 1Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74109738","B":"Lidocaine 2% Jelly 10Ml Urojet","C":"250","F":"17.2369901935484","G":"**"},{"Policy Line":"74109739","B":"Lidocaine 2% Jelly 20Ml Urojet","C":"250","F":"17.922","G":"**"},{"Policy Line":"74109750","B":"Opium Tincture 0.5Ml Chg","C":"637","F":"1.8"},{"Policy Line":"74109752","B":"Ciprofloxacin 200Mg IV","C":"636","D":"J0744","F":"3.09","G":"**"},{"Policy Line":"74109759","B":"Betaxolol 0.25% Op Susp 10Ml","C":"637","F":"255.375"},{"Policy Line":"74109768","B":"KCL10MEQ In Sterile Water100Ml","C":"636","D":"J3480","F":"17.7029733715477","G":"**"},{"Policy Line":"74109770","B":"KCL20MEQ In Sterile Water100Ml","C":"636","D":"J3480","F":"17.7074046787709","G":"**"},{"Policy Line":"74109771","B":"KCL40MEQ In Sterile Water100Ml","C":"636","D":"J3480","F":"17.7264745762712","G":"**"},{"Policy Line":"74109778","B":"Ciprofloxacin 400Mg/200Ml Iv","C":"636","D":"J0744","F":"17.674664051329","G":"**"},{"Policy Line":"74109788","B":"Nitroglycerin 0.2Mg Patch","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109789","B":"Nitroblycerin 0.4Mg Patch","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109790","B":"Nitroclycerin 0.1Gm Patch","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109797","B":"Ca Acetate 667Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109801","B":"Isradipine 2.5Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109802","B":"Lodine 300Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74109804","B":"Fentanyl Transdermal 25Mcg/Hr","C":"637","F":"5.625","G":"**"},{"Policy Line":"74109805","B":"Epoetin NonESRD 10000U/Ml Vial","C":"636","D":"J0885","F":"287.483062166963","G":"**"},{"Policy Line":"74109808","B":"Chlorpromazine 100Mg Tab","C":"637","F":"8.775"},{"Policy Line":"74109809","B":"Bupivacaine0.1%Epidur Cass100M","C":"250","F":"102.279"},{"Policy Line":"74109810","B":"Vitamin A + D Oint 5Gm","C":"637","F":"1.35"},{"Policy Line":"74109816","B":"Simvastatin 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109818","B":"Phenylephrine 2.5% Ophth Sol3M","C":"250","F":"17.4666315789474","G":"**"},{"Policy Line":"74109820","B":"Tropicamide 1% Ophth Sol 3Ml","C":"250","F":"16.9216531578947","G":"**"},{"Policy Line":"74109822","B":"Co-Trimoxazole Susp 120Ml","C":"637","F":"6.75"},{"Policy Line":"74109823","B":"Benazepril Hcl 5Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109825","B":"Fosinopril 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74109827","B":"Ampicillin 2Gm Adv","C":"636","D":"J0290","F":"17.614225785124","G":"**"},{"Policy Line":"74109828","B":"Fentanyl Transdermal 50Mcg/Hr","C":"637","F":"11.421","G":"**"},{"Policy Line":"74109829","B":"Fentanyl Transdermal 75Mcg/Hr","C":"637","F":"18","G":"**"},{"Policy Line":"74109832","B":"Fentanyl Transdermal 100Mcg/Hr","C":"637","F":"24.75","G":"**"},{"Policy Line":"74109837","B":"Nacl 0.9%%/Kcl 40Meq 1000Ml","C":"636","D":"J3480","F":"17.7387624309392","G":"**"},{"Policy Line":"74109838","B":"Nacl 0.9%%/Kcl 20Meq 1000Ml","C":"636","D":"J3480","F":"17.6270965497553","G":"**"},{"Policy Line":"74109839","B":"D5W/Nacl 0.9%/Kcl 20Meq 1000M","C":"258","F":"17.6667391304348","G":"**"},{"Policy Line":"74109840","B":"D5W/Rl/Kcl 20Meq 1000Ml","C":"258","F":"17.63154","G":"**"},{"Policy Line":"74109841","B":"Muro-128 2% Opth Sol 15Ml","C":"250","F":"17.304","G":"**"},{"Policy Line":"74109856","B":"Vasocidin Ophth Sol 5Ml","C":"637","F":"9.675"},{"Policy Line":"74109870","B":"Hydrocodone Syrup 1Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109873","B":"Octreotide Aceta 0.1Mg/Ml Inj","C":"636","D":"J2354","F":"17.7118243243243","G":"**"},{"Policy Line":"74109880","B":"Niferex-150 Forte Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109881","B":"Acyclovir 800Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109888","B":"Methadone 10Mg/Ml Liquid 1Ml","C":"637","F":"1.35"},{"Policy Line":"74109891","B":"Sodium Bicarbonate 4% 5 Ml Via","C":"250","F":"17.6292289915967","G":"**"},{"Policy Line":"74109892","B":"Albumin Human 25% 50Ml","C":"636","D":"P9047","F":"147.340334841629","G":"**"},{"Policy Line":"74109898","B":"D5W/Nacl 0.45%/Kcl 10Meq 1000","C":"258","F":"17.6727513812155","G":"**"},{"Policy Line":"74109899","B":"Clarithromycin 500Mg Tab","C":"637","F":"1.575","G":"**"},{"Policy Line":"74109904","B":"GI Cocktail Oral Liq 30Ml Ud","C":"637","F":"5.625","G":"**"},{"Policy Line":"74109910","B":"Pravastatin Sodium 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109911","B":"Diltiazem Hcl 5Mg/Ml Inj 10Ml","C":"250","F":"17.3699241035857","G":"**"},{"Policy Line":"74109912","B":"Nicotine Transdermal 21Mg/Day","C":"637","F":"1.8","G":"**"},{"Policy Line":"74109913","B":"Nicotine Transdermal 14Mg/Day","C":"637","F":"1.8","G":"**"},{"Policy Line":"74109914","B":"Nicotine Transdermal 7Mg/Day","C":"637","F":"5.625","G":"**"},{"Policy Line":"74109915","B":"D5W/Nacl 0.9%/Kcl 40Meq 1000M","C":"258","F":"17.6972727272727","G":"**"},{"Policy Line":"74109916","B":"Atracurium Besyl Charge 50Mg","C":"250","F":"17.922"},{"Policy Line":"74109919","B":"Hydromorphone Hp 10Mg/Ml Inj","C":"636","D":"J1170","F":"17.922","G":"**"},{"Policy Line":"74109920","B":"Morphine Sr 15Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109928","B":"Simvastatin 5Mg/Tab","C":"637","F":"1.35"},{"Policy Line":"74109929","B":"Diltiazem Cd 180Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109931","B":"Felodipine 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109933","B":"Ticopidine Hcl 250Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74109934","B":"Diclofenac Ophth Soln 0.1% 2.5","C":"637","F":"9.675","G":"**"},{"Policy Line":"74109937","B":"Metoprolol Succinate 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109940","B":"Sertraline Hcl 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109943","B":"Quinapril 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109948","B":"Nabumetone 500Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74109949","B":"Clarithromycin 250Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74109952","B":"Oxacillin 2Gm Adv","C":"250","F":"17.922"},{"Policy Line":"74109954","B":"Ramipril 2.5Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109959","B":"Ethanolamine 5% 2Ml Inj","C":"636","D":"J1430","F":"514.8558","G":"**"},{"Policy Line":"74109960","B":"Glyburide 3Mg Pres Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109966","B":"Stadol Nasal Spray","C":"637","F":"32.175"},{"Policy Line":"74109968","B":"Omnipaque 300 100 Ml","C":"255","D":"Q9967","F":"113.403"},{"Policy Line":"74109970","B":"Beta-Carotene 15Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109972","B":"Diliazem Cd 240Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109973","B":"Doxazosin Mesylate 4Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109976","B":"Depakote 125Mg Sprinkle","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109977","B":"Glyburide 1.25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109982","B":"Etodolac 200Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74109988","B":"Purinethol 50Mg Tab","C":"637","F":"2.925","G":"**"},{"Policy Line":"74109991","B":"Sandimumune 25Mg Gel Cap","C":"636","D":"J7515","F":"17.8050810810811","G":"**"},{"Policy Line":"74109992","B":"Carbidopa 50Mg+Levo 200Mg Cr","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109993","B":"Levothyroxine Sod 88Mcg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74109995","B":"Ampicillin/Sulbactam 3Gm Inj","C":"636","D":"J0295","F":"17.726475931677","G":"**"},{"Policy Line":"74109997","B":"Sandimmune 100 Mg Capsule","C":"636","D":"J7502","F":"17.922","G":"**"},{"Policy Line":"74111124","B":"Ampicillin 1Gm Vial","C":"636","D":"J0290","F":"17.7043991945289","G":"**"},{"Policy Line":"74111306","B":"Lidocaine 1% 0.25Ml Syr","C":"636","D":"J2001","F":"17.922"},{"Policy Line":"74111318","B":"Zemuron (Rocuronium)100Mg/10Ml","C":"250","F":"17.922"},{"Policy Line":"74111327","B":"Epinephrine Pf 1Mg/Ml Inj","C":"250","F":"17.922"},{"Policy Line":"74111330","B":"Vancomycin 5 Mg/0.1Ml Op Inj","C":"636","D":"J3370","F":"17.922"},{"Policy Line":"74111335","B":"Miostat 1.5Ml Opth Soln","C":"250","F":"17.654017699115","G":"**"},{"Policy Line":"74111343","B":"Sterile Talc 2 Gm","C":"250","F":"17.922"},{"Policy Line":"74113014","B":"Heparin 1000 U/Ml 1Ml Inj","C":"636","D":"J1644","F":"17.6873888888889","G":"**"},{"Policy Line":"74113018","B":"Erythromycin Opth Ud Oint","C":"250","F":"17.7256916208791","G":"**"},{"Policy Line":"74114015","B":"Nacl 0.9% 50Ml Miniplus","C":"258","F":"0"},{"Policy Line":"74118010","B":"K Glucon 20Meq/15Ml 60Ml","C":"637","F":"0"},{"Policy Line":"74118020","B":"Vicoprofen Tab","C":"637","F":"1.35"},{"Policy Line":"74118027","B":"Warfarin Sodium 7.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118028","B":"Warfarin Sodium 6Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118032","B":"Vancomycin 1Gm Inj","C":"636","D":"J3370","F":"17.6993271977716","G":"**"},{"Policy Line":"74118034","B":"Albumin Human 5% 500Ml","C":"636","D":"P9045","F":"271.170675","G":"**"},{"Policy Line":"74118035","B":"Albuterol 2Mg/5Ml Syrup 5Ml","C":"637","F":"1.35"},{"Policy Line":"74118036","B":"Alclometasone Cr 0.05% 15Gm","C":"637","F":"20.925"},{"Policy Line":"74118038","B":"Venlafaxine Hcl 75Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118041","B":"SOD. Bicarb 956Mg Effer","C":"637","F":"1.35"},{"Policy Line":"74118046","B":"Stavudine 20Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74118053","B":"Stavudine 15Mg Cap","C":"637","F":"0"},{"Policy Line":"74118055","B":"Venlafaxine Hcl 50Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74118056","B":"Timolol Xe 0.25% Ophth Sol","C":"637","F":"41.175"},{"Policy Line":"74118076","B":"Tobramycin 20Mg Inj","C":"636","D":"J3260","F":"17.922"},{"Policy Line":"74118077","B":"Amlodopine 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118078","B":"Amlodipine 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118086","B":"Trinsicon Cap","C":"637","F":"1.35"},{"Policy Line":"74118091","B":"Torsemide 100Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74118100","B":"Warfarin Sodium 4Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118104","B":"Warfarin Sodium 2.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118106","B":"Vitamin A + D Oint 60Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118109","B":"Zidovudine 50Mg/5Ml Syrug 90Ml","C":"637","F":"11.925"},{"Policy Line":"74118110","B":"Warfarin Sodium 3Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118111","B":"Acetylcystein 20% 10Ml","C":"250","F":"17.922"},{"Policy Line":"74118121","B":"Acetic Acid 2% Otic Sol 60Ml","C":"637","F":"51.75"},{"Policy Line":"74118122","B":"Vitamin Multi Therapeu 5Ml Liq","C":"637","F":"1.35"},{"Policy Line":"74118125","B":"Warfarin Sodium 10Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74118126","B":"Sterile Water 500Ml","C":"258","F":"17.922"},{"Policy Line":"74118127","B":"Sterile Water 100Ml","C":"258","F":"17.8876666666667","G":"**"},{"Policy Line":"74118131","B":"Sulfasalazine 500Mg Entab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118132","B":"Sulfacetamide Na 10% Opth 15Ml","C":"637","F":"31.95"},{"Policy Line":"74118134","B":"Sucralfate Susp 1Gm/10Ml Ud","C":"637","F":"7.65","G":"**"},{"Policy Line":"74118143","B":"Aquaphor 454 Gm","C":"637","F":"13.725","G":"**"},{"Policy Line":"74118146","B":"Thrombin 5:000 Units Top","C":"250","F":"91.0109324758842","G":"**"},{"Policy Line":"74118152","B":"Succinylcholine 20Mg/Ml 5Ml Ch","C":"250","F":"17.922","G":"**"},{"Policy Line":"74118157","B":"Taxotere (Docetraxl) 20Mg Inj","C":"636","D":"J9171","F":"70.452"},{"Policy Line":"74118158","B":"Thrombin Top Kit 20:000 Units","C":"250","F":"374.545293103449","G":"**"},{"Policy Line":"74118174","B":"Synemol Cream 30 Grams","C":"637","F":"2.7"},{"Policy Line":"74118175","B":"Talc For Pleurodesis 2.2Gm","C":"250","F":"17.922"},{"Policy Line":"74118176","B":"Talc For Pleurodesis 5 Gm","C":"250","F":"17.922"},{"Policy Line":"74118184","B":"Neomycin Oral 125Mg/5Ml 60Ml","C":"637","F":"4.5"},{"Policy Line":"74118185","B":"Theophylline 400Mg/D5W 500Ml","C":"636","D":"J2810","F":"17.922"},{"Policy Line":"74118187","B":"Sterile Water 100Ml","C":"258","F":"16.995"},{"Policy Line":"74118198","B":"Bacitracin Oint Pkt 0.9Gm","C":"250","F":"1.8488808719346","G":"**"},{"Policy Line":"74118207","B":"Atrovastatin 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118210","B":"SOD .Bicarb 1916Mg/Asa 325Mg T","C":"637","F":"0"},{"Policy Line":"74118212","B":"Sargramostim 250 Mcg Inj","C":"636","D":"J2820","F":"315.18"},{"Policy Line":"74118213","B":"Benazepril Hcl 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118214","B":"Simethicone 125Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118215","B":"Sevoflurane (Ultane) 30Ml Chg","C":"250","F":"29.2620729410961","G":"**"},{"Policy Line":"74118216","B":"Nisoldipine 10Mg Tab","C":"637","F":"12.6"},{"Policy Line":"74118229","B":"Testosterone Patch 2.5Mg/Day","C":"637","F":"3.375"},{"Policy Line":"74118230","B":"Tetanus-Diphtheria Ped Tox 0.5","C":"636","D":"90702","F":"61.491","G":"**"},{"Policy Line":"74118234","B":"Sertraline Hcl 100Mg Tablet","C":"637","F":"1.347","G":"**"},{"Policy Line":"74118242","B":"Astramorph Pf 5Mg/10Ml Inj","C":"636","D":"J2274","F":"17.7054539249147","G":"**"},{"Policy Line":"74118243","B":"Tetracaine Hcl 1% Inj 2Ml","C":"250","F":"17.922"},{"Policy Line":"74118245","B":"Trimethoprim 100Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118248","B":"Promethazine + Codine 5Ml","C":"637","F":"1.35"},{"Policy Line":"74118250","B":"Preparation H Supp","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118260","B":"Prednisolone 15Mg/5Ml Syrup","C":"636","D":"J7510","F":"17.6928997361478","G":"**"},{"Policy Line":"74118262","B":"Ranitidine Hcl 150Mg/10Ml Ud","C":"637","F":"6.075","G":"**"},{"Policy Line":"74118264","B":"Questran Light Packet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118266","B":"Ranitidine 50Mg/2Ml Inj","C":"636","D":"J2780","F":"17.922"},{"Policy Line":"74118269","B":"Ranitidine Syrup 150Mg/10Ml 60","C":"637","F":"1.575"},{"Policy Line":"74118273","B":"Prednisolone Acet 0.125% 5Ml","C":"250","F":"159.515307692308","G":"**"},{"Policy Line":"74118277","B":"Pyrimethamine 25Mg Tab","C":"637","F":"15.75"},{"Policy Line":"74118280","B":"Carbamazepine Xr 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118287","B":"Orajel 5Gm","C":"637","F":"6.975"},{"Policy Line":"74118295","B":"Opium Tincture 1Ml Unit Dose","C":"637","F":"3.375","G":"**"},{"Policy Line":"74118301","B":"Omnipaque 300 50Ml Syringe","C":"255","D":"Q9967","F":"105.06"},{"Policy Line":"74118307","B":"Podofiloz Topical Soln. 0.5% 3","C":"637","F":"77.85"},{"Policy Line":"74118326","B":"Rimantadine Hcl 100Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74118331","B":"Rifamate Cap","C":"637","F":"4.725"},{"Policy Line":"74118338","B":"Pseudoephedrine 12-Hour Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118344","B":"Quinine Sulfate 325Mg Tab","C":"637","F":"5.85","G":"**"},{"Policy Line":"74118347","B":"Ramipril 5Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118348","B":"Ranitidine 150Mg Gelcap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118352","B":"Prednisolone 1% Opth Susp 15Ml","C":"637","F":"36"},{"Policy Line":"74118356","B":"Ringers Solution 1000Ml","C":"258","F":"17.6998991633642","G":"**"},{"Policy Line":"74118369","B":"Pancrease Mt16 Cap","C":"637","F":"4.05","G":"**"},{"Policy Line":"74118373","B":"Parnate Tab 10Mg","C":"637","F":"2.475","G":"**"},{"Policy Line":"74118374","B":"Pancrease Mt10 Cap","C":"637","F":"5.175"},{"Policy Line":"74118383","B":"Pentamidine 300Mg Inhalation","C":"250","F":"210.532","G":"**"},{"Policy Line":"74118384","B":"Penicillin G Sodium 5M Units","C":"250","F":"56.856","G":"**"},{"Policy Line":"74118389","B":"Oxytocin 20 Units/Rl 1000 Ml","C":"250","F":"17.7343145311916","G":"**"},{"Policy Line":"74118396","B":"Alpha 1 Proteinase Inhib 10Mg","C":"636","D":"J0256","F":"5.78272537610421","G":"**"},{"Policy Line":"74118399","B":"Triamcinolone Oint 0.1% 80Gm","C":"637","F":"9.225","G":"**"},{"Policy Line":"74118404","B":"Triple Dye Ppk9","C":"637","F":"1.35"},{"Policy Line":"74118415","B":"Rocuronium 10Mg/Ml 5Ml Inj","C":"250","F":"17.6173468236289","G":"**"},{"Policy Line":"74118417","B":"Triamcinolone Acet 0.1% Oint45","C":"637","F":"30.15","G":"**"},{"Policy Line":"74118419","B":"Triamcinolone Acet 10Mg/Ml 5Ml","C":"636","D":"J3301","F":"17.6748","G":"**"},{"Policy Line":"74118425","B":"Ceftriaxone 2Gm Inj","C":"636","D":"J0696","F":"17.5687058349191","G":"**"},{"Policy Line":"74118428","B":"Nystatin Susp 5Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118430","B":"Ceftriaxone 35Mg/Ml Inj","C":"636","D":"J0696","F":"17.922"},{"Policy Line":"74118434","B":"Ceftriaxone 500Mg Inj","C":"636","D":"J0696","F":"19.8874980375783","G":"**"},{"Policy Line":"74118442","B":"Nystatin Vag Tab 15","C":"637","F":"7.2"},{"Policy Line":"74118448","B":"Nizatidne 150Mg Cap","C":"637","F":"4.275"},{"Policy Line":"74118450","B":"Nitroclycerin 0.6Mg Pp25","C":"637","F":"4.05"},{"Policy Line":"74118455","B":"Bupivacaine 0.25%W Epi 30Ml","C":"250","F":"17.6645816838675","G":"**"},{"Policy Line":"74118456","B":"Phenylephrine 1/8% 30Ml Drop","C":"637","F":"3.15","G":"**"},{"Policy Line":"74118460","B":"Pilocarpine 2% Op Sol 15Ml","C":"250","F":"101.867","G":"**"},{"Policy Line":"74118469","B":"Bumetanide 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118470","B":"Phenobarbital 65Mg Injection","C":"636","D":"J2560","F":"17.8012413793104","G":"**"},{"Policy Line":"74118471","B":"Oxaprozin 600Mg Cap","C":"637","F":"2.7"},{"Policy Line":"74118474","B":"Butabarbital Elix 60Mg/10Ml","C":"637","F":"10.8"},{"Policy Line":"74118477","B":"Phenylephrine 1/2% 15Ml Drop","C":"637","F":"4.725"},{"Policy Line":"74118480","B":"Permethrin 5% Cream 60Gm","C":"637","F":"4.5","G":"**"},{"Policy Line":"74118488","B":"Neostigmine 1-1000 5Cc Charge","C":"636","D":"J2710","F":"51.294"},{"Policy Line":"74118494","B":"Clindamycin/D5W 600Mg/50Ml Bag","C":"250","F":"17.65929667417","G":"**"},{"Policy Line":"74118495","B":"Nicardipine Sr 60Mg Cap","C":"637","F":"4.725"},{"Policy Line":"74118497","B":"Neostigmine 1:2000 Inj 1Ml","C":"636","D":"J2710","F":"17.304","G":"**"},{"Policy Line":"74118498","B":"Nacl 0.45% 250Ml","C":"258","F":"17.922","G":"**"},{"Policy Line":"74118502","B":"Neproxen Susp 25Mg/Ml 90Ml","C":"637","F":"8.55"},{"Policy Line":"74118503","B":"Naproxen Na Ds 550Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74118506","B":"Neoral 25Mg Gel Cap","C":"636","D":"J7515","F":"1.854","G":"**"},{"Policy Line":"74118510","B":"Nacl 0.45% 50Ml","C":"258","F":"16.995"},{"Policy Line":"74118512","B":"Nacl 0.45% 100Ml","C":"258","F":"16.995"},{"Policy Line":"74118517","B":"Cisatracurium 2Mg/Ml 5Ml Charg","C":"250","F":"17.9043428571428","G":"**"},{"Policy Line":"74118525","B":"Nacl 500Ml For Irrigation","C":"250","F":"17.922","G":"**"},{"Policy Line":"74118529","B":"Morphine Sr 60Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118534","B":"Murocel 1% Ophth Sol 15Ml","C":"250","F":"17.922"},{"Policy Line":"74118539","B":"Nafcillin 1Gm Inj","C":"250","F":"17.5578214285714","G":"**"},{"Policy Line":"74118540","B":"Navelbine 10Mg/Ml Inj","C":"636","D":"J9390","F":"13.596"},{"Policy Line":"74118541","B":"Neoral 100Mg Gel Cap","C":"636","D":"J7502","F":"17.304","G":"**"},{"Policy Line":"74118546","B":"Mometasone Fur 0.1% Oint 15Gm","C":"637","F":"2.7"},{"Policy Line":"74118548","B":"Midazolam/Atropine Oral 3Ml","C":"250","F":"17.922"},{"Policy Line":"74118553","B":"Mepivacaine Hcl 2% 50Ml Inj","C":"636","D":"J0670","F":"17.9167627118644","G":"**"},{"Policy Line":"74118559","B":"Midazolam 5Mg/Ml 1Ml Inj","C":"636","D":"J2250","F":"17.922"},{"Policy Line":"74118562","B":"Midazolam 1Mg/1Ml 5Ml Inj","C":"636","D":"J2250","F":"17.6519186403509","G":"**"},{"Policy Line":"74118567","B":"Morphine Conc 20Mg/Ml 1Ml Oral","C":"637","F":"6.3"},{"Policy Line":"74118570","B":"Mephobarbital 50Mg Tab","C":"637","F":"0"},{"Policy Line":"74118571","B":"Meperidine 10Mg/Ml 5Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118573","B":"Medroxyprogesterone150Mg/MLINJ","C":"636","D":"J1050","F":"67.7271818181819","G":"**"},{"Policy Line":"74118574","B":"Methadone 5Mg/5Ml 500Ml","C":"637","F":"0"},{"Policy Line":"74118575","B":"HOCM: Conray 60 50Ml","C":"636","D":"Q9961","F":"17.6548311654135","G":"**"},{"Policy Line":"74118576","B":"Methadone 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118582","B":"Neomycin-Bac-Poly Op Oint 3.5G","C":"250","F":"55.0257692307693","G":"**"},{"Policy Line":"74118584","B":"Methadone Oral Soln 5Mg/5Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118588","B":"Niconazole Nitrate 2% Cr 15Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118591","B":"Menthol/Eucalyptus Loz 30","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118600","B":"Levofloxacin 250Mg Iv","C":"636","D":"J1956","F":"17.6543312101911","G":"**"},{"Policy Line":"74118601","B":"Midazolam/Atrop/Mep Oral 3Ml","C":"250","F":"17.922"},{"Policy Line":"74118602","B":"Magnesium Sulfate 4Gm/100Ml","C":"636","D":"J3475","F":"17.6983815789474","G":"**"},{"Policy Line":"74118604","B":"Magnevist 10Ml","C":"636","D":"Q9951","F":"68.289"},{"Policy Line":"74118612","B":"Magnesium Gluc 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118622","B":"Lorazepam 4Mg/Ml Inj","C":"250","F":"17.922"},{"Policy Line":"74118631","B":"Lovastatin 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74118632","B":"D5W/Nacl 0.2%/Kcl 30Meq 1000M","C":"258","F":"17.922"},{"Policy Line":"74118634","B":"Lidocaine Viscous 2% 100Ml","C":"637","F":"2.925","G":"**"},{"Policy Line":"74118635","B":"D5W/Kcl 10Meq 1000Ml","C":"258","F":"17.922"},{"Policy Line":"74118637","B":"D5W/Nacl 0.3% 1000Ml","C":"258","F":"16.377","G":"**"},{"Policy Line":"74118642","B":"Lidocaine 2% Jelly Per Use","C":"250","F":"17.7984","G":"**"},{"Policy Line":"74118646","B":"Lidocaine 2% 5Ml Mpf","C":"636","D":"J2001","F":"17.6696348973607","G":"**"},{"Policy Line":"74118647","B":"Lidocaine 2% 10Ml Amp","C":"636","D":"J2001","F":"17.49558","G":"**"},{"Policy Line":"74118657","B":"Lidocaine 1.5% W Epi 5Ml Amp","C":"250","F":"17.922"},{"Policy Line":"74118663","B":"Lidocaine 1% 20Ml Vial","C":"636","D":"J2001","F":"17.4587335687732","G":"**"},{"Policy Line":"74118667","B":"Lidocaine 1% 5Ml Amp","C":"636","D":"J2001","F":"17.5982857142857","G":"**"},{"Policy Line":"74118669","B":"Lidocaine 1% 10Ml Mpf Ezoff","C":"636","D":"J2001","F":"17.7088965517241","G":"**"},{"Policy Line":"74118677","B":"Levofloxacin 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118678","B":"Dexamethasone 10Mg/Ml Syr","C":"636","D":"J1100","F":"17.3950996236559","G":"**"},{"Policy Line":"74118679","B":"Dexamethasone 10Mg/Ml 10Ml","C":"250","F":"17.922"},{"Policy Line":"74118680","B":"Levobunolol Hcl 0.25% 5Ml Op S","C":"637","F":"1.575"},{"Policy Line":"74118683","B":"Leucovorin Calcium 50Mg Inj","C":"636","D":"J0640","F":"8.6211","G":"**"},{"Policy Line":"74118691","B":"Lactobacillus Acidophilus Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118696","B":"Lactobacillus Acidophilus Pkt","C":"637","F":"1.35"},{"Policy Line":"74118699","B":"Lacrilube Np Opth Oint 0.7Gm","C":"250","F":"17.922"},{"Policy Line":"74118700","B":"Lactulose Syrup 90Ml","C":"637","F":"1.353","G":"**"},{"Policy Line":"74118702","B":"Lanolin Anhydrous 36.9Gm","C":"250","F":"17.7516458752515","G":"**"},{"Policy Line":"74118707","B":"Ketorolac Tromethamine 10Mg Tb","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118712","B":"Labetalol 300Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118714","B":"Ketamine 10Mg/Ml 20Ml Inj","C":"250","F":"17.4930905915493","G":"**"},{"Policy Line":"74118744","B":"Dicyclomine 20Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118750","B":"Isosorbide Dinitrate 30Mg Tabl","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118751","B":"Fentanyl 250Mcg/5Ml Inj","C":"636","D":"J3010","F":"17.6438410885609","G":"**"},{"Policy Line":"74118756","B":"Epinephrine 1:1000 Topical 30M","C":"637","F":"84.375"},{"Policy Line":"74118762","B":"Glycopyrrolate 1Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118779","B":"Famotidine 20Mg/2.5Ml Oral Liq","C":"637","F":"8.1","G":"**"},{"Policy Line":"74118782","B":"Guaifenesin Sugar-Free 120 Ml","C":"637","F":"1.35"},{"Policy Line":"74118785","B":"Guaifensein Ac 5Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118796","B":"Mitoxantrone Hcl 5Mg","C":"636","D":"J9293","F":"24.72"},{"Policy Line":"74118800","B":"Dipyridamole 5 Mg/Ml 2Ml Inj","C":"636","D":"J1245","F":"34.299"},{"Policy Line":"74118802","B":"Hydromorphone/Bupiv 8 Mg/100Ml","C":"258","F":"26.883"},{"Policy Line":"74118804","B":"Hydromorphone 4Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118810","B":"Interferon Alfa-2B Recomb 1Mu","C":"636","D":"J9214","F":"37.698"},{"Policy Line":"74118813","B":"Isoniazid Tab 100Mg","C":"637","F":"1.35"},{"Policy Line":"74118817","B":"Diltiazem 100Mg Mono Vial","C":"250","F":"71.997"},{"Policy Line":"74118818","B":"Insulin Novolin R 100U/Ml 1Ml","C":"637","D":"J1815","F":"12.6","G":"**"},{"Policy Line":"74118821","B":"Isoflurane Charge 13Ml","C":"250","F":"17.922"},{"Policy Line":"74118823","B":"Diphenhydramine 12.5Mg/5Ml Ud","C":"636","D":"Q0163","F":"1.85185416666667","G":"**"},{"Policy Line":"74118832","B":"Hepatitis B Immune Globulin 1M","C":"636","D":"90371","F":"184.473","G":"**"},{"Policy Line":"74118834","B":"Donnatal Elixir 20Ml Ud","C":"637","F":"22.05"},{"Policy Line":"74118837","B":"Iodine Strong Sol 30Ml","C":"250","F":"17.6323125","G":"**"},{"Policy Line":"74118846","B":"Edrophomium/Atropine Inj 15Ml","C":"250","F":"17.922"},{"Policy Line":"74118852","B":"Doxepin 75Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74118853","B":"Edrophonium+Atropine 5Ml Chg","C":"250","F":"17.922"},{"Policy Line":"74118865","B":"Flumazenil 0.1Mg/Ml Inj 10Ml","C":"250","F":"17.613","G":"**"},{"Policy Line":"74118866","B":"Fluconazole 200Mg/5Ml Susp","C":"637","F":"2.7","G":"**"},{"Policy Line":"74118870","B":"Edrophonium Cl Charge 5Ml","C":"250","F":"17.922"},{"Policy Line":"74118879","B":"Milrinone 20Mg In 100Ml D5W","C":"636","D":"J2260","F":"17.7759534342258","G":"**"},{"Policy Line":"74118885","B":"Fluconazole 200Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118887","B":"Fluoxetine Hcl 20Mg/5Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118899","B":"Famciclovir 250 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74118908","B":"Etodolac 400Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74118916","B":"Gemcitabine 200Mg Inj","C":"636","D":"J9201","F":"51.7099615384617","G":"**"},{"Policy Line":"74118918","B":"Enfamil Hum Milk Fortif 1 Pak","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118940","B":"Ergocalciferol 50000U Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118941","B":"Ergocalciferol (V-D) Drops 60M","C":"637","F":"30.6"},{"Policy Line":"74118948","B":"Epoetin NonESRD 20000U/Ml Vial","C":"636","D":"J0885","F":"316.640600451465","G":"**"},{"Policy Line":"74118949","B":"Excedrin Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74118952","B":"Epoetin NonESRD 2000U/Ml Vial","C":"636","D":"J0885","F":"57.474","G":"**"},{"Policy Line":"74118953","B":"Eye Stream Ophth Soln 30Ml","C":"250","F":"17.5369220689655","G":"**"},{"Policy Line":"74119563","B":"Medication Taken At Home","C":"637","F":"0"},{"Policy Line":"74120002","B":"Ca Citrate 950Mg Tab (Ca 200Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120006","B":"Trandolapril 2Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120007","B":"Flovent Inhaler 44 Mcg/Inh","C":"637","F":"139.5","G":"**"},{"Policy Line":"74120008","B":"Zafirlukast 20Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120009","B":"Gemzar (Gemcitabine) 1Gm/50Ml","C":"636","D":"J9201","F":"29.355"},{"Policy Line":"74120012","B":"Bisoprolol 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120015","B":"Gentamycin 120 Mg Iv","C":"636","D":"J1580","F":"17.4543890748899","G":"**"},{"Policy Line":"74120016","B":"Ferrous Subsulf(Monsel'S)60Ml","C":"637","F":"12.6","G":"**"},{"Policy Line":"74120020","B":"Estradiol 0.1Mg Top Patch","C":"637","F":"16.65","G":"**"},{"Policy Line":"74120022","B":"Oscal 500 + Vit D (Brand) Tab","C":"637","F":"1.35"},{"Policy Line":"74120023","B":"Mirtazapine 15Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120025","B":"Let Topical Soln 3Ml","C":"250","F":"17.4645219886363","G":"**"},{"Policy Line":"74120029","B":"Zinc Sulfate 220 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120032","B":"Olanzapine 5Mg Tab","C":"637","F":"1.344","G":"**"},{"Policy Line":"74120033","B":"Valacyclovir 500Mg Cap","C":"637","F":"3.372","G":"**"},{"Policy Line":"74120034","B":"Cisatracurium 10Mg/Ml 20 Ml","C":"250","F":"373.34925","G":"**"},{"Policy Line":"74120035","B":"DobutamineINJ 1000 Mg/250Cc Pm","C":"636","D":"J1250","F":"28.4170619469026","G":"**"},{"Policy Line":"74120037","B":"Atrovastatin 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120038","B":"Ibuprofen 100Mg/5Ml 5Ml","C":"637","F":"1.347","G":"**"},{"Policy Line":"74120040","B":"Bss Ophth Irrig 500Ml","C":"250","F":"17.922"},{"Policy Line":"74120041","B":"Fluticasone 220Mcg Inh","C":"637","F":"320.85","G":"**"},{"Policy Line":"74120042","B":"Glimepiride 2Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120043","B":"Misoprostol 100Mcg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74120044","B":"Lidex (Fluocinonide) .05% 60Ml","C":"637","F":"61.65"},{"Policy Line":"74120045","B":"Lidocaine 2% Jelly 5Ml","C":"250","F":"17.7072919418758","G":"**"},{"Policy Line":"74120049","B":"Tizanidine 4Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120050","B":"Donepezil 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120051","B":"Hep A Virus Vaccine Adult, IM","C":"250","D":"90632","F":"83.43","G":"**"},{"Policy Line":"74120055","B":"Epipen (Epinephrine) 0.3Mg Syr","C":"636","D":"J0171","F":"42.951","G":"**"},{"Policy Line":"74120056","B":"Carboxymethycell 0.4Ml Op Sol","C":"637","F":"1.35"},{"Policy Line":"74120057","B":"Chlorthalidone 15 Mg Tab","C":"637","F":"2.475"},{"Policy Line":"74120058","B":"Cleocin T 1% Gel 30Ml Pkg","C":"637","F":"62.1"},{"Policy Line":"74120060","B":"Lac-Hydrin 12% 400 Gm Lot","C":"637","F":"5.4","G":"**"},{"Policy Line":"74120062","B":"Atropine Tab 0.4Mg","C":"637","F":"1.35"},{"Policy Line":"74120063","B":"Carboplatin 50Mg Inj","C":"636","D":"J9045","F":"7.107"},{"Policy Line":"74120065","B":"Fosphenytoin 100Mg/2Ml Inj","C":"636","D":"Q2009","F":"17.8900344827586","G":"**"},{"Policy Line":"74120066","B":"Warfarin Sodium 5Mg Inj","C":"250","F":"17.922"},{"Policy Line":"74120069","B":"Zileuton 600Mg Tab","C":"637","F":"20.25","G":"**"},{"Policy Line":"74120070","B":"Fluticasone 110Mcg Inh","C":"637","F":"206.55","G":"**"},{"Policy Line":"74120071","B":"Ritonavir 100Mg Cap","C":"637","F":"12.6"},{"Policy Line":"74120072","B":"Carbidopa 25Mg+Levo 100Mg Cr","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120073","B":"Fluvoximine 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120074","B":"Lariam (Mefloquine) 250Mg Tab","C":"259","F":"17.922"},{"Policy Line":"74120076","B":"Diprosone Lotion 0.05% 60Ml","C":"637","F":"36"},{"Policy Line":"74120082","B":"Latanoprosst0.005%Op Sol 2.5Ml","C":"637","F":"5.175","G":"**"},{"Policy Line":"74120083","B":"Sarna Lotion 225Ml","C":"637","F":"7.2","G":"**"},{"Policy Line":"74120087","B":"Azelastine 137Mcg Nasal Spy","C":"637","F":"11.925","G":"**"},{"Policy Line":"74120088","B":"Lamotrigine 25Mg Tab","C":"637","F":"1.341","G":"**"},{"Policy Line":"74120093","B":"Valsartan 80Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120094","B":"Ibutilide 0.1Mg/Ml 10Ml","C":"636","D":"J1742","F":"575.667","G":"**"},{"Policy Line":"74120098","B":"Selenium Shampoo 1% 210Ml Bot","C":"637","F":"4.05","G":"**"},{"Policy Line":"74120099","B":"Sulfadiazine 500 Mg Tablet","C":"637","F":"3.375"},{"Policy Line":"74120100","B":"Temovate(Clobetasl).05% O 60Gm","C":"250","F":"356.586","G":"**"},{"Policy Line":"74120101","B":"Anastrozole 1Mg Tab","C":"636","D":"J9999","F":"1.854","G":"**"},{"Policy Line":"74120102","B":"Naropin 0.2% 20Ml Vial (Sample","C":"250","F":"17.7691612903226","G":"**"},{"Policy Line":"74120105","B":"Cyanocobalamin 100Mcg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120106","B":"Ciclopirox Olamine 1% Cr 15Gm","C":"637","F":"5.4","G":"**"},{"Policy Line":"74120109","B":"Lupron Depot 22.5Mg 3Mon Kit","C":"636","D":"J9217","F":"2794.081","G":"**"},{"Policy Line":"74120111","B":"Carbamazepine Xr 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120117","B":"MS Contin 100 Mg Tablet","C":"637","F":"4.05","G":"**"},{"Policy Line":"74120132","B":"Midodrine 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120134","B":"Levofloxacin 250Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120135","B":"Antithrombin Iii (Human)500 U","C":"636","D":"J7197","F":"2334.90157894737","G":"**"},{"Policy Line":"74120136","B":"Pilocarpine 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120137","B":"Charcocap (Charcoal) Caplet","C":"637","F":"1.35"},{"Policy Line":"74120139","B":"Vasopressin 200 Unit/10Ml Vial","C":"250","F":"17.922"},{"Policy Line":"74120140","B":"Vistide 375Mg/5Ml Vial","C":"636","D":"J0740","F":"633.759"},{"Policy Line":"74120143","B":"Taxotere(Docetaxl) 80Mg/2Ml Vl","C":"636","D":"J9171","F":"281.499"},{"Policy Line":"74120144","B":"Carvediol 3.125Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120145","B":"Visipaque 320 50 Ml","C":"255","D":"Q9967","F":"82.5018160919541","G":"**"},{"Policy Line":"74120146","B":"Carvediol 6.25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120150","B":"Depacon (Valproat)500Mg/5Ml Vl","C":"250","F":"17.584661543943","G":"**"},{"Policy Line":"74120156","B":"Eye Supplies: Er","C":"250","F":"22.557"},{"Policy Line":"74120158","B":"Crixivan (Indinavir) 400Mg Cap","C":"637","F":"2.25"},{"Policy Line":"74120160","B":"Desowen (Desonide) Lotion 2Oz","C":"637","F":"213.3"},{"Policy Line":"74120161","B":"Lodine Xl(Etodolac) 400Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120162","B":"Combivent Inhaler 14.7 Gm","C":"637","F":"194.625"},{"Policy Line":"74120163","B":"Haldol Deconate 100Mg/1Ml Amp","C":"636","D":"J1631","F":"45.114","G":"**"},{"Policy Line":"74120164","B":"Depo-Medrol 80Mg/1Cc Vial","C":"636","D":"J1040","F":"17.7065230024213","G":"**"},{"Policy Line":"74120170","B":"Coly-Mycin M(Colist)150Mg Vial","C":"636","D":"J0770","F":"35.1495735607677","G":"**"},{"Policy Line":"74120171","B":"Bupropion Sr 150Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120172","B":"Vantin (Cefpodoxime) 100Mg Tab","C":"637","F":"4.95"},{"Policy Line":"74120175","B":"Univasc (Moexipril) 7.5Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120176","B":"Levaquin 500Mg/100 Ml Pm Bag","C":"636","D":"J1956","F":"17.6447136302033","G":"**"},{"Policy Line":"74120177","B":"Oxycodone & Apap 5Ml Soln","C":"637","F":"1.35"},{"Policy Line":"74120178","B":"Metronidazole 500 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120181","B":"Viracept (Nelfinavir)250Mg Cap","C":"637","F":"2.25"},{"Policy Line":"74120186","B":"Ambisone 50Mg W/Filter Insert","C":"636","D":"J0289","F":"264.544091772152","G":"**"},{"Policy Line":"74120187","B":"Requip (Ropinirole) 1Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120188","B":"Azithromycin 500 Mg Vial","C":"636","D":"J0456","F":"40.940346714072","G":"**"},{"Policy Line":"74120189","B":"Robinul 1Mg Per 5Ml Vial","C":"250","F":"55.3928554555683","G":"**"},{"Policy Line":"74120190","B":"Amino Acid Tpn Chg Per 100Ml","C":"258","F":"55.0776723130173","G":"**"},{"Policy Line":"74120193","B":"Pyridoxine 100Mg/Ml IV Charge","C":"636","D":"J3415","F":"17.922"},{"Policy Line":"74120194","B":"Flomax (Tamsulosin) 0.4Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120195","B":"Albumin 25% Human 100 Ml Vial","C":"636","D":"P9047","F":"293.813405902149","G":"**"},{"Policy Line":"74120196","B":"Albumin 5% Human 250 Ml Vial","C":"636","D":"P9045","F":"147.696445751972","G":"**"},{"Policy Line":"74120199","B":"Nefazodone (Serzone)150Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120200","B":"Pimozide (Orap) 2Mg Tablet","C":"637","F":"2.25","G":"**"},{"Policy Line":"74120202","B":"Isoniazid 100Mg/Ml Injection","C":"250","F":"403.245"},{"Policy Line":"74120207","B":"Mometasone Fur Nasal Spray 17G","C":"637","F":"226.35","G":"**"},{"Policy Line":"74120209","B":"Doxorubicin Lipos 20Mg/10Ml Vl","C":"636","D":"Q2050","F":"1428.816"},{"Policy Line":"74120210","B":"Clopidogrel (Plavix) 75Mg Tab","C":"637","F":"1.575","G":"**"},{"Policy Line":"74120212","B":"Simvastatin (Zocor) 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120214","B":"Raloxifene (Eviste)60Mg Tablet","C":"637","F":"5.85","G":"**"},{"Policy Line":"74120221","B":"Diazepam Rectal Gel 10Mg App","C":"250","F":"370.8"},{"Policy Line":"74120222","B":"Ketorolac Im 60Mg Syringe","C":"636","D":"J1885","F":"3.399"},{"Policy Line":"74120224","B":"Carmustine (Gliadel)8 Wafr/Box","C":"636","F":"31381.113","G":"**"},{"Policy Line":"74120226","B":"Pancuronium Br 10Mg/10 Ml Vial","C":"250","F":"17.922"},{"Policy Line":"74120227","B":"Ropinirole (Requip) 0.25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120228","B":"Montelukast (Singulair)5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120229","B":"A-Tuss Dm Syrup 60 Ml Bottle","C":"637","F":"15.075"},{"Policy Line":"74120230","B":"Fosfomycin (Monurol) 3 Gm Pkt","C":"637","F":"64.71","G":"**"},{"Policy Line":"74120231","B":"Sevoflurane 250 Ml Bottle","C":"250","F":"374.199"},{"Policy Line":"74120235","B":"Irbesartan (Avapro) 150Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120236","B":"Mupirocin 2% Oint. 1 Gm Packet","C":"637","F":"15.3","G":"**"},{"Policy Line":"74120241","B":"Hyoscyamine (Levbid).375Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120243","B":"Becaplermin Gel .01% 15Gm Tube","C":"637","F":"913.5"},{"Policy Line":"74120244","B":"Diphenoxylat/Atr Soln 10Ml Cup","C":"637","F":"2.025","G":"**"},{"Policy Line":"74120250","B":"Tolterodine (Detrol)1Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120254","B":"Niacin Er (Niaspan) 500Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120256","B":"Lamotrigine 100 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120259","B":"Triamcinolone Cr .1% 454Gm Jar","C":"250","F":"17.922","G":"**"},{"Policy Line":"74120261","B":"Cefpodoxime 200 Mg Tablet","C":"637","F":"6.075"},{"Policy Line":"74120263","B":"Folic Acid 400 Mcg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120265","B":"Diltiazem 100Mg/Ns 100Ml Advan","C":"250","F":"17.8605760649087","G":"**"},{"Policy Line":"74120266","B":"Diltiazem 25Mg/5Ml Syringe","C":"250","F":"17.5793904658902","G":"**"},{"Policy Line":"74120271","B":"Dopamine 400 Mg Syringe","C":"636","D":"J1265","F":"17.922"},{"Policy Line":"74120274","B":"Migranal Nasal Spry 4Mg/Ml Amp","C":"250","F":"536.733"},{"Policy Line":"74120275","B":"Propafenone Hcl 225Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120280","B":"Paroxetine 30 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120281","B":"Repaglinide 0.5 Mg Tablet","C":"637","F":"2.475","G":"**"},{"Policy Line":"74120282","B":"Lepirudin (Rdna) 50 Mg Vial","C":"636","D":"J1945","F":"685.362"},{"Policy Line":"74120286","B":"Aluminum Hydroxide Gel 4Oz Bot","C":"637","F":"6.3"},{"Policy Line":"74120287","B":"Meperidine Syrup 50Mg/5Ml Cup","C":"637","F":"1.35"},{"Policy Line":"74120288","B":"Lortab Liq 15Ml","C":"637","F":"3.15"},{"Policy Line":"74120289","B":"Cadexomer-Iodine Gel 40Gm Tube","C":"250","F":"141.75375","G":"**"},{"Policy Line":"74120290","B":"Tricitrates Oral Soln 60Ml Bot","C":"637","F":"1.35"},{"Policy Line":"74120291","B":"K Citrate/Citrc Acid Sol 60Ml","C":"637","F":"1.35"},{"Policy Line":"74120292","B":"Desmopressin 0.2 Mg Tablet","C":"637","F":"2.025","G":"**"},{"Policy Line":"74120293","B":"Cetirizine 10 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120296","B":"Visipaque 320 100Ml","C":"255","D":"Q9967","F":"133.525931091811","G":"**"},{"Policy Line":"74120297","B":"Venlafaxine Xr 37.5Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120298","B":"Oxycodone Solution 5Mg/5Ml Cup","C":"637","F":"3.825","G":"**"},{"Policy Line":"74120299","B":"Tiagabine 4 Mg Tablet","C":"637","F":"4.725"},{"Policy Line":"74120300","B":"Cladribine 10Mg/10 Ml Vial","C":"636","D":"J9065","F":"231.75","G":"**"},{"Policy Line":"74120306","B":"Tobramycin 300Mg/5Ml Amp Inhal","C":"250","F":"81.885"},{"Policy Line":"74120307","B":"Human Factor VIII Chg Per Unit","C":"636","D":"J7192","F":"1.854"},{"Policy Line":"74120308","B":"Citalopram Hbr 20 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120309","B":"Nicotine Inhaler 10Mg --168","C":"637","F":"2.025"},{"Policy Line":"74120310","B":"Eptifibatide 20Mg/10 Ml Vial","C":"636","D":"J1327","F":"219.474272727273","G":"**"},{"Policy Line":"74120311","B":"Eptifibatide 75 Mg/100Ml Vial","C":"636","D":"J1327","F":"689.730136363635","G":"**"},{"Policy Line":"74120312","B":"Naltrexone Hcl 50 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120314","B":"Acitretin 25 Mg Capsule","C":"637","F":"13.05"},{"Policy Line":"74120315","B":"Baclofen 10Mg/20Ml Inj Kit","C":"636","D":"J0475","F":"273.774"},{"Policy Line":"74120320","B":"Topiramate 100 Mg Tablet","C":"637","F":"1.347","G":"**"},{"Policy Line":"74120321","B":"Simple Syrup 1 Ml Chg","C":"637","F":"0"},{"Policy Line":"74120322","B":"Niacin Er (Niaspan) 750 Mg Tab","C":"637","F":"6.525"},{"Policy Line":"74120324","B":"Baclofen 0.05 Mg/1 Ml Amp","C":"636","D":"J0476","F":"93.009"},{"Policy Line":"74120325","B":"Clotrimazole/Betameth 45 Gm Cr","C":"250","F":"45.9286363636365","G":"**"},{"Policy Line":"74120327","B":"Repaglinide 2 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120328","B":"Phenobarbital 20Mg/5 Ml Cup","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120329","B":"Arava 20 Mg Tablet","C":"637","F":"4.5","G":"**"},{"Policy Line":"74120331","B":"Astramorph 1Mg/1Ml 2Ml Amp","C":"636","D":"J2274","F":"19.467"},{"Policy Line":"74120336","B":"Amitriptyline 75Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120338","B":"Ascorbic Acid 500Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120343","B":"Metoclopramide 5Mg Tab","C":"636","D":"J8597","F":"1.854","G":"**"},{"Policy Line":"74120344","B":"Quinapril 20Mg Tab","C":"637","F":"4.05","G":"**"},{"Policy Line":"74120347","B":"Idarubicin Hcl 5 Mg Vial","C":"636","D":"J9211","F":"55.5224210526315","G":"**"},{"Policy Line":"74120348","B":"Gavapentin 400 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120349","B":"Losartin 50Mg/Hctz 12.5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120354","B":"Venlafaxine 150 Mg Xr Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120355","B":"Venlafaxine 100 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120357","B":"Lansoprazole 30 Mg Capsule","C":"637","F":"2.025"},{"Policy Line":"74120358","B":"Mycophenolate 250 Mg Capsule","C":"636","D":"J7517","F":"1.854","G":"**"},{"Policy Line":"74120360","B":"Simvastatin 40 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120361","B":"Fexofenadine 60 Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74120363","B":"Non Formulary IV Medication","C":"250","F":"17.922"},{"Policy Line":"74120364","B":"Paricalcitol 5 Mcg/Cc Vial","C":"636","D":"J2501","F":"17.8280076045627","G":"**"},{"Policy Line":"74120365","B":"Uniphyl 600 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120366","B":"Isosorbide Mononitrat 30Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120367","B":"Enoxaparin 60 Mg/0.6 Ml Syring","C":"636","D":"J1650","F":"19.81817","G":"**"},{"Policy Line":"74120368","B":"Enoxaparin 80 Mg/0.8 Ml Syring","C":"636","D":"J1650","F":"26.5057748879912","G":"**"},{"Policy Line":"74120369","B":"Enoxaparin 100Mg/1 Ml Syringe","C":"636","D":"J1650","F":"17.6907049784173","G":"**"},{"Policy Line":"74120371","B":"Acarbose 25 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120373","B":"Ropinirole 2 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120374","B":"Ropinirole 5 Mg Tablet","C":"637","F":"4.95","G":"**"},{"Policy Line":"74120375","B":"Midazolam 2 Mg/Ml Charge","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120376","B":"Midazolam 10Mg/5Ml Oral Syring","C":"250","F":"17.922"},{"Policy Line":"74120377","B":"Infliximab 100 Mg Inj Remicade","C":"636","D":"J1745","F":"1357.06907029817","G":"**"},{"Policy Line":"74120380","B":"Ferrous Sulfate 25Mg/Ml 50Ml","C":"637","F":"5.175","G":"**"},{"Policy Line":"74120383","B":"Oxycodone Hcl 40 Mg Cr Tablet","C":"637","F":"9.9","G":"**"},{"Policy Line":"74120392","B":"Losartan 50 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120393","B":"Levothyroxine 0.137 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120396","B":"Celecoxib 100 Mg Capsule","C":"637","F":"6.075","G":"**"},{"Policy Line":"74120397","B":"Lidocaine 1.5%/Epi 1:200 10ML","C":"250","F":"17.922"},{"Policy Line":"74120401","B":"Ritonavir Sol 80Mg/Ml 240Ml Bt","C":"637","F":"1475.55"},{"Policy Line":"74120402","B":"Reteplase 10U Inj","C":"636","D":"J2993","F":"1919.817"},{"Policy Line":"74120403","B":"Ziagen 300 Mg Tablet","C":"637","F":"8.325","G":"**"},{"Policy Line":"74120404","B":"Efavirenz 200 Mg Capsule","C":"637","F":"9.9"},{"Policy Line":"74120405","B":"Paroxetine 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120406","B":"Rituximab 100Mg Inj","C":"636","D":"J9312","F":"1136.56030188679","G":"**"},{"Policy Line":"74120409","B":"Amitrityline 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120416","B":"Oxycodone 40Mg Cr Tab","C":"637","F":"17.325"},{"Policy Line":"74120417","B":"Ocufloxacin 1Ml Ea","C":"250","F":"17.922"},{"Policy Line":"74120419","B":"Glipizide Xl 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120421","B":"Cipro 10 Gm/100 Ml Suspension","C":"637","F":"140.175"},{"Policy Line":"74120422","B":"Midazolam 1 Mg/Ml 10 Ml Vial","C":"250","F":"17.922"},{"Policy Line":"74120425","B":"Tolterodine 2 Mg Tablet","C":"637","F":"6.525"},{"Policy Line":"74120426","B":"Diclofenac/Misoprostol 75Mg Tb","C":"637","F":"6.75"},{"Policy Line":"74120427","B":"Hydrocodone 10Mg/Apap 325Mg Tb","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120428","B":"Candesartan 16 Mg Tablet","C":"637","F":"2.925","G":"**"},{"Policy Line":"74120430","B":"Clindamycin 300Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120431","B":"Gentamicin Ophth Drops 5Ml","C":"250","F":"17.613","G":"**"},{"Policy Line":"74120432","B":"Repaglinide 1Mg Tab","C":"637","F":"2.475","G":"**"},{"Policy Line":"74120433","B":"Varicella Zoster Vaccine 0.5Ml","C":"259","D":"90716","F":"145.848"},{"Policy Line":"74120434","B":"Hylan G-F 20 16Mg/2Ml Syringe","C":"636","D":"J7325","F":"528.081"},{"Policy Line":"74120436","B":"Brinzolamide 1% Opth Soln 5Ml","C":"250","F":"202.395"},{"Policy Line":"74120439","B":"Oxybutynin Cl Xl 5 Mg Tablet","C":"637","F":"2.475","G":"**"},{"Policy Line":"74120442","B":"Ciprofloxacin 0.3% Op Oint 3.5","C":"250","F":"257.397","G":"**"},{"Policy Line":"74120444","B":"Lidocaine 1% Mpf 1Ml Op Inj","C":"636","D":"J2001","F":"17.922"},{"Policy Line":"74120446","B":"Hyskon 32% Hysteroscopy Soltn","C":"250","F":"0"},{"Policy Line":"74120447","B":"Ciprofloxacin Hc Otic 10Ml","C":"637","F":"244.125","G":"**"},{"Policy Line":"74120448","B":"Levocarnitine 1000Mg/5Ml Inj","C":"250","F":"17.922"},{"Policy Line":"74120449","B":"Indocyanine Green 25Mg Inj","C":"250","F":"106.84559","G":"**"},{"Policy Line":"74120450","B":"Rosiglitazone 4 Mg Tablet","C":"637","F":"4.95"},{"Policy Line":"74120451","B":"Alteplase Recombint 1Mg/Ml Inj","C":"636","D":"J2997","F":"91.9956303566493","G":"**"},{"Policy Line":"74120454","B":"Paricalcitol 10 Mcg/2 Ml Vial","C":"636","D":"J2501","F":"38.625"},{"Policy Line":"74120458","B":"Oxycodone 20Mg/1Ml Oral Conc","C":"637","F":"3.6","G":"**"},{"Policy Line":"74120459","B":"Testosterone 4Mg Transdermal","C":"637","F":"16.875"},{"Policy Line":"74120460","B":"Quetiapine Fumarate 25Mg Tab","C":"637","F":"1.8","G":"**"},{"Policy Line":"74120462","B":"Fenoldopam 10Mg/1 Ml Amp","C":"250","F":"359.985"},{"Policy Line":"74120463","B":"Multivitamin Inject(Mvi12)10Ml","C":"250","F":"17.6246640540541","G":"**"},{"Policy Line":"74120464","B":"Octreotide Depot 20Mg Inject","C":"636","D":"J2353","F":"4892.57357142855","G":"**"},{"Policy Line":"74120465","B":"Montelukast 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120466","B":"Atovaquone 750Mg/5Ml 60Ml Bot","C":"637","F":"595.35"},{"Policy Line":"74120467","B":"Ofloxazin 0.3% Otic Soltn 5Ml","C":"637","F":"47.418","G":"**"},{"Policy Line":"74120469","B":"Lymphazurin 50mg/5 Ml 1%% Vial","C":"636","D":"Q9968","F":"880.100666666667","G":"**"},{"Policy Line":"74120470","B":"Cilostazol 50 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120471","B":"Pramipexole 0.25 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120473","B":"Topotecan 4 Mg Vial","C":"636","D":"J9351","F":"155.736","G":"**"},{"Policy Line":"74120474","B":"Eye Supplies: Oto Neurology","C":"250","F":"25.338"},{"Policy Line":"74120476","B":"Humalog Insulin Pen 3 Ml","C":"637","F":"13.725"},{"Policy Line":"74120477","B":"Humulin N Insulin Pen 3 Ml Inj","C":"637","D":"J1815","F":"11.025"},{"Policy Line":"74120478","B":"Humulin 70/30 Inuslin Pen 3 Ml","C":"637","F":"11.025"},{"Policy Line":"74120480","B":"Rosiglitazone Mal 2 Mg Tablet","C":"637","F":"3.15"},{"Policy Line":"74120482","B":"Rizatriptan (Maxalt) 5Mg Tab","C":"637","F":"32.85","G":"**"},{"Policy Line":"74120483","B":"Phenol Liquid 1Ml","C":"250","F":"17.922"},{"Policy Line":"74120484","B":"Brilliant Green Solutn 1Ml","C":"637","F":"1.35"},{"Policy Line":"74120487","B":"Orlistat 120Mg Cap","C":"637","F":"5.85"},{"Policy Line":"74120488","B":"Topiramate 25Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120491","B":"Mile'S Solution 120Ml","C":"637","F":"6.3"},{"Policy Line":"74120492","B":"Pioglitazone Hcl 15 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120493","B":"Penciclovir 1% Cream 1.5G Tube","C":"637","F":"695.475"},{"Policy Line":"74120495","B":"Palivizumab 100Mg Inj","C":"636","D":"90378","F":"2926.23"},{"Policy Line":"74120497","B":"Temazepam 7.5 Mg Capsule","C":"637","F":"2.925","G":"**"},{"Policy Line":"74120498","B":"Zaleplon 5 Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74120499","B":"Gentamicin 4Mg/Ml Inj","C":"636","D":"J1580","F":"17.922"},{"Policy Line":"74120500","B":"Bupivacaine 0.25% W/Epi 50Ml A","C":"250","F":"17.6525578301887","G":"**"},{"Policy Line":"74120505","B":"Ropivacaine 150Mg/30Ml Inj","C":"636","D":"J2795","F":"35.4037011026142","G":"**"},{"Policy Line":"74120507","B":"Synercid 500Mg Inj","C":"636","D":"J2770","F":"516.648"},{"Policy Line":"74120508","B":"Levalbuterol .63Mg/3Ml Neb","C":"637","F":"2.925","G":"**"},{"Policy Line":"74120510","B":"Olopatadine .1% Opth Drops 5Ml","C":"637","F":"192.375"},{"Policy Line":"74120511","B":"Cosopt Opth Drops 5 Ml Bot","C":"637","F":"45","G":"**"},{"Policy Line":"74120512","B":"Oseltamivir 75 Mg Capsule","C":"250","F":"17.7706159663865","G":"**"},{"Policy Line":"74120514","B":"Enlaprilat 1.25 Mg/Ml 1Ml Vial","C":"250","F":"17.8620447761194","G":"**"},{"Policy Line":"74120515","B":"Epoetin NonESRD 40000U/Ml Vial","C":"636","D":"J0885","F":"634.920149068323","G":"**"},{"Policy Line":"74120517","B":"Bupivacaine 0.75% W/Dex 2Mlamp","C":"250","F":"17.6951392405063","G":"**"},{"Policy Line":"74120518","B":"Zanamivir 5Mg Disk Inhaler","C":"637","F":"49.95"},{"Policy Line":"74120519","B":"Halobetasol 0.05% Cr 15 Gm Tub","C":"637","F":"41.85"},{"Policy Line":"74120520","B":"Metronidazole .75% Gel 1Oz Tub","C":"637","F":"69.075","G":"**"},{"Policy Line":"74120521","B":"Hydroxyzine Hcl 10Mg/5Ml Cups","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120523","B":"Telmisartan 40 Mg Tablet","C":"637","F":"3.375","G":"**"},{"Policy Line":"74120525","B":"Glipizide Er 2.5 Mg Tablet","C":"637","F":"1.347","G":"**"},{"Policy Line":"74120529","B":"Mag Sulfate 1Gm/D5W 100Ml Bag","C":"636","D":"J3475","F":"17.6928640305118","G":"**"},{"Policy Line":"74120530","B":"Carbidopa 25 Mg Tablet","C":"637","F":"5.625","G":"**"},{"Policy Line":"74120531","B":"Dipyridamol 200Mg/Asa 25Mg Tab","C":"637","F":"4.95","G":"**"},{"Policy Line":"74120532","B":"Intubation Med Kit","C":"250","F":"98.262"},{"Policy Line":"74120533","B":"Tobradex 0.5Ml Ophth Syringe","C":"250","F":"24.411"},{"Policy Line":"74120534","B":"Adatosil 5000","C":"250","F":"455.024571428571","G":"**"},{"Policy Line":"74120539","B":"Carvediol 12.5 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120540","B":"Digoxin 0.05Mg/Ml Elix 2.5Ml","C":"637","F":"2.925","G":"**"},{"Policy Line":"74120541","B":"Rabeprazole Na 20 Mg Tablet","C":"637","F":"12.6"},{"Policy Line":"74120542","B":"Meropenem 1 Gm Vial","C":"636","D":"J2185","F":"17.6765791701948","G":"**"},{"Policy Line":"74120543","B":"Itraconazole 250 Mg Vial","C":"636","D":"J1835","F":"311.472"},{"Policy Line":"74120545","B":"Leuprolide Acet 30Mg 4 Mo (Im)","C":"636","D":"J9217","F":"5518.431"},{"Policy Line":"74120549","B":"Polyethylene Glycol 17 Gm Bot","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120550","B":"Modafinil 200Mg Tab","C":"637","F":"9","G":"**"},{"Policy Line":"74120551","B":"Tacrolimus Oral ImRel 1Mg Cap","C":"636","D":"J7507","F":"1.854","G":"**"},{"Policy Line":"74120552","B":"Tenecteplase 50Mg Inj","C":"636","D":"J3101","F":"5562.618"},{"Policy Line":"74120553","B":"Vancomycin 125Mg Cap","C":"637","F":"12.6","G":"**"},{"Policy Line":"74120554","B":"Hepatitis B Vaccine 20Mcg/1Ml","C":"636","D":"90746","F":"69.4220000000001","G":"**"},{"Policy Line":"74120555","B":"Simvastatin 80Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120556","B":"Pantoprazole Na 40 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120557","B":"Ursodiol 250 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120558","B":"Risperidone 0.25 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120559","B":"Ferrous Fumarate 325Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120560","B":"Vitamin D 400 Iu Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120562","B":"Acyclovir 200Mg/5Ml Cup","C":"637","F":"3.825","G":"**"},{"Policy Line":"74120563","B":"Naproxen 220Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120564","B":"Hyoscyamine Sulfate 0.5Mg/Ml","C":"636","D":"J1980","F":"69.4734999999999","G":"**"},{"Policy Line":"74120566","B":"Robitussin Dm 120Ml Bottle","C":"637","F":"1.35"},{"Policy Line":"74120567","B":"Loratadine Reditab 10Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120568","B":"Montelukast 4Mg Tab","C":"637","F":"1.176","G":"**"},{"Policy Line":"74120570","B":"Baclofen Inj 10Mg/5Ml Amp","C":"636","D":"J0475","F":"273.774"},{"Policy Line":"74120571","B":"Thymoglobulin 25Mg Vial","C":"636","D":"J7511","F":"960.681"},{"Policy Line":"74120573","B":"Testosterone 5Mg Td Patch","C":"637","F":"8.775"},{"Policy Line":"74120574","B":"Budesonide 0.5% Neb 2Ml Sol","C":"250","D":"J7633","F":"17.6838597318708","G":"**"},{"Policy Line":"74120575","B":"Levofloxacin 750Mg/150Ml Pm","C":"636","D":"J1956","F":"17.6674879064382","G":"**"},{"Policy Line":"74120577","B":"Rhinocort Aq Inhaler 32Mcg","C":"637","F":"76.725"},{"Policy Line":"74120583","B":"Clarithromycin Xl 500Mg Tab","C":"637","F":"3.375"},{"Policy Line":"74120590","B":"Allopurinol 500Mg Inj","C":"250","F":"5075.634"},{"Policy Line":"74120591","B":"Levofloxacin 750Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120592","B":"Nacl 0.9% 10Ml Vial","C":"250","F":"0"},{"Policy Line":"74120593","B":"Pegaspargase 3750Iu/5Ml","C":"636","D":"J9266","F":"8055.321","G":"**"},{"Policy Line":"74120594","B":"Testosterone 1% Gel 5 Gm Pkt","C":"637","F":"17.55","G":"**"},{"Policy Line":"74120595","B":"Epoprostenol Na 0.5 Mg Vial","C":"636","D":"J1325","F":"17.922"},{"Policy Line":"74120596","B":"Glycine Dilutent 50 Ml Vial","C":"637","F":"12.6","G":"**"},{"Policy Line":"74120597","B":"Metformin Hcl Xr 500 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120598","B":"Quinapril 5 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120599","B":"Dofetilide 125Mcg Cap","C":"637","F":"8.55","G":"**"},{"Policy Line":"74120600","B":"Dofetilide 250Mcg Cap","C":"637","F":"8.55","G":"**"},{"Policy Line":"74120603","B":"Sumatriptan 20Mg Nasal Spray","C":"637","F":"44.325","G":"**"},{"Policy Line":"74120604","B":"Sumatriptan 5Mg Nasal Spray","C":"637","F":"67.95"},{"Policy Line":"74120605","B":"Salmeterol Diskus 50Mcg Inhale","C":"637","F":"6.75"},{"Policy Line":"74120606","B":"Bupivacaine 0.5% W/Epi30Mlvial","C":"250","F":"17.716167416577","G":"**"},{"Policy Line":"74120607","B":"Topical Ophth Dilating Plegets","C":"250","F":"123.6"},{"Policy Line":"74120608","B":"Beta Galactosidase 3000U Tab","C":"637","F":"1.35"},{"Policy Line":"74120609","B":"Fexfenadine+Pseudoephr 60Mg","C":"637","F":"1.35"},{"Policy Line":"74120610","B":"Progesterone Micronized 100Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120611","B":"Buspirone 15Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120612","B":"Sumatriptan 25Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120613","B":"Exemestane 25Mg Tab","C":"637","F":"9.675","G":"**"},{"Policy Line":"74120615","B":"Perindopril 4Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120616","B":"Rivastigmine 1.5Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120617","B":"Fluvoxamine 50Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120618","B":"Atorvastatin 80Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120619","B":"Glyburide 1.25Mg-Metformin250","C":"637","F":"1.35"},{"Policy Line":"74120622","B":"Linezolid (Zyvox) 600Mg Tablet","C":"637","F":"2.925","G":"**"},{"Policy Line":"74120624","B":"Ramipril 10 Mg Capsule","C":"637","F":"6.075","G":"**"},{"Policy Line":"74120628","B":"Leuprolide 11.25Mg 3Month (Im)","C":"636","D":"J1950","F":"2843.5725","G":"**"},{"Policy Line":"74120629","B":"Leuprolide Depot 3.75Mg Kit(Im","C":"636","D":"J1950","F":"936.27","G":"**"},{"Policy Line":"74120630","B":"Dofetilide 500Mcg Cap","C":"637","F":"8.55","G":"**"},{"Policy Line":"74120631","B":"Dexmedetomidine 200Mcg/2Ml Via","C":"250","F":"17.4949914285714","G":"**"},{"Policy Line":"74120632","B":"Hydromorphone 5Mg/5Ml Ud Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120634","B":"Ondansetron 8 Mg Odt Tablet","C":"636","D":"Q0162","F":"17.673635978162","G":"**"},{"Policy Line":"74120637","B":"Foltx (Folic Acid:B-6:B-12 Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120638","B":"Levetiracetam 500 Mg Tablet","C":"637","F":"1.347","G":"**"},{"Policy Line":"74120641","B":"Naratriptan Hcl 1 Mg Tablet","C":"637","F":"50.85"},{"Policy Line":"74120642","B":"Alendronate Na 70 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120643","B":"Risedronate Na 5 Mg Tablet","C":"637","F":"9.45"},{"Policy Line":"74120644","B":"Caspofungin 50 Mg Vial","C":"636","D":"J0637","F":"430.128"},{"Policy Line":"74120645","B":"Caspofungin 70 Mg Vial","C":"636","D":"J0637","F":"446.814"},{"Policy Line":"74120646","B":"Ferric Na Gluconate 62.5Mg/5Ml","C":"636","D":"J2916","F":"17.7181947221767","G":"**"},{"Policy Line":"74120648","B":"Lidocaine 700 Mg Patch","C":"637","F":"6.75","G":"**"},{"Policy Line":"74120650","B":"Atorvastatin 40 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120651","B":"InterferonBeta-1B 0.3MgInj Kit","C":"636","D":"J1830","F":"558.363","G":"**"},{"Policy Line":"74120653","B":"Remifentanil 1Mg Inj","C":"250","F":"77.5106347826088","G":"**"},{"Policy Line":"74120654","B":"Interferon Beta 1A 30Mcg(Avonx","C":"636","D":"Q3027","F":"6164.241"},{"Policy Line":"74120657","B":"Glatiramer 20Mg Inj","C":"636","D":"J1595","F":"301.893"},{"Policy Line":"74120659","B":"Topical Opth Dilating Solution","C":"250","F":"17.7113358490566","G":"**"},{"Policy Line":"74120661","B":"Oxcarbazepine 300Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74120662","B":"Esomeprazole","C":"637","F":"4.5","G":"**"},{"Policy Line":"74120664","B":"RHO(D) Immune Globulin 5000Iu","C":"636","D":"J2792","F":"1656.24","G":"**"},{"Policy Line":"74120665","B":"Nateglinide 60 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120666","B":"Sevelamer 400Mg Tablet","C":"637","F":"3.15"},{"Policy Line":"74120667","B":"Sevelamer 800Mg Tablet","C":"637","F":"1.575","G":"**"},{"Policy Line":"74120669","B":"Licocaine 1%/Epi 1:200 10Ml Vl","C":"250","F":"17.6891304347826","G":"**"},{"Policy Line":"74120670","B":"Cefepime 2 Gm Vial","C":"636","D":"J0692","F":"17.744737","G":"**"},{"Policy Line":"74120671","B":"Entacapone 200 Mg Tablet","C":"637","F":"6.525","G":"**"},{"Policy Line":"74120672","B":"Tolterodine La 2 Mg Capsule","C":"637","F":"5.85"},{"Policy Line":"74120673","B":"Pantoprozole Sodium 40Mg Vial","C":"636","D":"C9113","F":"17.6960088922462","G":"**"},{"Policy Line":"74120674","B":"Imatinib Mesylate 100Mg Cap","C":"636","D":"J8999","F":"34.917"},{"Policy Line":"74120675","B":"Amphetamine-Dextroamphet 5Mg","C":"637","F":"5.4"},{"Policy Line":"74120679","B":"Insulin Glargine 10Ml 100U/Ml","C":"637","D":"J1815","F":"217.125"},{"Policy Line":"74120681","B":"Xanax (Alprazolam) 0.5Mg Brand","C":"637","F":"1.35"},{"Policy Line":"74120682","B":"Morphine Sulfate 15 Mg Ir Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120684","B":"Alcoholic Beverage 1 Ea Bottle","C":"637","F":"0"},{"Policy Line":"74120685","B":"Morrhuate 5% 30Ml Vial","C":"250","F":"88.992"},{"Policy Line":"74120687","B":"Tolterodine La 4Mg Capsule","C":"637","F":"5.85","G":"**"},{"Policy Line":"74120689","B":"Advair 100/50 Inhaler","C":"637","F":"109.8","G":"**"},{"Policy Line":"74120691","B":"Advair 500/50 Inhaler","C":"637","F":"178.875","G":"**"},{"Policy Line":"74120694","B":"Metoprolol 25 Mg Xl Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120695","B":"Ramipril 1.25 Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74120698","B":"Lactulose 10 Gm Packet","C":"637","F":"6.075"},{"Policy Line":"74120699","B":"Anagrelide Hcl 0.5 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120702","B":"Atropine 1% Ophth Soltn 5Ml","C":"250","F":"17.625287007874","G":"**"},{"Policy Line":"74120704","B":"Na Citrate & Citric Acid 30 Ml","C":"637","F":"1.35"},{"Policy Line":"74120705","B":"Palivizumab 50Mg Inj","C":"636","D":"90378","F":"1907.457"},{"Policy Line":"74120706","B":"Tacrolimus Oral ImmRel 5Mg Cap","C":"636","D":"J7507","F":"17.8856470588235","G":"**"},{"Policy Line":"74120707","B":"Anagrelide Hcl 1 Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74120708","B":"Alteplase: Recombinant 2Mg/2Ml","C":"636","D":"J2997","F":"183.608901931649","G":"**"},{"Policy Line":"74120709","B":"Epirubicin 50Mg/25Ml Inj","C":"636","D":"J9178","F":"37.698"},{"Policy Line":"74120710","B":"Cytomegalovirus Imm Glob 2.5Gm","C":"636","D":"J0850","F":"1635.846"},{"Policy Line":"74120715","B":"Drotrecogin Alfa 5Mg Vial","C":"250","F":"441.561"},{"Policy Line":"74120716","B":"FactorIX Recomb1iU Benefix Inj","C":"636","D":"J7195","F":"1.854"},{"Policy Line":"74120717","B":"Didanosine Ec 200 Mg Tablet","C":"637","F":"4.05"},{"Policy Line":"74120719","B":"Lansoprazole 30Mg Granules Pkt","C":"637","F":"5.625"},{"Policy Line":"74120720","B":"Factor 7 1000Mcg","C":"636","D":"J7189","F":"2276.403"},{"Policy Line":"74120721","B":"Galantamine 8 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120722","B":"Enoxaparin Na 120 Mg Syringe","C":"636","D":"J1650","F":"17.6846014418126","G":"**"},{"Policy Line":"74120723","B":"Enoxaparin Na 150 Mg Syringe","C":"636","D":"J1650","F":"140.499871179039","G":"**"},{"Policy Line":"74120724","B":"Oxcarbazepine 150 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120729","B":"Colesevelam Hcl 625Mg Tab","C":"637","F":"2.925","G":"**"},{"Policy Line":"74120730","B":"Risedronate Na 30Mg Tab","C":"637","F":"66.825"},{"Policy Line":"74120731","B":"Zoledronic Acid 4Mg Inj","C":"636","D":"J3489","F":"119.819294117647","G":"**"},{"Policy Line":"74120732","B":"Lamivudine/Zidovudine 150/300","C":"637","F":"2.025"},{"Policy Line":"74120733","B":"Fosinopril Na 20 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120736","B":"Perindopril 2Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120737","B":"Tenofovir Disoproxil 300Mg Tab","C":"637","F":"31.95","G":"**"},{"Policy Line":"74120740","B":"Tramadol 37.5Mg/Apap Tab","C":"637","F":"1.35"},{"Policy Line":"74120741","B":"Fondaparinux Na 2.5Mg Syringe","C":"636","D":"J1652","F":"40.3288317757011","G":"**"},{"Policy Line":"74120742","B":"Lansoprazole Granules 15Mg Pkt","C":"637","F":"5.175"},{"Policy Line":"74120744","B":"Desloratadine 5 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120747","B":"Lidocaine 4% Topical 5Gm Tube","C":"250","F":"17.7229706673931","G":"**"},{"Policy Line":"74120748","B":"Olanzapine 2.5Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120749","B":"Argatroban 250Mg/2.5Ml","C":"636","D":"J0883","F":"1378.758","G":"**"},{"Policy Line":"74120751","B":"Fluoxetine 90Mg Capsule","C":"637","F":"32.625"},{"Policy Line":"74120752","B":"Bupropion Hcl 100Mg Sr Tablet","C":"637","F":"1.344","G":"**"},{"Policy Line":"74120753","B":"Miconazole Af Powder 90Gm","C":"637","F":"4.275","G":"**"},{"Policy Line":"74120754","B":"Oxcarbazepine 300Mg/5Ml 60 Ml","C":"637","F":"12.825"},{"Policy Line":"74120756","B":"Hydromorphone 25Mg/25Ml Pca","C":"250","F":"149.100631578947","G":"**"},{"Policy Line":"74120757","B":"Mycophenolate Mofetil 500Mg Vl","C":"250","F":"137.505","G":"**"},{"Policy Line":"74120758","B":"Azithromycin 600 Mg Tablet","C":"637","F":"4.05","G":"**"},{"Policy Line":"74120759","B":"Pegfilgrastim 6Mg/0.6Ml Inj","C":"636","D":"J2505","F":"5049.5235","G":"**"},{"Policy Line":"74120760","B":"Arsenic Trioxide 10Mg/10Ml Inj","C":"636","D":"J9017","F":"821.94"},{"Policy Line":"74120761","B":"Lorazepam 2Mg/Ml Oral Conc 1Ml","C":"637","F":"1.35"},{"Policy Line":"74120763","B":"Cefazolin 2Gm Inj","C":"636","D":"J0690","F":"17.922","G":"**"},{"Policy Line":"74120764","B":"Cefazolin 500Mg Inj","C":"636","D":"J0690","F":"17.8344955752212","G":"**"},{"Policy Line":"74120765","B":"Olanzapine Zydis 10 Mg Tablet","C":"637","F":"0"},{"Policy Line":"74120766","B":"Famciclovir 125 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120767","B":"Ziprasidone Hcl 20 Mg Capsule","C":"637","F":"2.484","G":"**"},{"Policy Line":"74120768","B":"Ziprasidone Hcl40 Mg Capsule","C":"637","F":"12.309","G":"**"},{"Policy Line":"74120769","B":"Fexofenadine Hcl 180 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120770","B":"Galantamine Hbr 4 Mg Tablet","C":"637","F":"2.25","G":"**"},{"Policy Line":"74120771","B":"Asparaginase 10:000 Unit Vial","C":"636","D":"J9020","F":"77.559"},{"Policy Line":"74120772","B":"Paroxetine Hcl Cr 12.5 Mg Tab","C":"637","F":"4.05","G":"**"},{"Policy Line":"74120774","B":"Tiagabine Hcl 2 Mg Tablet","C":"637","F":"6.975"},{"Policy Line":"74120775","B":"Chromagen Forte Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120777","B":"Doxercalciferol 2.5 Mcg Cap","C":"637","F":"30.375"},{"Policy Line":"74120779","B":"Aminocaproic Aci1000mg/4ml Liq","C":"637","F":"35.1"},{"Policy Line":"74120780","B":"Divalpoex Na Er 500 Mg Tablet","C":"637","F":"4.89","G":"**"},{"Policy Line":"74120781","B":"Loxapine 25 Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74120782","B":"Meloxicam 7.5 Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120783","B":"Mirtazapine Soltb 15 Mg Tablet","C":"637","F":"4.275","G":"**"},{"Policy Line":"74120784","B":"Capecitabine 500 Mg Capsule","C":"636","D":"J8521","F":"44.4552527472528","G":"**"},{"Policy Line":"74120787","B":"Hyoscyamine 0.125Mg/5 Ml 60Ml","C":"637","F":"9"},{"Policy Line":"74120788","B":"Didanosine Ec 400 Mg Capsule","C":"637","F":"7.875"},{"Policy Line":"74120789","B":"Magnesium Oxide 250 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120790","B":"Augmentin 600Mg Susp 75 Ml Bot","C":"637","F":"18.225"},{"Policy Line":"74120791","B":"Fulvastatin XL 80 Mg Tablet","C":"637","F":"9.225"},{"Policy Line":"74120792","B":"Heparin 2000 U/2 Ml Inj","C":"636","D":"J1644","F":"17.724","G":"**"},{"Policy Line":"74120793","B":"Clindamycin 900Mg/50Ml Pm","C":"250","F":"17.7146126377235","G":"**"},{"Policy Line":"74120797","B":"Risedronate Na 35 Mg Tablet","C":"637","F":"66.825"},{"Policy Line":"74120798","B":"Oxaliplatin 100Mg Inj","C":"636","D":"J9263","F":"77.559","G":"**"},{"Policy Line":"74120799","B":"Hydromorphone Syrp 1 Mg/Ml Chg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120800","B":"Thyrotropin Alfa Inj 1.1Mg","C":"636","D":"J3240","F":"1872.78475247525","G":"**"},{"Policy Line":"74120801","B":"Racepinephrine 2.25% Inh 0.5Ml","C":"250","F":"17.3425648051948","G":"**"},{"Policy Line":"74120803","B":"Olanzapine 5 Mg Quick Dis Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120804","B":"Antithymocute Globulin 250Mg","C":"636","D":"J7504","F":"2206.26"},{"Policy Line":"74120805","B":"Haloperidol Conc. 2Mg/1Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120806","B":"Gatiramer Ace 20Mg/Ml Syr Inj","C":"636","D":"J1595","F":"286.134"},{"Policy Line":"74120809","B":"Escitalopram 10Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120810","B":"Temozolomide 100Mg Capsule","C":"636","D":"J8700","F":"75.705"},{"Policy Line":"74120811","B":"Baclofen 20Mg Tab","C":"637","F":"1.347","G":"**"},{"Policy Line":"74120813","B":"Cetirizine 5Mg/5Ml Syrup","C":"637","F":"1.35"},{"Policy Line":"74120814","B":"Cetirizine 10Mg/10Ml Syrup","C":"637","F":"1.35"},{"Policy Line":"74120815","B":"Didanosine Ec 250Mg Capsule","C":"637","F":"5.175"},{"Policy Line":"74120817","B":"Methscopolamine 2.5Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74120818","B":"Carbamazepine Susp 200Mg/10Ml","C":"637","F":"2.25"},{"Policy Line":"74120819","B":"Voriconazole 200 Mg Tablet","C":"637","F":"7.425","G":"**"},{"Policy Line":"74120820","B":"Esmolol 2500Mg/Ns 250Ml Bag","C":"250","F":"455.8059","G":"**"},{"Policy Line":"74120821","B":"Niacinamide 500 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120822","B":"Cilostazol 100 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120823","B":"Zyvox 100Mg/5Ml 150Ml Susp","C":"637","F":"500.625"},{"Policy Line":"74120824","B":"Linezolid 600Mg/300 Ml Bag","C":"636","D":"J2020","F":"34.8075846982758","G":"**"},{"Policy Line":"74120825","B":"Fosphenytion 500 Mg/10 Ml Vial","C":"636","D":"Q2009","F":"17.2042942241379","G":"**"},{"Policy Line":"74120826","B":"Tacrolimus Inj 5Mg/1MlAmp","C":"636","D":"J7525","F":"240.402"},{"Policy Line":"74120827","B":"Foscarnet Na 6000Mg/250 Ml Bot","C":"636","D":"J1455","F":"476.787","G":"**"},{"Policy Line":"74120829","B":"Bimatoprost.03% Opth Sol 2.5Ml","C":"637","F":"147.825","G":"**"},{"Policy Line":"74120830","B":"Ziprasidone Mes. 20 Mg Vial","C":"636","D":"J3486","F":"45.2343527980923","G":"**"},{"Policy Line":"74120831","B":"Losartan 100 Mg Tablet","C":"637","F":"4.5","G":"**"},{"Policy Line":"74120832","B":"Valsartan 40 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120833","B":"Voriconazole 200 Mg Vial","C":"636","D":"J3465","F":"188.242289256198","G":"**"},{"Policy Line":"74120834","B":"Darbepoetin Alfa 200Mcg/1Ml","C":"636","D":"J0881","F":"1800.543"},{"Policy Line":"74120835","B":"DarbepoetinAlfa100Mcg/0.5ml In","C":"636","D":"J0881","F":"900.117"},{"Policy Line":"74120837","B":"Octreotide 30Mg Depot Kit Inj","C":"636","D":"J2353","F":"7403.331","G":"**"},{"Policy Line":"74120840","B":"Access Pak Hiv Pep Expand. Kit","C":"637","F":"1.35"},{"Policy Line":"74120841","B":"Access Pak Hiv Pep Basic Kit","C":"637","F":"1.35"},{"Policy Line":"74120842","B":"Modafinil 100 Mg Tablet","C":"637","F":"8.325","G":"**"},{"Policy Line":"74120843","B":"Zonisamide 100 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120844","B":"Cefotaxime 95Mg/1Ml Syringe","C":"250","F":"17.7297333333333","G":"**"},{"Policy Line":"74120845","B":"Metoclopramide 5Mg/1Ml Charge","C":"636","D":"J2765","F":"17.922"},{"Policy Line":"74120846","B":"Ertapenem Na 1 Gm Vial","C":"636","D":"J1335","F":"154.172093201439","G":"**"},{"Policy Line":"74120847","B":"Levofloxacin 0.5% Opth Sol 5Ml","C":"250","F":"79.722"},{"Policy Line":"74120848","B":"Carvediol 25 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120850","B":"Pentosan Polysulf Na 100Mg Cap","C":"637","F":"7.425","G":"**"},{"Policy Line":"74120851","B":"Vesanoid 10Mg Cap","C":"637","F":"24.75","G":"**"},{"Policy Line":"74120852","B":"Pimecrolimus 1% Cr 30Gm Tube","C":"637","F":"232.875","G":"**"},{"Policy Line":"74120853","B":"Dextrose 10% 5Ml Ampule","C":"258","F":"17.922"},{"Policy Line":"74120855","B":"Teriparatide 750Mcg/3Ml Injpen","C":"637","D":"J3110","F":"664.425","G":"**"},{"Policy Line":"74120856","B":"Pentobarbital 1000Mg/20Ml Vial","C":"636","D":"J2515","F":"1375.05","G":"**"},{"Policy Line":"74120857","B":"Brimodine 0.15% 0.5Ml Op Syrin","C":"637","F":"11.925"},{"Policy Line":"74120859","B":"Valproate Na Syp 50Mg/1Ml 5Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120860","B":"Dutasteride 0.5 Mg Capsule","C":"637","F":"5.4","G":"**"},{"Policy Line":"74120861","B":"Olmesartan Medoxomil 20Mg Tab","C":"637","F":"6.3","G":"**"},{"Policy Line":"74120862","B":"Fluconazole 400Mg/200Ml Pm","C":"636","D":"J1450","F":"17.7421268292683","G":"**"},{"Policy Line":"74120863","B":"Ezetimibe 10 Mg Tablet","C":"637","F":"9.444","G":"**"},{"Policy Line":"74120864","B":"Nevirapine 200 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120866","B":"Bivalirudin 250 Mg Vial","C":"636","D":"J0583","F":"1205.7432384106","G":"**"},{"Policy Line":"74120867","B":"Fomepizole 1.5Gm/1.5Ml Inj","C":"636","D":"J1451","F":"866.951000000001","G":"**"},{"Policy Line":"74120868","B":"Albendazole 200 Mg Tablet","C":"637","F":"91.8","G":"**"},{"Policy Line":"74120870","B":"Augmentin Xr 1000Mg Tab","C":"637","F":"4.95","G":"**"},{"Policy Line":"74120873","B":"Moxifloxacin 400Mg/Ns 250MlINJ","C":"636","D":"J2280","F":"43.5916599999999","G":"**"},{"Policy Line":"74120874","B":"Letrozole 2.5Mg Tab","C":"636","D":"C9399","F":"1.854","G":"**"},{"Policy Line":"74120875","B":"Oxazepam 15 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120876","B":"Moxifloxacin 400 Mg Tablet","C":"637","F":"9","G":"**"},{"Policy Line":"74120877","B":"Budesonide Ec 3 Mg Capsule","C":"637","F":"16.425","G":"**"},{"Policy Line":"74120879","B":"Granisetron 100Mcg/1Ml Syringe","C":"636","D":"J1626","F":"1.854"},{"Policy Line":"74120881","B":"Paroxetine Er 37.5 Mg Tablet","C":"637","F":"4.275"},{"Policy Line":"74120882","B":"Pravastatin 80 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120884","B":"Adenosine 90Mg/30Ml Vial","C":"636","D":"J0153","F":"85.593"},{"Policy Line":"74120887","B":"Crofab Snake Antiven<=1GM Vial","C":"636","D":"J0840","F":"2851.69478571428","G":"**"},{"Policy Line":"74120888","B":"Valganciclovir 450 Mg Tablet","C":"637","F":"75.15","G":"**"},{"Policy Line":"74120889","B":"Nacl 0.45%%/Kcl 20 Meq 1000 Ml","C":"636","D":"J3480","F":"17.6994917000572","G":"**"},{"Policy Line":"74120893","B":"Interferon Beta-1A 22Mcg(Rebif","C":"636","D":"Q3027","F":"703.284"},{"Policy Line":"74120894","B":"Olmesartan Medoxomil 40Mg Tab","C":"637","F":"8.775","G":"**"},{"Policy Line":"74120895","B":"Caffeine Citrate 60Mg/3Ml Vial","C":"636","D":"J0706","F":"17.613","G":"**"},{"Policy Line":"74120896","B":"Caffeine Citrate 20Mg/1Ml Liq","C":"637","F":"10.35","G":"**"},{"Policy Line":"74120897","B":"Caffeine&Na Benzoate 500Mg/2Ml","C":"250","F":"17.922","G":"**"},{"Policy Line":"74120898","B":"Adderall Xr 25Mg","C":"637","F":"6.3"},{"Policy Line":"74120901","B":"Sildenafil 50Mg Tablet","C":"637","F":"52.65"},{"Policy Line":"74120902","B":"Bupivacaine O.5% W/Epi 50Ml Vl","C":"250","F":"17.6973743218807","G":"**"},{"Policy Line":"74120904","B":"Buproprion Xl 150Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120905","B":"Atazanavir 200Mg Cap","C":"637","F":"20.925"},{"Policy Line":"74120906","B":"Voriconazole 50Mg Tab","C":"637","F":"5.175","G":"**"},{"Policy Line":"74120907","B":"Aripiprazole 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120910","B":"Prednisone Liquid 5Mg/5 Ml Cup","C":"636","D":"J7512","F":"1.854","G":"**"},{"Policy Line":"74120911","B":"Quetiapine Fumarate 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120912","B":"Quetiapine Fumarate 200 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120913","B":"Quinapril 40 Mg Tablet","C":"637","F":"4.05","G":"**"},{"Policy Line":"74120914","B":"Eprosartan 600 Mg Tablet","C":"637","F":"2.475"},{"Policy Line":"74120915","B":"Goserelin Acetate 10.8Mg Syrin","C":"636","D":"J9202","F":"2310.702"},{"Policy Line":"74120916","B":"Aprepitant 125Mg Cap","C":"636","D":"J8501","F":"395.829"},{"Policy Line":"74120917","B":"Aprepitant 80Mg Cap","C":"636","D":"J8501","F":"253.38"},{"Policy Line":"74120918","B":"Lamivudine Soln 25Mg/5Ml 60Ml","C":"637","F":"43.875"},{"Policy Line":"74120919","B":"Bortezomib 3.5Mg Vial","C":"636","D":"J9041","F":"2014.268","G":"**"},{"Policy Line":"74120920","B":"InsulinAspartProt/Aspar10MLInj","C":"637","D":"J1815","F":"37.125","G":"**"},{"Policy Line":"74120921","B":"Insulin Novolog 1000U/10Ml Via","C":"637","F":"37.35","G":"**"},{"Policy Line":"74120923","B":"Stalevo 50","C":"637","F":"6.525"},{"Policy Line":"74120924","B":"Stalevo 100 Tab","C":"637","F":"6.525","G":"**"},{"Policy Line":"74120925","B":"Stalevo 150","C":"637","F":"6.525","G":"**"},{"Policy Line":"74120926","B":"Gefitinib 250Mg Tab","C":"636","D":"J8565","F":"322.287"},{"Policy Line":"74120927","B":"Aripiprazole 5 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120928","B":"Aripiprazole 15Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120929","B":"Secretin Acetate 16Mcg Vial","C":"636","D":"J2850","F":"668.367"},{"Policy Line":"74120930","B":"Pramipexole 1Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120931","B":"Pramipexole 0.125Mg Tablet","C":"637","F":"5.175","G":"**"},{"Policy Line":"74120932","B":"Hepatitis A (Inac)/Hepatitis B","C":"250","F":"122.982"},{"Policy Line":"74120934","B":"Dexamethasone 1Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120935","B":"Ca Carbonate 1250Mg/5Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120936","B":"Eplerenone 25 Mg Tablet","C":"637","F":"9.45","G":"**"},{"Policy Line":"74120937","B":"Calcitonin Nasal Spray 30 Dose","C":"637","F":"56.475","G":"**"},{"Policy Line":"74120938","B":"Mesna 400 Mg Tablet","C":"637","F":"70.65"},{"Policy Line":"74120939","B":"Guaifenesin 600Mg Tbsa","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120940","B":"Morphine Sulfate Beads 30Mg Sa","C":"637","F":"4.05"},{"Policy Line":"74120941","B":"Kaletra 400/100 Liq 60 Ml Bot","C":"637","F":"9.9"},{"Policy Line":"74120942","B":"Somatropin Inj 0.4 Mg Syringe","C":"636","D":"J2941","F":"62.418"},{"Policy Line":"74120944","B":"Alfuzosin Hcl 10 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120945","B":"Rosuvastatin Ca 10 Mg Tablet","C":"637","F":"7.875","G":"**"},{"Policy Line":"74120946","B":"Memantine Hcl 5 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120947","B":"Atazanavir Sulfate 150Mg Cap","C":"637","F":"22.05","G":"**"},{"Policy Line":"74120948","B":"Fosamprenavir Ca 700 Mg Tablet","C":"637","F":"17.325"},{"Policy Line":"74120949","B":"Emrticitabine 200 Mg Capsule","C":"637","F":"16.2","G":"**"},{"Policy Line":"74120950","B":"Valsartan 320 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120951","B":"Sirolimus 1 Mg Tablet","C":"636","D":"J7520","F":"17.7653835616438","G":"**"},{"Policy Line":"74120953","B":"Nacl 0.9% 25Ml Bag","C":"258","F":"17.7001538461538","G":"**"},{"Policy Line":"74120956","B":"Magnebind-400 Tablet","C":"637","F":"1.335","G":"**"},{"Policy Line":"74120958","B":"Propafenone Sr 325Mg Tbsa","C":"637","F":"6.75","G":"**"},{"Policy Line":"74120960","B":"Daptomycin 500 Mg Vial","C":"636","D":"J0878","F":"559.315365671643","G":"**"},{"Policy Line":"74120961","B":"Zolmitriptan Zmt 2.5 Mg Tablet","C":"637","F":"87.75","G":"**"},{"Policy Line":"74120962","B":"Midazolam 100Mg/100Ml Drip","C":"636","D":"J2250","F":"81.709645229682","G":"**"},{"Policy Line":"74120963","B":"Buprenorphine-Naloxone 8Mgsltb","C":"637","F":"6.075","G":"**"},{"Policy Line":"74120964","B":"Fentanyl 2Mcg/Mlw/Marc 100Mlob","C":"636","D":"J3010","F":"32.7244738049451","G":"**"},{"Policy Line":"74120967","B":"Lansoprazole 30 Mg Soluble Tab","C":"637","F":"11.925","G":"**"},{"Policy Line":"74120968","B":"Tiotropium Inhaler/5 Capsules","C":"637","F":"34.2","G":"**"},{"Policy Line":"74120969","B":"Palonosetron 0.25Mg/5Ml Inj","C":"636","D":"J2469","F":"185.532841121495","G":"**"},{"Policy Line":"74120972","B":"Rasburicase 1.5Mg Inj","C":"636","D":"J2783","F":"978.411206896554","G":"**"},{"Policy Line":"74120973","B":"Doxorubicin 50Mg Inj","C":"636","D":"J9000","F":"35.1560802919707","G":"**"},{"Policy Line":"74120975","B":"Megestrol 400Mg/10Ml Liq Ud","C":"250","D":"J9999","F":"17.6720599161174","G":"**"},{"Policy Line":"74120976","B":"Metronidazole 0.75% Cream 45Gm","C":"637","F":"199.575","G":"**"},{"Policy Line":"74120977","B":"Cyclosporine (Gengraf) 25Mg","C":"636","D":"J7515","F":"17.922","G":"**"},{"Policy Line":"74120978","B":"Cyclosporine (Gengraf) 100Mg","C":"636","D":"J7502","F":"17.8705","G":"**"},{"Policy Line":"74120979","B":"Venlafaxine Hcl 75Mg Cpsa","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120981","B":"Oxandrolone 10 Mg Tablet","C":"637","F":"6.525"},{"Policy Line":"74120982","B":"Lansoprazole 15 Mg Soluble Tab","C":"637","F":"11.925"},{"Policy Line":"74120983","B":"Atovaquone Susp 750Mg/5Ml Pkt","C":"637","F":"24.525","G":"**"},{"Policy Line":"74120984","B":"Verapamil Pm 100Mg (Verelan)","C":"637","F":"1.35","G":"**"},{"Policy Line":"74120987","B":"Alendronate 35Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74120988","B":"Arginine Hcl 10% 300Ml","C":"250","F":"43.878"},{"Policy Line":"74120989","B":"Azacitidine 100Mg Inj","C":"636","D":"J9025","F":"734.784833333331","G":"**"},{"Policy Line":"74120990","B":"Acetylcysteine200Mg/ML INJ30ML","C":"636","D":"J0132","F":"236.98755","G":"**"},{"Policy Line":"74120991","B":"SOD Bicarbonate 4.2% 5 Ml Vial","C":"250","F":"17.922"},{"Policy Line":"74120992","B":"Metaxalone 800 Mg Tablet","C":"637","F":"4.95","G":"**"},{"Policy Line":"74120993","B":"Cyclosporin Sol 100Mg/Ml 50Ml","C":"636","D":"J7502","F":"553.11"},{"Policy Line":"74120994","B":"Pemetrexed 500Mg Inj","C":"636","D":"J9305","F":"4037.394"},{"Policy Line":"74120995","B":"Leuprolide Acetate 22.5Mg (Sq)","C":"636","D":"J9217","F":"1725.147"},{"Policy Line":"74120997","B":"Alprazolam Xr 1Mg Tbsa","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121003","B":"Hydromorphone 1Mg/1Ml Inj","C":"636","D":"J1170","F":"17.4873897122087","G":"**"},{"Policy Line":"74121004","B":"Duloxetine 30 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121005","B":"Novolin 70/30 100Units/1Ml Inj","C":"637","D":"J1815","F":"1.35"},{"Policy Line":"74121009","B":"Genteal Lubricant Eyegel 3.5Ml","C":"250","F":"17.5501775182482","G":"**"},{"Policy Line":"74121010","B":"Ketorolac 0.1Ml Ophth Syringe","C":"250","F":"17.922"},{"Policy Line":"74121011","B":"Cenestin 0.3Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74121014","B":"Venofer 100Mg/5Ml Vial","C":"636","D":"J1756","F":"37.6230909090909","G":"**"},{"Policy Line":"74121016","B":"Amiodarone Hcl 150Mg Syringe","C":"636","D":"J0282","F":"17.6244444444444","G":"**"},{"Policy Line":"74121017","B":"Cetuximab 100Mg Vial","C":"636","D":"J9055","F":"734.802"},{"Policy Line":"74121018","B":"Cromolyn Oral Conc. 100Mg/5Ml","C":"637","F":"1.35"},{"Policy Line":"74121019","B":"Lactobacillus Capsule","C":"637","F":"1.35"},{"Policy Line":"74121021","B":"Bumetanide 0.5Mg/2Ml Vial","C":"250","F":"17.922"},{"Policy Line":"74121022","B":"Amiodarone 450 Mg Vial","C":"250","F":"17.922"},{"Policy Line":"74121023","B":"Enfuvirtide 90 Mg Vial","C":"636","D":"J1324","F":"57.165"},{"Policy Line":"74121024","B":"Adderall Xr 5Mg","C":"637","F":"6.3"},{"Policy Line":"74121025","B":"Oxybutynin 3.9Mg/24Hr Patch","C":"637","F":"66.6","G":"**"},{"Policy Line":"74121026","B":"Natalizumab 300Mg/15Ml Vial","C":"636","D":"J2323","F":"5772.67967625","G":"**"},{"Policy Line":"74121028","B":"Trypan Blue (Vision Blue)0.5Ml","C":"250","F":"63.6988167938931","G":"**"},{"Policy Line":"74121029","B":"Trandolapril 4Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121031","B":"Fenofibrate 145 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74121032","B":"VonWilbrndFctr Com Inj 1IU","C":"636","D":"J7187","F":"3.10777815853548","G":"**"},{"Policy Line":"74121033","B":"Paclitaxel Proteinbnd Inj100Mg","C":"636","D":"J9264","F":"1478.874","G":"**"},{"Policy Line":"74121034","B":"Olanzapine/Fluoxeti 6/25Mg Cap","C":"637","F":"12.6"},{"Policy Line":"74121035","B":"Sodium Citrate 4% 3Ml Syringe","C":"250","F":"17.6748","G":"**"},{"Policy Line":"74121036","B":"Metformin 500Ml/5Mg Soln Ud","C":"637","F":"1.35"},{"Policy Line":"74121037","B":"Baclofen Inj 40 Mg/2O Ml","C":"636","D":"J0475","F":"842.643"},{"Policy Line":"74121040","B":"Fenofibrate 48Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74121041","B":"Gambro Bgk 2/0 5000Ml Bag","C":"250","F":"105.678","G":"**"},{"Policy Line":"74121042","B":"Gambro 4/0 5000Ml Bag","C":"250","F":"24.8054680851064","G":"**"},{"Policy Line":"74121043","B":"Acd Formula A 2.2% 1000Ml Bag","C":"250","F":"17.6725593784684","G":"**"},{"Policy Line":"74121044","B":"Ropinirole Hcl 4 Mg Tablet","C":"637","F":"4.95","G":"**"},{"Policy Line":"74121049","B":"Cadexomer Iodine 10Gm Pad","C":"250","F":"17.5982857142857","G":"**"},{"Policy Line":"74121050","B":"Duloxetine 20Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121051","B":"Nitazoxanide 500 Mg Tablet","C":"637","F":"72.45","G":"**"},{"Policy Line":"74121052","B":"Bupivacaine 0.5% 50 Ml Vial","C":"250","F":"17.7294347826087","G":"**"},{"Policy Line":"74121053","B":"Bupivacaine 0.25% 50 Ml Vial","C":"250","F":"17.6407752808989","G":"**"},{"Policy Line":"74121054","B":"Cytarabine Liposome 50Mg/5Ml","C":"636","D":"J9098","F":"3773.508"},{"Policy Line":"74121055","B":"Propafenone Sr 225 Mg Tablet","C":"637","F":"5.175","G":"**"},{"Policy Line":"74121056","B":"Cyclosporine 0.05% Opth 0.4 Ml","C":"250","F":"17.7199338076923","G":"**"},{"Policy Line":"74121058","B":"Phenylephrine 10%Viscous 5Mlop","C":"637","F":"0"},{"Policy Line":"74121059","B":"Cefdinir 300Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121060","B":"Cefdinir 125Mg/5Ml 60Ml Susp","C":"637","F":"2.025","G":"**"},{"Policy Line":"74121061","B":"Cefdinir 250Mg/5Ml 60Ml Susp","C":"637","F":"78.525"},{"Policy Line":"74121062","B":"Azithromycin 500Mg/Ns 250Ml","C":"636","D":"J0456","F":"67.362"},{"Policy Line":"74121063","B":"Hyaluronidase,Ovine200UnitsInj","C":"636","D":"J3471","F":"94.863"},{"Policy Line":"74121064","B":"Albuterol 0.5% 2.5Mg/0.5Ml Neb","C":"250","F":"17.5041646120929","G":"**"},{"Policy Line":"74121065","B":"Senna Syrup 5 Ml Dose","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121066","B":"Rifaximin 200Mg Tablet","C":"637","F":"15.75","G":"**"},{"Policy Line":"74121070","B":"Liothyronine Na 25 Mcg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121073","B":"Loteprednol 0.5% 5 Ml Opthdrop","C":"637","F":"185.175","G":"**"},{"Policy Line":"74121075","B":"Definity 1.1Mg/1Ml Vial","C":"636","D":"Q9957","F":"246.842479338843","G":"**"},{"Policy Line":"74121076","B":"Estrogens Conjugated 0.45Mg Tb","C":"637","F":"4.725"},{"Policy Line":"74121077","B":"Tigecycline 50 Mg Vial","C":"636","D":"J3243","F":"193.1256695","G":"**"},{"Policy Line":"74121078","B":"Ciprofloxacin-Dexam.Otic 7.5Ml","C":"637","F":"178.65","G":"**"},{"Policy Line":"74121079","B":"Fentanyl 5Mcg/Ml W/Marc 0.075%","C":"636","D":"J3010","F":"97.8527837837838","G":"**"},{"Policy Line":"74121080","B":"Pregabalin 75Mg Capsule","C":"637","F":"6.747","G":"**"},{"Policy Line":"74121081","B":"Fentanyl Transdermal12.5Mcg/Hr","C":"637","F":"7.2","G":"**"},{"Policy Line":"74121083","B":"Moxifloxacin 0.5% 3Ml Opth Sol","C":"250","F":"195.00475","G":"**"},{"Policy Line":"74121086","B":"Pregabalin 25 Mg Capsule","C":"637","F":"6.3","G":"**"},{"Policy Line":"74121087","B":"Cinacalcet Hcl 30 Mg Tablet","C":"637","F":"24.3","G":"**"},{"Policy Line":"74121088","B":"Isovue (Ioamidol) 61%% 100 Ml","C":"255","D":"Q9967","F":"27.2521386401674","G":"**"},{"Policy Line":"74121091","B":"Pregabalin 50Mg Capsule","C":"637","F":"6.744","G":"**"},{"Policy Line":"74121092","B":"Penicillin G Benzathine 2.4Mu","C":"636","D":"J0561","F":"345.0440775","G":"**"},{"Policy Line":"74121093","B":"Vancomycin 25Mg/0.25Ml Op Inj","C":"636","D":"J3370","F":"17.922"},{"Policy Line":"74121095","B":"Hydrocortisone 0.5% Oint","C":"637","F":"1.35"},{"Policy Line":"74121097","B":"Sildenafil Citrate 20Mg Tab","C":"637","F":"39.15","G":"**"},{"Policy Line":"74121098","B":"Ramelteon 8Mg Tablet","C":"637","F":"10.8","G":"**"},{"Policy Line":"74121099","B":"Carbonyl Iron 45 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121100","B":"Lithium Citrate 300Mg/5Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121101","B":"Darifenacin Hbr 7.5Mg Tablet","C":"637","F":"10.8"},{"Policy Line":"74121103","B":"Mometasone (Oral)Inh 220Mcg","C":"637","F":"63.225","G":"**"},{"Policy Line":"74121105","B":"Metformin Hcl Xr 750 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121107","B":"Zonisamide 25 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121108","B":"Ondansetron 4Mg Odt Tablet","C":"250","D":"Q0162","F":"17.4623937161951","G":"**"},{"Policy Line":"74121109","B":"Albuterol Inhaler Per Use 1Inh","C":"637","F":"1.35"},{"Policy Line":"74121110","B":"Lidocaine 1% Mpf 2Ml Vial","C":"636","D":"J2001","F":"17.7416385789114","G":"**"},{"Policy Line":"74121111","B":"Visipaque 320Mg/Ml 200 Ml Bot","C":"255","D":"Q9967","F":"222.789"},{"Policy Line":"74121115","B":"Poractant Alfa 240Mg/3Ml Vial","C":"250","F":"966.003438202245","G":"**"},{"Policy Line":"74121116","B":"Cefazolin/D5W 1000Mg/50Ml Bag","C":"636","D":"J0690","F":"17.6431879374111","G":"**"},{"Policy Line":"74121117","B":"Ceftriaxone/D5W 1000Mg/50Mlbag","C":"636","D":"J0696","F":"17.922"},{"Policy Line":"74121118","B":"Ceftriaxone/D5W 2000Mg/50Mlbag","C":"636","D":"J0696","F":"17.716","G":"**"},{"Policy Line":"74121119","B":"Amiodarone 400Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121120","B":"Talc (Intrapleural) 4Gm Aer","C":"250","F":"17.922"},{"Policy Line":"74121121","B":"Isradipine Cr 10Mg","C":"637","F":"3.6"},{"Policy Line":"74121122","B":"Lipase-Amylase-Proteas Creon20","C":"637","F":"4.95","G":"**"},{"Policy Line":"74121123","B":"Risperidone 50 Mg Im Inj Kit","C":"636","D":"J2794","F":"1100.658","G":"**"},{"Policy Line":"74121124","B":"Ropivacaine 1% 200Mg/20Ml Amp","C":"250","F":"17.922"},{"Policy Line":"74121125","B":"Ropivacaine 0.2% 200 Mg/100Ml","C":"250","F":"51.4210233236151","G":"**"},{"Policy Line":"74121126","B":"Fluphenazine Decan 25Mg/Ml Inj","C":"636","D":"J2680","F":"80.649"},{"Policy Line":"74121128","B":"Non-Formulary Oral Antibiotic","C":"637","F":"6.3"},{"Policy Line":"74121129","B":"Tetracaine 0.5% Ophth 5 Ml Bot","C":"250","F":"17.922"},{"Policy Line":"74121132","B":"Phenol Applicator(Apdyne)0.2Ml","C":"250","F":"17.4163636363636","G":"**"},{"Policy Line":"74121133","B":"Etanercept 25Mg/1Ml Inj","C":"636","D":"J1438","F":"706.992"},{"Policy Line":"74121134","B":"Etanercept 50Mg/1Ml Inj","C":"636","D":"J1438","F":"1442.721"},{"Policy Line":"74121135","B":"Gabapentin 200Mg/4Ml Soln Chg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121137","B":"Glycerin U.S.P. 20Ml Bottle","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121138","B":"Exenatide 300 Mcg/1.2Ml Pen","C":"637","F":"601.425"},{"Policy Line":"74121139","B":"Lopinavir-Ritonavir 200Mg/50Mg","C":"637","F":"7.2","G":"**"},{"Policy Line":"74121140","B":"Trypsin W/Castor Oil&Peruv Oin","C":"637","F":"49.95"},{"Policy Line":"74121142","B":"Ropivacaine Hcl 0.2% 10Ml Amp","C":"250","F":"17.6288461538462","G":"**"},{"Policy Line":"74121143","B":"Lamotrigine 5 Mg Chew Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121144","B":"Levalbuterol Tart 17Gm Inhaler","C":"637","F":"61.425","G":"**"},{"Policy Line":"74121145","B":"Felodipine 10Mg Tabsa","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121146","B":"Felodipine 2.5Mg Tabsa","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121147","B":"Risperidone 1 Mg/Ml Soln Chg","C":"637","F":"9.9","G":"**"},{"Policy Line":"74121149","B":"Telithromycin 400Mg Tab","C":"637","F":"14.625"},{"Policy Line":"74121150","B":"Acamprosate Ca 333 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121151","B":"Emtricitabine/Tenofovir Tablet","C":"637","F":"46.59","G":"**"},{"Policy Line":"74121156","B":"Nacl 0.9% 10Ml Charge","C":"250","F":"17.922"},{"Policy Line":"74121157","B":"Lubiprostone 24 Mcg Capsule","C":"637","F":"5.175","G":"**"},{"Policy Line":"74121158","B":"Tetracycline Syrup 500Mg/20Ml","C":"637","F":"106.425"},{"Policy Line":"74121159","B":"Trimethobenzamide 300Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74121160","B":"Decitabine 50Mg Inj Vial","C":"636","D":"J0894","F":"896.504076923076","G":"**"},{"Policy Line":"74121161","B":"Albuterol Inh Hfa 200 Inh 18Gm","C":"637","F":"45.255","G":"**"},{"Policy Line":"74121162","B":"Sodium Cl (Ayr)Nasal Gel 14.1G","C":"637","F":"2.25","G":"**"},{"Policy Line":"74121163","B":"Cefoxitin/D5W 1Gm/50Ml Bag","C":"636","D":"J0694","F":"17.922"},{"Policy Line":"74121164","B":"Cefoxitin/D5W 2Gm/50Ml","C":"636","D":"J0694","F":"25.75","G":"**"},{"Policy Line":"74121165","B":"Loteprednol 0.2% 5Ml Opth Drop","C":"637","F":"175.725"},{"Policy Line":"74121166","B":"Levetiracetam 500Mg/5 Ml Vial","C":"636","D":"J1953","F":"17.7007184579439","G":"**"},{"Policy Line":"74121168","B":"Isosorbide 20Mg/Hydralaz37.5Mg","C":"637","F":"2.925","G":"**"},{"Policy Line":"74121169","B":"Levetiracetam 100Mg/1Ml60Mlliq","C":"637","F":"13.725"},{"Policy Line":"74121173","B":"Candesartan 8Mg Tablet","C":"637","F":"2.925"},{"Policy Line":"74121174","B":"Bismuth Subgallate 200Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74121175","B":"Amoxicillin 875Mg Tablets","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121177","B":"Bupivacaine 0.75% 30Ml Mpf Via","C":"250","F":"17.922","G":"**"},{"Policy Line":"74121178","B":"Vecuronium 20Mg Inj","C":"250","F":"17.922","G":"**"},{"Policy Line":"74121179","B":"Phenylephrine 1% 50Mg/5Ml Inj","C":"636","D":"J2370","F":"35.209238207547","G":"**"},{"Policy Line":"74121180","B":"Multivitamin Childrens Chew Fe","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121181","B":"Multivitamin Childrens Chew","C":"637","F":"1.35"},{"Policy Line":"74121185","B":"Insulin Glargine 100U/Ml 3Ml","C":"637","D":"J1815","F":"67.05","G":"**"},{"Policy Line":"74121186","B":"Novolog70/30Mix 100U/Ml 3MLInj","C":"637","D":"J1815","F":"13.482","G":"**"},{"Policy Line":"74121187","B":"NovologInsulin 100U/Ml 3Ml Inj","C":"637","D":"J1815","F":"13.485","G":"**"},{"Policy Line":"74121189","B":"Isradipine Er 5 Mg Tablet","C":"637","F":"2.25"},{"Policy Line":"74121190","B":"Levalbuterol 1.25Mg/0.5Ml Neb","C":"250","F":"17.6907633354881","G":"**"},{"Policy Line":"74121191","B":"Eszopiclone 1Mg Tablet","C":"637","F":"12.6","G":"**"},{"Policy Line":"74121192","B":"Eszopiclone 2Mg Tablet","C":"637","F":"12.6"},{"Policy Line":"74121193","B":"Amoxicillin Susp 400Mg/5Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121194","B":"Varenicline 0.5 Mg Tablet","C":"637","F":"5.85","G":"**"},{"Policy Line":"74121195","B":"Lanthanum Carbonate 500Mg Chew","C":"637","F":"10.8","G":"**"},{"Policy Line":"74121196","B":"Rasagiline Mes. 0.5 Mg Tablet","C":"637","F":"20.925","G":"**"},{"Policy Line":"74121197","B":"Omega 3 Acid 1 Gm Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121198","B":"Lidocaine 4% Topical Per Use","C":"250","F":"17.7216586286433","G":"**"},{"Policy Line":"74121199","B":"Panitubumab 100Mg Injection","C":"636","D":"J9303","F":"1397.916"},{"Policy Line":"74121201","B":"Rasagiline 1Mg Tab","C":"637","F":"11.025","G":"**"},{"Policy Line":"74121202","B":"Cimetidine 200Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74121203","B":"Methylprednisolone 2000Mg Inj","C":"636","D":"J2930","F":"97.953"},{"Policy Line":"74121205","B":"Oxychlorosene Na Powder 2 Gm","C":"637","F":"9"},{"Policy Line":"74121207","B":"Atripla Tablet","C":"637","F":"61.026","G":"**"},{"Policy Line":"74121208","B":"Torsemide 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121209","B":"Vitamin E 1000 Intntunits Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121211","B":"Telmisartan 20Mg Tab","C":"637","F":"3.375","G":"**"},{"Policy Line":"74121212","B":"Estradiol 0.075Mg Pat","C":"637","F":"4.95","G":"**"},{"Policy Line":"74121213","B":"Estradiol 0.025Mg Pat","C":"637","F":"3.825"},{"Policy Line":"74121214","B":"Pramoxine 1%/Hc 1% 30Gm Cream","C":"637","F":"52.2","G":"**"},{"Policy Line":"74121215","B":"Pramoxone 2.5%/Hc 1% Crm 30Gm","C":"637","F":"96.3","G":"**"},{"Policy Line":"74121216","B":"Niacin 250Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74121217","B":"Saquinavir 500 Mg Tablet","C":"637","F":"9"},{"Policy Line":"74121218","B":"Melphalan 50Mg Inj Vial","C":"636","D":"J9245","F":"0"},{"Policy Line":"74121220","B":"Cetaphil Cream 454Gm","C":"637","F":"10.125","G":"**"},{"Policy Line":"74121221","B":"Cetaphil Compounding Veh 453Gm","C":"637","F":"11.475","G":"**"},{"Policy Line":"74121222","B":"Cromolyn Na 4% Ophth 10Ml","C":"637","F":"3.375","G":"**"},{"Policy Line":"74121223","B":"Carbamide Peroxide Liq 60Ml","C":"637","F":"6.975","G":"**"},{"Policy Line":"74121225","B":"Solifenacin Succinate 5Mg Tab","C":"637","F":"9.45","G":"**"},{"Policy Line":"74121227","B":"Sitagliptin Phosphate 50Mg Tab","C":"637","F":"12.6","G":"**"},{"Policy Line":"74121228","B":"Fat Emulsion 30% 500 Ml Bottle","C":"258","F":"69.216"},{"Policy Line":"74121229","B":"Nacl With Aloe Nasal Swab (Ayr","C":"637","F":"1.35"},{"Policy Line":"74121230","B":"Morphine 1Mg/1Ml 100Ml Epi Cas","C":"258","F":"36.771"},{"Policy Line":"74121231","B":"Hydromorphone 0.1Mg/1Ml 100Ml","C":"250","F":"17.922"},{"Policy Line":"74121232","B":"Sitagliptin 25Mg Tablet","C":"637","F":"12.6","G":"**"},{"Policy Line":"74121233","B":"Sitagliptin 100Mg Tablet","C":"637","F":"12.6","G":"**"},{"Policy Line":"74121234","B":"Risperidone 37.5 Mg Im Inj Kit","C":"636","D":"J2794","F":"768.792"},{"Policy Line":"74121238","B":"Heparin Lock Flush 500U/5Ml Vl","C":"636","D":"J1642","F":"8.69678704793028","G":"**"},{"Policy Line":"74121239","B":"Heparin LockFlush 300U/3Ml Inj","C":"636","D":"J1642","F":"17.5046344186046","G":"**"},{"Policy Line":"74121240","B":"Linezolid Susp 600Mg/30 Ml Chg","C":"637","F":"68.175","G":"**"},{"Policy Line":"74121241","B":"Meperidine 10Mg/Ml 25Ml PCA","C":"250","F":"17.7178899082569","G":"**"},{"Policy Line":"74121242","B":"Dextroamphetamine Er 5Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74121243","B":"Ropivacaine 0.2% Cassett 100Ml","C":"250","F":"156.5085","G":"**"},{"Policy Line":"74121246","B":"Fentanyl Pca 1250Mcg/25Ml Syrg","C":"636","D":"J3010","F":"33.0346769346357","G":"**"},{"Policy Line":"74121247","B":"Gambro 4/2.5 5000 Ml Bag","C":"250","F":"112.476"},{"Policy Line":"74121248","B":"HOCM: Gastrograffin 30 Ml Soln","C":"255","D":"Q9963","F":"17.7084158623694","G":"**"},{"Policy Line":"74121249","B":"Triple Nipple Cream 45Gm","C":"637","F":"60.525","G":"**"},{"Policy Line":"74121250","B":"Adalimumab 40Mg/0.8Ml Inj","C":"636","D":"J0135","F":"2826.732","G":"**"},{"Policy Line":"74121252","B":"Carvediol Er 10 Mg Capsule","C":"637","F":"8.325","G":"**"},{"Policy Line":"74121253","B":"Tropsium Cl 20 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121256","B":"Ondansetron 4Mg/5Ml Liq Ud","C":"636","D":"Q0162","F":"17.922","G":"**"},{"Policy Line":"74121257","B":"Ondansetron 2Mg/2.5Ml Ud Liq","C":"636","D":"J8597","F":"23.175"},{"Policy Line":"74121259","B":"Carvediol Er 40 Mg Capsule","C":"637","F":"8.325","G":"**"},{"Policy Line":"74121260","B":"Aliskiren 150Mg Tablet","C":"637","F":"4.95","G":"**"},{"Policy Line":"74121261","B":"Levetiracetam 500Mg/5Ml Cup","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121262","B":"Lamivudine 100Mg Tablet","C":"637","F":"14.625","G":"**"},{"Policy Line":"74121263","B":"Paliperidone 9Mg Tbsa","C":"637","F":"45.675"},{"Policy Line":"74121265","B":"Fondaparinux 7.5Mg/0.6Ml Inj","C":"636","D":"J1652","F":"119.995","G":"**"},{"Policy Line":"74121267","B":"Olanzapine 10Mg Inj Vial","C":"250","F":"41.5226092574259","G":"**"},{"Policy Line":"74121268","B":"Amantadine Syrup 50Mg/5Ml Cup","C":"637","F":"2.025"},{"Policy Line":"74121269","B":"Acetic Acid 0.25% Irr 500Ml","C":"250","F":"17.922"},{"Policy Line":"74121270","B":"Exenatide 600 Mcg/2.4Ml Pen","C":"637","F":"601.425"},{"Policy Line":"74121271","B":"Tipranavir 250Mg Capsule","C":"637","F":"11.25"},{"Policy Line":"74121272","B":"Lanthanum Carbonate 1000Mg Chw","C":"637","F":"10.8"},{"Policy Line":"74121274","B":"Torsemide 10 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121276","B":"Leflunomide 10Mg Tablet","C":"637","F":"4.5","G":"**"},{"Policy Line":"74121277","B":"Riboflavin 100Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121278","B":"Clozapine 25Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74121279","B":"Ranolazine 500Mg Tbsa","C":"637","F":"5.397","G":"**"},{"Policy Line":"74121280","B":"Lidocaine 1% 1Ml Syringe","C":"636","D":"J2001","F":"17.3050582191781","G":"**"},{"Policy Line":"74121283","B":"Lidocaine 4% Topical 50Ml Nc","C":"250","F":"0"},{"Policy Line":"74121284","B":"Ropivacaine 100Mg/20Ml Inj","C":"636","D":"J2795","F":"17.4906612244898","G":"**"},{"Policy Line":"74121285","B":"Budesibude 90Mcg Powder Flxhle","C":"637","F":"145.575","G":"**"},{"Policy Line":"74121286","B":"Candesartan 4 Mg Tablet","C":"637","F":"2.925","G":"**"},{"Policy Line":"74121287","B":"Ethacrynic Acid 25Mg Tablet","C":"637","F":"19.125"},{"Policy Line":"74121288","B":"Diphenhydramine 2% Cream 30Gm","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121289","B":"Prosed Ds (Urised Ds) 1 Ea Tab","C":"637","F":"2.475"},{"Policy Line":"74121290","B":"Cyanocobalamin 1000Mcg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121292","B":"Epoprostenol Na 1.5 Mg Vial","C":"636","D":"J1325","F":"55.929","G":"**"},{"Policy Line":"74121293","B":"Omnipaque 180Mg/Ml 10 Ml Vial","C":"636","D":"Q9965","F":"48.9761434615383","G":"**"},{"Policy Line":"74121296","B":"Omnipaque 300 Mg/Ml 200 Ml Via","C":"255","D":"Q9967","F":"353.805"},{"Policy Line":"74121298","B":"Omnipaque 350 Mg/Ml 50 Ml Vial","C":"255","D":"Q9967","F":"114.33"},{"Policy Line":"74121299","B":"Omnipaque 350 Mg/Ml 100 Ml Via","C":"255","D":"Q9967","F":"128.544"},{"Policy Line":"74121300","B":"Omnipaque 350 Mg/Ml 125 Ml Via","C":"255","D":"Q9967","F":"0"},{"Policy Line":"74121301","B":"Omnipaque 350 Mg/Ml 150 Ml Via","C":"255","D":"Q9967","F":"177.366"},{"Policy Line":"74121303","B":"Piroxicam 10Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74121304","B":"Budesonide 180 Mcg Inhaler","C":"637","F":"194.85","G":"**"},{"Policy Line":"74121305","B":"Gelfilm 12.5 Sq/Cm Pad","C":"250","F":"260.487"},{"Policy Line":"74121306","B":"Gelfoam (12 - 7 Mm) 12 Sq/Cm","C":"250","F":"17.922"},{"Policy Line":"74121307","B":"Balzalazide 750 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121308","B":"Arformoterol 15Mcg/2Ml Neb","C":"250","F":"17.8666567164179","G":"**"},{"Policy Line":"74121310","B":"Symbicort 80/4.5 Mcg 6Gm Inh","C":"637","F":"164.025","G":"**"},{"Policy Line":"74121311","B":"Symbicort 160/4.5 Mcg 6Gm Inh","C":"637","F":"188.775","G":"**"},{"Policy Line":"74121316","B":"Tretinoin 0.1% Cream 20gm tube","C":"637","F":"98.55","G":"**"},{"Policy Line":"74121317","B":"Polymyxin B 100000 Unit/Ns 5Ml","C":"250","F":"17.922"},{"Policy Line":"74121318","B":"Temsirolimus 25Mg Vial","C":"636","D":"J9330","F":"2143.842"},{"Policy Line":"74121319","B":"Fenofibrate 200Mg Capsule","C":"637","F":"2.025","G":"**"},{"Policy Line":"74121320","B":"Fenofibrate 67Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121321","B":"Fenofibrate 134Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121322","B":"Dornase Alfa Neb. Sol 1 Mg/Ml","C":"250","F":"136.80975","G":"**"},{"Policy Line":"74121323","B":"Retisert 0.59Mg Implant","C":"636","D":"J7311","F":"19392.3765","G":"**"},{"Policy Line":"74121324","B":"Mycophenolate 1000Mg/5Ml Susp","C":"636","D":"J7517","F":"50.058","G":"**"},{"Policy Line":"74121325","B":"Metoprolol Tartrate 25 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121326","B":"Nepafenac 0.1% Opth Soln 5Ml","C":"637","F":"222.525"},{"Policy Line":"74121329","B":"Sulfur Soap 10 % Bar","C":"637","F":"6.3"},{"Policy Line":"74121330","B":"Adefovir Dipivoxil 10 Mg Tab","C":"637","F":"22.05"},{"Policy Line":"74121332","B":"Abatacept 250 Mg/10 Ml Inj","C":"636","D":"J0129","F":"691.768250847456","G":"**"},{"Policy Line":"74121333","B":"Ixabepilone 15 Mg Vial","C":"636","D":"J9207","F":"1430.67"},{"Policy Line":"74121335","B":"Rivastigmine 4.6 Mg Patch","C":"637","F":"5.625","G":"**"},{"Policy Line":"74121336","B":"Cevimeline Hcl 30 Mg Capsule","C":"637","F":"6.3","G":"**"},{"Policy Line":"74121337","B":"Insulin Detemir 300 U/3Ml INJ","C":"637","D":"J1815","F":"30.6"},{"Policy Line":"74121338","B":"Retapamulin 1% Oint 15 Gm Tube","C":"637","F":"214.2"},{"Policy Line":"74121339","B":"Methenamine Mandelate 0.5 Gm","C":"637","F":"1.35"},{"Policy Line":"74121340","B":"Mesalamine 1.2 Gm Tab","C":"637","F":"8.325","G":"**"},{"Policy Line":"74121341","B":"Rivastigmine 9.5 Mg Patch","C":"637","F":"6.075","G":"**"},{"Policy Line":"74121342","B":"Benzocaine-Glycerin Spr .75 Oz","C":"637","F":"3.825"},{"Policy Line":"74121343","B":"Doxycycline 100Mg/Ns 250Ml","C":"250","F":"17.7237735849056","G":"**"},{"Policy Line":"74121344","B":"Erlotinib 100 Mg Tab","C":"636","D":"C9399","F":"301.584"},{"Policy Line":"74121345","B":"Erlotinib 150 Mg Tab","C":"636","D":"C9399","F":"331.866"},{"Policy Line":"74121346","B":"Tramadol Er 100Mg Tbsa","C":"637","F":"2.475"},{"Policy Line":"74121347","B":"Raltegravir 400Mg Tab","C":"637","F":"20.88","G":"**"},{"Policy Line":"74121348","B":"Esmomeprazole 40Mg Inj","C":"250","F":"17.922"},{"Policy Line":"74121349","B":"Rosuvastatin 5Mg Tab","C":"637","F":"7.875","G":"**"},{"Policy Line":"74121350","B":"Temozolomide 20 Mg Capsule","C":"636","D":"J8700","F":"49.44"},{"Policy Line":"74121351","B":"Rosuvastatin Ca 40 Mg Tablet","C":"637","F":"7.875","G":"**"},{"Policy Line":"74121352","B":"Stalevo 200 Tablet","C":"637","F":"6.525","G":"**"},{"Policy Line":"74121355","B":"Esomeprazole 20 Mg Cap","C":"637","F":"7.425"},{"Policy Line":"74121356","B":"Carbidopa/Levo 25/100 1 Ea Odt","C":"637","F":"1.353","G":"**"},{"Policy Line":"74121357","B":"Clopidogrel 300 Mg Tablet","C":"250","F":"17.7303417721519","G":"**"},{"Policy Line":"74121358","B":"Omalizumab 150 Mg/1.2 Ml Vial","C":"636","D":"J2357","F":"1289.29034831461","G":"**"},{"Policy Line":"74121359","B":"Tiotropium Inhaler 30 Capsules","C":"637","F":"233.1","G":"**"},{"Policy Line":"74121363","B":"Heparin 30,000 UnitS/30Ml Vial","C":"636","D":"J1644","F":"17.6595289575289","G":"**"},{"Policy Line":"74121364","B":"Cefotetan/D5W 1 Gm/50 Ml Bag","C":"250","F":"17.5751632653061","G":"**"},{"Policy Line":"74121365","B":"Cefotetan/D5W 2Gm/50Ml Bag","C":"250","F":"17.6873164556962","G":"**"},{"Policy Line":"74121366","B":"Nebivolol 5Mg Tablet","C":"637","F":"3.6","G":"**"},{"Policy Line":"74121368","B":"Triesence 40Mg/Ml Ophth Inj","C":"636","D":"J3300","F":"191.58","G":"**"},{"Policy Line":"74121369","B":"Erlotinib 25Mg Tab","C":"636","D":"C9399","F":"106.914"},{"Policy Line":"74121370","B":"Galantamine Hydrobrom Er 8 Mg","C":"637","F":"4.5","G":"**"},{"Policy Line":"74121371","B":"Galantamine Hydrobrom Er 16 Mg","C":"637","F":"9.675"},{"Policy Line":"74121372","B":"Caphosol Artificial Saliva30Ml","C":"637","F":"6.75","G":"**"},{"Policy Line":"74121373","B":"Anti-Inhibitor Coag 1 Unit Chg","C":"636","D":"J7198","F":"1.854","G":"**"},{"Policy Line":"74121374","B":"Dalteparin Sodium 2500 Units","C":"636","D":"J1645","F":"32.136"},{"Policy Line":"74121375","B":"Adderal Xr 10Mg","C":"637","F":"6.3"},{"Policy Line":"74121376","B":"Paliperidone 3 Mg Tbsa","C":"637","F":"30.6","G":"**"},{"Policy Line":"74121377","B":"Entecavir 0.5 Mg Tablet","C":"637","F":"41.175","G":"**"},{"Policy Line":"74121378","B":"Etomidate 2 Mg/Ml 20 Ml Vial","C":"250","F":"17.586477960644","G":"**"},{"Policy Line":"74121380","B":"Regadenoson 0.4 Mg/5Ml Syringe","C":"636","D":"J2785","F":"298.224038839286","G":"**"},{"Policy Line":"74121381","B":"Lidocaine 4% 4 Ml Kit","C":"250","F":"17.922","G":"**"},{"Policy Line":"74121382","B":"Bendamustine Hcl 100 Mg/20 Ml","C":"636","D":"J9033","F":"3783.396"},{"Policy Line":"74121383","B":"Poole'S Diaper Rash Cream120Gm","C":"637","F":"13.5","G":"**"},{"Policy Line":"74121384","B":"Dalteparin Sodium 12500 Units","C":"636","D":"J1645","F":"130.398"},{"Policy Line":"74121385","B":"Dalteparin Sodium 15000 Units","C":"636","D":"J1645","F":"156.663"},{"Policy Line":"74121386","B":"Dalteparin Sodium 18000 Units","C":"636","D":"J1645","F":"188.181"},{"Policy Line":"74121387","B":"Dalteparin Sodium 5000 Units","C":"636","D":"J1645","F":"52.221"},{"Policy Line":"74121388","B":"Dalteparin Sodium 10000 Units","C":"636","D":"J1645","F":"104.442"},{"Policy Line":"74121389","B":"Dalteparin Sodium 7500 Units","C":"636","D":"J1645","F":"78.177"},{"Policy Line":"74121390","B":"Meropenem 500 Mg Vial","C":"636","D":"J2185","F":"17.7198736621823","G":"**"},{"Policy Line":"74121391","B":"Maraviroc 150Mg Tablet","C":"637","F":"13.95"},{"Policy Line":"74121392","B":"Amphetamine-Dextroamphet 20Mg","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121393","B":"Amphetamine-Dextroamphet 10Mg","C":"637","F":"1.35"},{"Policy Line":"74121394","B":"Fondaparinux Na 5 Mg/0.4 Ml","C":"636","D":"J1652","F":"121.128","G":"**"},{"Policy Line":"74121395","B":"Clofarabine 20 Mg/20 Ml Vial","C":"636","D":"J9027","F":"1909.62","G":"**"},{"Policy Line":"74121396","B":"Zolpidem 12.5Mg Tbsa","C":"637","F":"15.075"},{"Policy Line":"74121397","B":"Nisoldipine 8.5 Mg Er Tablet","C":"637","F":"4.05","G":"**"},{"Policy Line":"74121398","B":"Ca Gluconate 650Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74121399","B":"Morphine 5Mg Inj","C":"636","D":"J2270","F":"17.922"},{"Policy Line":"74121400","B":"Advair 250/50 Mcg 14 Dose Inh","C":"637","F":"108.978","G":"**"},{"Policy Line":"74121401","B":"Micafungin Sodium 100 Mg Vial","C":"636","D":"J2248","F":"79.5123986013984","G":"**"},{"Policy Line":"74121403","B":"Diclofenac 1% Gel 100 Gm Tube","C":"637","F":"45.9","G":"**"},{"Policy Line":"74121404","B":"Insulin Reg Hum 500 U/Ml 20ML","C":"636","D":"J1815","F":"88.992","G":"**"},{"Policy Line":"74121405","B":"Cabergoline 0.5 Mg Tablet","C":"636","D":"J8515","F":"20.5656666666667","G":"**"},{"Policy Line":"74121406","B":"Dimethyl Sulfoxide 50% 50 Ml","C":"636","D":"J1212","F":"668.676","G":"**"},{"Policy Line":"74121407","B":"Hyaluronidase 150 Mg/1Ml/Vial","C":"636","D":"J3470","F":"45.423"},{"Policy Line":"74121408","B":"Levetiracetam Xr 500Mg Tab","C":"637","F":"6.3","G":"**"},{"Policy Line":"74121409","B":"Lubiprostone 8 Mcg Capsule","C":"637","F":"5.175","G":"**"},{"Policy Line":"74121410","B":"Clindamycin 300 Mg/50Ml Premix","C":"250","F":"17.6443867303102","G":"**"},{"Policy Line":"74121411","B":"Cefazolin 2 Gm/100 Ml Premix","C":"250","F":"17.7024090469249","G":"**"},{"Policy Line":"74121412","B":"Tussionex Syrup 5 Ml Dose","C":"637","F":"2.25","G":"**"},{"Policy Line":"74121413","B":"Budesonide 0.25% Neb Soln","C":"250","F":"17.922"},{"Policy Line":"74121414","B":"Alvimopan 12Mg Cap","C":"637","F":"118.8","G":"**"},{"Policy Line":"74121415","B":"Desvenlafaxine 50Mg Tablet","C":"637","F":"7.425","G":"**"},{"Policy Line":"74121416","B":"Tetan/Diph/Acel Tdap 0.5ml Inj","C":"636","D":"90715","F":"50.5938684505263","G":"**"},{"Policy Line":"74121418","B":"Daclizumab 25 Mg/5 Ml Vial","C":"636","D":"J7513","F":"882.813"},{"Policy Line":"74121419","B":"Febuxostat 40Mg Tablet","C":"637","F":"4.95","G":"**"},{"Policy Line":"74121420","B":"Hyaluronidase (Hylenex)150Unit","C":"636","D":"J3473","F":"70.4538727272729","G":"**"},{"Policy Line":"74121422","B":"Estradiol 0.1 Mg Pat (Vivelle)","C":"637","F":"19.8","G":"**"},{"Policy Line":"74121423","B":"Estradiol 0.075 Mg Pat (Vivell","C":"637","F":"19.8"},{"Policy Line":"74121424","B":"Estradiol 0.0375 Mg Pat (Vivel","C":"637","F":"4.95","G":"**"},{"Policy Line":"74121425","B":"Pantoprazole Sodium 40 Mg Pkt","C":"637","F":"12.6"},{"Policy Line":"74121426","B":"Somatropin 8.8 Mg Vial","C":"636","D":"J2941","F":"1477.947"},{"Policy Line":"74121428","B":"Fluocinolone Ace. Shampoo Bot","C":"637","F":"338.175"},{"Policy Line":"74121429","B":"Didanosine Ec 125 Mg Capsule","C":"637","F":"4.05"},{"Policy Line":"74121431","B":"Insulin Glulisine 300 Unit/3Ml","C":"637","F":"88.65"},{"Policy Line":"74121432","B":"Beclomethasone Hfa Oral 80Mcg","C":"637","F":"74.475","G":"**"},{"Policy Line":"74121433","B":"Teniposide 50 Mg/5 Ml Inj","C":"636","D":"Q2017","F":"3177.756"},{"Policy Line":"74121434","B":"Methadone 5Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121435","B":"Posaconazole 105Ml 200 Mg/5Ml","C":"250","F":"1192.122"},{"Policy Line":"74121436","B":"Guaifen-Phenyle 400Mg/10Mgtab","C":"637","F":"1.35"},{"Policy Line":"74121437","B":"Guaife-Phenyle 100Mg/7.5Mg-5Ml","C":"637","F":"4.725"},{"Policy Line":"74121438","B":"Iothalamate Meglumine 250 Ml","C":"255","D":"Q9958","F":"17.7139352752294","G":"**"},{"Policy Line":"74121439","B":"Darunavir 400 Mg Tab","C":"637","F":"18.9"},{"Policy Line":"74121440","B":"Darunavir 600 Mg Tab","C":"637","F":"22.05","G":"**"},{"Policy Line":"74121441","B":"Phenylephrine-Chlorphen-Dm60Ml","C":"637","F":"8.55"},{"Policy Line":"74121442","B":"Etravirine 100 Mg Tab","C":"637","F":"8.775","G":"**"},{"Policy Line":"74121443","B":"Clozapine 100 Mg Tablet","C":"637","F":"1.575","G":"**"},{"Policy Line":"74121444","B":"Dapsone 100Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121446","B":"Cadexomer Iodine Sterile 5 Gm","C":"250","F":"17.716","G":"**"},{"Policy Line":"74121453","B":"Cadexomer Iodine 40 Gm Nocharg","C":"250","F":"0"},{"Policy Line":"74121454","B":"Hydromorphone Hcl 8 Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74121455","B":"Tapentadol 50 Mg Tab","C":"637","F":"4.725","G":"**"},{"Policy Line":"74121456","B":"Permethrin 1 % Lotion 60Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121457","B":"Na Hyaluronate 25 Mg/2.5Ml Syr","C":"636","D":"J7321","F":"293.241"},{"Policy Line":"74121458","B":"Norepinephrine/D5W 16Mg/250Mg","C":"250","F":"72.7957313084112","G":"**"},{"Policy Line":"74121459","B":"Remifentanil Hcl 2Mg Injection","C":"250","F":"156.045"},{"Policy Line":"74121460","B":"Imatinib Mesylate 400 Mg Tab","C":"636","D":"J8999","F":"146.603333333333","G":"**"},{"Policy Line":"74121461","B":"Non Formulary Liquid 60Ml","C":"637","F":"18.9"},{"Policy Line":"74121462","B":"Selegiline 6 Mg/24 Hr Pat","C":"637","F":"47.025","G":"**"},{"Policy Line":"74121463","B":"Non-Formulary Drug 5 Ml Syra","C":"637","F":"1.35"},{"Policy Line":"74121465","B":"Dizoxide Oral 50 Mg/Ml Dose","C":"637","F":"8.55"},{"Policy Line":"74121466","B":"Humalog 50/50 300 Unit/3Ml Pen","C":"637","F":"17.1"},{"Policy Line":"74121467","B":"Fulvestrant 250 Mg/5 Ml Inj","C":"636","D":"J9395","F":"1145.463"},{"Policy Line":"74121468","B":"Ferumoxytol 510 Mg/17 Ml Vial","C":"636","D":"Q0138","F":"904.805347941174","G":"**"},{"Policy Line":"74121469","B":"Risedronate Na 150 Mg Tab","C":"637","F":"289.35"},{"Policy Line":"74121470","B":"Quetiapine Xr 300 Mg Tbsa","C":"637","F":"18.12","G":"**"},{"Policy Line":"74121471","B":"Alum & Mag Hydrox-Sim 30Ml Cup","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121472","B":"Proteinase Inhibitor 1Mg Inj","C":"636","D":"J0256","F":"1.854"},{"Policy Line":"74121474","B":"Posaconazole Susp 200Mg/5Ml Ud","C":"637","F":"56.475","G":"**"},{"Policy Line":"74121475","B":"Prasugrel 5 Mg Tablet","C":"637","F":"13.725","G":"**"},{"Policy Line":"74121476","B":"Prasugrel 10 Mg Tablet","C":"250","F":"17.7246606606607","G":"**"},{"Policy Line":"74121478","B":"Dronedarone Hcl 400 Mg Tablet","C":"637","F":"9","G":"**"},{"Policy Line":"74121479","B":"Aztreonam 1 Gm/50 Ml Bag","C":"250","F":"42.333"},{"Policy Line":"74121480","B":"Aztreonam 2 Gm/50 Ml Bag","C":"250","F":"84.975"},{"Policy Line":"74121481","B":"Vancomycin/D5W 1Gm/200 Ml Ivpb","C":"636","D":"J3370","F":"17.922"},{"Policy Line":"74121482","B":"Memantine Hcl 10 Mg Tablet","C":"637","F":"6.075","G":"**"},{"Policy Line":"74121484","B":"Cocaine 4% 10Ml Solution","C":"250","F":"539.823"},{"Policy Line":"74121485","B":"Lidocaine Hcl 3.5 %/5 Ml Gel","C":"250","F":"17.6748","G":"**"},{"Policy Line":"74121486","B":"Cyanocobalamin 250 Mcg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121487","B":"Pyridostigmine 60 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74121488","B":"Hydromorphone 30 Mg/30 Ml Syrd","C":"250","F":"284.28"},{"Policy Line":"74121489","B":"Cocaine 4% 4 Ml Solution","C":"250","F":"215.682","G":"**"},{"Policy Line":"74121490","B":"Nitroglycerin 50 Mg/D5W 500Ml","C":"250","F":"17.922"},{"Policy Line":"74121491","B":"Clonazepam 0.5 Mg Odt","C":"637","F":"1.35"},{"Policy Line":"74121492","B":"Interferon Beta-1A 44Mcg/0.5Ml","C":"250","D":"Q3028","F":"703.284"},{"Policy Line":"74121493","B":"Zoledronic Acid 5Mg/100Ml Bot","C":"636","D":"J3489","F":"1375.668","G":"**"},{"Policy Line":"74121494","B":"Adenosine 90 Mg/Ns 90 Ml Bag","C":"636","D":"J0153","F":"84.4394000000001","G":"**"},{"Policy Line":"74121495","B":"Ranolazine 1000 Mg Tbsa","C":"637","F":"8.775","G":"**"},{"Policy Line":"74121496","B":"Diclofenac Epolamine 1.3 % Pat","C":"637","F":"10.575","G":"**"},{"Policy Line":"74121997","B":"Azelastine Hcl Opth 0.05% 6 Ml","C":"637","F":"8.325","G":"**"},{"Policy Line":"74121998","B":"Conivaptan/D5W 20 Mg/100Ml Bag","C":"636","D":"C9488","F":"763.848"},{"Policy Line":"74121999","B":"Vancomycin 250Mg/5 Ml Oral Sol","C":"637","F":"1.575","G":"**"},{"Policy Line":"74122000","B":"Paricalcitol 1 Mcg Cap","C":"637","F":"7.875"},{"Policy Line":"74122002","B":"Pseudoephedrine W/ Dm-Gg 10 Ml","C":"637","F":"1.35"},{"Policy Line":"74122003","B":"Prednisolone 10Mg Odt Tablet","C":"637","F":"10.35","G":"**"},{"Policy Line":"74122004","B":"Prednisolone 15Mg Odt Tablet","C":"637","F":"17.325","G":"**"},{"Policy Line":"74122005","B":"Prednisolone 15Mg/5Ml Soltn","C":"636","D":"J7510","F":"88.065"},{"Policy Line":"74122008","B":"Buprenorphine Sl 8Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122009","B":"Fluconazole 100Mg/50 Ml Pm","C":"636","D":"J1450","F":"17.922"},{"Policy Line":"74122010","B":"Mannitol 15% 75 Gm/500 Ml Bag","C":"636","D":"J2150","F":"45.1772598425196","G":"**"},{"Policy Line":"74122011","B":"Diazepam 2.5Mg Rectal Gel","C":"637","F":"234.675"},{"Policy Line":"74122012","B":"Albuterol Hfa Inh 60Inh 8Gm","C":"637","F":"19.8","G":"**"},{"Policy Line":"74122013","B":"Pralatrexate 40 Mg/2 Ml Vial","C":"636","D":"J9307","F":"10442.964"},{"Policy Line":"74122014","B":"Sodium Cl/Bicarb Sinus Rinse","C":"637","F":"6.525","G":"**"},{"Policy Line":"74122015","B":"Tacrolimus Orl ImRel 0.5Mg Cap","C":"636","D":"J7507","F":"1.854","G":"**"},{"Policy Line":"74122016","B":"Trospium Chloride Xr 60 Mg Cap","C":"637","F":"4.95"},{"Policy Line":"74122017","B":"Atomoxetine Hcl 60Mg Cap","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122018","B":"Triptorelin Depot 3.75Mg Inj","C":"636","D":"J3315","F":"758.904"},{"Policy Line":"74122019","B":"Nicardipine/Ns 40 Mg/200Ml Iv","C":"250","F":"238.495613320965","G":"**"},{"Policy Line":"74122020","B":"Pravastatin Na 10 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122021","B":"Miconzole Powder 1.5 Oz Bot","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122022","B":"Tadalafil 5 Mg Tab","C":"637","F":"9.225","G":"**"},{"Policy Line":"74122023","B":"Lipase-Protease-Amyla Creondr6","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122024","B":"Lipas-Proteas-Amyla Zenpepdr20","C":"637","F":"4.95","G":"**"},{"Policy Line":"74122025","B":"Nebivolol Hcl 2.5 Mg Tab","C":"637","F":"3.6","G":"**"},{"Policy Line":"74122026","B":"Ibandronate Sodium 3Mg/3Ml Inj","C":"636","D":"J1740","F":"671.457"},{"Policy Line":"74122027","B":"Ibandronate Sodium 150 Mg Tab","C":"637","F":"99.9"},{"Policy Line":"74122029","B":"Cholecalciferol 50Ml 400U/Mllq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122030","B":"Immune Globulin (Gamunex) 1 Gm","C":"636","D":"J1561","F":"107.841","G":"**"},{"Policy Line":"74122031","B":"Immune Globulin (Privigen) 1Gm","C":"636","D":"J1459","F":"100.025315217391","G":"**"},{"Policy Line":"74122032","B":"Immune Globulin (Gammagard)1Gm","C":"636","D":"J1569","F":"107.461265060241","G":"**"},{"Policy Line":"74122033","B":"Triptorelin Depot 11.25Mg Inj","C":"636","D":"J3315","F":"2276.094"},{"Policy Line":"74122037","B":"Erythromycin 400 Mg/5 Ml Ud","C":"637","F":"18.45","G":"**"},{"Policy Line":"74122038","B":"Sertraline 20Mg/Ml ORAL Syr","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122039","B":"Ofatumumab 100 Mg/5 Ml Vial","C":"636","D":"J9302","F":"675.361190476191","G":"**"},{"Policy Line":"74122040","B":"Acetaminophen 80 Mg/0.8Ml Liq","C":"637","F":"1.35"},{"Policy Line":"74122041","B":"Ferric Subsulfate (Monsel) 8Ml","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122042","B":"Iloprost 10 Mcg/Ml Neb Soln","C":"250","F":"157.59"},{"Policy Line":"74122043","B":"Quetiapine Xr 50 Mg Tab","C":"637","F":"7.398","G":"**"},{"Policy Line":"74122044","B":"Quetiaapine Xr 200 Mg Tablet","C":"637","F":"14.361","G":"**"},{"Policy Line":"74122045","B":"Saxagliptin Hcl 5 Mg Tablet","C":"637","F":"11.475","G":"**"},{"Policy Line":"74122046","B":"Liraglttide 18 Mcg/3 Ml Pen","C":"637","F":"242.1","G":"**"},{"Policy Line":"74122047","B":"Sevelamer Carbonate 2.4 Gm Pkt","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122048","B":"Lacosamide 100 Mg Tablet","C":"637","F":"12.591","G":"**"},{"Policy Line":"74122049","B":"Fesoterodine 8 Mg Er Tablet","C":"637","F":"9"},{"Policy Line":"74122050","B":"Milnacipran 50Mg Tablet","C":"637","F":"4.725"},{"Policy Line":"74122051","B":"Gatifloxacin Opth 0.5% 2.5Ml","C":"637","F":"149.85"},{"Policy Line":"74122052","B":"Rufinamide 200 Mg Tablet","C":"637","F":"8.55"},{"Policy Line":"74122053","B":"Aripiprazole 2 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122054","B":"Cabazitaxel 60 Mg/1.5 Ml Vial","C":"636","D":"J9043","F":"10022.724"},{"Policy Line":"74122055","B":"Milnacipran Hcl 25 Mg Tablet","C":"637","F":"4.725","G":"**"},{"Policy Line":"74122056","B":"Milnacipran Hcl 100 Mg Tablet","C":"637","F":"4.725"},{"Policy Line":"74122057","B":"Azithromycin 200 Mg/5 Ml Syro","C":"637","F":"7.875","G":"**"},{"Policy Line":"74122058","B":"Heparin Na 20000 Unit Vial","C":"250","F":"17.922"},{"Policy Line":"74122059","B":"Rifaximin 550 Mg Tablet","C":"637","F":"29.925","G":"**"},{"Policy Line":"74122060","B":"Oseltamivir 6 Mg/1Ml Liq","C":"637","F":"2.25","G":"**"},{"Policy Line":"74122061","B":"Pravastatin 40 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122062","B":"Denosumab 60 Mg/Ml Inj. Syra","C":"636","D":"J0897","F":"1348.91324479087","G":"**"},{"Policy Line":"74122064","B":"Lipase-Protease-Amylase 10500U","C":"637","F":"2.475","G":"**"},{"Policy Line":"74122065","B":"Fat Emulsion 20% 250 Ml Bag","C":"258","F":"17.6589219143577","G":"**"},{"Policy Line":"74122066","B":"Gentamicin In Ns 100 Mg/100 Ml","C":"636","D":"J1580","F":"17.7259038461538","G":"**"},{"Policy Line":"74122067","B":"Torsemide 50 Mg/5 Ml Vial","C":"250","F":"17.922"},{"Policy Line":"74122068","B":"Lamivudine 25 Mg/5 Ml Soltn","C":"637","F":"4.5"},{"Policy Line":"74122069","B":"Micro. Collagen Hemostat 1 Gm","C":"250","F":"241.947"},{"Policy Line":"74122070","B":"Doxercalciferol 4 Mcg/2Ml Vial","C":"250","D":"J1270","F":"17.6256033070866","G":"**"},{"Policy Line":"74122071","B":"Dabigatran Eiexilat 150 Mg Cap","C":"637","F":"5.625","G":"**"},{"Policy Line":"74122072","B":"Lamivudine 50 Mg/5 Ml Solution","C":"637","F":"1.35"},{"Policy Line":"74122075","B":"Tranexamic Acid 1000Mg/10Ml Am","C":"250","F":"62.9962463932506","G":"**"},{"Policy Line":"74122076","B":"Meningococcal Vac (Menactra)","C":"636","D":"90733","F":"140.3478","G":"**"},{"Policy Line":"74122077","B":"Etoposide Phosphate 100 Mg Via","C":"636","D":"J9181","F":"6.489"},{"Policy Line":"74122079","B":"Dabigatran Etexilate 75Mg Tab","C":"637","F":"5.625","G":"**"},{"Policy Line":"74122080","B":"Rabies Vaccine, Pcec 2.5 Intun","C":"636","D":"90675","F":"386.551365882354","G":"**"},{"Policy Line":"74122081","B":"Desmopressin 0.1 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122083","B":"Mag Sulfate 20Gm/Water 500Ml","C":"636","D":"J3475","F":"17.7363228699552","G":"**"},{"Policy Line":"74122084","B":"Cholecalciferol 1000 Units Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122085","B":"Hydrocodone 5Mg/Apap 325Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122087","B":"Oxycodone 10Mg/Apap 325Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122088","B":"Cetaphil Moisturizing Lot 16Oz","C":"637","F":"15.975"},{"Policy Line":"74122089","B":"Cetaphil Skin Cleanser 8 Oz","C":"637","F":"5.625","G":"**"},{"Policy Line":"74122090","B":"Lacosamide 50 Mg/5 Ml Syro","C":"637","F":"6.075","G":"**"},{"Policy Line":"74122091","B":"Lacosamide 100 Mg/10 Ml Syro","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122092","B":"Octreotide Depot 10 Mg Inject","C":"636","D":"J2353","F":"2472"},{"Policy Line":"74122093","B":"Methylnaltrexone 12Mg/0.6Mlinj","C":"636","D":"J2212","F":"123.363924","G":"**"},{"Policy Line":"74122094","B":"Mexiletime Hcl 250 Mg Capsule","C":"637","F":"1.35"},{"Policy Line":"74122095","B":"Eribulin Mesylate 1 Mg/2 Mlinj","C":"636","D":"J9179","F":"1385.247"},{"Policy Line":"74122097","B":"Benzocaine 20%% 0.5Ml Spray","C":"250","F":"17.6949173859433","G":"**"},{"Policy Line":"74122098","B":"Pain Ease Topical Anest 1 Ea","C":"637","F":"1.335","G":"**"},{"Policy Line":"74122099","B":"Lidocaine 1% Mpf Polyamp 10Ml","C":"636","D":"J2001","F":"17.922","G":"**"},{"Policy Line":"74122104","B":"Lacosamide 200 Mg/20 Ml Vial","C":"636","D":"C9254","F":"45.8102278481013","G":"**"},{"Policy Line":"74122105","B":"Ceftaroline Fosamil 600Mg Vial","C":"636","D":"J0712","F":"154.689613636364","G":"**"},{"Policy Line":"74122106","B":"Sevelamer Carbonate 0.8 Gm Pkt","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122107","B":"Gadobenate Dim(Multihance)10Ml","C":"255","D":"A9577","F":"47.3680663141995","G":"**"},{"Policy Line":"74122108","B":"Bupivacaine 0.25% 100 Ml Cass","C":"250","F":"17.922"},{"Policy Line":"74122109","B":"Ropivacaine 0.2% On-Q Pump 500","C":"250","F":"213.398397228637","G":"**"},{"Policy Line":"74122110","B":"Hydroxyurea 200 Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122111","B":"Bupivacaine 0.5% On-Q 100Ml","C":"250","F":"85.284"},{"Policy Line":"74122112","B":"Bupivacaine 0.25% On-Q 100Ml","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122114","B":"Bupivacaine 0.25% On-Q 400Ml","C":"250","F":"94.554"},{"Policy Line":"74122116","B":"Amiodarone 360 Mg/200 Ml Bag","C":"636","D":"J0282","F":"58.3262350838604","G":"**"},{"Policy Line":"74122117","B":"Phenylephrine 500 Mcg/5 Ml Inj","C":"636","D":"J2370","F":"17.922"},{"Policy Line":"74122118","B":"Thiothixene 10 Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74122119","B":"Mesalamine 800 Mg Tablet","C":"637","F":"8.1","G":"**"},{"Policy Line":"74122120","B":"Fixodent 21Gm Cream","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122121","B":"Fesoterodine Fumurate 4Mg Tab","C":"637","F":"9","G":"**"},{"Policy Line":"74122122","B":"Dulera 200 Mcg/5 Mcg Inhaler","C":"637","F":"214.425"},{"Policy Line":"74122123","B":"Colesevelam Powder 3.75 Gm Pkt","C":"637","F":"17.775","G":"**"},{"Policy Line":"74122124","B":"Levetiracetam 750 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122125","B":"Fidaxomicin 200 Mg Tab","C":"637","F":"158.4","G":"**"},{"Policy Line":"74122126","B":"Dextromethorphan Poli 30Mg/5Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122128","B":"Dextromethorphan Hbr 30Mg/10Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122129","B":"Dextrometh/Quinidine 20Mg/10Mg","C":"637","F":"11.25","G":"**"},{"Policy Line":"74122131","B":"Lidocaine 2% 10 Ml Vial","C":"636","D":"J2001","F":"17.5776102564103","G":"**"},{"Policy Line":"74122132","B":"Magnesium Sulfate 2 Gm/50Ml Sw","C":"250","D":"J3475","F":"17.7058401193317","G":"**"},{"Policy Line":"74122133","B":"Hydroxyzine 25Mg/1 Ml Vial","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122134","B":"Fosaprepitant 150Mg Inj","C":"636","D":"J1453","F":"403.941654545457","G":"**"},{"Policy Line":"74122135","B":"Tolvaptan 15 Mg Tab","C":"637","F":"351.675","G":"**"},{"Policy Line":"74122138","B":"Nelfinavir Mesylate 625 Mg Tab","C":"637","F":"8.325"},{"Policy Line":"74122139","B":"Donepezil Hcl 23 Mg Tablet","C":"637","F":"2.025","G":"**"},{"Policy Line":"74122140","B":"Methylene Blue 1%% 1Mg/Ml Amp","C":"636","D":"Q9968","F":"17.922"},{"Policy Line":"74122141","B":"Acetaminophen 1000Mg/100Ml Inj","C":"636","D":"J0131","F":"66.7994130356499","G":"**"},{"Policy Line":"74122142","B":"Zoster Vaccine Live 0.65Ml Inj","C":"250","F":"283.971"},{"Policy Line":"74122143","B":"Trastuzumab 21 Mg/1 Ml Inj","C":"636","D":"J9355","F":"261.723","G":"**"},{"Policy Line":"74122145","B":"Lidocaine 1% With Epi 10Ml Via","C":"250","F":"17.6972727272727","G":"**"},{"Policy Line":"74122146","B":"Plasma-Lyte A 1000 Ml Bag","C":"250","F":"17.6500484693878","G":"**"},{"Policy Line":"74122147","B":"Denosumab Inj 120 Mg","C":"636","D":"J0897","F":"2733.723"},{"Policy Line":"74122148","B":"Rivaroxaban 10 Mg Tablet","C":"637","F":"12.57","G":"**"},{"Policy Line":"74122149","B":"Chlorhexidine Gluc 0.12% 15Ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122150","B":"Advair 230-21 Mcg Hfa 8Gm Inh","C":"637","F":"260.1","G":"**"},{"Policy Line":"74122151","B":"Epoprostenol (Veletri)1.5Mg Vl","C":"636","D":"J1325","F":"104.299384615385","G":"**"},{"Policy Line":"74122152","B":"Silodosin 8 Mg Capsule","C":"637","F":"6.75","G":"**"},{"Policy Line":"74122153","B":"Oxymorphone Hcl 5 Mg Tab","C":"637","F":"5.625"},{"Policy Line":"74122154","B":"Levothyroine Na 100 Mcg Vial","C":"250","F":"115.469278418451","G":"**"},{"Policy Line":"74122156","B":"Camphor-Eucalyptus-Mentho 50Gm","C":"637","F":"1.35"},{"Policy Line":"74122158","B":"Tocilizumab 20 Mg/1 Ml Inj","C":"636","D":"J3262","F":"125.263846153846","G":"**"},{"Policy Line":"74122159","B":"Pilocarpine 1% Opth Soln 15 Ml","C":"250","F":"100.116","G":"**"},{"Policy Line":"74122162","B":"Belimumab 80 Mg/1 Ml Inj","C":"636","D":"J0490","F":"530.421295081965","G":"**"},{"Policy Line":"74122163","B":"Calcium W/ Vitamin D 200 Mg Ta","C":"637","F":"1.35"},{"Policy Line":"74122164","B":"Isovue 300 Mg/Ml 50 Ml Vial","C":"255","D":"Q9967","F":"17.922"},{"Policy Line":"74122165","B":"Levofloxacin 250 Mg/10 Ml Inj","C":"636","D":"J1956","F":"5.871"},{"Policy Line":"74122168","B":"Gadobenate Dim(Multihance)15Ml","C":"255","D":"A9577","F":"105.734496137012","G":"**"},{"Policy Line":"74122169","B":"Gadobenate Dim(Multihance)20Ml","C":"255","D":"A9577","F":"131.614390522648","G":"**"},{"Policy Line":"74122172","B":"Isovue 370 100 Ml Vial","C":"255","D":"Q9967","F":"17.6992406779661","G":"**"},{"Policy Line":"74122173","B":"Isovue 370 150 Ml Bot","C":"255","D":"Q9967","F":"42.5402117647059","G":"**"},{"Policy Line":"74122174","B":"Isovue-M 200 10 Ml Vial","C":"636","D":"Q9966","F":"40.1391","G":"**"},{"Policy Line":"74122175","B":"Isovue 300 200 Ml Bot","C":"255","D":"Q9967","F":"49.0282738368582","G":"**"},{"Policy Line":"74122176","B":"Isovue-M 200 20 Ml Vial","C":"636","D":"Q9966","F":"109.933616666667","G":"**"},{"Policy Line":"74122177","B":"Isovue 370 50 Mlvial","C":"255","D":"Q9967","F":"17.4011142857143","G":"**"},{"Policy Line":"74122179","B":"Benzoin Tincture 4Oz Spray","C":"637","F":"1.35"},{"Policy Line":"74122180","B":"Sunitinib Maleate 25 Mg Capsul","C":"636","D":"C9399","F":"423.33"},{"Policy Line":"74122182","B":"Hydrocodone/Apap 5Mg/325Mg Cup","C":"637","F":"2.925"},{"Policy Line":"74122183","B":"Romiplostim 250 Mcg/0.5 Ml Via","C":"636","D":"J2796","F":"2177.1522","G":"**"},{"Policy Line":"74122184","B":"Bevacizumab 10 Mg/0.4 Ml Inj","C":"636","D":"J9035","F":"97.2745873469388","G":"**"},{"Policy Line":"74122185","B":"Ropivacaine 1% 100 Mg/10 Mlinj","C":"250","F":"17.922"},{"Policy Line":"74122186","B":"Dulera 100Mcg/5Mcg Inhaler","C":"637","F":"267.975","G":"**"},{"Policy Line":"74122187","B":"Diclofenac 1.5% Top Soln 150Ml","C":"637","F":"171.45"},{"Policy Line":"74122188","B":"Roflumilast 500 Mcg Tablet","C":"637","F":"9.675","G":"**"},{"Policy Line":"74122189","B":"Silikon 1000 Ophth","C":"250","F":"619.147714285716","G":"**"},{"Policy Line":"74122190","B":"Rivaroxaban 15 Mg Tablet","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122191","B":"Dextrose 20% 500 Ml Bag","C":"258","F":"17.922"},{"Policy Line":"74122192","B":"Milk Of Magnesia 10Ml Concentr","C":"637","F":"1.35"},{"Policy Line":"74122193","B":"SOD . Thiosulfate 25% 50Ml Via","C":"250","F":"126.852631578947","G":"**"},{"Policy Line":"74122194","B":"Interferon Gamma 1B 100Mcg Via","C":"637","F":"335.7"},{"Policy Line":"74122195","B":"Ticagrelor 90 Mg Tablet","C":"637","F":"4.947","G":"**"},{"Policy Line":"74122196","B":"Efavirenz 600 Mg Tablet","C":"637","F":"29.475","G":"**"},{"Policy Line":"74122197","B":"Argatroban 50 Mg/50 Ml Vial","C":"636","D":"J0883","F":"282.606878048781","G":"**"},{"Policy Line":"74122198","B":"Linagliptin 5 Mg Tablet","C":"637","F":"11.475","G":"**"},{"Policy Line":"74122199","B":"Dasatinib 100 Mg Tab","C":"636","D":"J8999","F":"512.322"},{"Policy Line":"74122201","B":"Lidocaine Hc1 1% 50 Ml Vial","C":"636","D":"J2001","F":"17.922"},{"Policy Line":"74122202","B":"Lenalidomide 10Mg Cap","C":"636","D":"C9399","F":"0"},{"Policy Line":"74122203","B":"Lenalidomide 15Mg Cap","C":"636","D":"C9399","F":"0"},{"Policy Line":"74122204","B":"Lenalidomide 25Mg Cap","C":"636","D":"C9399","F":"885.285"},{"Policy Line":"74122205","B":"Penicillin Gk 2.5Mu/Ns 100Ml","C":"636","D":"J2540","F":"45.423"},{"Policy Line":"74122206","B":"Duke'S Mouthwash 237Mlbottle","C":"637","F":"33.525","G":"**"},{"Policy Line":"74122207","B":"Mouthwash Blm 237 Ml","C":"637","F":"22.05","G":"**"},{"Policy Line":"74122208","B":"Potassium Chl. 40Meq/20 Ml Liq","C":"637","F":"4.725"},{"Policy Line":"74122209","B":"Ritonavir 100 Mg Tab","C":"637","F":"7.65","G":"**"},{"Policy Line":"74122210","B":"Lidocaine 2% 50 Ml Vial","C":"636","D":"J2001","F":"17.922"},{"Policy Line":"74122211","B":"Rivaroxaban 20 Mg Tab","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122213","B":"Bupivacaine Liposome 1.3% 20Ml","C":"636","D":"C9290","F":"621.724159377432","G":"**"},{"Policy Line":"74122214","B":"Glycopyrrolate 0.4 Mg/2 Ml Ml","C":"250","F":"17.922"},{"Policy Line":"74122215","B":"Hydrocodone 7.5Mg/Apap 325Mg T","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122216","B":"Mannitol Inh Powder Test Kit","C":"250","F":"17.922"},{"Policy Line":"74122217","B":"Gabapentin Enacarbil Er Tab","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122219","B":"Formoterol 20 Mcq/2 Ml Neb Sol","C":"250","F":"17.7518665912945","G":"**"},{"Policy Line":"74122220","B":"Vancomycin 1250Mg/Ns 250Ml Bag","C":"636","D":"J3370","F":"41.5514401369239","G":"**"},{"Policy Line":"74122221","B":"Vancomycin 1500Mg/Ns 300Ml Bag","C":"636","D":"J3370","F":"41.5554837766788","G":"**"},{"Policy Line":"74122222","B":"Lansoprazole Sus 3Mg/Ml 90Ml","C":"637","F":"32.625","G":"**"},{"Policy Line":"74122223","B":"Vancomycin 750Mg/Ns 250Ml Inj","C":"636","D":"J3370","F":"36.4827731092437","G":"**"},{"Policy Line":"74122224","B":"Vilazodone Hcl 20 Mg Tablet","C":"637","F":"6.75","G":"**"},{"Policy Line":"74122225","B":"Pitavastatin Ca 2 Mg Tablet","C":"637","F":"7.425","G":"**"},{"Policy Line":"74122226","B":"Ribavirin 200 Mg Tablet","C":"637","F":"7.2"},{"Policy Line":"74122227","B":"Brimonidine/Timolol Opth 5 Ml","C":"637","F":"132.3","G":"**"},{"Policy Line":"74122229","B":"Levetiracetam/Ns 500 Mg/100Ml","C":"636","D":"J1953","F":"17.7236377118644","G":"**"},{"Policy Line":"74122230","B":"Levetiracetam/Ns 1000Mg/100Ml","C":"636","D":"J1953","F":"39.0927081712062","G":"**"},{"Policy Line":"74122231","B":"Vilazodone Hcl 10 Mg Tablet","C":"637","F":"6.75"},{"Policy Line":"74122232","B":"Rotigotine 1 Mg/24 Hr Patch","C":"637","F":"18.675","G":"**"},{"Policy Line":"74122233","B":"Levetiracetam Xr 750 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122234","B":"Metoclopramide 5 Mg Odt Tablet","C":"637","F":"1.35"},{"Policy Line":"74122235","B":"Ferrous Sufate Er 140Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122238","B":"Fluzone-Intradermal 0.1Ml Syr","C":"636","D":"90630","F":"17.922","G":"**"},{"Policy Line":"74122239","B":"Fluzone-High Dose 0.5Ml Syr","C":"636","D":"90662","F":"46.6481101321587","G":"**"},{"Policy Line":"74122240","B":"Ibuprofen 800 Mg/8Ml Injection","C":"636","D":"J1741","F":"17.5990810810811","G":"**"},{"Policy Line":"74122241","B":"Abatacept 125 Mg/1 Ml Syringe","C":"636","D":"J0129","F":"1218.696"},{"Policy Line":"74122242","B":"Ceftaroline Fosamil 400Mg Vial","C":"636","D":"J0712","F":"154.383623376623","G":"**"},{"Policy Line":"74122243","B":"Lidocaine 1%-Phenyleph1.5% Inj","C":"250","F":"17.922"},{"Policy Line":"74122244","B":"Saxagliptin Hcl 2.5 Mg Tablet","C":"637","F":"11.475","G":"**"},{"Policy Line":"74122245","B":"Terconazole 0.8% Vag Cr 20Gm","C":"637","F":"27.45","G":"**"},{"Policy Line":"74122246","B":"Terconazole 0.4% Vag Cr 45Gm","C":"637","F":"26.55"},{"Policy Line":"74122248","B":"Magnesium Hydroxide 311 Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74122249","B":"Tapentadol Er 100Mg Tablet","C":"637","F":"9.45"},{"Policy Line":"74122250","B":"Eculizumab 300Mg/30Ml Vial","C":"636","D":"J1300","F":"4519.7777625","G":"**"},{"Policy Line":"74122251","B":"Docusate Na 60Mg/15Ml Liq","C":"637","F":"1.35"},{"Policy Line":"74122252","B":"Carfilzomib 60Mg Vial","C":"636","D":"J9047","F":"2607.96","G":"**"},{"Policy Line":"74122253","B":"Docusate 150Mg/15Ml","C":"637","F":"1.35"},{"Policy Line":"74122254","B":"Pertuzumab 30 Mg/Ml Inj","C":"636","D":"J9306","F":"442.488"},{"Policy Line":"74122255","B":"Atropine 0.4Mg/Ml 2Ml Syringe","C":"250","F":"17.922"},{"Policy Line":"74122257","B":"Oseltamivir Phosphate 30Mg Cap","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122258","B":"Oseltamivir Phosphate 45Mg Cap","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122260","B":"Brinzolamide 1% Opth Soln 10Ml","C":"250","F":"349.788","G":"**"},{"Policy Line":"74122261","B":"Timolol Opth Soln 0.25% 5Ml","C":"637","F":"2.25"},{"Policy Line":"74122262","B":"Lidocaine 1% 50Mg/5Ml Syringe","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122265","B":"Alpha Prot Inhib 1000Mg/50Ml","C":"636","D":"J0257","F":"661.878"},{"Policy Line":"74122267","B":"Sumatriptan-Naproxen 85-500Mg","C":"637","F":"83.7"},{"Policy Line":"74122268","B":"Ranitidine 15Mg/Ml Oral Syr","C":"637","F":"1.35"},{"Policy Line":"74122269","B":"Brentuximab 50Mg Vial","C":"636","D":"J9042","F":"7342.149","G":"**"},{"Policy Line":"74122270","B":"Cefazolin/D5 2 Gm/50 Ml Bag","C":"636","D":"J0690","F":"17.348258104645","G":"**"},{"Policy Line":"74122271","B":"Calcitriol 1Mcg/Ml Oral Sol","C":"637","F":"8.55","G":"**"},{"Policy Line":"74122272","B":"Complera Tablet","C":"637","F":"80.325","G":"**"},{"Policy Line":"74122273","B":"Ambrisentan (Letairis) 5Mg Tab","C":"637","F":"277.65","G":"**"},{"Policy Line":"74122274","B":"Dexilant 30Mg Capsule","C":"637","F":"7.65"},{"Policy Line":"74122275","B":"Combivent Respimat 4Gm Inh","C":"637","F":"310.5","G":"**"},{"Policy Line":"74122276","B":"Isovue 370 125 Ml Bot","C":"255","D":"Q9967","F":"29.664"},{"Policy Line":"74122277","B":"Acthrel 100Mcg Vial","C":"636","D":"J0795","F":"1011.048"},{"Policy Line":"74122278","B":"Immune Globulin (Octagam) 1 Gm","C":"636","D":"J1568","F":"131.634"},{"Policy Line":"74122279","B":"Augmentin 250Mg/5Ml Suspension","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122280","B":"Acyclovir 5% 5 Gm Cream","C":"637","F":"657.675","G":"**"},{"Policy Line":"74122281","B":"Kadcyla 100Mg Vial","C":"636","D":"J9354","F":"3747.552"},{"Policy Line":"74122282","B":"Certolizmab 200 Mg Vial","C":"636","D":"J0717","F":"1628.121"},{"Policy Line":"74122283","B":"Nxstage Rfp 453 5000 Ml Bag","C":"250","F":"24.8253732718894","G":"**"},{"Policy Line":"74122284","B":"Nxstage Rfp 401 5000 Ml Bag","C":"250","F":"45.423"},{"Policy Line":"74122285","B":"Nxstage Rfp 454 5000 Ml Bag","C":"250","F":"45.423"},{"Policy Line":"74122286","B":"Linaclotide 145 Mcg Capsule","C":"637","F":"11.658","G":"**"},{"Policy Line":"74122287","B":"Oxymorphone Hcl Er 10 Tablet","C":"637","F":"4.5","G":"**"},{"Policy Line":"74122288","B":"Clobazam 10 Mg Tablet","C":"637","F":"15.075","G":"**"},{"Policy Line":"74122289","B":"Hydroxyprogesterone 250Mg/1Ml","C":"636","D":"J1726","F":"973.041"},{"Policy Line":"74122290","B":"Daunorubicin 20Mg/4Ml Vial","C":"636","D":"J9150","F":"168.0754","G":"**"},{"Policy Line":"74122291","B":"Dexmedetomidin 400Mcg/100Ml Vl","C":"250","F":"104.994454545455","G":"**"},{"Policy Line":"74122292","B":"Gelfoam 1 Gm Powder","C":"250","F":"93.627","G":"**"},{"Policy Line":"74122293","B":"Doxercalciferol 0.5 Mcg Tablet","C":"637","F":"5.175","G":"**"},{"Policy Line":"74122294","B":"Lurasidone Hcl 40 Mg Tablet","C":"637","F":"33.975","G":"**"},{"Policy Line":"74122295","B":"Apixaban 2.5 Mg Tab","C":"637","F":"5.85","G":"**"},{"Policy Line":"74122296","B":"Linaclotide Base 290 Mcg Cap","C":"637","F":"10.575","G":"**"},{"Policy Line":"74122297","B":"Rivastigmine 13.3 Patch","C":"637","F":"6.525","G":"**"},{"Policy Line":"74122298","B":"Ambrisentan 10 Mg Tab","C":"637","F":"277.65","G":"**"},{"Policy Line":"74122299","B":"Treprostinil 50Mg/20Ml Inj","C":"636","D":"J3285","F":"4973.046","G":"**"},{"Policy Line":"74122300","B":"Dextrose 70% 50 Ml Syrd","C":"250","F":"17.922"},{"Policy Line":"74122301","B":"Calcium Citrate 950 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122302","B":"Isovue 300 150 Ml Bottle","C":"255","D":"Q9967","F":"31.7322399999999","G":"**"},{"Policy Line":"74122303","B":"Riluzole 50 Mg Tab","C":"637","F":"2.475","G":"**"},{"Policy Line":"74122304","B":"Risperidone 0.5 Mg Odt Tablet","C":"637","F":"3.15"},{"Policy Line":"74122305","B":"Silodosin 4 Mg Cap","C":"637","F":"6.75","G":"**"},{"Policy Line":"74122306","B":"Carisoproldol 250 Mg Tablet","C":"637","F":"5.625","G":"**"},{"Policy Line":"74122307","B":"Ipilimumab 200 Mg/40 Ml Vial","C":"636","D":"J9228","F":"16868.31"},{"Policy Line":"74122308","B":"Ipilimumab 50 Mg/10 Ml Vial","C":"636","D":"J9228","F":"4217.232"},{"Policy Line":"74122309","B":"SOD Phosphat 20 Mmol/20 Ml Via","C":"250","F":"17.5435727848101","G":"**"},{"Policy Line":"74122310","B":"Saccharomyces Bou. 250 Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122312","B":"Diatrizone Na/Meg 100 Ml Bot","C":"255","F":"17.922"},{"Policy Line":"74122313","B":"Ritonavir 80 Mg/1 Ml Solution","C":"637","F":"2.025"},{"Policy Line":"74122315","B":"Hydromorphone 0.5 Mg/0.5 Mlinj","C":"636","D":"J1170","F":"17.624565788326","G":"**"},{"Policy Line":"74122316","B":"Besifloxacin 0.6% 5 Ml Bot","C":"637","F":"131.85","G":"**"},{"Policy Line":"74122317","B":"Loteprednol0.5%/Tobramycin0.3%","C":"637","F":"192.6"},{"Policy Line":"74122318","B":"Urea 10% Cr 85 Gm Tube","C":"637","F":"6.75","G":"**"},{"Policy Line":"74122319","B":"Hyaluronate Na 4 Mg/0.4 Ml Syr","C":"636","D":"J7321","F":"46.659"},{"Policy Line":"74122321","B":"Dexlansoprazole 60 Mg Capusule","C":"637","F":"7.65","G":"**"},{"Policy Line":"74122322","B":"Stalevo 75 Tablet","C":"637","F":"2.7"},{"Policy Line":"74122323","B":"Ropinirole Er 2 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122324","B":"Aclidinium 400Mcg/Dose Inhaler","C":"637","F":"267.75","G":"**"},{"Policy Line":"74122325","B":"Buprenorphin2Mg/Nalox0.5Mgfilm","C":"637","F":"3.825","G":"**"},{"Policy Line":"74122327","B":"Darunavir 800 Mg Tablet","C":"637","F":"43.875","G":"**"},{"Policy Line":"74122328","B":"Nimodipine 60 Mg/20Ml Solution","C":"637","F":"70.2","G":"**"},{"Policy Line":"74122329","B":"Phenylephrine 1% 15 Ml Spray","C":"637","F":"3.6","G":"**"},{"Policy Line":"74122330","B":"Tetracaine 0.5% 0.6Ml Opth Sol","C":"250","F":"17.922"},{"Policy Line":"74122331","B":"Doxycycline 100 Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122332","B":"Mineral Oil Lt Sterile 25 Ml","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122333","B":"Rifampin 150 Mg Capsule","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122334","B":"Ceftazidime 500 Mg Vial","C":"636","D":"J0713","F":"17.7984","G":"**"},{"Policy Line":"74122336","B":"Rimexolone 1% Opth Soln 5 Ml","C":"637","F":"76.725"},{"Policy Line":"74122337","B":"Nacl 0.9% Cold 1000Ml Bag","C":"636","D":"J7030","F":"17.5688571428572","G":"**"},{"Policy Line":"74122338","B":"Oxymetazoline/Lidocaine Nasal","C":"250","F":"17.922"},{"Policy Line":"74122339","B":"Darbepoetin Alfa 500Mcg/1Ml","C":"636","D":"J0881","F":"4500.894"},{"Policy Line":"74122341","B":"Lidocaine 2% Jelly 1 Ml Chg","C":"637","F":"1.35"},{"Policy Line":"74122342","B":"Hydromorphone/Bupiv 4Mg/100Ml","C":"250","F":"26.883"},{"Policy Line":"74122343","B":"Non-Formulary IV Antibiotic","C":"250","F":"17.922"},{"Policy Line":"74122344","B":"Midazolam Syrup 10 Mg/5Ml","C":"637","F":"5.226","G":"**"},{"Policy Line":"74122345","B":"Clindamycin 75Mg/5Ml Liq 100Ml","C":"637","F":"1.8","G":"**"},{"Policy Line":"74122346","B":"Cefotetan 1Gm/50 Ml Ns Bag","C":"250","F":"28.119"},{"Policy Line":"74122347","B":"Levofloxaxin 750 Mg Vial","C":"250","F":"68.289"},{"Policy Line":"74122348","B":"Pseudoephedrine 60 Mg Tablet","C":"637","F":"1.35"},{"Policy Line":"74122349","B":"Sodium Bicarbonate 50Meq Vial","C":"250","F":"17.7380177267987","G":"**"},{"Policy Line":"74122350","B":"Metronidazole 500 Mg Iv","C":"250","F":"17.6983815789474","G":"**"},{"Policy Line":"74122351","B":"Tetracaine 0.5% Opth Sol 1 App","C":"250","F":"17.922"},{"Policy Line":"74122352","B":"Non-Formulary Chemo Oral","C":"250","F":"17.922"},{"Policy Line":"74122353","B":"Sodium Chloride 0.9% 10Ml Vial","C":"250","F":"1.854","G":"**"},{"Policy Line":"74122355","B":"Non-Formulary Opth/Otic/Inhalr","C":"250","F":"17.922"},{"Policy Line":"74122356","B":"Oxybutynin 10% Gel 1 Gm Packet","C":"637","F":"10.35"},{"Policy Line":"74122357","B":"Wound Dressing-Ca Alginate Pad","C":"250","F":"17.922"},{"Policy Line":"74122358","B":"Fingolimod Hydrochloride 0.5Mg","C":"637","F":"240.075","G":"**"},{"Policy Line":"74122359","B":"Canagliflozin 100 Mg Tablet","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122360","B":"Hydrocod-Acetaminoph Cup 7.5Mg","C":"637","F":"2.475","G":"**"},{"Policy Line":"74122361","B":"Escitalopram 10Mg/10Ml Soln","C":"637","F":"5.625","G":"**"},{"Policy Line":"74122362","B":"Nxstage Rfp 404 5000 Ml Bag","C":"250","F":"24.7802536669543","G":"**"},{"Policy Line":"74122363","B":"Advair 115/21 Mcg Hfa Inhaler","C":"637","F":"325.35","G":"**"},{"Policy Line":"74122364","B":"Vaganciclovir 450 Mg/9 Ml Soln","C":"637","F":"92.925"},{"Policy Line":"74122365","B":"DEXMEDETOMIDINE 200MCG/50ML VL","C":"250","F":"59.019"},{"Policy Line":"74122366","B":"Magnesium Cl 10,000mg/50 ml vl","C":"250","F":"17.922"},{"Policy Line":"74122367","B":"TOBRAMYCIN 300 MG NEBULIZER","C":"250","F":"17.7177682403433","G":"**"},{"Policy Line":"74122368","B":"MORPHINE 10MG CPSA KADIAN","C":"637","F":"3.375","G":"**"},{"Policy Line":"74122369","B":"ISOVUE-IOPAMIDOL 370 200ML BOT","C":"255","D":"Q9967","F":"53.69840625","G":"**"},{"Policy Line":"74122370","B":"CONRAY 43 250 ML VIAL","C":"255","D":"Q9960","F":"15.9135"},{"Policy Line":"74122371","B":"VANCOMYCIN 1750MG/350ML IV BAG","C":"636","D":"J3370","F":"41.5370478110946","G":"**"},{"Policy Line":"74122372","B":"VANCOMYCIN 2000MG/400ML IV BAG","C":"636","D":"J3370","F":"38.3981033966073","G":"**"},{"Policy Line":"74122374","B":"DIGOXIN 0.05 MG/ML 5ML CUP","C":"637","F":"5.625","G":"**"},{"Policy Line":"74122375","B":"Pnuemoccocal 13 vaccine","C":"636","D":"90670","F":"212.710846153846","G":"**"},{"Policy Line":"74122376","B":"Indomethacin 50 mg rec supp.","C":"637","F":"87.294","G":"**"},{"Policy Line":"74122377","B":"Prothrombin Com(KCentra)1 unit","C":"636","D":"C9132","F":"1.854","G":"**"},{"Policy Line":"74122378","B":"Cadexomer Iodine Gel 10gm tube","C":"250","F":"17.7534545454546","G":"**"},{"Policy Line":"74122379","B":"Gentamicin0.1% cream 15gm tube","C":"637","F":"20.025","G":"**"},{"Policy Line":"74122380","B":"BELATACEPT(NULOJIX) 250MG VIAL","C":"636","D":"J0485","F":"1194.07004347826","G":"**"},{"Policy Line":"74122382","B":"Ciclesonide 80mcg/actu inhaler","C":"637","F":"206.1"},{"Policy Line":"74122383","B":"Carboxymethylcel. op gel .02ml","C":"637","F":"1.35"},{"Policy Line":"74122384","B":"Mirabegron","C":"637","F":"9.675","G":"**"},{"Policy Line":"74122385","B":"Phenylephrine2.5% Opth sol 5ml","C":"250","F":"39.552"},{"Policy Line":"74122386","B":"Bumetanide 2.5 mg/10 ml vial","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122387","B":"Ferric Carboxyma 750mg/15ml IV","C":"636","D":"J1439","F":"982.573915869981","G":"**"},{"Policy Line":"74122388","B":"Filgrastim TBO-Grani300MCG Inj","C":"636","D":"J1447","F":"198.820550847458","G":"**"},{"Policy Line":"74122389","B":"Filgrastim TBO Grani480MCG Inj","C":"636","D":"J1447","F":"316.562536082472","G":"**"},{"Policy Line":"74122391","B":"Famotidine in NS 20 mg/50ml PM","C":"250","F":"17.304","G":"**"},{"Policy Line":"74122392","B":"Augmentin susp. 400mg/5ml 5ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122393","B":"NA Nitrite/NA Thiosulfate Kit","C":"250","F":"17.922"},{"Policy Line":"74122395","B":"Morphine Conc. 10mg/0.5ML Oral","C":"637","F":"3.15","G":"**"},{"Policy Line":"74122396","B":"Phenylephrine 2.5% 15 ML OP","C":"250","F":"111.24","G":"**"},{"Policy Line":"74122398","B":"Vedolizumab 300 MG","C":"636","D":"J3380","F":"7286.66076129567","G":"**"},{"Policy Line":"74122399","B":"Aclidinum 400 MCG/ACT 30 Puff","C":"637","F":"64.8","G":"**"},{"Policy Line":"74122400","B":"Augmentin 125 mg/5ml oral dose","C":"637","F":"23.85"},{"Policy Line":"74122401","B":"Augmentin 600 mg/5ml oral dose","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122402","B":"Ciprofloxacin 500mg/5ml oral","C":"637","F":"6.525","G":"**"},{"Policy Line":"74122403","B":"Naproxen 125 mg/5 ml oral dose","C":"637","F":"3.825"},{"Policy Line":"74122404","B":"Idursulfase 6mg/3ml vial","C":"250","F":"3991.971"},{"Policy Line":"74122405","B":"Micafungin Sodium 50 mg vial","C":"636","D":"J2248","F":"39.7896923076924","G":"**"},{"Policy Line":"74122406","B":"Prepen 1ML INJ","C":"250","F":"125.8248","G":"**"},{"Policy Line":"74122407","B":"Histamine Positive Control 1ML","C":"250","F":"17.7366","G":"**"},{"Policy Line":"74122408","B":"Penicillin 10,000 Units Inj.","C":"250","F":"17.6748","G":"**"},{"Policy Line":"74122409","B":"SALINE NEGATIVE CONTROL 1ML S","C":"250","F":"1.854","G":"**"},{"Policy Line":"74122410","B":"Methylnaltrexone 8mg/0.4ml Inj","C":"636","D":"J2212","F":"126.018260869565","G":"**"},{"Policy Line":"74122411","B":"Pamidronate 90 mg vial","C":"636","D":"J2430","F":"47.3799999999999","G":"**"},{"Policy Line":"74122412","B":"Phenylephrine OPTH 0.5ML OPSY","C":"250","F":"17.922"},{"Policy Line":"74122416","B":"EPHEDrine Sulfate 25mg/5ml syr","C":"250","F":"17.922"},{"Policy Line":"74122417","B":"Acyclovir 5% ointment 5gm tube","C":"637","F":"95.625","G":"**"},{"Policy Line":"74122418","B":"Piperacillian/Tazobactam 13.5g","C":"636","D":"J2543","F":"70.3804771145037","G":"**"},{"Policy Line":"74122419","B":"Triamcinolone 0.025% LOT 60ml","C":"637","F":"26.1","G":"**"},{"Policy Line":"74122420","B":"Clotrimazole 1% CR 30gm tube","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122421","B":"Phenylephrine 2.5% 0.5 ML OP","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122422","B":"DOXOrubicin 10 mg vial","C":"636","D":"J9000","F":"7.107","G":"**"},{"Policy Line":"74122423","B":"NAFCILLIN 12 GM","C":"250","F":"71.05411311054","G":"**"},{"Policy Line":"74122424","B":"PSEUDOEPH-BROM-DM 20ML LIQ","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122425","B":"Conray 43 50ml vial","C":"636","D":"Q9960","F":"17.3658","G":"**"},{"Policy Line":"74122426","B":"MEDIHONEY WOUND PASTE 44ML TUB","C":"637","F":"12.6"},{"Policy Line":"74122427","B":"Gabapentin soln 300 mg/6ml cup","C":"637","F":"1.8"},{"Policy Line":"74122428","B":"Memantine HCl ER 28mg capsule","C":"637","F":"11.7","G":"**"},{"Policy Line":"74122429","B":"Memantine HCL ER 7mg capsule","C":"637","F":"11.7","G":"**"},{"Policy Line":"74122430","B":"LevETIRAcetam/NS 1500mg/100ml","C":"636","D":"J1953","F":"50.6945972222223","G":"**"},{"Policy Line":"74122431","B":"Vancomycin Retent Enema 1000MG","C":"636","F":"17.3746285714285","G":"**"},{"Policy Line":"74122432","B":"Dulera 200mcg/5mcg 60 puff inh","C":"637","F":"181.35","G":"**"},{"Policy Line":"74122433","B":"Tacrolimus 0.03% ointment 30gm","C":"637","F":"218.7"},{"Policy Line":"74122434","B":"Tacrolimus 0.1% ointment 30gm","C":"637","F":"218.7"},{"Policy Line":"74122435","B":"Eletriptan 20 mg tablet","C":"637","F":"51.3"},{"Policy Line":"74122436","B":"Acyclovir 1000 mg injection","C":"636","D":"J0133","F":"17.922"},{"Policy Line":"74122437","B":"RID COMPLETE 1-2-3 LICE KIT","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122438","B":"Cefotaxime 2 gm vial","C":"250","F":"17.922"},{"Policy Line":"74122439","B":"Pyridostigmine 60 mg/5ml syrup","C":"637","F":"10.125","G":"**"},{"Policy Line":"74122440","B":"Calcium Acetate 667mg/5ml soln","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122441","B":"Treprostinil 100 mg/20 ml vial","C":"636","D":"J3285","F":"6097.806"},{"Policy Line":"74122442","B":"Tromethamine 36mg/ml 500ml bot","C":"250","F":"308.691"},{"Policy Line":"74122443","B":"Apixaban 5 mg tablet","C":"637","F":"5.85","G":"**"},{"Policy Line":"74122444","B":"Telbivudine 600mg tablet","C":"637","F":"32.175"},{"Policy Line":"74122445","B":"Boceprevir 200 mg capsule","C":"637","F":"18"},{"Policy Line":"74122446","B":"Trizivir tablet","C":"637","F":"20.925"},{"Policy Line":"74122447","B":"Rilpivirine 25 mg tablet","C":"637","F":"29.025","G":"**"},{"Policy Line":"74122448","B":"Epzicom tablet","C":"637","F":"38.7","G":"**"},{"Policy Line":"74122449","B":"Rotigotine 4mg/24HR TD Patch","C":"637","F":"18.675","G":"**"},{"Policy Line":"74122450","B":"Dolutegravir Na 50 mg tablet","C":"637","F":"43.875","G":"**"},{"Policy Line":"74122451","B":"Dapagliflozin 5 mg tablet","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122452","B":"Tadalafil 20 mg tablet","C":"637","F":"51.975","G":"**"},{"Policy Line":"74122453","B":"Memantine XR 21 mg capsule","C":"637","F":"11.7"},{"Policy Line":"74122454","B":"Memantine XR 14 mg capsule","C":"637","F":"11.7","G":"**"},{"Policy Line":"74122455","B":"Selenium 2.5% lotion 118ml bot","C":"637","F":"9"},{"Policy Line":"74122456","B":"Tenofovir 40mg oral powder","C":"637","F":"8.775"},{"Policy Line":"74122457","B":"Nystatin&Triamcinolone Cr 60gm","C":"637","F":"40.725","G":"**"},{"Policy Line":"74122458","B":"Pylera packet of 3 capsules","C":"637","F":"6.075"},{"Policy Line":"74122459","B":"Docosanol 10% cream 2gm tube","C":"637","F":"13.95","G":"**"},{"Policy Line":"74122460","B":"ATROPINE 1% 15ML BOTTLE","C":"250","F":"97.026"},{"Policy Line":"74122461","B":"Pyrimethamine 25 mg tablet","C":"637","F":"675"},{"Policy Line":"74122462","B":"Stalevo 125 tablet","C":"637","F":"6.525"},{"Policy Line":"74122463","B":"Ivermection 3 mg tablet","C":"637","F":"3.825","G":"**"},{"Policy Line":"74122464","B":"Selegiline HCl 1.25mg tablet","C":"637","F":"58.05"},{"Policy Line":"74122465","B":"Saliva stimulant oral spray","C":"637","F":"4.05","G":"**"},{"Policy Line":"74122466","B":"Mometasone 0.1%cream 45gm tube","C":"637","F":"9"},{"Policy Line":"74122467","B":"Fluocinonide 0.05% Cr 60gmtube","C":"637","F":"45.45","G":"**"},{"Policy Line":"74122468","B":"Ciprofloxacin 0.3% opth 2.5ml","C":"250","F":"17.716","G":"**"},{"Policy Line":"74122469","B":"MEROPENEM 2GM VIAL","C":"636","D":"J2185","F":"40.8457570093455","G":"**"},{"Policy Line":"74122470","B":"FLUCONAZOLE 2MG/ML SYR (NUR)","C":"636","D":"J1450","F":"17.922"},{"Policy Line":"74122471","B":"ACYCLOVIR 5MG/ML SYR (NURSERY)","C":"636","D":"J0133","F":"5.85775714285716","G":"**"},{"Policy Line":"74122472","B":"CLINDAMYCIN 6MG/ML SYR (NUR)","C":"250","F":"9.75066666666669","G":"**"},{"Policy Line":"74122473","B":"GENTAMICIN 4MG/ML SYR (NUR)","C":"636","D":"J1580","F":"17.798824742268","G":"**"},{"Policy Line":"74122474","B":"metroNIDAZOLE 5MG/ML SYR (NUR)","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122475","B":"PENICILLIN 100,000 UNITS SYR","C":"636","D":"J2540","F":"17.7101142857143","G":"**"},{"Policy Line":"74122476","B":"VANCOMYCIN 5 MG/ML SYR (NUR)","C":"636","D":"J3370","F":"17.6859101123596","G":"**"},{"Policy Line":"74122477","B":"ZIDOVUDINE 4MG/ML SYR (NUR)","C":"636","D":"J3485","F":"17.922"},{"Policy Line":"74122478","B":"NAFCILLIN 40MG/ML SYR (NUR)","C":"250","F":"17.304","G":"**"},{"Policy Line":"74122479","B":"THIORIDAZINE HCL 10MG TABLET","C":"637","F":"1.35"},{"Policy Line":"74122480","B":"PEGLOTICASE 8MG/ML VIAL","C":"636","D":"J2507","F":"15037.3661538462","G":"**"},{"Policy Line":"74122481","B":"Malarone 250-100 mg Tablet","C":"637","F":"6.075"},{"Policy Line":"74122482","B":"Magnesium Sulf. 40meq/10ml syr","C":"636","D":"J3475","F":"17.922"},{"Policy Line":"74122483","B":"Benzocaine 20% gel 7.5ml tube","C":"637","F":"8.1","G":"**"},{"Policy Line":"74122484","B":"Rifaximin 200mg/10ml Oral Susp","C":"637","F":"15.75","G":"**"},{"Policy Line":"74122485","B":"STIBILD tabl(150-150-200-300)","C":"637","F":"88.2"},{"Policy Line":"74122486","B":"Dalbavancin HCl 500 mg vial","C":"636","D":"J0875","F":"1712.10722575","G":"**"},{"Policy Line":"74122487","B":"Celecoxib 50 mg capsule","C":"637","F":"1.35"},{"Policy Line":"74122488","B":"Tedizolid Phosphat 200mg tabl","C":"250","F":"409.734"},{"Policy Line":"74122489","B":"Tedizolid Phosphate 200mg vial","C":"636","D":"J3090","F":"326.613"},{"Policy Line":"74122490","B":"Gabapentin soln 250 mg/5ml cup","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122491","B":"Anoro 62.5/25mcg 7dose inhaler","C":"637","F":"60.525","G":"**"},{"Policy Line":"74122492","B":"Azilsartan Medoxomil 40mg tabl","C":"637","F":"5.4","G":"**"},{"Policy Line":"74122493","B":"Pentoxifylline Susp 400mg/20ml","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122494","B":"Eltrombopaq 12.5 mg tablet","C":"637","F":"136.8"},{"Policy Line":"74122495","B":"Opium tincture 6mg/0.6ml","C":"637","F":"2.025"},{"Policy Line":"74122496","B":"KETORALAC 15MG/ML INJ","C":"636","D":"J1885","F":"17.819","G":"**"},{"Policy Line":"74122497","B":"Hydroxyurea 500mg/12.5 ml oral","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122499","B":"GOLIMUMAB 50 MG/4 ML VIAL","C":"636","D":"J1602","F":"2002.13975","G":"**"},{"Policy Line":"74122500","B":"Amiodarone/D5W 150mg/100ml bag","C":"636","D":"J0282","F":"43.840052631579","G":"**"},{"Policy Line":"74122501","B":"Meningococ Vac (Menomune)","C":"636","D":"90733","F":"156.045"},{"Policy Line":"74122502","B":"Epinephrine PF sulf fr 1mg amp","C":"250","F":"17.6867032474804","G":"**"},{"Policy Line":"74122504","B":"DICLEGIS DR Tablet","C":"637","F":"5.625","G":"**"},{"Policy Line":"74122505","B":"Ketamine/NS 50 mg/5 ml syringe","C":"250","F":"17.7189428571428","G":"**"},{"Policy Line":"74122506","B":"OXYBUTYNIN syrup 5mg/5ml oral","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122507","B":"ceFEPime/D5w 16m/50ml bag","C":"636","D":"J0692","F":"17.304","G":"**"},{"Policy Line":"74122508","B":"Ramucirumab 100 Mg/10 mL Inj","C":"636","D":"J9308","F":"1412.748"},{"Policy Line":"74122509","B":"Methylphenidate 20Mg Tab","C":"637","F":"1.344","G":"**"},{"Policy Line":"74122510","B":"Mesalamine 0.375 gm Cap","C":"637","F":"3.6","G":"**"},{"Policy Line":"74122511","B":"TELAVANCIN (VIBATIV) 750MG","C":"636","D":"J3095","F":"519.719823529413","G":"**"},{"Policy Line":"74122512","B":"ORITAVANCIN (ORBACTIV) 400 MG","C":"636","D":"J2407","F":"1230.747"},{"Policy Line":"74122513","B":"Paiperidone 234mg/1.5ml syr","C":"636","D":"J2426","F":"3035.925"},{"Policy Line":"74122514","B":"Dexmedetomidine/NS 80mcg/20ml","C":"250","F":"17.922"},{"Policy Line":"74122515","B":"Estradiol Valerate 20mg/2mlInj","C":"636","D":"J1380","F":"33.681"},{"Policy Line":"74122516","B":"Riociguat (Adempas) 0.5mg tab","C":"637","F":"92.025"},{"Policy Line":"74122517","B":"Lubriderm 6oz bottle","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122518","B":"Isovue-Iopamidol-370 100ml chg","C":"255","D":"Q9967","F":"29.5490295547407","G":"**"},{"Policy Line":"74122520","B":"Fibrin Sealant Kit 2ml- EVICEL","C":"250","F":"273.229408839779","G":"**"},{"Policy Line":"74122521","B":"NS 0.9% 50ML Charge","C":"258","F":"17.2807020463847","G":"**"},{"Policy Line":"74122522","B":"Ganciclovir 0.15% opth gel 5gm","C":"637","F":"273.6","G":"**"},{"Policy Line":"74122523","B":"Senna syrup 528 mg/15ml cup","C":"637","F":"1.35"},{"Policy Line":"74122524","B":"FECAL MICROBIOTA PREPARATION","C":"250","F":"487.704999999999","G":"**"},{"Policy Line":"74122525","B":"Heparin 500U 0.45% NACL500ml","C":"636","F":"17.922"},{"Policy Line":"74122526","B":"Breo Ellipta 100/25mcg 14 dose","C":"637","F":"58.803","G":"**"},{"Policy Line":"74122528","B":"Amino Acid 10%% 500ml Neonate","C":"250","F":"17.7984","G":"**"},{"Policy Line":"74122529","B":"Lisinopril 2.5mg Tab","C":"637","F":"1.35"},{"Policy Line":"74122530","B":"TELVANCIN (VIBATIV)","C":"636","D":"J3095","F":"266.049"},{"Policy Line":"74122531","B":"Morphine 0.4mg/ml Oral Solutn","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122532","B":"Naloxegol Oxalate 25 mg tablet","C":"637","F":"9.45","G":"**"},{"Policy Line":"74122533","B":"Epinephrine Intraocular 1mg/ml","C":"250","F":"17.922"},{"Policy Line":"74122534","B":"Vancomycin 10mg/1ml opth Inj","C":"636","D":"J3370","F":"17.304","G":"**"},{"Policy Line":"74122535","B":"cefTAZadime 20mg/1ml opth Inj","C":"636","D":"J0713","F":"17.304","G":"**"},{"Policy Line":"74122536","B":"Vancomycin 100mg/1ml opth Inj","C":"636","D":"J3370","F":"17.304","G":"**"},{"Policy Line":"74122537","B":"Propranolol 20mg/5ml Oral SYR","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122538","B":"Dexamethasone 4mg/1ml opth Inj","C":"636","D":"J1100","F":"17.51","G":"**"},{"Policy Line":"74122539","B":"cefTAZadime 200mg/1ml opth Inj","C":"636","D":"J0713","F":"17.304","G":"**"},{"Policy Line":"74122540","B":"Vancomycin 5mg/1ml opth Inj","C":"636","D":"J7999","F":"17.304","G":"**"},{"Policy Line":"74122541","B":"Vancomycin 500mg/10ml opth bot","C":"250","F":"17.51","G":"**"},{"Policy Line":"74122542","B":"cefTAZidime 500mg/10ml op bott","C":"250","F":"17.51","G":"**"},{"Policy Line":"74122543","B":"DIGOXIN 100MCG/ML NEONATE INJ","C":"636","D":"J1160","F":"98.571"},{"Policy Line":"74122544","B":"DIGOXIN 10MCG/ML NEONATE INJ","C":"636","D":"J1160","F":"98.571"},{"Policy Line":"74122545","B":"Posaconazole 100 mg tablet","C":"637","F":"56.475","G":"**"},{"Policy Line":"74122546","B":"Amikacin 2mg/ml opth Inj","C":"636","D":"J0278","F":"17.922"},{"Policy Line":"74122547","B":"Amikacin 1mg/ml opth Inj","C":"636","D":"J0278","F":"17.922"},{"Policy Line":"74122548","B":"Amikacin 80mg/ml opth Inj","C":"636","D":"J0278","F":"17.922"},{"Policy Line":"74122549","B":"Digoxin 0.5mg/ml Oral Syringe","C":"637","F":"1.35"},{"Policy Line":"74122550","B":"Phenylephrine2.5% opth sol 2ml","C":"250","F":"17.4066858301158","G":"**"},{"Policy Line":"74122551","B":"Propranolol 4mg/ml Oral Syr","C":"637","F":"1.35"},{"Policy Line":"74122552","B":"Propranolol 0.1mg/ml syr (Neo)","C":"636","D":"J1800","F":"17.922"},{"Policy Line":"74122553","B":"PHENobarbital 10mg/ml IV (Neo)","C":"636","D":"J2560","F":"17.922","G":"**"},{"Policy Line":"74122554","B":"FentANYL 10mcg/ml - Neonate","C":"636","D":"J3010","F":"17.304","G":"**"},{"Policy Line":"74122555","B":"Neostigmine 4mg/4ml inj","C":"636","D":"J2710","F":"51.294"},{"Policy Line":"74122556","B":"Indomethacin 1mg/ml Inj","C":"636","D":"J3490","F":"428.274"},{"Policy Line":"74122557","B":"DOCEtaxel 10MG/ML INJ","C":"636","D":"J9171","F":"35.063775","G":"**"},{"Policy Line":"74122558","B":"CEFTAZIDIME/AVIBACTAM 2.5GM IV","C":"636","D":"J0714","F":"374.806252173912","G":"**"},{"Policy Line":"74122559","B":"Thrombin Top. 20,000 unit vial","C":"250","F":"353.401936073061","G":"**"},{"Policy Line":"74122560","B":"Furosemide oral 10mg/1 ml cup","C":"637","F":"1.8","G":"**"},{"Policy Line":"74122561","B":"IdaruCIZUMAB 2.5gm/50ml vial","C":"636","D":"C9399","F":"2152.185","G":"**"},{"Policy Line":"74122562","B":"Ivabradine 5 mg tablet","C":"637","F":"6.525","G":"**"},{"Policy Line":"74122564","B":"Entresto 24mg/26mg tablet","C":"637","F":"6.525","G":"**"},{"Policy Line":"74122565","B":"Mugard oral rinse 240ml bottle","C":"637","F":"477"},{"Policy Line":"74122566","B":"Cefazolin/NS 3000mg/100ml bag","C":"636","D":"J0690","F":"17.7425806451613","G":"**"},{"Policy Line":"74122567","B":"DARUNAVIR/COBICISTAT TABLET","C":"637","F":"50.175","G":"**"},{"Policy Line":"74122568","B":"Enzalutamide (Xtandi) 40mg cap","C":"637","F":"0"},{"Policy Line":"74122569","B":"Suvorexant (Belsomra) 10mg tab","C":"637","F":"9.225","G":"**"},{"Policy Line":"74122570","B":"Armodafinil (Nuvigil) 50mg tab","C":"637","F":"6.525"},{"Policy Line":"74122571","B":"Phenyleprine& Ketorolac 4ml vl","C":"636","D":"J1097","F":"590.767475409837","G":"**"},{"Policy Line":"74122572","B":"Tobramycin 5mg/ml Lock Soltn","C":"636","D":"J3260","F":"17.922"},{"Policy Line":"74122573","B":"Epinephrine-LidocainePFSF 2ml","C":"636","D":"J0171","F":"25.4392008733624","G":"**"},{"Policy Line":"74122574","B":"Palbociclib(Ibrance) 125mg cap","C":"636","D":"J8999","F":"664.659"},{"Policy Line":"74122575","B":"Ponatinib(Iclusig) 45mg tab","C":"637","F":"287.325"},{"Policy Line":"74122576","B":"Olopatadine HCL 30.5gm Nasinh","C":"637","F":"248.175"},{"Policy Line":"74122577","B":"Ergoloid Mesylates 1mg tablet","C":"637","F":"5.85"},{"Policy Line":"74122578","B":"NEPAFENAC/ILEVRO 0.3%% 3ML OPT","C":"637","F":"222.525"},{"Policy Line":"74122579","B":"Isavuconazonium 372mg Inj","C":"636","D":"J1833","F":"347.625"},{"Policy Line":"74122580","B":"Blephamide eye oint 3.5gm tube","C":"637","F":"108.45"},{"Policy Line":"74122581","B":"FLOVENT DISKUS 50MCG","C":"637","F":"132.3","G":"**"},{"Policy Line":"74122582","B":"Vortioxetine HBR 10 mg tablet","C":"637","F":"10.35","G":"**"},{"Policy Line":"74122583","B":"Lamotrigine ODT 100 mg tablet","C":"637","F":"7.2"},{"Policy Line":"74122584","B":"NELARABINE 250MG/50ML VIAL","C":"636","D":"J9261","F":"935.961"},{"Policy Line":"74122585","B":"Abiraterone (Zytiga) 250mg tab","C":"637","F":"70.425"},{"Policy Line":"74122586","B":"Cytarabine 100mg/5ml PF vial","C":"636","D":"J9100","F":"7.88641791044775","G":"**"},{"Policy Line":"74122587","B":"Cytarabine 2GM/20ml PF vial","C":"636","D":"J9100","F":"27.7393244680851","G":"**"},{"Policy Line":"74122588","B":"Fluocinolone 0.01% 60ml soln","C":"637","F":"68.4"},{"Policy Line":"74122589","B":"Nivolumab 40 mg/4ml vial","C":"636","D":"J9299","F":"1315.413"},{"Policy Line":"74122590","B":"Nivolumab 100mg/10ml vial","C":"636","D":"J9299","F":"3288.687"},{"Policy Line":"74122591","B":"Rytary ER 36.25/145mg cap","C":"637","F":"2.25"},{"Policy Line":"74122592","B":"RYTARY ER 23.75-95 MG CAPSULE","C":"637","F":"2.25","G":"**"},{"Policy Line":"74122593","B":"DARUNAVIR 100 MG/ML ORAL SUSP","C":"637","F":"3.6"},{"Policy Line":"74122594","B":"Vorapaxar Sulfate 2.08 mg tab","C":"637","F":"8.55"},{"Policy Line":"74122595","B":"Zerbaxa 1.5 gm vial","C":"636","D":"J0695","F":"121.135923076923","G":"**"},{"Policy Line":"74122596","B":"Palbociclib 100mg caps","C":"636","D":"J8999","F":"664.659"},{"Policy Line":"74122597","B":"Palbociclib 75mg caps","C":"636","D":"J8999","F":"664.659"},{"Policy Line":"74122598","B":"Harvoni 90-400mg tab","C":"637","F":"1012.5"},{"Policy Line":"74122599","B":"DARBEPOETIN ALFA 100 MCG/MLINJ","C":"636","D":"J0881","F":"900.117"},{"Policy Line":"74122600","B":"Trypsin W/Castor Oil&Peruv CAN","C":"637","F":"10.125"},{"Policy Line":"74122601","B":"Ursodiol Susp 60mg/ml Syr oral","C":"637","F":"5.4"},{"Policy Line":"74122602","B":"Aquadeks Ped 60ml drops","C":"637","F":"18.9"},{"Policy Line":"74122603","B":"Hyaluronate Na 20 mg/2 ml vial","C":"636","D":"J7321","F":"240.5256","G":"**"},{"Policy Line":"74122605","B":"Breo Ellipta 200/25mcg 14 dose","C":"637","F":"58.884","G":"**"},{"Policy Line":"74122606","B":"Risperidone 25 Mg Im Inj Kit","C":"636","F":"550.329","G":"**"},{"Policy Line":"74122607","B":"Cadexomer 5gm Pad","C":"637","F":"14.4","G":"**"},{"Policy Line":"74122608","B":"Gelclair oral 15ml gel pack","C":"637","F":"34.2"},{"Policy Line":"74122609","B":"Dymista nasal spray","C":"637","F":"160.875","G":"**"},{"Policy Line":"74122610","B":"Tacrolimus XL EXREL 1mg cap","C":"636","D":"J7508","F":"5.562","G":"**"},{"Policy Line":"74122612","B":"Peramivir 200mg/20ml vial","C":"636","D":"J2547","F":"403.245","G":"**"},{"Policy Line":"74122614","B":"Cholecalciferol 5000 Units Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122615","B":"Tapentadol Er 50Mg Tablet","C":"637","F":"5.175","G":"**"},{"Policy Line":"74122616","B":"Dextrose 50%% 500ml bag","C":"250","D":"J7799","F":"17.6848604651163","G":"**"},{"Policy Line":"74122617","B":"Iodine tincture 30ml bottle","C":"637","F":"1.35"},{"Policy Line":"74122618","B":"Bendamustine (BENDEKA) 25MG/ML","C":"636","D":"J9034","F":"732.639"},{"Policy Line":"74122619","B":"Olmesartan Medoxomil 5mg tab","C":"637","F":"5.175","G":"**"},{"Policy Line":"74122620","B":"Dasatinib Chemo RX140mg Tab","C":"636","D":"J8999","F":"512.322"},{"Policy Line":"74122621","B":"Tyvaso 1.74mg/2.9ml neb","C":"250","F":"235.458"},{"Policy Line":"74122622","B":"Ofloxacin 0.3% Opth 10ml","C":"250","F":"17.922"},{"Policy Line":"74122623","B":"Diclofenac Sodium 37.5 mg vial","C":"636","D":"J1130","F":"17.922"},{"Policy Line":"74122624","B":"Teriparatide 600mcg/2.4ml INJ","C":"637","D":"J3110","F":"2698.2","G":"**"},{"Policy Line":"74122625","B":"Genvoya tablet","C":"637","F":"82.575","G":"**"},{"Policy Line":"74122626","B":"Cobicistat 150 mg tablet","C":"637","F":"6.075"},{"Policy Line":"74122627","B":"Elvitegravir 85 mg tablet","C":"637","F":"36.225"},{"Policy Line":"74122628","B":"Elvitegravir 150 mg tablet","C":"637","F":"36.225"},{"Policy Line":"74122630","B":"Sugammadex Na 200mg/2ml vial","C":"636","D":"J3490","F":"146.395334433523","G":"**"},{"Policy Line":"74122631","B":"Ciprofloxacin 60mg/ml Inj Susp","C":"636","D":"J7342","F":"347.867358999999","G":"**"},{"Policy Line":"74122632","B":"Mepolizumab 100mg Vial","C":"636","D":"J2182","F":"2555.95061818182","G":"**"},{"Policy Line":"74122633","B":"Daratumumab 100mg/5ml SDV","C":"636","D":"J9145","F":"612.830064516129","G":"**"},{"Policy Line":"74122634","B":"Daratumumab 400mg/20ml SDV","C":"636","D":"J9145","F":"2462.421"},{"Policy Line":"74122635","B":"Ketoconazole 2%% Cr 30Gm","C":"637","F":"37.575"},{"Policy Line":"74122637","B":"Lurasidone HCl 20mg Tablet","C":"637","F":"33.975","G":"**"},{"Policy Line":"74122638","B":"Bourdreaux's butt paste","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122639","B":"Lansoprazole Sus 3mg/ml Oral","C":"637","F":"1.35"},{"Policy Line":"74122640","B":"Tranexamic Acid 650mg Tablet","C":"637","F":"3.825","G":"**"},{"Policy Line":"74122641","B":"Reslizumab 100mg/10ml vial","C":"636","D":"J2786","F":"1081.55200990099","G":"**"},{"Policy Line":"74122642","B":"Heparin 30U INJ 1/2NS 30ml Syr","C":"636","F":"17.7761797752809","G":"**"},{"Policy Line":"74122643","B":"Heparin 30U IV 1/2NaACE 30mlSy","C":"250","F":"17.883375","G":"**"},{"Policy Line":"74122644","B":"Cangrelor 50 mg vial","C":"636","D":"C9460","F":"953.574"},{"Policy Line":"74122645","B":"Gemcitabine 1000MG/26.3ml vial","C":"636","D":"J9201","F":"179.529"},{"Policy Line":"74122646","B":"Ketorolac 0.5%% 3 ml Op Sol","C":"250","F":"4.326","G":"**"},{"Policy Line":"74122647","B":"Ibrutinib 140mg capsule","C":"637","F":"110.925"},{"Policy Line":"74122648","B":"Ruxolitinib 10mg tablet","C":"637","F":"173.25"},{"Policy Line":"74122649","B":"Dobutamine Inj 500Mg/250ml","C":"636","D":"J1250","F":"17.922"},{"Policy Line":"74122650","B":"Dopamine 400Mg Inj D5W 250Ml","C":"636","D":"J1265","F":"17.304","G":"**"},{"Policy Line":"74122651","B":"Ibuprofen 800 Mg/100Ml IV Bag","C":"636","D":"J1741","F":"17.6654716981132","G":"**"},{"Policy Line":"74122652","B":"Mifepristone 300mg tablet","C":"637","F":"388.8"},{"Policy Line":"74122653","B":"Sorafenib Tosylate 200mg tab","C":"637","F":"123.525"},{"Policy Line":"74122654","B":"Triumeq tablet","C":"637","F":"74.025","G":"**"},{"Policy Line":"74122655","B":"Brimonidine 0.2%% Opth Sol 5Ml","C":"250","F":"17.7099411764706","G":"**"},{"Policy Line":"74122656","B":"Edoxaban 30 Mg Tablet","C":"637","F":"6.75","G":"**"},{"Policy Line":"74122657","B":"Zerbaxa 4.5 gm vial","C":"636","D":"J0695","F":"343.823927710842","G":"**"},{"Policy Line":"74122658","B":"Heparin 500Units D10W500ml INJ","C":"636","D":"J1644","F":"17.922"},{"Policy Line":"74122659","B":"MEDIHONEY WOUND GEL 15 ML TUBE","C":"637","F":"4.275"},{"Policy Line":"74122660","B":"Raltegravir 100Mg Chew tab","C":"637","F":"5.175"},{"Policy Line":"74122661","B":"Apremilast 30 mg Tablet","C":"637","F":"44.325"},{"Policy Line":"74122662","B":"Nabumetone 500mgTablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122663","B":"Factor 7 2000Mcg","C":"636","D":"J7189","F":"4379.457"},{"Policy Line":"74122664","B":"Factor 7 5000Mcg","C":"636","D":"J7189","F":"10948.488"},{"Policy Line":"74122665","B":"Factor 7 8000Mcg","C":"636","D":"J7189","F":"17517.519"},{"Policy Line":"74122666","B":"Oxymorphone Hcl Er 5mgTablet","C":"637","F":"1.35"},{"Policy Line":"74122668","B":"Atezolizumab 1200mg/20ml SDV","C":"636","D":"J9022","F":"9049.992"},{"Policy Line":"74122669","B":"Etravirine 200 Mg Tab","C":"637","F":"17.55"},{"Policy Line":"74122670","B":"Oxycodone 15 Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122671","B":"Raltegravir 100Mg powder pack","C":"637","F":"5.175"},{"Policy Line":"74122672","B":"Clonidine 20 mcg/ml ORAL SYR","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122673","B":"Tapentadol Er 250Mg Tablet","C":"637","F":"19.35"},{"Policy Line":"74122674","B":"Brivaracetam 50 mg/5ml vial","C":"636","D":"C9399","F":"54.384"},{"Policy Line":"74122675","B":"Atomoxetine Hcl 80Mg Cap","C":"637","F":"13.95"},{"Policy Line":"74122676","B":"Alogliptin 25 mf tablet","C":"637","F":"11.25"},{"Policy Line":"74122677","B":"Vortioxetine HBR 5 mg tablet","C":"637","F":"10.35","G":"**"},{"Policy Line":"74122678","B":"Patiromer Ca Sorbitex8.4gm pkt","C":"637","F":"26.775","G":"**"},{"Policy Line":"74122680","B":"LOCM Visipaque 320MGI 150 Ml","C":"255","D":"Q9967","F":"190.035"},{"Policy Line":"74122681","B":"Insulin Degludec 300 Unit/3Ml","C":"637","F":"26.55","G":"**"},{"Policy Line":"74122682","B":"Phytonadione (K1) 5Mg /0.5ml","C":"637","F":"15.075","G":"**"},{"Policy Line":"74122683","B":"ceFEPime/D5w 2000mg/50ml bag","C":"636","D":"J0692","F":"17.922"},{"Policy Line":"74122684","B":"Estazolam 2Mg Tab","C":"637","F":"1.35"},{"Policy Line":"74122685","B":"USTEKINUMAB IV INJ 130MG/26ML","C":"636","D":"J3358","F":"2004.98215384615","G":"**"},{"Policy Line":"74122686","B":"Ustekinumab 45mg/0.5ml Inj","C":"636","D":"J3357","F":"9866.37"},{"Policy Line":"74122687","B":"Ustekinumab 90mg/ml Inj","C":"636","D":"J3357","F":"19560.627","G":"**"},{"Policy Line":"74122688","B":"Dehydrated alcohol 5Ml VIAL","C":"250","F":"119.583","G":"**"},{"Policy Line":"74122689","B":"Phytonadione (K1) 1Mg /0.5ml","C":"637","F":"13.299","G":"**"},{"Policy Line":"74122690","B":"Dasatinib 50 Mg Tab","C":"636","D":"J8999","F":"284.589"},{"Policy Line":"74122691","B":"Ruxolitinib 5mg tablet","C":"637","F":"164.025"},{"Policy Line":"74122692","B":"Theophylline Sa 100Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122693","B":"Theophylline Sa 200Mg Tab","C":"637","F":"2.475","G":"**"},{"Policy Line":"74122694","B":"Ryanodex 250mg vial","C":"250","D":"J3490","F":"2323.371","G":"**"},{"Policy Line":"74122695","B":"Vemurafenib 240mg tab","C":"636","D":"J8999","F":"57.474"},{"Policy Line":"74122696","B":"Sildenafil 2.5mg/ml syringe","C":"637","F":"4.725"},{"Policy Line":"74122697","B":"Ticagrelor 60 Mg Tablet","C":"637","F":"4.95","G":"**"},{"Policy Line":"74122698","B":"Incruse Ellipta 7dose inhaler","C":"637","F":"35.412","G":"**"},{"Policy Line":"74122699","B":"Triamcinalone 025%% Cr 454GM","C":"637","F":"12.15","G":"**"},{"Policy Line":"74122700","B":"Mycophenolate 500 Mg Capsule","C":"636","D":"J7517","F":"17.7297462406015","G":"**"},{"Policy Line":"74122701","B":"Neulasta Inj Delivery Kit 6mg","C":"636","D":"J2505","F":"6144.156"},{"Policy Line":"74122702","B":"Oral GLucose 3ml syr","C":"637","F":"1.35"},{"Policy Line":"74122703","B":"Ferrous Sulfate 15Mg/Ml SYR","C":"637","F":"1.35"},{"Policy Line":"74122704","B":"Isovue (Ioamidol) 61%% 100 Ml","C":"255","D":"Q9967","F":"17.82312"},{"Policy Line":"74122705","B":"Fluocinolone Ace.0.01%%Oil Bo","C":"637","F":"158.85"},{"Policy Line":"74122706","B":"Tetracaine 0.5%% 4Ml Opth Sol","C":"250","F":"17.6575624907885","G":"**"},{"Policy Line":"74122708","B":"Gammagard 30gm vial","C":"636","D":"J1569","F":"3207.18825","G":"**"},{"Policy Line":"74122709","B":"Gammagard 20Gm vial","C":"636","D":"J1569","F":"2133.977999","G":"**"},{"Policy Line":"74122710","B":"Gammagard 10gm vial","C":"636","D":"J1569","F":"1039.95168342857","G":"**"},{"Policy Line":"74122711","B":"Gammagard Liquid 5gm vial","C":"636","D":"J1569","F":"497.897617021278","G":"**"},{"Policy Line":"74122712","B":"Dexamethasone 10Mg/Ml PF Neo","C":"250","F":"16.377","G":"**"},{"Policy Line":"74122713","B":"ChemoTher-Pazopanib 200mg tab","C":"636","D":"J8999","F":"116.802"},{"Policy Line":"74122714","B":"Privigen 5 gm Vial","C":"636","D":"J1459","F":"458.246147586207","G":"**"},{"Policy Line":"74122715","B":"Ketotifen 0.25%%Opth 5Ml/Drops","C":"637","F":"3.375","G":"**"},{"Policy Line":"74122716","B":"Privigen 40gm Vial","C":"636","D":"J1459","F":"3943.91821276596","G":"**"},{"Policy Line":"74122717","B":"Privigen 20gm Vial","C":"636","D":"J1459","F":"1859.16659035714","G":"**"},{"Policy Line":"74122718","B":"Privigen 10gm vial","C":"636","D":"J1459","F":"947.067302727273","G":"**"},{"Policy Line":"74122719","B":"Pentacel Vaccine 0.5Ml Inj","C":"636","D":"90698","F":"106.605","G":"**"},{"Policy Line":"74122720","B":"Sucralfate Susp 0.1Gm/1 Ml syr","C":"637","F":"1.35"},{"Policy Line":"74122722","B":"Trabectedin 1mg vial","C":"636","D":"J9352","F":"3576.057"},{"Policy Line":"74122723","B":"Temozolomide 250Mg Capsule Orl","C":"636","D":"J8700","F":"515.412"},{"Policy Line":"74122725","B":"Naloxegol Oxalate 12.5 mg Tab","C":"637","F":"9.45","G":"**"},{"Policy Line":"74122726","B":"Lifitegrast 5%% Opth 0.2 ml","C":"250","F":"17.51","G":"**"},{"Policy Line":"74122727","B":"LOCM Isovue 300 1 Ml","C":"255","D":"Q9967","F":"0.309002190611562","G":"**"},{"Policy Line":"74122728","B":"LOCM Visipaque 320 1 Ml","C":"255","D":"Q9967","F":"1.854","G":"**"},{"Policy Line":"74122729","B":"Albuterol/Ipratrop2.5/0.5MGNeb","C":"250","F":"17.655846893342","G":"**"},{"Policy Line":"74122730","B":"Pomalidomide 1Mg Cap","C":"637","F":"737.1"},{"Policy Line":"74122731","B":"Eluxadoline 100 mg tablet","C":"637","F":"12.6","G":"**"},{"Policy Line":"74122732","B":"Albuterol 0.5%% 2.5Mg/3 Ml Neb","C":"250","F":"17.922"},{"Policy Line":"74122733","B":"Amphotericin B 50mcg/ml Op Syr","C":"250","F":"17.922"},{"Policy Line":"74122735","B":"Tenofovir Alafenamide 25MgTab","C":"637","F":"29.925","G":"**"},{"Policy Line":"74122736","B":"Hydrocortisone 2%% 28Gm Oint","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122738","B":"Insulin Detemir 100 U/1Ml Inj","C":"637","D":"J1815","F":"8.1","G":"**"},{"Policy Line":"74122739","B":"Doxercalciferol 2 Mcg/1Ml Vial","C":"250","D":"J1270","F":"17.69025","G":"**"},{"Policy Line":"74122740","B":"Cefazolin 6000mg IV Soltn","C":"636","D":"J0690","F":"17.7500347826087","G":"**"},{"Policy Line":"74122741","B":"Meningococcal B Vac (Bexero)","C":"636","D":"90620","F":"162.30225","G":"**"},{"Policy Line":"74122742","B":"Lidocaine 5%% Oint 1 APP Charg","C":"250","F":"17.922"},{"Policy Line":"74122743","B":"Infliximab-Dyyb100Mg Inflectra","C":"636","D":"Q5103","F":"828.5178375","G":"**"},{"Policy Line":"74122744","B":"Ocrelizumab 300mg/10ml vial","C":"636","D":"J2350","F":"15038.4406231579","G":"**"},{"Policy Line":"74122745","B":"C1 Esterase Berin Inh 500U Inj","C":"636","D":"J0597","F":"2911.707"},{"Policy Line":"74122746","B":"Levothyroxine 25mcg/ml sus syr","C":"637","F":"1.35"},{"Policy Line":"74122747","B":"Top Opth Dilating SolNO Tetrac","C":"250","F":"33.0328536585366","G":"**"},{"Policy Line":"74122748","B":"Morphine 0.5MG/ML Inj","C":"636","D":"J2270","F":"17.819","G":"**"},{"Policy Line":"74122749","B":"Pembrolizumab 100mg/4ml vial","C":"636","D":"J9271","F":"5662.116","G":"**"},{"Policy Line":"74122752","B":"Methylene Blue INJ 50MG/10Ml","C":"636","D":"Q9968","F":"190.13242245283","G":"**"},{"Policy Line":"74122753","B":"Bicitra 1Ml SYR","C":"637","F":"1.35"},{"Policy Line":"74122754","B":"Nevirapine 50MG/5ML Susp","C":"637","F":"3.375"},{"Policy Line":"74122755","B":"Minocycline 100Mg Inj","C":"636","D":"J2265","F":"196.833","G":"**"},{"Policy Line":"74122756","B":"Gamunex Immune Glob Inj 10 Gm","C":"636","D":"J1561","F":"1108.98911538462","G":"**"},{"Policy Line":"74122757","B":"Gamunex Immune Glob Inj 20 Gm","C":"636","D":"J1561","F":"2220.474","G":"**"},{"Policy Line":"74122758","B":"Gamunex Immune Glob Inj 5 Gm","C":"636","D":"J1561","F":"554.071333333332","G":"**"},{"Policy Line":"74122759","B":"Perit Dia Dex 4.25%% 2000mll","C":"250","F":"17.5378378378378","G":"**"},{"Policy Line":"74122760","B":"Diazepam 2 Mg Inj Syr","C":"636","D":"J3360","F":"17.8337142857143","G":"**"},{"Policy Line":"74122761","B":"Perit Dia Dex 4.25%% SS 2000ml","C":"250","F":"17.819","G":"**"},{"Policy Line":"74122762","B":"Perit Dia Dex 4.25%% 5000mll","C":"250","F":"17.6959024390244","G":"**"},{"Policy Line":"74122763","B":"Perit Dia Dex 2.5%% SS 2000mll","C":"250","F":"17.5861989795918","G":"**"},{"Policy Line":"74122764","B":"Perit Dia Dex 2.5%% SS 2000mll","C":"250","F":"17.6748","G":"**"},{"Policy Line":"74122765","B":"Perit Dia Dex 2.5%% 5000mll","C":"250","F":"17.7064005037783","G":"**"},{"Policy Line":"74122766","B":"Perit Dia Dex 1.5% 2000ml","C":"250","F":"17.6857058823529","G":"**"},{"Policy Line":"74122767","B":"Perit Dia Dex 1.5%% SS 2000mll","C":"250","F":"17.7277714285714","G":"**"},{"Policy Line":"74122768","B":"Perit Dia Dex 1.5%% SS 5000mll","C":"250","F":"17.752443778111","G":"**"},{"Policy Line":"74122769","B":"Midostaurin 25mg capsule","C":"636","D":"J8999","F":"170.259","G":"**"},{"Policy Line":"74122770","B":"Isavuconazonium 186mg caps","C":"637","F":"72","G":"**"},{"Policy Line":"74122772","B":"Dexmedetomidine 400Mcg/4Ml Via","C":"250","F":"37.9550188906179","G":"**"},{"Policy Line":"74122773","B":"Chemo RX,Trametinib 2mg caps","C":"636","D":"J8999","F":"444.651"},{"Policy Line":"74122774","B":"Lidocaine 1.5%%/Epi 1:200 30ML","C":"250","F":"17.7617777777778","G":"**"},{"Policy Line":"74122776","B":"Hyaluronate 7.7 Mg/0.55 Ml Sy","C":"250","F":"133.6116","G":"**"},{"Policy Line":"74122777","B":"Dronabinol 5mg/1ml soln","C":"637","F":"26.325"},{"Policy Line":"74122778","B":"Chemo RX, Dabrafenib 75mg caps","C":"636","D":"J8999","F":"102.588"},{"Policy Line":"74122779","B":"Topiramate 25Mg Sprinkle","C":"637","F":"5.175"},{"Policy Line":"74122780","B":"Albuterol Inh Hfa 200Inh 8.5Gm","C":"637","F":"46.575","G":"**"},{"Policy Line":"74122781","B":"Clevipidine 25mg/50ml vial","C":"636","D":"C9248","F":"77.9270224719102","G":"**"},{"Policy Line":"74122782","B":"Volumen 450Ml","C":"255","F":"7.92322641509436","G":"**"},{"Policy Line":"74122783","B":"Bezlotoxumab 1000mg/40ml Inj","C":"636","D":"J0565","F":"3892.57599999999","G":"**"},{"Policy Line":"74122784","B":"Gelfilm 125 mm sheet","C":"250","F":"2235.615"},{"Policy Line":"74122785","B":"ELIGARD 7.5 MG SYR (SQ)","C":"636","D":"J9217","F":"174.276","G":"**"},{"Policy Line":"74122786","B":"Copanlisib 60mg vial","C":"636","D":"J9057","F":"4344.54"},{"Policy Line":"74122787","B":"Chlorhexidine Gluc 0.12%% 118M","C":"637","F":"6.075","G":"**"},{"Policy Line":"74122788","B":"Temozolomide 140Mg Oral Cap","C":"636","D":"J8700","F":"68.598"},{"Policy Line":"74122789","B":"Mycophenolate 180mg tablet DR","C":"636","D":"J7518","F":"6.15236585365854","G":"**"},{"Policy Line":"74122791","B":"Lidocaine 1%% With Epi 50Ml","C":"250","D":"J3490","F":"17.922","G":"**"},{"Policy Line":"74122792","B":"Itraconazole Sol 50mg/5ml dose","C":"637","F":"8.55"},{"Policy Line":"74122793","B":"Obinutuzumab 1000mg/40ml Vial","C":"636","D":"J9301","F":"6418.239"},{"Policy Line":"74122794","B":"Hemin 350mg/50ml Vial","C":"636","D":"J1640","F":"7479.963","G":"**"},{"Policy Line":"74122795","B":"Cyclopentolate 1%% Op Sol 10Ml","C":"250","F":"17.304"},{"Policy Line":"74122796","B":"Difluprednate 0.05%% Opth 5ml","C":"250","F":"196.871625","G":"**"},{"Policy Line":"74122797","B":"Insulin Reg Hum 1500 Unit/3Ml","C":"636","D":"J1815","F":"342.2484","G":"**"},{"Policy Line":"74122798","B":"Tobramycin Sulfate 4MG/ML Inj","C":"636","D":"J3260","F":"17.304","G":"**"},{"Policy Line":"74122799","B":"Heparin 2000 U/NS 1000ML","C":"250","F":"17.922"},{"Policy Line":"74122800","B":"Urea 15 gm powder pkt","C":"637","F":"3.375","G":"**"},{"Policy Line":"74122801","B":"Oxcarbazepine 300Mg/5Ml oral","C":"637","F":"2.25","G":"**"},{"Policy Line":"74122804","B":"Empagliflozin 25Mg Tablet","C":"637","F":"13.275","G":"**"},{"Policy Line":"74122805","B":"Empagliffozin 10Mg Tablet","C":"637","F":"13.275","G":"**"},{"Policy Line":"74122806","B":"Immune Globulin INJ 200MG/1ML","C":"636","F":"23.793"},{"Policy Line":"74122808","B":"Vancomycin 1000mg/250ml PM INJ","C":"636","D":"J3370","F":"23.5747155963303","G":"**"},{"Policy Line":"74122809","B":"Degarelix 80mg Vial","C":"636","D":"J9155","F":"367.092"},{"Policy Line":"74122810","B":"Benralizumab 30mg/ml syr","C":"636","F":"4872.76785148515","G":"**"},{"Policy Line":"74122811","B":"Vyxeos 44mg/100ml Vial","C":"636","F":"8016.696","G":"**"},{"Policy Line":"74122812","B":"Tropicamide 0.5%% Opth 15Ml","C":"250","F":"7.77650000000001","G":"**"},{"Policy Line":"74122813","B":"Regorafenib 40mg Tablet","C":"636","D":"J9999","F":"236.694"},{"Policy Line":"74122814","B":"Alteplase-Recomb 1Mg/2Ml Inj","C":"636","D":"J2997","F":"92.0657806191117","G":"**"},{"Policy Line":"74122815","B":"Abacavir son 300mg/15ml","C":"637","F":"7.875"},{"Policy Line":"74122816","B":"Entresto 49mg/51mg tablet","C":"637","F":"6.525","G":"**"},{"Policy Line":"74122817","B":"Betamethasone Val 0.1%% Lt 60m","C":"637","F":"31.95","G":"**"},{"Policy Line":"74122818","B":"Radicava 30mg/100ml bag","C":"636","D":"J1301","F":"681.129265243902","G":"**"},{"Policy Line":"74122819","B":"Acetic Acid 0.25%% Irr 1000Ml","C":"250","F":"17.922","G":"**"},{"Policy Line":"74122820","B":"Asenapine 5 Mg SL Tab","C":"637","F":"17.1"},{"Policy Line":"74122821","B":"Submucosal Endo Composite 10ml","C":"250","F":"97.9639058823528","G":"**"},{"Policy Line":"74122823","B":"Nacl Conc 2.5Meq Per Ml Chg","C":"250","F":"17.922"},{"Policy Line":"74122824","B":"Novolin-N 100U/1ML INJ","C":"637","D":"J1815","F":"1.8","G":"**"},{"Policy Line":"74122825","B":"Lidocaine 2%% W Epi 50Ml Vial","C":"250","F":"17.6682160784314","G":"**"},{"Policy Line":"74122826","B":"Topiramate 25Mg ER capsule","C":"637","F":"7.65","G":"**"},{"Policy Line":"74122827","B":"TRELEGY ELLIPTA INH","C":"637","F":"116.775","G":"**"},{"Policy Line":"74122828","B":"Morphine 2Mg/2Ml Inj","C":"636","D":"J2270","F":"17.922"},{"Policy Line":"74122829","B":"Vitamin Multi Therap 15Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122830","B":"Lidocaine 1%% With Epi 30Ml","C":"250","D":"J3490","F":"17.7595612648222","G":"**"},{"Policy Line":"74122832","B":"Talc For Intrapleural 4Gm","C":"250","F":"176.598483870968","G":"**"},{"Policy Line":"74122833","B":"Nifedipine 30mg/7.5ml","C":"637","F":"2.7","G":"**"},{"Policy Line":"74122834","B":"Alemtuzumab 12mg/1.2ml vial","C":"636","D":"J0202","F":"22549.893"},{"Policy Line":"74122835","B":"Fentanyl .05Mg/Ml 50Ml Inj","C":"636","D":"J3010","F":"19.776","G":"**"},{"Policy Line":"74122836","B":"Potassium Acetate 100Meq Inj.","C":"250","F":"17.922"},{"Policy Line":"74122837","B":"Venetoclax 10mg Tab (Chemo)","C":"636","D":"J8999","F":"11.742"},{"Policy Line":"74122838","B":"Venetoclax 50 mg tab (Chemo)","C":"636","D":"J8999","F":"59.328"},{"Policy Line":"74122839","B":"Clonazepam 1 Mg Odt","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122840","B":"Crizotinib 250mg Capsule","C":"636","D":"J9999","F":"341.136"},{"Policy Line":"74122841","B":"Heparin Flush 5 Unit/5Ml Inj","C":"636","D":"J1642","F":"17.922"},{"Policy Line":"74122842","B":"Sirolimus 1 Mg/1Ml solution","C":"636","D":"J7520","F":"35.535"},{"Policy Line":"74122843","B":"Delafloxacin 450 Mg Tablet","C":"637","F":"58.05","G":"**"},{"Policy Line":"74122844","B":"Anakinra 100mg/0.67ml Syringe","C":"636","D":"J9999","F":"177.984"},{"Policy Line":"74122845","B":"Fondaparinux 10Mg/0.8Ml Inj","C":"636","D":"J1652","F":"151.41"},{"Policy Line":"74122846","B":"Cabozantinib 40mg Tablet","C":"636","D":"J9999","F":"725.532"},{"Policy Line":"74122847","B":"Nintedanib 100mg Capsule","C":"637","F":"137.7"},{"Policy Line":"74122848","B":"Nintedanib 150mg Capsule","C":"637","F":"137.7"},{"Policy Line":"74122849","B":"Progesterone 100mg Vag Supp","C":"637","F":"3.375"},{"Policy Line":"74122850","B":"Ceftriaxone 35Mg/ML Inj","C":"636","D":"J0696","F":"1.854","G":"**"},{"Policy Line":"74122851","B":"Rabies Immune Glob 300Unit/1Ml","C":"636","D":"90376","F":"802.988000000001","G":"**"},{"Policy Line":"74122852","B":"Rabies ImmuneGlob1500Unit/5Ml","C":"636","D":"90376","F":"3199.50230898876","G":"**"},{"Policy Line":"74122853","B":"Patiromer Sorbitex16.8gm pkt","C":"637","F":"26.775","G":"**"},{"Policy Line":"74122854","B":"Lithium Carbonate 300Mg ERTab","C":"637","F":"1.35"},{"Policy Line":"74122855","B":"Dextrose 15gm Oral Gel","C":"637","F":"2.7","G":"**"},{"Policy Line":"74122856","B":"Linaclotide 72 Mcg Capsule","C":"637","F":"11.025","G":"**"},{"Policy Line":"74122857","B":"TIOTROPIUM/OLODATEROL 60 INH","C":"637","F":"221.85","G":"**"},{"Policy Line":"74122858","B":"Sirolimus 0.5 Mg Tablet","C":"636","D":"J7520","F":"6.50960000000001","G":"**"},{"Policy Line":"74122859","B":"Crysvita 10 mg/ml syringe","C":"636","D":"J0584","F":"3517.038"},{"Policy Line":"74122860","B":"Crysvita 20 mg/ml syr","C":"636","D":"J0584","F":"7033.767","G":"**"},{"Policy Line":"74122861","B":"Crysvita 30 mg/ml syr","C":"636","D":"J0584","F":"10550.805","G":"**"},{"Policy Line":"74122862","B":"Mepivacaine Hcl 1%% 50Ml Inj","C":"636","D":"J0670","F":"17.922","G":"**"},{"Policy Line":"74122863","B":"Descovy 200-25mg Tablet","C":"637","F":"48.15","G":"**"},{"Policy Line":"74122864","B":"Hydrocortisone2.5%%Pram 1%%30G","C":"637","F":"105.075","G":"**"},{"Policy Line":"74122865","B":"Tiotropium 2.5mcg Inh 4 gm","C":"637","F":"33.75","G":"**"},{"Policy Line":"74122866","B":"Dulera 100Mcg/5Mcg 50puf Inh","C":"637","F":"181.35","G":"**"},{"Policy Line":"74122867","B":"Maraviroc 300Mg Tablet","C":"637","F":"13.95"},{"Policy Line":"74122868","B":"Ritonavir 100mg powder Pkt","C":"637","F":"7.425"},{"Policy Line":"74122869","B":"Vortioxetine HBR 20 mg tablet","C":"637","F":"10.8","G":"**"},{"Policy Line":"74122870","B":"Arsenic Trioxide 12Mg/6Ml Inj","C":"636","D":"J9017","F":"1079.028","G":"**"},{"Policy Line":"74122871","B":"Erythromycin 25mg/ml 90ml Top","C":"637","F":"24.75","G":"**"},{"Policy Line":"74122872","B":"FluBlok 0.5ml syringe","C":"636","D":"90682","F":"56.547"},{"Policy Line":"74122873","B":"Factor XA,Inactiva 100mg vial","C":"636","D":"C9399","F":"2844.654"},{"Policy Line":"74122874","B":"Lamotrigine ODT 50 mg tablet","C":"637","F":"6.3","G":"**"},{"Policy Line":"74122875","B":"Polymyxin B 500000 Unit/Ns 5Ml","C":"250","F":"17.922"},{"Policy Line":"74122876","B":"Clotrimazole 1%% Sol 30ml","C":"637","F":"40.725","G":"**"},{"Policy Line":"74122877","B":"Lenalidomide 10 Mg Cap","C":"636","D":"C9399","F":"885.285","G":"**"},{"Policy Line":"74122878","B":"Lenalidomide 15Mg Cap","C":"636","D":"C9399","F":"885.285"},{"Policy Line":"74122879","B":"Lenalidomide 20Mg Cap","C":"636","D":"C9399","F":"885.285"},{"Policy Line":"74122880","B":"Carboplatin 10mg/ml","C":"636","D":"J9045","F":"1.545"},{"Policy Line":"74122881","B":"Eltrombopaq 50mg tablet","C":"637","F":"247.5"},{"Policy Line":"74122882","B":"Alprazolam Xr 0.5 Mg Tbsa","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122883","B":"TOUJEO INSULIN 450 U/1.5ML","C":"636","D":"J1815","F":"105.678","G":"**"},{"Policy Line":"74122884","B":"Nevirapine ER 400 Mg Tablet","C":"637","F":"4.5"},{"Policy Line":"74122885","B":"RomiDEPsin 10mg/2ML","C":"636","D":"J9315","F":"3172.194"},{"Policy Line":"74122887","B":"Desvenlafaxine 25Mg Tablet","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122888","B":"VABOMERE 2GM IV","C":"636","D":"C9399","F":"191.271"},{"Policy Line":"74122889","B":"Rivaroxaban 2.5 Mg Tablet","C":"637","F":"4.5","G":"**"},{"Policy Line":"74122890","B":"ERAVACYCLINE DI-HCL 50MG IV","C":"636","D":"C9399","F":"54.6550929368028","G":"**"},{"Policy Line":"74122891","B":"Improvue Surg Ophth 2ml","C":"250","F":"41.6879160655737","G":"**"},{"Policy Line":"74122892","B":"Eltrombopaq 75mg tablet","C":"637","F":"371.475"},{"Policy Line":"74122893","B":"Danocrine 200Mg Cap","C":"637","F":"3.825","G":"**"},{"Policy Line":"74122894","B":"PLAZOMICIN SULFATE 500MG/10ML","C":"636","D":"J0291","F":"389.34"},{"Policy Line":"74122895","B":"Nystatin-Triamcinolone Cr 30Gm","C":"637","F":"26.55","G":"**"},{"Policy Line":"74122896","B":"Buspirone 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122897","B":"Antihemo FVIII NovoEight 1unit","C":"636","F":"1.236"},{"Policy Line":"74122898","B":"Carbidopa 10Mg++Levo 100Mg ODT","C":"637","F":"1.35"},{"Policy Line":"74122899","B":"Omacetaxine 3.5mg vial","C":"636","F":"1275.552"},{"Policy Line":"74122900","B":"Alglucosidase 50mg/10ml Inj","C":"636","D":"J0221","F":"835.845"},{"Policy Line":"74122901","B":"Factor XA,Inactiva 200mg vial","C":"636","D":"C9041","F":"5671.74650000001","G":"**"},{"Policy Line":"74122902","B":"Venetoclax 100 mg tab (Chemo)","C":"636","D":"J9999","F":"114.948","G":"**"},{"Policy Line":"74122903","B":"Submucosal Lifting Aget 20ml","C":"250","F":"211.15","G":"**"},{"Policy Line":"74122904","B":"Ethiodized Oil 10ml Amp","C":"250","F":"1352.184","G":"**"},{"Policy Line":"74122905","B":"Lithium Carbonate 150Mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122906","B":"TILDRAKIZUMAB-ASMIN 100MG/ML","C":"636","D":"C9399","F":"13312.338","G":"**"},{"Policy Line":"74122907","B":"Gemtuzumab 4.5mg Inj","C":"636","D":"J9203","F":"8608.8945","G":"**"},{"Policy Line":"74122908","B":"Cariprazine 1.5MG Capsule","C":"637","F":"34.425","G":"**"},{"Policy Line":"74122909","B":"Semaglutide 2mg/1.5ml Pen","C":"637","D":"C9399","F":"332.775","G":"**"},{"Policy Line":"74122910","B":"Guaifensein Ac 10Ml Ud","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122911","B":"Topiramate 200Mg ER capsule","C":"637","F":"29.025","G":"**"},{"Policy Line":"74122912","B":"Abiraterone (Zytiga) 500mg tab","C":"637","F":"156.375"},{"Policy Line":"74122913","B":"Oxytocin 30 Units/Rl 500 Ml","C":"250","F":"17.304"},{"Policy Line":"74122914","B":"DULAGLUTIDE 1.5MG/0.5ML PEN","C":"636","F":"224.643"},{"Policy Line":"74122915","B":"CALCIFEDIOL 30 Mcg Cap","C":"637","F":"31.05"},{"Policy Line":"74122916","B":"Dexamethasone 0.2mg/ml Inj","C":"636","D":"J1100","F":"17.304"},{"Policy Line":"74122917","B":"INFLIXIMAB-ABDA INJ 100MG","C":"636","D":"Q5104","F":"502.804265192307","G":"**"},{"Policy Line":"74122918","B":"ROMOSOZUMAG 105mg/1.17ml Inj","C":"636","D":"J3111","F":"1127.85","G":"**"},{"Policy Line":"74122919","B":"cefTAZadime 22.5mg/1ml Op Inj","C":"636","D":"J0713","F":"17.304","G":"**"},{"Policy Line":"74122921","B":"Sodium Acetate 400Meq/100Ml","C":"250","F":"17.304","G":"**"},{"Policy Line":"74122922","B":"Omadacycline 100mg vial","C":"636","D":"J3490","F":"426.42","G":"**"},{"Policy Line":"74122923","B":"Pomalidomide 4Mg Cap","C":"637","F":"737.1"},{"Policy Line":"74122924","B":"Epoetin EPBX NonESRD 2000U/Ml","C":"636","D":"Q5106","F":"22.248","G":"**"},{"Policy Line":"74122925","B":"Epoetin EPBX NonESRD 3000U/Ml","C":"636","D":"Q5106","F":"33.372"},{"Policy Line":"74122926","B":"Epoetin EPBX NonESRD 4000U/Ml","C":"636","D":"Q5106","F":"44.805","G":"**"},{"Policy Line":"74122927","B":"Epoetin EPBX NonESRD 10000U/Ml","C":"636","D":"Q5106","F":"111.373032533253","G":"**"},{"Policy Line":"74122928","B":"Epoetin EPBX NonESRD 40000U/Ml","C":"636","D":"Q5106","F":"446.505","G":"**"},{"Policy Line":"74122929","B":"Cannabidiol (CBD) 100mg/ml Liq","C":"637","F":"11.025"},{"Policy Line":"74122930","B":"Fluticasone Furoate 100mcg Inh","C":"637","F":"58.95","G":"**"},{"Policy Line":"74122931","B":"Fluticasone Furoate 200mcg Inh","C":"637","F":"78.75","G":"**"},{"Policy Line":"74122932","B":"Azathioprine 75Mg Tablet","C":"636","D":"J7500","F":"19.776","G":"**"},{"Policy Line":"74122933","B":"Loperamide 2 Mg/15 Ml Cup","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122934","B":"CIDOFOVIR 1%% TOP CM 40GM","C":"637","F":"461.475"},{"Policy Line":"74122935","B":"Gamunex Immune Glob Inj 40 Gm","C":"636","D":"J1561","F":"3839.634","G":"**"},{"Policy Line":"74122936","B":"Gammagard 2.5GM Vial","C":"636","D":"J1569","F":"270.066","G":"**"},{"Policy Line":"74122937","B":"Lamotrigine 50Mg XRTab","C":"637","F":"2.7","G":"**"},{"Policy Line":"74122938","B":"Bosutinib 100mg Tab","C":"637","D":"C9399","F":"112.05"},{"Policy Line":"74122939","B":"LUMASON 25MG/5ML INJ VIAL","C":"636","D":"Q9950","F":"165.624","G":"**"},{"Policy Line":"74122940","B":"DarbepoetinAlfa60Mcg/0.3ml In","C":"636","D":"J0881","F":"537.351","G":"**"},{"Policy Line":"74122941","B":"Thrombin 5:000 Units Top Kit","C":"250","F":"58.092","G":"**"},{"Policy Line":"74122942","B":"Penicillin G Procaine 600000U","C":"636","D":"J2510","F":"38.625","G":"**"},{"Policy Line":"74122943","B":"Arsenic Trioxide 10Mg/10Ml Inj","C":"636","D":"J9017","F":"137.196"},{"Policy Line":"74122944","B":"DEXMEDETOMIDINE 12MCG/3 ML","C":"250","F":"16.9395873825503","G":"**"},{"Policy Line":"74122945","B":"Biktarvy 50-200-25mg Tab","C":"637","F":"90.45","G":"**"},{"Policy Line":"74122948","B":"Risperidone 12.5 Mg Kit IM","C":"636","D":"J2794","F":"276.864","G":"**"},{"Policy Line":"74122949","B":"Cal Gluconate 2GM/100ML bag","C":"636","D":"J0610","F":"23.793","G":"**"},{"Policy Line":"74122950","B":"Hydrocortisone 5Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122951","B":"Phenobarbital 4Mg/1 Ml Liq","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122952","B":"Hyaluronate 13.3 Mg/0.85 Ml","C":"250","F":"175.512"},{"Policy Line":"74122953","B":"Liothyronine Na 10 Mcg vial","C":"250","F":"349.479","G":"**"},{"Policy Line":"74122955","B":"LONSURF 15/6.14MG TAB","C":"637","F":"148.5"},{"Policy Line":"74122956","B":"LONSURF 20/8.19MG TAB","C":"637","F":"198"},{"Policy Line":"74122957","B":"Sunitinib Maleate 50 Mg Capsul","C":"636","D":"C9399","F":"788.568"},{"Policy Line":"74122958","B":"COPPER CHLORIDE 4MG/10ML","C":"636","D":"C9399","F":"23.793","G":"**"},{"Policy Line":"74122959","B":"SYMTUZA COMBO TAB","C":"637","F":"108.9","G":"**"},{"Policy Line":"74122960","B":"Copper Gluconate 2mg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122961","B":"Entresto 97mg/103mg tablet","C":"637","F":"7.2","G":"**"},{"Policy Line":"74122962","B":"Apalutamide 60mg Tablet","C":"636","D":"C9399","F":"120.201"},{"Policy Line":"74122963","B":"Calcitriol 0.5Mcg Cap","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122964","B":"Trastuzumab-anns 21 Mg/1 Ml","C":"636","D":"Q5117","F":"220.626","G":"**"},{"Policy Line":"74122965","B":"Methotrexate 1000mg/20ml vial","C":"636","D":"J9260","F":"74.16","G":"**"},{"Policy Line":"74122968","B":"Ibuprofen 800 Mg/200Ml IV Bag","C":"636","D":"J1741","F":"24.411","G":"**"},{"Policy Line":"74122969","B":"Famotidine 10Mg Tab","C":"637","F":"1.35","G":"**"},{"Policy Line":"74122970","B":"Diliazem CP 420Mg Cap","C":"637","F":"1.35"},{"Policy Line":"74122972","B":"Simethicone Drops 20Mg/0.3Ml","C":"637","F":"2.7","G":"**"},{"Policy Line":"74122973","B":"Cal Gluconate 1GM/50ML bag","C":"636","D":"J0610","F":"17.922","G":"**"},{"Policy Line":"74122974","B":"DULAGLUTIDE 0.75MG/0.5ML PEN","C":"636","D":"J8999","F":"221.244"},{"Policy Line":"74122975","B":"Vanicream 454 Gm","C":"637","F":"9.45","G":"**"},{"Policy Line":"74122976","B":"Roflumilast 250 Mcg Tablet","C":"637","F":"9.45","G":"**"},{"Policy Line":"74122977","B":"VANCOMYCIN 2250MG/500ML IV BAG","C":"636","D":"J3370","F":"42.024","G":"**"},{"Policy Line":"74122978","B":"VANCOMYCIN 2500MG/500ML IV BAG","C":"636","D":"J3370","F":"42.024","G":"**"},{"Policy Line":"74122979","B":"Dasatinib 80 Mg Tab","C":"636","D":"J8999","F":"581.229"},{"Policy Line":"74122980","B":"Pomalidomide 2 Mg Cap","C":"636","F":"1073.466"},{"Policy Line":"74122981","B":"Carfilzomib 10Mg Vial","C":"636","D":"J9047","F":"501.816"},{"Policy Line":"74122982","B":"Mesalamine 400Mg DR cap","C":"637","F":"1.35"},{"Policy Line":"74122983","B":"Osimertinib 40mg Tab","C":"636","D":"J8999","F":"614.292"},{"Policy Line":"74122984","B":"Osimertinib 80 Mg Tab","C":"636","D":"J8999","F":"614.292"},{"Policy Line":"74122985","B":"Recarbrio 1.25 G","C":"636","D":"C9399","F":"330.63"},{"Policy Line":"75385621","B":"OASIS ULTRA 5X7CM 306813000013","C":"636","D":"Q4124","F":"398.301"},{"Policy Line":"76970196","B":"Albumin 5%% Human 250 Ml Vial","C":"636","D":"P9045","F":"95.481"},{"Policy Line":"76970425","B":"Meningococcal (A,C,Y&W-135)Pol","C":"636","D":"90733","F":"192.198"},{"Policy Line":"76970511","B":"Fluzone-High Dose 0.5Ml Syr","C":"636","D":"90662","F":"14.214"},{"Policy Line":"76971282","B":"Ascorbic Acid 500Mg/ 1Ml","C":"250","F":"17.922","G":"**"},{"Policy Line":"76971492","B":"Prochlorperazine 10Mg2Ml Inj","C":"636","D":"J0780","F":"9.27","G":"**"},{"Policy Line":"76972018","B":"Hydrocodone 5MG/APAP 325MG TAB","C":"637","F":"1.35","G":"**"},{"Policy Line":"76972019","B":"HYDRALAZINE 20 MG/ML","C":"636","D":"J0360","F":"17.922"},{"Policy Line":"76972020","B":"TUBERCULIN VL 5TU/0.1ML","C":"254","F":"17.922"},{"Policy Line":"76972021","B":"IPOL","C":"636","D":"90713","F":"38.54775","G":"**"},{"Policy Line":"76972022","B":"ISOVUE EA 1ML","C":"255","D":"Q9967","F":"0.309"},{"Policy Line":"76972023","B":"LABETALOL 20MG/4ML","C":"250","F":"17.922"},{"Policy Line":"76972024","B":"LOPERAMIDE 2 MG CAPSULE","C":"637","F":"1.125","G":"**"},{"Policy Line":"76972026","B":"METOCLOPRPAMIDE 10MG/2ML INJ","C":"636","D":"J2765","F":"17.922"},{"Policy Line":"76972027","B":"METOCLOPRAMIDE 10MG 1TAB","C":"637","F":"1.35"},{"Policy Line":"76972028","B":"MEASLES-MUMPS-RUBELLA II","C":"636","D":"90707","F":"80.8962","G":"**"},{"Policy Line":"76972029","B":"OXYCODONE 5MG TAB","C":"637","F":"0.9"},{"Policy Line":"76972030","B":"OXYCODONE 5MG/APAP 325MG TAB","C":"637","F":"1.305","G":"**"},{"Policy Line":"76972031","B":"PROBENECID 500MG TAB","C":"637","F":"1.35"},{"Policy Line":"76972032","B":"PROCHLORPERAZINE Oral ea 5mg","C":"636","D":"Q0164","F":"1.854"},{"Policy Line":"76972033","B":"PROMETHAZINE 25MG TAB","C":"637","F":"1.35"},{"Policy Line":"76972034","B":"BELIMUMAB/BENLYSTA INJ 10MG","C":"636","D":"J0490","F":"53.457"},{"Policy Line":"76972035","B":"SODIUM POLYSTYRENE SULF ORAL","C":"637","F":"5.4"},{"Policy Line":"76972036","B":"SOD. THIOSULFATE 25% 50ML VIAL","C":"250","F":"4.326"},{"Policy Line":"76972037","B":"ALBUTEROL INHALER PER USE 1INH","C":"637","F":"1.35"},{"Policy Line":"76972038","B":"LORATADINE 10MG TAB","C":"637","F":"1.35","G":"**"},{"Policy Line":"76972039","B":"CALCIUM GLUCONATE 10ML INJ","C":"636","D":"J0610","F":"16.3946311764706","G":"**"},{"Policy Line":"76972041","B":"DIPHENOXYLATE/ATROPIN 2.5MGTAB","C":"637","F":"1.35"},{"Policy Line":"76972043","B":"PREDNISONE 5 MG TAB","C":"637","F":"1.35"},{"Policy Line":"76972044","B":"PEDAXHIB VACCINE 7.5ug / 0.5mL","C":"636","D":"90647","F":"30.282"},{"Policy Line":"76972045","B":"PREVNAR 13 SYRINGE","C":"636","D":"90670","F":"17.728875","G":"**"},{"Policy Line":"76972046","B":"PROMETHAZINE UP TO 50 MG","C":"636","D":"J2550","F":"14.1516610465116","G":"**"},{"Policy Line":"76972047","B":"SODIUM BICARB 8.4% VIAL","C":"250","F":"17.922"},{"Policy Line":"76972048","B":"NACL 0.45% 1000ML","C":"258","F":"17.922","G":"**"},{"Policy Line":"76972049","B":"HYDROCORTISONE NA SUC 100MGINJ","C":"636","D":"J1720","F":"1.34106","G":"**"},{"Policy Line":"76972051","B":"WINRHO EACH 100 IU","C":"636","D":"J2792","F":"29.973"},{"Policy Line":"76972052","B":"PHYTONADIONE/VIT K EA 1MG","C":"636","D":"J3430","F":"1.854"},{"Policy Line":"76972053","B":"HepB Vac 20mcg/1ml","C":"636","D":"90747","F":"29.046","G":"**"},{"Policy Line":"76972054","B":"TDAP VACCINE","C":"636","D":"90715","F":"51.21675","G":"**"},{"Policy Line":"76972055","B":"ARSENIC TRIOX(6ML VL) 1 MG EA","C":"636","D":"J9017","F":"49.749"},{"Policy Line":"76972057","B":"HYDROMORPHONE 4 MG","C":"636","D":"J1170","F":"17.6748","G":"**"},{"Policy Line":"76972058","B":"GLUCAGEN INJ 1 MG","C":"636","D":"J1610","F":"215.373"},{"Policy Line":"76972059","B":"TRIPTORELIN DEPO 3.75 MG Inj","C":"636","D":"J3315","F":"758.904"},{"Policy Line":"76972060","B":"GOSERELIN ACETATE EA 3.6 MG","C":"636","D":"J9202","F":"762.491086956522","G":"**"},{"Policy Line":"76972061","B":"ALBUTEROL HFA MDI 60INH 8GM","C":"636","D":"J3535","F":"24.411"},{"Policy Line":"76972062","B":"TEMOZOLOMIDE ORAL EA 5 MG","C":"636","D":"J8700","F":"4.017"},{"Policy Line":"76972063","B":"LACTATED RINGERS 500 ML","C":"258","D":"J7120","F":"17.304","G":"**"},{"Policy Line":"76972064","B":"LACTATED RINGERS 1000 ML","C":"258","D":"J7120","F":"17.922","G":"**"},{"Policy Line":"76972065","B":"Hydromorphone HCL 1MG/ML Inj","C":"636","D":"J1170","F":"17.922"},{"Policy Line":"76972066","B":"Hydrocodon/Aceto10mg/325mg Tab","C":"637","F":"1.35"},{"Policy Line":"76972068","B":"GRANISETRON HCL 1 MG TAB","C":"636","D":"Q0166","F":"1.545"},{"Policy Line":"76972069","B":"FUROSEMIDE 20 MG TAB","C":"637","F":"1.125","G":"**"},{"Policy Line":"76972070","B":"FLUMAZENIL 0.1MG/ML 5ML INJ MD","C":"636","D":"J3490","F":"4.944"},{"Policy Line":"76972072","B":"ASPARAGINASE 10,000 UNITS","C":"636","D":"J9020","F":"126.381"},{"Policy Line":"76972073","B":"D5W 500 ML","C":"636","D":"J7060","F":"16.6628748387097","G":"**"},{"Policy Line":"76972074","B":"D5W 1000 ML","C":"636","D":"J7070","F":"16.995"},{"Policy Line":"76972075","B":"D5W/NACL 0.9%% 500ML","C":"636","D":"J7042","F":"17.7793846153846","G":"**"},{"Policy Line":"76972076","B":"D5W/NACL 0.45% 1000 ML","C":"258","F":"17.922","G":"**"},{"Policy Line":"76972078","B":"DEFEROXAMINE 500 MG INJ","C":"636","D":"J0895","F":"16.377","G":"**"},{"Policy Line":"76972079","B":"CYTARABINE 100 MG","C":"636","D":"J9100","F":"7.725","G":"**"},{"Policy Line":"76972080","B":"INSULIN Flex Pen EA 5U INJ","C":"636","D":"J1815","F":"0.927"},{"Policy Line":"76972081","B":"MANVEO VACCINE","C":"636","D":"90734","F":"160.989","G":"**"},{"Policy Line":"76972082","B":"ActHIB VACCIN 4DoseIM","C":"636","D":"90648","F":"44.9904","G":"**"},{"Policy Line":"76972083","B":"Hylenex Inj Ea 1.0 USP Unit","C":"636","D":"J3473","F":"0.618"},{"Policy Line":"76972084","B":"Pneumococcal 23 Vac Conj 0.5ml","C":"636","D":"90732","F":"111.3636","G":"**"},{"Policy Line":"76972085","B":"NACL 0.45%500 ML","C":"258","F":"17.922"},{"Policy Line":"76972086","B":"ENOXAPARIN EA 10 MG","C":"636","D":"J1650","F":"3.708"},{"Policy Line":"76972087","B":"LEUPROLIDE ACETATE INJ 3.75MG","C":"636","D":"J1950","F":"1426.44915363636","G":"**"},{"Policy Line":"76972088","B":"MEPERIDINE UP TO 100 MG","C":"636","D":"J2175","F":"15.3987942857143","G":"**"},{"Policy Line":"76972089","B":"MORPHINE INJ EA 10 MG","C":"636","D":"J2270","F":"17.6972727272727","G":"**"},{"Policy Line":"76972090","B":"ECULIZUMAB EA 10 MG","C":"636","D":"J1300","F":"149.965216216216","G":"**"},{"Policy Line":"76972091","B":"RANITIDINE/ZANTAC EA 25 MG","C":"636","D":"J2780","F":"8.652"},{"Policy Line":"76972092","B":"IDARUBICIN EA 5 MG","C":"636","D":"J9211","F":"55.929"},{"Policy Line":"76972093","B":"Dexamethasone 2Mg Tab","C":"637","F":"1.35"},{"Policy Line":"76972094","B":"CEFTRIAXONE EA 250 MG","C":"636","D":"J0696","F":"10.0846363636363","G":"**"},{"Policy Line":"76972095","B":"VISTIDE 375 MG","C":"636","D":"J0740","F":"863.346"},{"Policy Line":"76972097","B":"CORTROSYN 0.25 MG","C":"636","D":"J0834","F":"23.69","G":"**"},{"Policy Line":"76972098","B":"DACTINOMYCIN 0.5 MG","C":"636","D":"J9120","F":"787.641"},{"Policy Line":"76972099","B":"OLARATUMAB 500MG/50ML VIAL","C":"636","D":"J9999","F":"3004.407"},{"Policy Line":"76972100","B":"LIBATAYO 350 MG/7 ML VIAL","C":"636","F":"2162.3511","G":"**"},{"Policy Line":"76972102","B":"ZIPRASIDONE MESYLATE EA 10 MG","C":"636","D":"J3486","F":"23.793"},{"Policy Line":"76972103","B":"KETOROLAC TROMETHAMINE 15MG LC","C":"636","D":"J1885","F":"13.5407331428572","G":"**"},{"Policy Line":"76972105","B":"Heparin Sodium per 10 unit inj","C":"636","D":"J1642","F":"0.358611043850406","G":"**"},{"Policy Line":"76972106","B":"NORMAL SALINE 1000 CC","C":"636","D":"J7030","F":"5.76420325249644","G":"**"},{"Policy Line":"76972107","B":"NORMAL SALINE 500ML","C":"258","D":"J7040","F":"5.56433093881224","G":"**"},{"Policy Line":"76972108","B":"Normal Saline 250 Cc","C":"636","D":"J7050","F":"5.871","G":"**"},{"Policy Line":"76972109","B":"Lipidox Ea 10 Mg","C":"636","D":"Q2049","F":"436.617"},{"Policy Line":"76972111","B":"Interferon Alfa 2B 1 M Units","C":"636","D":"J9214","F":"37.698"},{"Policy Line":"76972112","B":"Gammagard Ea 500 MG","C":"636","D":"J1569","F":"63.2051418461541","G":"**"},{"Policy Line":"76972113","B":"BAVENCIO 200 MG/10 ML VIAL","C":"636","D":"J9023","F":"480.924970212765","G":"**"},{"Policy Line":"76972116","B":"Ipilimumab Ea 1 Mg","C":"636","D":"J9228","F":"145.166037900875","G":"**"},{"Policy Line":"76972117","B":"Solumedrol Up to 125 MG","C":"636","D":"J2930","F":"17.644518","G":"**"},{"Policy Line":"76972118","B":"Furosemide/Lasix Ea 20 MG","C":"636","D":"J1940","F":"17.6327234042553","G":"**"},{"Policy Line":"76972119","B":"Iron Sucrose Ea 1 Mg Inj","C":"636","D":"J1756","F":"1.545"},{"Policy Line":"76972120","B":"Carf Ilzomib/kyprolis 1MG Inj","C":"636","D":"J9047","F":"41.6064324324324","G":"**"},{"Policy Line":"76972121","B":"DECITABINE/DACOGEN Inj EA 1MG","C":"636","D":"J0894","F":"18.0462717391304","G":"**"},{"Policy Line":"76972122","B":"Sipuleucel-T/Provenge Per Vial","C":"636","D":"Q2043","F":"23314.359"},{"Policy Line":"76972123","B":"Vincristine Ea 1 Mg","C":"636","D":"J9370","F":"17.5169931578947","G":"**"},{"Policy Line":"76972126","B":"Dexrazoxane/Zinecard 250 Mg","C":"636","D":"J1190","F":"166.242"},{"Policy Line":"76972127","B":"Vinblastine Ea 1 Mg","C":"636","D":"J9360","F":"4.017","G":"**"},{"Policy Line":"76972128","B":"GAMUNEX INJ EA 500 MG","C":"636","D":"J1561","F":"55.311","G":"**"},{"Policy Line":"76972129","B":"ONDANSETRON/ZOFRAN EA 1 MG","C":"636","D":"J2405","F":"2.10941359372644","G":"**"},{"Policy Line":"76972130","B":"Cladribine/Leustatin Ea 1 Mg","C":"636","D":"J9065","F":"23.175"},{"Policy Line":"76972132","B":"ZOLEDRONIC ACID IV-ea 1mg","C":"636","F":"268.595306099291","G":"**"},{"Policy Line":"76972135","B":"D5W 250 Ml","C":"258","F":"5.871"},{"Policy Line":"76972138","B":"PANITUMUMAB EA 10 MG","C":"636","D":"J9303","F":"138.452328947369","G":"**"},{"Policy Line":"76972139","B":"LORAZEPAM TABLET 0.5mg Tab","C":"637","F":"1.125","G":"**"},{"Policy Line":"76972140","B":"ONDANSETRON TABLET EA 1 MG","C":"636","D":"Q0162","F":"1.545","G":"**"},{"Policy Line":"76972141","B":"KADCYLA EA 1 MG","C":"636","D":"J9354","F":"30.098354969574","G":"**"},{"Policy Line":"76972142","B":"DOXORUBICIN/DOXIL EA 10 MG","C":"636","D":"Q2050","F":"690.443125622775","G":"**"},{"Policy Line":"76972143","B":"BRENTUXIMAB/ADCETRIS EA 1 MG","C":"636","D":"J9042","F":"137.062892307692","G":"**"},{"Policy Line":"76972144","B":"CLOFARABINE/CLOLAR EA 1 MG","C":"636","D":"J9027","F":"180.147"},{"Policy Line":"76972145","B":"FILGRAMSTIM(G-CSG) EA1MCG INJ","C":"636","D":"J1442","F":"1.545","G":"**"},{"Policy Line":"76972146","B":"PERTUZUMAB/PERJETA EA 1 MG","C":"636","D":"J9306","F":"14.4078593155894","G":"**"},{"Policy Line":"76972147","B":"GRANIX/TBO-FILGRASTIM Inj 1Mcg","C":"636","D":"J1447","F":"5.871"},{"Policy Line":"76972148","B":"TOPOTECAN EA 0.1 MG LCRP","C":"636","D":"J9351","F":"4.017","G":"**"},{"Policy Line":"76972149","B":"Lorazepam Ea 2mg","C":"636","D":"J2060","F":"17.7392112676057","G":"**"},{"Policy Line":"76972150","B":"DEXTROSE 5%/0.45% NACL 500ml","C":"258","F":"17.922"},{"Policy Line":"76972151","B":"EPINEPHRINE 0.1 MG","C":"636","D":"J0171","F":"1.854"},{"Policy Line":"76972152","B":"PACLITAXEL PROTEIN BND 1MG INJ","C":"636","D":"J9264","F":"15.011572368421","G":"**"},{"Policy Line":"76972153","B":"Fluorouracil 500MG","C":"636","D":"J9190","F":"17.1441572819216","G":"**"},{"Policy Line":"76972154","B":"PEMETREXED/ALIMTA 10 MG INJ","C":"636","D":"J9305","F":"61.3191727389","G":"**"},{"Policy Line":"76972155","B":"PALONOSETRON/ALOXI 25MCG","C":"636","D":"J2469","F":"18.7489808423913","G":"**"},{"Policy Line":"76972156","B":"ATROPINE SULFATE 0.01 MG","C":"636","D":"J0461","F":"1.46685235675603","G":"**"},{"Policy Line":"76972157","B":"Bevacizumab 10MG Inj LCRP","C":"636","D":"J9035","F":"93.013566746988","G":"**"},{"Policy Line":"76972158","B":"Bleomycin Sulfate 15Units Inj","C":"636","D":"J9040","F":"41.8264426229508","G":"**"},{"Policy Line":"76972160","B":"IRINOTECAN 20 MG INJ","C":"636","D":"J9206","F":"3.99240463143255","G":"**"},{"Policy Line":"76972161","B":"Carboplatin Ea 50MG","C":"636","D":"J9045","F":"16.2601221579587","G":"**"},{"Policy Line":"76972162","B":"Alteplase 1 MG Inj LCRP","C":"636","D":"J2997","F":"89.8951945291482","G":"**"},{"Policy Line":"76972163","B":"Cisplatin EA 10 MG Inj","C":"636","D":"J9060","F":"3.708","G":"**"},{"Policy Line":"76972165","B":"B-12 INJ Up to 1000 MCG","C":"636","D":"J3420","F":"16.1520079856115","G":"**"},{"Policy Line":"76972166","B":"CYCLOPHOSPHAMIDE 100 MG LCRP","C":"636","D":"J9070","F":"51.8703710654409","G":"**"},{"Policy Line":"76972167","B":"DACARBAZINE/DTIC 100 MG LCRP","C":"636","D":"J9130","F":"8.85685236768804","G":"**"},{"Policy Line":"76972169","B":"DEXAMETHASONE EA 1 MG","C":"636","D":"J1100","F":"1.80164723730451","G":"**"},{"Policy Line":"76972170","B":"Diphenhydramine HCL Up To 50MG","C":"636","D":"J1200","F":"16.8981763684442","G":"**"},{"Policy Line":"76972171","B":"DOCETAXEL 1 MG INJ","C":"636","D":"J9171","F":"3.58781432807214","G":"**"},{"Policy Line":"76972172","B":"DOXORUBICIN HCL 10 MG","C":"636","D":"J9000","F":"6.82432345945947","G":"**"},{"Policy Line":"76972173","B":"FOSAPREPITANT EA 1MG","C":"636","D":"J1453","F":"2.71195904841402","G":"**"},{"Policy Line":"76972174","B":"EPIRUBICIN HCL 2 MG","C":"636","D":"J9178","F":"4.326"},{"Policy Line":"76972175","B":"CETUXIMAB 10 MG INJ","C":"636","D":"J9055","F":"69.3777837830433","G":"**"},{"Policy Line":"76972176","B":"Famotidine ea 20mg","C":"250","F":"16.699154624105","G":"**"},{"Policy Line":"76972177","B":"ERIBULIN MESYLATE 0.1 MG INJ","C":"636","D":"J9179","F":"128.846339491917","G":"**"},{"Policy Line":"76972178","B":"ROMIPLOSTIM/NPLATE 10MCG","C":"636","F":"72.7717414930098","G":"**"},{"Policy Line":"76972179","B":"DENOSUMAB Inj EA 1 MG","C":"636","D":"J0897","F":"22.2047742382271","G":"**"},{"Policy Line":"76972180","B":"OCTREOTIDE DEPOT IM INJ EA 1MG","C":"636","D":"J2353","F":"175.1721","G":"**"},{"Policy Line":"76972181","B":"Bortizomib / Velcade Ea 0.1MG","C":"636","D":"J9041","F":"57.6870663096147","G":"**"},{"Policy Line":"76972182","B":"Azacitidine Ea 1 Mg","C":"636","D":"J9025","F":"7.33114777139307","G":"**"},{"Policy Line":"76972183","B":"DARBEPOETIN ALFA EA 1 MCG","C":"636","D":"J0881","F":"8.961"},{"Policy Line":"76972184","B":"Mesna ea 200 MG LCRP","C":"636","D":"J9209","F":"7.840875","G":"**"},{"Policy Line":"76972185","B":"IXABEPILONE 1 MG","C":"636","D":"J9207","F":"95.481"},{"Policy Line":"76972186","B":"Cabazitaxel 1 MG","C":"636","D":"J9043","F":"165.164675675676","G":"**"},{"Policy Line":"76972187","B":"Methotrexate Ea 50 MG","C":"636","D":"J9260","F":"3.09","G":"**"},{"Policy Line":"76972188","B":"EPO INJ NonESRD EA 1000Units","C":"636","D":"J0885","F":"33.704945884374","G":"**"},{"Policy Line":"76972192","B":"FLUDARBINE EA 50MG","C":"636","D":"J9185","F":"77.559"},{"Policy Line":"76972193","B":"GEMCITABINE Inj EA 200 MG","C":"636","D":"J9201","F":"47.7725501372214","G":"**"},{"Policy Line":"76972194","B":"InjectAFer EA 1 MG","C":"636","D":"J1439","F":"1.84507206642066","G":"**"},{"Policy Line":"76972195","B":"GRANISETRON HCL EA 100 MCG","C":"636","D":"J1626","F":"1.854","G":"**"},{"Policy Line":"76972196","B":"Neulasta/Pegfilgramsim 6MG Inj","C":"636","D":"J2505","F":"4871.87983829787","G":"**"},{"Policy Line":"76972197","B":"Pamidronate 30 MG Inj","C":"636","D":"J2430","F":"15.759","G":"**"},{"Policy Line":"76972198","B":"RITUXAN EA 100 MG INJ","C":"636","F":"1118.27304635762","G":"**"},{"Policy Line":"76972199","B":"VINORELBINE/NAVELB 10MG","C":"636","D":"J9390","F":"17.4497073170732","G":"**"},{"Policy Line":"76972200","B":"Copper, 0.4mg/ml, Inj","C":"636","D":"J3490","F":"46.003052631579","G":"**"},{"Policy Line":"76972201","B":"IFOSFAMIDE/IFEX 1 GM","C":"636","D":"J9208","F":"40.17"},{"Policy Line":"76972204","B":"MITOXANTRONE HCL 5 MG","C":"636","D":"J9293","F":"24.72","G":"**"},{"Policy Line":"76972205","B":"Magnesium Citrate","C":"637","F":"1.35"},{"Policy Line":"76972206","B":"KCL 20 MEQ /15 ML ORAL","C":"637","F":"1.125"},{"Policy Line":"76972208","B":"DESMOPRESSIN ACETATE 1 MCG","C":"636","D":"J2597","F":"13.9625379310345","G":"**"},{"Policy Line":"76972209","B":"FULVESTRANT/FASLODEX 25 MG","C":"636","D":"J9395","F":"109.779117260464","G":"**"},{"Policy Line":"76972210","B":"FERUMOXYTOL 1 MG","C":"636","D":"Q0138","F":"1.76666684210526","G":"**"},{"Policy Line":"76972211","B":"FERRIC NA GLUCONATE 12.5 MG","C":"636","D":"J2916","F":"3.20032976744187","G":"**"},{"Policy Line":"76972212","B":"TRASTUZUMAB/HERCE MDV 10 MGINJ","C":"636","D":"J9355","F":"102.897","G":"**"},{"Policy Line":"76972213","B":"KCL 2 mEq","C":"636","D":"J3480","F":"5.72101644336177","G":"**"},{"Policy Line":"76972214","B":"Acetaminophen 10Mg Inj","C":"636","D":"J0131","F":"0.618"},{"Policy Line":"76972216","B":"FLUZONE VACCINE V4","C":"636","D":"90686","F":"23.175","G":"**"},{"Policy Line":"76972218","B":"Cyramza Ea 5 MG","C":"636","D":"J9308","F":"69.6900684039087","G":"**"},{"Policy Line":"76972219","B":"ELELYSO EA 10 UNITS","C":"636","D":"J3060","F":"49.749"},{"Policy Line":"76972220","B":"Meningococcal Vac IM 0.5ml Inj","C":"636","D":"90734","F":"140.904"},{"Policy Line":"76972223","B":"TRANSDERM-SCOP 1PATCH","C":"637","F":"18.45"},{"Policy Line":"76972224","B":"TEMSIROLIMUS/TORISEL 1 MG","C":"636","D":"J9330","F":"85.593","G":"**"},{"Policy Line":"76972225","B":"BENDAMUSTINE/TREANDA EA 1 MG","C":"636","D":"J9033","F":"38.007"},{"Policy Line":"76972226","B":"Etoposide/Toposar 10 MG","C":"636","D":"J9181","F":"1.854","G":"**"},{"Policy Line":"76972227","B":"PRIVIGEN EA 500 MG","C":"636","D":"J1459","F":"49.7743234524849","G":"**"},{"Policy Line":"76972228","B":"PACLITAXEL 1.0 MG","C":"636","D":"J9267","F":"6.1893056428674","G":"**"},{"Policy Line":"76972229","B":"PROCHLORPERAZINE <=10 MG INJ","C":"636","D":"J0780","F":"19.467","G":"**"},{"Policy Line":"76972230","B":"OXALIPLATIN INJ 0.5 MG","C":"636","D":"J9263","F":"1.50731750285063","G":"**"},{"Policy Line":"76972231","B":"SARGRAMOSTIM INJ EA 50 MCG","C":"636","D":"J2820","F":"39.243"},{"Policy Line":"76972232","B":"TESTOSTERONE CYPIONATE 1MG","C":"636","D":"J1071","F":"17.7085090909091","G":"**"},{"Policy Line":"76972233","B":"BICNU 100 MG","C":"636","D":"J9050","F":"218.463","G":"**"},{"Policy Line":"76972234","B":"MITOMYCIN 5 MG","C":"636","D":"J9280","F":"166.46448","G":"**"},{"Policy Line":"76972235","B":"MANNITOL 25%, 50ml VIAL","C":"636","D":"J2150","F":"5.78233043478261","G":"**"},{"Policy Line":"76972236","B":"MG SULFATE 500 MG","C":"636","D":"J3475","F":"5.74019490142761","G":"**"},{"Policy Line":"76972237","B":"LEUCOVORIN CALCIUM INJ EA 50MG","C":"636","D":"J0640","F":"8.24124938890851","G":"**"},{"Policy Line":"76972238","B":"INFED/IRON DEXTRAN EA 50 MG","C":"636","D":"J1750","F":"23.9041660433807","G":"**"},{"Policy Line":"76972239","B":"HEPARIN PER 1000 UNITS INJ","C":"636","D":"J1644","F":"17.4585","G":"**"},{"Policy Line":"76972240","B":"ZIV-AFLIBERCEPT/ZALTRAP EA 1MG","C":"636","D":"J9400","F":"27.81"},{"Policy Line":"76972241","B":"Neulasta Delivery Kit 6mg INJ","C":"636","D":"J2505","F":"4620.79214703999","G":"**"},{"Policy Line":"76972242","B":"Keytruda Inj 1mg","C":"636","D":"J9271","F":"57.5952033932538","G":"**"},{"Policy Line":"76972243","B":"Mycafungin - Micamine ea 1MG","C":"636","D":"J2248","F":"0.927"},{"Policy Line":"76972244","B":"ZARXIO,FILGRSTM(G-CSF) BS 1MCG","C":"636","D":"Q5101","F":"1.854","G":"**"},{"Policy Line":"76972245","B":"Trabectedin/Yondelis 0.1MG INJ","C":"636","D":"J9352","F":"351.818571428571","G":"**"},{"Policy Line":"76972246","B":"Pentostatin/Nipent Inj 10MG","C":"636","D":"J9268","F":"2507.226"},{"Policy Line":"76972247","B":"Pegaspargase Inj SDV 3750IU5ml","C":"636","D":"J9266","F":"16655.1","G":"**"},{"Policy Line":"76972248","B":"CIPROFLOXACIN 500MG ORAL TAB","C":"637","F":"1.35"},{"Policy Line":"76972250","B":"Gazyva / Obinutuzumab 10MG Inj","C":"636","D":"J9301","F":"56.3526798113208","G":"**"},{"Policy Line":"76972251","B":"Gammaplex Inj 500mg","C":"636","D":"J1557","F":"48.204"},{"Policy Line":"76972252","B":"Aminocaproic Acid 250mg/ml Inj","C":"636","D":"J3490","F":"1.854"},{"Policy Line":"76972253","B":"Albuterol-Nebulizer NonCom 1mg","C":"250","D":"J7611","F":"1.854","G":"**"},{"Policy Line":"76972254","B":"Iron Sucrose Comp Inj 1mg","C":"636","D":"J1756","F":"1.854","G":"**"},{"Policy Line":"76972255","B":"BENDAMUSTINE/BENDEKA 1MG MDV","C":"636","D":"J9034","F":"25.5175742120106","G":"**"},{"Policy Line":"76972256","B":"Ertapenem Na Inj 500 mg","C":"636","D":"J1335","F":"779.298"},{"Policy Line":"76972257","B":"ISTODAX/RomiDEPsin pwdr 1mg","C":"636","D":"J9315","F":"373.272"},{"Policy Line":"76972258","B":"DEXAMETHASONE ORAL EA 0.25MG","C":"636","D":"J8540","F":"0.927","G":"**"},{"Policy Line":"76972259","B":"IMLYGIC/TalLah 1M PFU/ml Inj","C":"636","D":"J9325","F":"59.328"},{"Policy Line":"76972260","B":"IMLYGIC 100XM PFU Inj EA Vial","C":"636","D":"J9325","F":"29.046"},{"Policy Line":"76972261","B":"Engerix-B 10mcg/0.5 ml Ped SDV","C":"636","D":"90744","F":"28.428"},{"Policy Line":"76972262","B":"Amlodipine 5MG Oral Tab","C":"637","F":"0.675"},{"Policy Line":"76972263","B":"Darzalex 10mg Inj","C":"636","D":"J9145","F":"60.803037735849","G":"**"},{"Policy Line":"76972266","B":"CIPROFLOXACIN 200MG IV INJ","C":"636","D":"J0744","F":"3.09"},{"Policy Line":"76972267","B":"HEP A VACC PED/ADOL 2DSE IMINJ","C":"636","D":"90633","F":"37.698"},{"Policy Line":"76972268","B":"PREDNISONE IR/DR ORAL 1MG TAB","C":"636","D":"J7512","F":"1.545"},{"Policy Line":"76972269","B":"ARRANON INJ EA 50MG","C":"636","D":"J9261","F":"178.911"},{"Policy Line":"76972270","B":"CYCLOPHOSPHAMIDE CAP EA 25MG","C":"636","D":"J8530","F":"7.107"},{"Policy Line":"76972271","B":"EMEND CAP EA 5 MG","C":"636","D":"J8501","F":"12.978"},{"Policy Line":"76972272","B":"Rasburicase/Elitek 0.5mg Inj","C":"636","D":"J2783","F":"318.372999999999","G":"**"},{"Policy Line":"76972273","B":"Leuprolide Acet/Eligard 7.5Mg","C":"636","D":"J9217","F":"557.436","G":"**"},{"Policy Line":"76972275","B":"GANCICLOVIR 500MG PWVL","C":"636","D":"J1570","F":"101.97"},{"Policy Line":"76972277","B":"ELOTUZUMAB/EMPLICITI INJ 1MG","C":"636","D":"J9176","F":"7.91455637700138","G":"**"},{"Policy Line":"76972278","B":"MENACWY VACCINE IM SDV","C":"636","D":"90734","F":"136.9488","G":"**"},{"Policy Line":"76972279","B":"CIPROFLOXACIN 250MG ORAL TAB","C":"637","F":"1.125"},{"Policy Line":"76972280","B":"Bleomycin 15 Un Inj (Imported)","C":"636","D":"J9040","F":"183.855"},{"Policy Line":"76972281","B":"PEGINTERFERON ALFA2A 180MCG/ML","C":"636","D":"J3490","F":"1205.0073","G":"**"},{"Policy Line":"76972282","B":"HYDROCORTISONE NONCHEMO10MGTAB","C":"636","D":"J8499","F":"1.854"},{"Policy Line":"76972283","B":"TECENTRIQ/ATEZOLIZUMAB INJ10MG","C":"636","D":"J9022","F":"74.0556498648648","G":"**"},{"Policy Line":"76972284","B":"Vancomycin HCL 500Mg Inj","C":"636","D":"J3370","F":"24.411"},{"Policy Line":"76972285","B":"Chlorpromazine HCL Inj to 50MG","C":"636","D":"J3230","F":"34.608"},{"Policy Line":"76972286","B":"SUSTOL INJ 10MG/0.4ML INJ","C":"636","F":"646.119"},{"Policy Line":"76972287","B":"Tranexamic Acid 10ml IV","C":"250","F":"65.508"},{"Policy Line":"76972288","B":"Infanrix DTAP Peds 0.5ml Syr","C":"636","D":"90700","F":"27.771375","G":"**"},{"Policy Line":"76972289","B":"Ofatumumab/Arzerra 10mg Inj","C":"636","D":"J9302","F":"63.9012","G":"**"},{"Policy Line":"76972290","B":"ALBUTEROL HFA MDI 200INH 18GM","C":"636","D":"J3535","F":"55.311"},{"Policy Line":"76972292","B":"Fentanyl Ptch-Xtd Rel 25mcg/hr","C":"637","F":"2.7"},{"Policy Line":"76972293","B":"HYQVIA IMMUNGLOBULIN INJ 100MG","C":"636","D":"J1575","F":"2775.438"},{"Policy Line":"76972294","B":"FLUCONAZOLE/DIFLUCAN INJ 200MG","C":"636","D":"J1450","F":"8.75499999999999","G":"**"},{"Policy Line":"76972295","B":"Hydralazine 25Mg Tab","C":"637","F":"1.125"},{"Policy Line":"76972296","B":"ELOSULFASEALFA,VIMIZIM INJ 1MG","C":"636","D":"J1322","F":"292.005"},{"Policy Line":"76972297","B":"GALSULFASE/NAGLAZYM INJ 1MG","C":"636","D":"J1458","F":"466.281"},{"Policy Line":"76972298","B":"ImmuneGlobul-Octagam 500mg Inj","C":"636","D":"J1568","F":"66.126"},{"Policy Line":"76972299","B":"Varubi Inj 166.5mg/92.5ml Vial","C":"636","D":"J3490","F":"375.435"},{"Policy Line":"76972301","B":"Degarelix/Firmagon Inj 1MG","C":"636","D":"J9155","F":"4.635","G":"**"},{"Policy Line":"76972322","B":"DEPO_MEDROL 40 MG INJ","C":"636","D":"J1030","F":"8.343","G":"**"},{"Policy Line":"76972345","B":"Filgrastim-Neupogen Inj 1Mcg","C":"636","D":"J1442","F":"1.46279709468526","G":"**"},{"Policy Line":"76972346","B":"Montelukast Sod 10mg Tab","C":"637","F":"1.2","G":"**"},{"Policy Line":"76972352","B":"ALLOPURINOL 300MG TAB","C":"637","F":"1.35"},{"Policy Line":"76972353","B":"ALLOPURINOL 100MG TAB","C":"637","F":"1.35","G":"**"},{"Policy Line":"76972354","B":"NIVOLUMAB / OPDIVO, INJ 1MG","C":"636","D":"J9299","F":"32.3276013720582","G":"**"},{"Policy Line":"76972355","B":"Somatuline Depot ea 1mg, Inj","C":"636","D":"J1930","F":"79.0061344296144","G":"**"},{"Policy Line":"76972356","B":"ALEMTUZUMAB/CAMPATH Inj 1mg","C":"636","D":"J0202","F":"0"},{"Policy Line":"76972357","B":"Levoleucovorin Calcm Inj 0.5mg","C":"636","D":"J0641","F":"2.472"},{"Policy Line":"76972358","B":"CARPUJET,MORPH SULF 4MG/ML INJ","C":"250","F":"22.557","G":"**"},{"Policy Line":"76972359","B":"OLARATUMAB INJ 10MG","C":"636","D":"J9285","F":"61.491"},{"Policy Line":"76972360","B":"Sustol Inj ea 0.1mg","C":"636","D":"J1627","F":"678.255"},{"Policy Line":"76972361","B":"TRASTUZUMAB/HER INJ SDV 10MG","C":"636","D":"J9355","F":"124.714477249163","G":"**"},{"Policy Line":"76972362","B":"IRINOTECAN LIP/ONIVYDE INJ 1MG","C":"636","D":"J9205","F":"50.367","G":"**"},{"Policy Line":"76972363","B":"FLEBOGAMMA IG 5%%DIF 500MG INJ","C":"636","D":"J1572","F":"51.603"},{"Policy Line":"76972364","B":"Fentanyl 100mcg/2Ml Inj SDV","C":"636","D":"J3010","F":"17.922"},{"Policy Line":"76972365","B":"Copanlisib/Aliqopa 1mg Inj","C":"636","D":"J9057","F":"5346.936"},{"Policy Line":"76972366","B":"DURVALUMAB/IMFINZI INJ 10MG","C":"636","F":"71.7873959303985","G":"**"},{"Policy Line":"76972367","B":"IMMUNE GLOBULIN POWDER 500 MG","C":"636","D":"J1566","F":"36.771"},{"Policy Line":"76972368","B":"Vedolizumab/Entyvio Inj, 1mg","C":"636","D":"J3380","F":"24.72"},{"Policy Line":"76972369","B":"GEMTUZUMAB OZOGAMICIN IN 0.1MG","C":"636","D":"J9203","F":"231.75"},{"Policy Line":"76972370","B":"AMLODIPENE BESYLATE 10MG TAB","C":"637","F":"1.125"},{"Policy Line":"76972371","B":"METOPROLOL TARTRATE 100MG TAB","C":"637","F":"1.125"},{"Policy Line":"76972372","B":"HAVRIX 1440U/ 1ML SYR INJ","C":"250","F":"79.1658","G":"**"},{"Policy Line":"76972373","B":"9VHPVGARDASIL VAC2-3D 0.5MLINJ","C":"636","D":"90651","F":"241.638"},{"Policy Line":"76972400","B":"RITUXAN EA 10 MG INJ","C":"636","D":"J9312","F":"111.6726","G":"**"},{"Policy Line":"76972424","B":"Magnesium Cl 10,000mg/50 ml vl","C":"250","F":"4.017"},{"Policy Line":"76972425","B":"Emicizumab-KXWH 0.5 mg","C":"636","D":"J7170","F":"45.94212"},{"Policy Line":"76972450","B":"Cemiplimab-rwlc (Libtayo) 1MG","C":"636","D":"J9119","F":"22.659485","G":"**"},{"Policy Line":"76972451","B":"Fulphila 0.5mg inj","C":"636","D":"Q5108","F":"335.574","G":"**"},{"Policy Line":"76972452","B":"Metoprolol 5mg/5ml vial","C":"250","F":"17.304"},{"Policy Line":"76972454","B":"Mogamulizumab--kpkc 1 mg EA","C":"636","D":"J9204","F":"109.328511627907","G":"**"},{"Policy Line":"76972455","B":"POLATUZUMAB 1 MG VIAL","C":"636","D":"J9999","F":"107.532"},{"Policy Line":"76972456","B":"PENTAMIDINE ISET 300MG INH PWD","C":"250","D":"J2545","F":"125.454","G":"**"},{"Policy Line":"76972457","B":"Carvedilol 12.5MG Oral Tab","C":"637","F":"1.125"},{"Policy Line":"76972458","B":"Ravulizumab-CWVZ EA 10 MG","C":"636","D":"J1303","F":"214.446","G":"**"},{"Policy Line":"76972459","B":"Romosozumab-AQQG 1mg ea","C":"636","D":"J3111","F":"10.506"},{"Policy Line":"76972460","B":"Bevacizumab-AWWB 10mg (MVASI)","C":"636","D":"Q5107","F":"80.649"},{"Policy Line":"76972461","B":"TRASTUZ-ANNS (KANJINTI) 10MG","C":"636","D":"Q5117","F":"85.284","G":"**"},{"Policy Line":"76972462","B":"Clindamycin 300mg/50ml IVPB","C":"636","D":"J3490","F":"16.377","G":"**"},{"Policy Line":"76972463","B":"Magnesium Hydroxide Oral 30ml","C":"637","F":"1.35"},{"Policy Line":"76972464","B":"NaPhos 45mmol/15ml vial","C":"250","F":"39.552"},{"Policy Line":"76972465","B":"Pentam 300mg INJ pwd vial","C":"250","F":"194.361"},{"Policy Line":"76972466","B":"Enfortumab Vedotin-ejfv 1mg","C":"636","D":"J3590","F":"105.987","G":"**"},{"Policy Line":"76972467","B":"Melphalan HCL 50mg vial","C":"636","D":"J9245","F":"602.55","G":"**"},{"Policy Line":"76972468","B":"TRUXIMA 10 MG","C":"636","D":"Q5115","F":"79.413"},{"Policy Line":"76972469","B":"Reblozyl 1mg inj","C":"636","D":"J3590","F":"138.123"},{"Policy Line":"76972471","B":"Varicella-Zoster GE 0.5ml","C":"636","D":"90750","F":"172.731","G":"**"},{"Policy Line":"76972500","B":"Abatacept 10mg SDV INJ","C":"636","D":"J0129","F":"47.895"},{"Policy Line":"76972501","B":"Amifostine 500mg","C":"636","D":"J0207","F":"448.359"},{"Policy Line":"76972502","B":"Amikacin Sulfate 100mg","C":"636","D":"J0278","F":"16.995"},{"Policy Line":"76972504","B":"Cerezyme (Imiglucerase) 10Unit","C":"636","D":"J1786","F":"50.676"},{"Policy Line":"76972505","B":"Methylprednisolone 40MG Inj","C":"636","D":"J2920","F":"17.5726956521739","G":"**"},{"Policy Line":"76972506","B":"Leuprolide Depot Ea 7.5Mg","C":"636","D":"J9217","F":"1753.76004752852","G":"**"},{"Policy Line":"76972508","B":"Vitamin K (Mephyton) ea 5mg","C":"250","F":"71.379"},{"Policy Line":"76972509","B":"Folic Acid ea 1mg","C":"250","F":"1.854"},{"Policy Line":"76972510","B":"Levofloxacin/Levaquin 250 mg","C":"636","D":"J1956","F":"5.871"},{"Policy Line":"76972511","B":"Magnesium Oxide 400mg Tab","C":"637","F":"1.35"},{"Policy Line":"76972512","B":"Praltrexate / Folotyn ea 1MG","C":"636","D":"J9307","F":"261.105"},{"Policy Line":"76972513","B":"Cefepime/Maxepine Inj ea 500MG","C":"636","D":"J0692","F":"4.635"},{"Policy Line":"76972516","B":"Tetanus-Diptheria (Tenivac)0.5","C":"636","D":"90714","F":"28.119","G":"**"},{"Policy Line":"76972517","B":"ADDAMEL N INJ10ML AMP (TRA ME)","C":"250","F":"19.467"},{"Policy Line":"76972518","B":"Velaglucerase Alfa/VPRIV100UIn","C":"636","D":"J3385","F":"433.755391304346","G":"**"},{"Policy Line":"76972638","B":"Gammagard S/D 500 mg Powder","C":"636","D":"J1566","F":"76.323"},{"Policy Line":"76972646","B":"EPOETIN ALFA -EBX 1000U","C":"636","D":"Q5106","F":"3.19815","G":"**"},{"Policy Line":"76972899","B":"OMACETAXINE 0.01 MG","C":"636","D":"J9262","F":"3.53805","G":"**"},{"Policy Line":"76977534","B":"Lidocaine 1%% 2Ml Amp","C":"636","D":"J2001","F":"15.45"},{"Policy Line":"76977537","B":"Lidocaine 1%% 30Ml Vial","C":"636","D":"J2001","F":"0.618"},{"Policy Line":"76977538","B":"Lidocaine 1%% 30Ml Vial","C":"636","D":"J2001","F":"0.618"},{"Policy Line":"76979017","B":"ARSENIC TRIOXIDE 10MG/10ML VL","C":"636","F":"1758.519"},{"Policy Line":"76979467","B":"RITUXIMAB/HYALURONIDASE","C":"636","D":"J9311","F":"2093.166"},{"Policy Line":"76979468","B":"RITUXIMAB/HYALURONIDASE","C":"636","D":"J9311","F":"203.21385","G":"**"},{"Policy Line":"J7182","B":"ANTIHEMO FVIII NovoEight 1 Uni","C":"636","F":"1.236"},{"Policy Line":"0040","B":"Device Emb LC Beads 100-300","C":"278","F":"2355.588"},{"Policy Line":"0091","B":"Clip Localization / Marker","C":"272","F":"157.284","G":"**"},{"Policy Line":"6103","B":"MW PMTA APPLICATOR 14,19CM","C":"272","F":"2551.122"},{"Policy Line":"61502880","B":"Circumcisio-D","C":"270","F":"0"},{"Policy Line":"61550194","B":"ARISTA Adhesn Barrier 1 GM","C":"272","F":"167.994","G":"**"},{"Policy Line":"61550195","B":"ARISTA Adhesn Barrier 3 GM","C":"272","F":"333.846","G":"**"},{"Policy Line":"61550196","B":"ARISTA Adhesn Barrier 5 GM","C":"272","F":"439.416"},{"Policy Line":"61552820","B":"Resuscitation: Neonate Comp-D","C":"270","F":"0"},{"Policy Line":"61554278","B":"BALLOON POSTPARTUM","C":"272","F":"388.62"},{"Policy Line":"61554670","B":"Pack: Resuscitation Neo Comple","C":"272","F":"139.842"},{"Policy Line":"61557535","B":"Filshie Clips","C":"278","F":"145.044","G":"**"},{"Policy Line":"61557930","B":"Interceed Adhesion Barrier","C":"278","F":"314.262","G":"**"},{"Policy Line":"61600097","B":"Bili Mask","C":"270","F":"8.874"},{"Policy Line":"61800055","B":"Arctic Sun Gel Pad Set","C":"272","F":"1132.812"},{"Policy Line":"61800056","B":"Arctic Sun Universal Gel Pad","C":"272","F":"425.34"},{"Policy Line":"61900600","B":"Kit: ICP Monitor & Drain","C":"272","F":"1009.188"},{"Policy Line":"61900602","B":"Bag: Icp/Lumbar Drainage Repl","C":"272","F":"55.386"},{"Policy Line":"61900603","B":"Drainage System: Icp/Lumbar","C":"272","F":"209.61"},{"Policy Line":"61900605","B":"Cath: Icp Drainage Only","C":"278","F":"185.436"},{"Policy Line":"61900608","B":"Kit: ICP Cranial Access","C":"272","F":"348.84"},{"Policy Line":"61901600","B":"Kit: ICP Drain Only-D","C":"272","F":"0"},{"Policy Line":"63148666","B":"TIP YANK WAVEGUIDE","C":"272","F":"410.652"},{"Policy Line":"63300010","B":"Cast Light Long Leg","C":"270","F":"322.524"},{"Policy Line":"63300011","B":"Cast Light Short Leg","C":"270","F":"187.272"},{"Policy Line":"63300088","B":"Trac Russills","C":"270","F":"62.118"},{"Policy Line":"63301098","B":"Splint Post - Fiberglass Arm","C":"270","F":"65.484"},{"Policy Line":"63301099","B":"Splint Post - Fiberglass Leg","C":"270","F":"75.888"},{"Policy Line":"63301186","B":"BACKSUPPORT ULTRALIGN++LSO","C":"274","D":"L0637","F":"435.438"},{"Policy Line":"63301187","B":"BACK SUPPORT SAG RIGID PRECST","C":"274","D":"L0627","F":"140.454"},{"Policy Line":"63301188","B":"AFO MULTI-PODUS PRE CST","C":"274","D":"L4396","F":"153.918"},{"Policy Line":"63301189","B":"COLLAR, ASPEN","C":"274","D":"L0172","F":"44.064"},{"Policy Line":"63302482","B":"TLSO Aspen","C":"274","D":"L0462","F":"724.302"},{"Policy Line":"63302484","B":"LSO Aspen L/Prof","C":"274","D":"L0631","F":"386.478"},{"Policy Line":"63302485","B":"LSO Aspen","C":"274","D":"L0631","F":"570.384"},{"Policy Line":"63304000","B":"TLSO Rigid Frame Hyperex Pre","C":"274","D":"L0472","F":"664.02"},{"Policy Line":"63304001","B":"TLSO Rigid Plastic Cust Fab","C":"274","D":"L0484","F":"2165.562"},{"Policy Line":"63304002","B":"TLSO Rigidlined Cust Fab Two","C":"274","D":"L0486","F":"2144.754"},{"Policy Line":"63304003","B":"Lo Sagitt Rigid Panel Prefab","C":"274","D":"L0627","F":"637.704"},{"Policy Line":"63304004","B":"LSO Sag-Coro Rigid Frame Pre","C":"274","D":"L0631","F":"1256.436"},{"Policy Line":"63304005","B":"Ho Post-Op Hip Abduction","C":"274","D":"L1686","F":"1134.036"},{"Policy Line":"63304007","B":"KO Adj Jnt Pos Rigid Support","C":"274","D":"L1832","F":"922.284"},{"Policy Line":"63304009","B":"AFO Rig Ant Tib Prefab Tcf/=","C":"274","D":"L1932","F":"1092.42"},{"Policy Line":"63304012","B":"AFO Pos Solid Ank Plastic Mo","C":"274","D":"L1960","F":"799.272"},{"Policy Line":"63304013","B":"AFO Plastic Molded W/Ankle J","C":"274","D":"L1970","F":"933.3"},{"Policy Line":"63304014","B":"Kafo Fem Fx Cast Molded To P","C":"274","D":"L2128","F":"1951.362"},{"Policy Line":"63304016","B":"Plastic Mod Low Ext Pad/Line","C":"274","D":"L2275","F":"189.414"},{"Policy Line":"63304018","B":"Hip Adj Flex Ext Abduct Cont","C":"274","D":"L2624","F":"601.902"},{"Policy Line":"63304019","B":"Soft Interface Below Knee Se","C":"274","D":"L2820","F":"152.388"},{"Policy Line":"63304020","B":"Acromio/Clavicular Canvas&We","C":"274","D":"L3670","F":"201.96"},{"Policy Line":"63304021","B":"Wrist Cock-Up Non-Molded","C":"274","D":"L3908","F":"102.204"},{"Policy Line":"63304022","B":"Pneumati Walking Boot Prefab","C":"274","D":"L4360","F":"424.422"},{"Policy Line":"63304023","B":"Non-Pneum Walk Boot Prefab","C":"274","D":"L4386","F":"246.636"},{"Policy Line":"63304024","B":"Static Afo","C":"274","D":"L4396","F":"260.1"},{"Policy Line":"63304025","B":"Postop App Non-Wgt Bear Dsg","C":"274","D":"L5450","F":"629.136"},{"Policy Line":"63304029","B":"Shrinker Below Knee","C":"274","D":"L8440","F":"0"},{"Policy Line":"63304030","B":"Shrinker Below Knee","C":"274","D":"L8460","F":"0"},{"Policy Line":"64100047","B":"Pacemaker Gen Single Grp1","C":"275","D":"C1786","F":"3246.048"},{"Policy Line":"64100070","B":"Rezoom Conventional Iol","C":"276","F":"261.63"},{"Policy Line":"64100071","B":"Rezoom Presbyopia Lens -D","C":"276","F":"0"},{"Policy Line":"64100073","B":"Toric Lens -D","C":"276","F":"788.256"},{"Policy Line":"64100074","B":"Toric Conventional Iol","C":"276","F":"261.63"},{"Policy Line":"64100077","B":"Lens Toric A-C Function","C":"276","D":"V2787","F":"185.742","G":"**"},{"Policy Line":"64100084","B":"Encore Inflation Dev 15-105","C":"272","D":"C1725","F":"66.402"},{"Policy Line":"64100135","B":"Pacer Enrythm Gen & Leads D","C":"275","F":"5985.054"},{"Policy Line":"64100179","B":"Rod Group 5","C":"278","F":"1264.086"},{"Policy Line":"64100181","B":"Pacemaker System Versa -D","C":"275","F":"5745.456"},{"Policy Line":"64100187","B":"Defib Virtuoso Sgl D154Vwc","C":"275","D":"C1722","F":"21697.236"},{"Policy Line":"64100191","B":"Alloderm Tissue 6X16 102196","C":"278","D":"Q4116","F":"3198.312"},{"Policy Line":"64100192","B":"Alloderm 6X16 Xthick 982196","C":"278","D":"Q4116","F":"3301.434"},{"Policy Line":"64100194","B":"Alloderm 6X12 102072","C":"278","D":"Q4116","F":"3051.738"},{"Policy Line":"64100232","B":"Alloderm 8X16 Xthick 982128","C":"278","D":"Q4116","F":"4402.422"},{"Policy Line":"64100233","B":"Alloderm 2X4","C":"278","D":"Q4116","F":"398.106"},{"Policy Line":"64100235","B":"Graftjacket Mesh 4X04 CM","C":"278","D":"Q4107","F":"1938.204"},{"Policy Line":"64100238","B":"Graftjacket Mesh 86Tm-4X08","C":"278","D":"Q4107","F":"2764.404"},{"Policy Line":"64100239","B":"Graftjacket 5X5 8600-5X05","C":"278","D":"Q4107","F":"10578.114"},{"Policy Line":"64100240","B":"GraftJacket 4X7 86Um-4X07","C":"278","D":"Q4107","F":"10578.114"},{"Policy Line":"64100242","B":"GraftJacket 4X7Cm 8600-4X07","C":"278","D":"Q4107","F":"10578.114"},{"Policy Line":"64100245","B":"Sealant Surg/Closure Dev Grp 1","C":"272","F":"282.132","G":"**"},{"Policy Line":"64100246","B":"Sealant Surg/Closure Dev Grp 2","C":"272","F":"627.912","G":"**"},{"Policy Line":"64100247","B":"Graft Vascular Grp 1","C":"278","D":"C1768","F":"188.802"},{"Policy Line":"64100248","B":"Graft Vascular Grp 2","C":"278","D":"C1768","F":"277.542","G":"**"},{"Policy Line":"64100249","B":"Graft Vascular Grp 3","C":"278","D":"C1768","F":"467.874","G":"**"},{"Policy Line":"64100250","B":"Graft Vascular Grp 4","C":"278","D":"C1768","F":"677.484","G":"**"},{"Policy Line":"64100253","B":"Graft Vascular Grp 5","C":"278","D":"C1768","F":"770.202","G":"**"},{"Policy Line":"64100254","B":"Graft Vascular Grp 6","C":"278","D":"C1768","F":"1538.262","G":"**"},{"Policy Line":"64100257","B":"Graft Vascular Grp 7","C":"278","D":"C1768","F":"2848.86","G":"**"},{"Policy Line":"64100258","B":"Graft Vascular Grp 8","C":"278","D":"C1768","F":"2981.358","G":"**"},{"Policy Line":"64100259","B":"Graft Vascular Grp 11","C":"278","D":"C1768","F":"9433.98","G":"**"},{"Policy Line":"64100260","B":"Gamma Graft 12X30 Cm2 Gg400","C":"278","D":"Q4111","F":"318.24"},{"Policy Line":"64100261","B":"Cath Guiding Grp 2","C":"272","D":"C1887","F":"272.646","G":"**"},{"Policy Line":"64100263","B":"Cath Guiding Grp 3","C":"272","D":"C1887","F":"509.49","G":"**"},{"Policy Line":"64100264","B":"Pacemaker Sys Adpata Addrs1-D","C":"275","F":"0"},{"Policy Line":"64100265","B":"Gen Addrs1","C":"275","D":"C1785","F":"5272.686"},{"Policy Line":"64100269","B":"Spinal Cage/Spacer Grp 1","C":"278","F":"1139.238","G":"**"},{"Policy Line":"64100270","B":"Spinal Cage/Spacer Grp 2","C":"278","F":"1116.288","G":"**"},{"Policy Line":"64100271","B":"Spinal Cage/Spacer Grp 3","C":"278","F":"1555.704","G":"**"},{"Policy Line":"64100272","B":"Spinal Cage/Spacer Grp 4","C":"278","F":"2863.854","G":"**"},{"Policy Line":"64100273","B":"Spinal Cage/Spacer Grp 5","C":"278","F":"3044.088","G":"**"},{"Policy Line":"64100274","B":"Spinal Cage/Spacer Grp 6","C":"278","F":"3723.102","G":"**"},{"Policy Line":"64100275","B":"Spinal Cage/Spacer Grp 7","C":"278","F":"4241.466","G":"**"},{"Policy Line":"64100276","B":"Spinal Cage/Spacer Grp 8","C":"278","F":"4739.022","G":"**"},{"Policy Line":"64100279","B":"Rod Grp 6","C":"278","F":"1850.688","G":"**"},{"Policy Line":"64100280","B":"Sizer Mammary Grp","C":"272","F":"83.538"},{"Policy Line":"64100287","B":"Cath Coronary Grp 2","C":"272","F":"1432.386"},{"Policy Line":"64100293","B":"Morcellator","C":"272","D":"C1782","F":"795.6","G":"**"},{"Policy Line":"64100296","B":"Elevate Anterior 720093-01","C":"278","D":"C1781","F":"2391.084"},{"Policy Line":"64100301","B":"Alloderm 4X12 Cm","C":"278","D":"Q4116","F":"1472.166"},{"Policy Line":"64100302","B":"Bone Morphogenic Protein","C":"278","F":"4967.298"},{"Policy Line":"64100303","B":"Bone Osteogenic Protein","C":"278","F":"5071.95"},{"Policy Line":"64100308","B":"Gen Zephyr Xl Dr 5826","C":"275","D":"C1785","F":"7155.504"},{"Policy Line":"64100314","B":"Pacer Zephyr Xl Dr 5826 Sys-D","C":"275","F":"0"},{"Policy Line":"64100317","B":"Cath Atherectomy","C":"272","D":"C1724","F":"3418.326","G":"**"},{"Policy Line":"64100359","B":"Cath Relieva Sinus Balloon","C":"272","D":"C1726","F":"849.762","G":"**"},{"Policy Line":"64100386","B":"Stent Non Cov/No Deliv","C":"278","D":"C1877","F":"2433.924"},{"Policy Line":"64100389","B":"Cement Bone Group 3","C":"278","D":"C1713","F":"869.04","G":"**"},{"Policy Line":"64100392","B":"Contigen","C":"278","D":"L8603","F":"643.518"},{"Policy Line":"64100393","B":"Cath Intradiscal (Idet)","C":"272","D":"C1754","F":"1638.018"},{"Policy Line":"64100394","B":"Gen Prime Advanced Neurostim","C":"278","D":"C1767","F":"5824.71"},{"Policy Line":"64100395","B":"Lead Kit Neurostim 39565","C":"278","D":"C1778","F":"5679.666"},{"Policy Line":"64100396","B":"Programmer Impl Neurostim","C":"272","D":"C1787","F":"989.604"},{"Policy Line":"64100397","B":"Cement Bone Group 2","C":"278","D":"C1713","F":"291.312","G":"**"},{"Policy Line":"64100398","B":"Ablator Sys Atricure Disp","C":"272","F":"3196.17","G":"**"},{"Policy Line":"64100401","B":"Cath Occlusion","C":"272","D":"C2628","F":"577.422"},{"Policy Line":"64100405","B":"Pacemaker Sys Empulse E2Dr01-D","C":"275","F":"0"},{"Policy Line":"64100406","B":"Bmp Infuse Xsm","C":"278","F":"2297.142","G":"**"},{"Policy Line":"64100407","B":"Bmp Infuse Xxsm","C":"278","F":"1149.336"},{"Policy Line":"64100487","B":"Suture Guide Heart Gfs-10","C":"272","F":"100.368","G":"**"},{"Policy Line":"64100495","B":"Knife Bayonet 9560659","C":"272","F":"415.242","G":"**"},{"Policy Line":"64100509","B":"Lead Locking Device","C":"272","D":"C1773","F":"752.148"},{"Policy Line":"64100532","B":"Gen Nuerostim Sc-1110-02","C":"278","D":"C1820","F":"15676.992"},{"Policy Line":"64100534","B":"Spacer Relieva Sinus System","C":"272","F":"1017.45"},{"Policy Line":"64100575","B":"Rod Axia Lif Interbody Device","C":"278","D":"C1713","F":"7882.254"},{"Policy Line":"64100579","B":"Plate Grp 10","C":"278","D":"C1713","F":"4506.768","G":"**"},{"Policy Line":"64100595","B":"Plate Grp 8","C":"278","D":"C1713","F":"2131.596","G":"**"},{"Policy Line":"64100596","B":"Plate Grp 9","C":"278","D":"C1713","F":"2716.362","G":"**"},{"Policy Line":"64100600","B":"Sling No Cost C1771","C":"278","D":"C1771","F":"0.306"},{"Policy Line":"64100616","B":"Cath Guiding Acclarent","C":"272","D":"C1887","F":"720.324"},{"Policy Line":"64100658","B":"No Cost Mesh C1781","C":"278","D":"C1781","F":"0.306"},{"Policy Line":"64100684","B":"Sealant Duraseal 202050","C":"278","F":"1083.24","G":"**"},{"Policy Line":"64100706","B":"Lead Coronary Sinus","C":"275","D":"C1900","F":"3023.28"},{"Policy Line":"64100731","B":"Prowler Cath Neuro Embolectomy","C":"272","D":"C1887","F":"1112.616"},{"Policy Line":"64100759","B":"Pacer Sys Adsr01 -D","C":"275","F":"0"},{"Policy Line":"64100765","B":"Stent Palmaz","C":"278","D":"C1876","F":"2183.004","G":"**"},{"Policy Line":"64100795","B":"Stent Graft Conlat - Endurant","C":"278","F":"6524.226","G":"**"},{"Policy Line":"64100796","B":"Prosth Penile Reservoir-TITAN","C":"278","D":"C1813","F":"2284.596","G":"**"},{"Policy Line":"64100797","B":"Prosth Penile Reservr-100ML IZ","C":"278","D":"C1813","F":"2670.428","G":"**"},{"Policy Line":"64100798","B":"BLADE DISPOSABLE GRP 6","C":"272","F":"1092.42","G":"**"},{"Policy Line":"64100799","B":"Protector Nerve 7mmX2Cm NW720","C":"278","D":"C9353","F":"2527.56"},{"Policy Line":"64100808","B":"Cath Turbohawk Atherectomy","C":"272","D":"C1714","F":"3241.764"},{"Policy Line":"64100850","B":"Sling Avaulta","C":"278","D":"C1763","F":"2078.352"},{"Policy Line":"64100860","B":"Pacer System Altrua S401 -D","C":"275","F":"4047.462"},{"Policy Line":"64100866","B":"Pacer Altrua S403 Dr -D","C":"275","F":"0"},{"Policy Line":"64100869","B":"Pacer Gen Altrua S403 Dr","C":"275","D":"C1785","F":"4260.438"},{"Policy Line":"64100871","B":"Fascia Lata Tissue Implant GR2","C":"278","D":"C1762","F":"2096.1"},{"Policy Line":"64100874","B":"Xenograft Implant","C":"278","D":"C1763","F":"2126.394"},{"Policy Line":"64100876","B":"Anchor Bone Grp 4","C":"278","D":"C1713","F":"763.776","G":"**"},{"Policy Line":"64100878","B":"Inforce Matrix-CnTiss Nonhuman","C":"278","D":"C1763","F":"3061.224","G":"**"},{"Policy Line":"64100889","B":"Pacemaker Contak Renewal","C":"275","D":"C2621","F":"8670.816"},{"Policy Line":"64100912","B":"BMP Infuse Small","C":"278","F":"3640.482","G":"**"},{"Policy Line":"64100913","B":"BMP Infuse Medium","C":"278","F":"5070.114","G":"**"},{"Policy Line":"64100914","B":"BMP Infuse Large","C":"278","F":"5733.216","G":"**"},{"Policy Line":"64100915","B":"Prosthes Penile-AccesryKit 800","C":"272","F":"1499.706","G":"**"},{"Policy Line":"64100916","B":"GraftJacket 2X4 8600-2X04","C":"278","D":"Q4107","F":"1648.422"},{"Policy Line":"64100922","B":"NS Kit Lead Trial 50cm","C":"278","D":"C1778","F":"1535.508"},{"Policy Line":"64100926","B":"External Fixator Cmpnts Grp 3A","C":"272","F":"1168.92","G":"**"},{"Policy Line":"64100930","B":"External Fixator Cmpnts Grp 3B","C":"272","F":"1428.102","G":"**"},{"Policy Line":"64100939","B":"Plate Grp 5A","C":"278","D":"C1713","F":"1490.526","G":"**"},{"Policy Line":"64100956","B":"Graft Vascular Grp 9","C":"278","D":"C1768","F":"4576.536","G":"**"},{"Policy Line":"64100957","B":"Graft Vascular Grp 10","C":"278","D":"C1768","F":"6492.096","G":"**"},{"Policy Line":"64100958","B":"Graft Vascular Grp 12","C":"278","D":"C1768","F":"11595.258","G":"**"},{"Policy Line":"64100961","B":"Nail, Ortho Grp 6","C":"278","D":"C1713","F":"2250.018","G":"**"},{"Policy Line":"64100962","B":"Nail, Ortho Grp 7","C":"278","D":"C1713","F":"2536.128","G":"**"},{"Policy Line":"64101013","B":"Sys Fem Filter Recover Rf-310F","C":"278","D":"C1880","F":"1897.812"},{"Policy Line":"64101053","B":"Nerve Locator/Stimulator","C":"272","F":"95.778","G":"**"},{"Policy Line":"64101054","B":"Stimulator Test Interstim 3625","C":"272","F":"1017.45"},{"Policy Line":"64101062","B":"Stent Complete Se","C":"278","D":"C1876","F":"1727.676"},{"Policy Line":"64101092","B":"Neurostim Interstim 3023-101","C":"278","D":"C1767","F":"8926.632"},{"Policy Line":"64101093","B":"Neurostim Itrel 2 7425","C":"278","D":"C1767","F":"7907.346"},{"Policy Line":"64101095","B":"Lead Icd Sprint Quattro 6721S","C":"275","D":"C1896","F":"1343.646"},{"Policy Line":"64101100","B":"Attain Cath Venogram 6215","C":"272","D":"C1725","F":"256.122"},{"Policy Line":"64101170","B":"FORCEP BIPOLAR, INTUITIVE","C":"272","F":"3246.048"},{"Policy Line":"64101189","B":"Impl NS Lead Test Kit","C":"278","D":"C1897","F":"1913.418","G":"**"},{"Policy Line":"64101194","B":"Fixator Circular Sidekick","C":"272","F":"5692.824"},{"Policy Line":"64101198","B":"Primatrix 4X4 Sq Cm","C":"278","D":"Q4110","F":"823.752"},{"Policy Line":"64101206","B":"Primatrix 6X6 Sq Cm","C":"278","D":"Q4110","F":"1451.358"},{"Policy Line":"64101226","B":"PriMatrix 8X8 Sq Cm","C":"278","D":"Q4110","F":"2962.998"},{"Policy Line":"64101230","B":"Kit Platelet","C":"272","F":"278.766","G":"**"},{"Policy Line":"64101237","B":"Brachytherapy Needle Fn18","C":"278","D":"C1715","F":"199.206","G":"**"},{"Policy Line":"64101239","B":"Artelon Tissue Implant","C":"278","D":"L8658","F":"3196.17"},{"Policy Line":"64101240","B":"Crystalens -D","C":"276","F":"0"},{"Policy Line":"64101242","B":"Crystalens Presby-C Functn","C":"276","D":"V2788","F":"390.456"},{"Policy Line":"64101246","B":"Vein Saphenous Lp230-39Cm","C":"278","F":"10771.812"},{"Policy Line":"64101247","B":"Vein Saphenous V010","C":"278","F":"10366.974","G":"**"},{"Policy Line":"64101248","B":"Vein Saphenous Cv46-60","C":"278","F":"5878.566"},{"Policy Line":"64101249","B":"Guidewire Grp 2","C":"272","D":"C1769","F":"193.086","G":"**"},{"Policy Line":"64101251","B":"Screw Group 7","C":"278","D":"C1713","F":"1492.668","G":"**"},{"Policy Line":"64101252","B":"Screw Group 8","C":"278","D":"C1713","F":"1779.084","G":"**"},{"Policy Line":"64101255","B":"Prosthesis Breast Grp 4","C":"278","D":"C1789","F":"1712.376","G":"**"},{"Policy Line":"64101270","B":"Allograft Orth/Neuro Grp7","C":"278","F":"2953.512","G":"**"},{"Policy Line":"64101271","B":"Allograft Orth/Neuro Grp8","C":"278","F":"4332.042","G":"**"},{"Policy Line":"64101272","B":"Allograft Oats 268003","C":"278","D":"C1762","F":"6593.688"},{"Policy Line":"64101273","B":"Allograft Human 268021","C":"278","D":"C1762","F":"6644.484","G":"**"},{"Policy Line":"64101355","B":"Aigisrx Pm Antibacterial Envel","C":"278","F":"889.542"},{"Policy Line":"64101511","B":"MatrixWnd w/Mesh 5x5cm Mwm2021","C":"278","D":"C9363","F":"2213.91"},{"Policy Line":"64101547","B":"Anchor Kit - Neurostim","C":"278","F":"597.006","G":"**"},{"Policy Line":"64101548","B":"Flexhd 6X16 Derm Tissue 471616","C":"278","D":"Q4128","F":"3193.11"},{"Policy Line":"64101549","B":"Flexhd 6X12 Cm Derm Tissue","C":"278","D":"Q4128","F":"2640.78"},{"Policy Line":"64101552","B":"Flexhd 2X4 Cm Derm Tissue","C":"278","D":"Q4128","F":"722.466"},{"Policy Line":"64101553","B":"Repliform","C":"278","D":"C1762","F":"862.614"},{"Policy Line":"64101555","B":"Spacer Mold Hip Cement","C":"278","F":"351.9"},{"Policy Line":"64101569","B":"ICD Gen Incepta Vr He E160","C":"275","D":"C1722","F":"16298.478"},{"Policy Line":"64101576","B":"ICD Gen Contak Renew Biv H215","C":"275","D":"C1882","F":"24886.062"},{"Policy Line":"64101579","B":"Ams Spectra Penile Prosthesis","C":"278","D":"C2622","F":"5336.334","G":"**"},{"Policy Line":"64101663","B":"Coupler Gem Vasc Anastomoses","C":"272","F":"550.8","G":"**"},{"Policy Line":"64101668","B":"Screw Cover, Ext Cochlear","C":"272","F":"250.308","G":"**"},{"Policy Line":"64101670","B":"Gen NS-Restore 37712","C":"278","D":"C1820","F":"18540.234"},{"Policy Line":"64101671","B":"Lead Neurostim","C":"278","D":"C1778","F":"914.328"},{"Policy Line":"64101674","B":"Disk Artificial","C":"278","F":"4564.908"},{"Policy Line":"64101675","B":"Spacer Anterior Stt36110-12Lt","C":"278","F":"6694.974"},{"Policy Line":"64101677","B":"Cage Pillar Alif","C":"278","F":"6725.574"},{"Policy Line":"64101678","B":"Spacer Alif Xsm 364.009","C":"278","F":"7970.076"},{"Policy Line":"64101679","B":"SCREW EXTRACTION 309.510","C":"272","F":"160.038"},{"Policy Line":"64101682","B":"BOLT EXTRACTION 4.5MM","C":"272","F":"193.086"},{"Policy Line":"64101683","B":"SCREW CONICAL EXTRACTION","C":"272","F":"259.488"},{"Policy Line":"64101687","B":"GUIDE PIN, NON IMPLNT GR 3","C":"272","F":"895.662","G":"**"},{"Policy Line":"64101689","B":"Allograft BiofixFlow 0.5CC","C":"278","D":"Q4162","F":"3071.322"},{"Policy Line":"64101691","B":"ALLGRFT AMNIO MEM BIOFIX 4X4CM","C":"278","D":"Q4163","F":"3164.958"},{"Policy Line":"64101700","B":"NS EXT PT RECHARG SYSTEM REPL","C":"274","D":"L8689","F":"2687.292"},{"Policy Line":"64101701","B":"ALLOGRAFT BIOFIX FLOW 1CC BFA","C":"278","D":"Q4162","F":"3530.016"},{"Policy Line":"64101703","B":"Plate Grp 9A","C":"278","D":"C1713","F":"3295.926","G":"**"},{"Policy Line":"64101704","B":"Plug, Acetabular","C":"278","F":"145.044","G":"**"},{"Policy Line":"64101707","B":"DEVICE,INFLATION-ENCORE 26","C":"272","F":"138.924"},{"Policy Line":"64101708","B":"Cytology Brush Sheathed","C":"272","F":"213.894"},{"Policy Line":"64101709","B":"Pin Guide, Tibia 25mm","C":"272","F":"48.348"},{"Policy Line":"64101710","B":"Prosthesis Penile Pump Grp 3","C":"278","D":"C1813","F":"9862.992","G":"**"},{"Policy Line":"64101711","B":"Intro/Sheath,Fixed,Peel-Away","C":"272","D":"C1892","F":"125.766","G":"**"},{"Policy Line":"64101712","B":"SPINE ROD TRIAL IMPLANT","C":"278","F":"171.666","G":"**"},{"Policy Line":"64101715","B":"SPINE ROD CURVED 65MM","C":"278","F":"162.18"},{"Policy Line":"64101716","B":"SPINE ROD GRP 1","C":"278","F":"185.13"},{"Policy Line":"64101717","B":"SPINE ROD GRP 2","C":"278","F":"246.636","G":"**"},{"Policy Line":"64101738","B":"SPINE ROD GRP 3","C":"278","F":"312.12","G":"**"},{"Policy Line":"64101739","B":"SPINE ROD GRP 4","C":"278","F":"374.544","G":"**"},{"Policy Line":"64101741","B":"Valvulotome-Expandable","C":"272","F":"2609.262","G":"**"},{"Policy Line":"64101745","B":"Neurawrap Nerve Protector 2Cm","C":"278","D":"C9353","F":"1391.688"},{"Policy Line":"64101746","B":"Neurawrap Nerve Protector","C":"278","D":"C9353","F":"2028.78","G":"**"},{"Policy Line":"64101747","B":"Neuragen Nerve Guide 2 Cm","C":"278","D":"C9352","F":"1828.35"},{"Policy Line":"64101748","B":"Neuragen Nerve Guide 3 Cm","C":"278","D":"C9352","F":"2458.098","G":"**"},{"Policy Line":"64101749","B":"SPINE ROD GRP 5","C":"278","F":"468.18","G":"**"},{"Policy Line":"64101752","B":"SPINE ROD GRP 6","C":"278","F":"571.302","G":"**"},{"Policy Line":"64101756","B":"SPINE ROD GRP 7","C":"278","F":"699.21","G":"**"},{"Policy Line":"64101778","B":"SPINE ROD GRP 8","C":"278","F":"856.8","G":"**"},{"Policy Line":"64101779","B":"SPINE ROD GRP 9","C":"278","F":"1047.132"},{"Policy Line":"64101780","B":"SPINE ROD GRP 10","C":"278","F":"1279.692","G":"**"},{"Policy Line":"64101784","B":"SPINE ROD GRP 11","C":"278","F":"1560.6"},{"Policy Line":"64101786","B":"SPINE ROD GRP 12","C":"278","F":"1910.052","G":"**"},{"Policy Line":"64101788","B":"SPINE ROD OFFSET 20MM","C":"278","F":"2303.568"},{"Policy Line":"64101789","B":"SPINE ROD W CORD 152.XXXX","C":"278","F":"2840.292"},{"Policy Line":"64101793","B":"SPINE ROD W/TUBING 40MM","C":"278","F":"3043.17"},{"Policy Line":"64101794","B":"Connector Orth/Neuro Grp 2A","C":"278","F":"780.3","G":"**"},{"Policy Line":"64101801","B":"Stackhouse Filter Lfs-103","C":"272","F":"126.684"},{"Policy Line":"64101805","B":"SPINE STAB-TRANS SPOOL 152.202","C":"278","F":"96.696"},{"Policy Line":"64101806","B":"NS Kit PatientTrial SC-6500-32","C":"272","F":"135.558"},{"Policy Line":"64101810","B":"Kit,Rotation w/Tendon Stples","C":"278","D":"C1713","F":"1238.076"},{"Policy Line":"64101813","B":"Introducer/Sheath Grp 2B","C":"272","D":"C1894","F":"237.762","G":"**"},{"Policy Line":"64101819","B":"Introducer Sheath 14FR X 28CM","C":"272","D":"C1894","F":"318.24","G":"**"},{"Policy Line":"64101821","B":"Cath Balloon Angioplasty Grp1C","C":"272","D":"C1725","F":"385.254","G":"**"},{"Policy Line":"64101822","B":"Cath Balloon Angioplasty Grp1E","C":"272","D":"C1725","F":"471.24","G":"**"},{"Policy Line":"64101826","B":"Dermis Hmatrix 5X4 Cm 208032","C":"278","D":"Q4134","F":"810.288"},{"Policy Line":"64101828","B":"PICO 10X20Cm Ns Pump 66800951","C":"272","F":"351.594","G":"**"},{"Policy Line":"64101832","B":"Bony Void Filler Grp 10","C":"278","D":"C1713","F":"4347.954","G":"**"},{"Policy Line":"64101833","B":"ORTHOCORD","C":"272","F":"52.938","G":"**"},{"Policy Line":"64101836","B":"Screw Grp 2A","C":"278","D":"C1713","F":"302.634","G":"**"},{"Policy Line":"64101838","B":"Screw Grp 3A","C":"278","D":"C1713","F":"491.742","G":"**"},{"Policy Line":"64101842","B":"Patch Fibrin Sealant 2x4in","C":"278","F":"992.052","G":"**"},{"Policy Line":"64101845","B":"Rod Humeral 8x240","C":"278","D":"C1713","F":"3126.096","G":"**"},{"Policy Line":"64101847","B":"NAIL VALOR 11.5X250","C":"278","D":"C1713","F":"4276.044"},{"Policy Line":"64101848","B":"COMP FEM OXNM SZ3","C":"278","D":"C1776","F":"7017.192"},{"Policy Line":"64101850","B":"Allogrft Tiss-Cartilage Denovo","C":"278","F":"4828.374","G":"**"},{"Policy Line":"64101852","B":"NS Kit, Lead Introducer","C":"272","F":"135.558"},{"Policy Line":"64101853","B":"Wire Ortho Supply Grp 1A","C":"272","F":"137.394"},{"Policy Line":"64101854","B":"Wire Ortho Supply Grp 1B","C":"272","F":"171.666","G":"**"},{"Policy Line":"64101855","B":"Wire Ortho Supply Grp 1C","C":"272","F":"207.774","G":"**"},{"Policy Line":"64101860","B":"Burr Grp 2B","C":"272","F":"323.136"},{"Policy Line":"64101861","B":"Burr Grp 2C","C":"272","F":"393.21","G":"**"},{"Policy Line":"64101865","B":"Bit Drill Grp 2A","C":"272","F":"279.378","G":"**"},{"Policy Line":"64101866","B":"Bit Drill Grp 2B","C":"272","F":"341.802","G":"**"},{"Policy Line":"64101867","B":"Implant Joint Grp 5A","C":"278","D":"C1776","F":"1179.936","G":"**"},{"Policy Line":"64101868","B":"Implant Hammerlock 20mm","C":"278","D":"C1713","F":"1439.424","G":"**"},{"Policy Line":"64101872","B":"DBS/NS Adaptor Pocket 1x4","C":"278","D":"C1883","F":"788.256"},{"Policy Line":"64101875","B":"Bone Stimulator 01-203-0001","C":"278","F":"2571.624"},{"Policy Line":"64101879","B":"KIT JUGGER KNOT SZ1 OR 2","C":"278","D":"C1713","F":"818.856","G":"**"},{"Policy Line":"64101880","B":"Prosthesis Ams Cuff W/IH, OCCL","C":"278","D":"C1815","F":"5737.5","G":"**"},{"Policy Line":"64101882","B":"Plate Grp 3 A","C":"278","D":"C1713","F":"401.166","G":"**"},{"Policy Line":"64101883","B":"Plate Grp 3 B","C":"278","D":"C1713","F":"489.906","G":"**"},{"Policy Line":"64101884","B":"Staple Bone Grp 3 D","C":"278","D":"C1713","F":"1357.722"},{"Policy Line":"64101885","B":"Plate Grp 3 C","C":"278","D":"C1713","F":"597.618","G":"**"},{"Policy Line":"64101887","B":"Plate Grp 3 D","C":"278","D":"C1713","F":"730.422","G":"**"},{"Policy Line":"64101888","B":"Port Power 8FR SGL","C":"278","D":"C1788","F":"373.932","G":"**"},{"Policy Line":"64101889","B":"Sternalock Plate - GR 1","C":"278","D":"C1713","F":"526.932"},{"Policy Line":"64101896","B":"Sternalock Plate - GR 3","C":"278","D":"C1713","F":"836.604"},{"Policy Line":"64101897","B":"Valve Heart MAGNA 330TFX25","C":"278","F":"10042.614"},{"Policy Line":"64101898","B":"Plate Grp 9 B","C":"278","D":"C1713","F":"4054.5","G":"**"},{"Policy Line":"64101908","B":"Bit Drill 16mm Synthes","C":"272","F":"1286.73","G":"**"},{"Policy Line":"64101910","B":"Mesh Genl Surg C1781 Grp 5 A","C":"278","D":"C1781","F":"1521.738","G":"**"},{"Policy Line":"64101915","B":"Cath Central Venous Grp 2 A","C":"278","D":"C1751","F":"618.12"},{"Policy Line":"64101918","B":"Cath Central Venous Grp 2 B","C":"278","D":"C1751","F":"755.208","G":"**"},{"Policy Line":"64101921","B":"Prosthesis Kit Penile/Uri GR2","C":"278","D":"C1815","F":"888.012","G":"**"},{"Policy Line":"64101925","B":"Prosthesis Kit Penile/Uri GR3","C":"278","D":"C1815","F":"1086.3"},{"Policy Line":"64101927","B":"Graft Vascular Grp 6 A","C":"278","D":"C1768","F":"1878.84","G":"**"},{"Policy Line":"64101929","B":"Bit Drill Grp 4 A","C":"272","F":"824.058","G":"**"},{"Policy Line":"64101935","B":"GUIDE PIN, NON IMPLNT GR 1","C":"272","F":"599.148"},{"Policy Line":"64101938","B":"GUIDE PIN, NON IMPLNT GR 2","C":"272","F":"733.482"},{"Policy Line":"64101940","B":"External Fixator Cmpnts Grp2A","C":"272","F":"390.15"},{"Policy Line":"64101942","B":"External Fixator Cmpnts Grp2C","C":"272","F":"583.542"},{"Policy Line":"64101944","B":"Bony Void Filler Grp 3A","C":"278","D":"C1713","F":"1047.132","G":"**"},{"Policy Line":"64101945","B":"Valve Heart Grp A","C":"278","F":"3870.288"},{"Policy Line":"64101946","B":"Mesh Genl Surg C1781 Grp 4A","C":"278","D":"C1781","F":"987.768","G":"**"},{"Policy Line":"64101947","B":"Mesh Genl Surg C1781 Grp 3A","C":"278","D":"C1781","F":"567.936","G":"**"},{"Policy Line":"64101948","B":"Mesh Genl Surg C1781 Grp 3B","C":"278","D":"C1781","F":"694.62","G":"**"},{"Policy Line":"64101950","B":"IMP TRAY TIBIAL ROTATG PLTFRM","C":"278","D":"C1776","F":"7241.184"},{"Policy Line":"64101951","B":"Cath Balloon Angioplasty Grp1A","C":"272","D":"C1725","F":"315.18","G":"**"},{"Policy Line":"64101954","B":"Cath Balloon Angioplasty Grp1D","C":"272","D":"C1725","F":"385.56"},{"Policy Line":"64101955","B":"Cannula OH FEM/VEN 23/25FR","C":"272","F":"559.98","G":"**"},{"Policy Line":"64101956","B":"Implant-Ossicular Ti 636-080","C":"278","D":"L8613","F":"208.386","G":"**"},{"Policy Line":"64101957","B":"Imp Cath Port C1788 Grp A","C":"278","D":"C1788","F":"302.634","G":"**"},{"Policy Line":"64101958","B":"Mesh Hernia Phasix 20X25CM","C":"278","D":"C1781","F":"8470.386"},{"Policy Line":"64101959","B":"Allograft Orth/Neuro Grp 6B","C":"278","F":"2965.14","G":"**"},{"Policy Line":"64101961","B":"Bony Void Filler Actifuse","C":"278","D":"C1713","F":"4235.652"},{"Policy Line":"64101962","B":"Prodense 87Sr-Ck15 Bone Filler","C":"278","D":"C1713","F":"5646.618","G":"**"},{"Policy Line":"64101963","B":"Prodense 87Sr-0420 Bone Filler","C":"278","D":"C1713","F":"4542.57","G":"**"},{"Policy Line":"64101967","B":"Bony Void Filler Grp 1","C":"278","D":"C1713","F":"264.078","G":"**"},{"Policy Line":"64101972","B":"Bony Void Filler Grp 2","C":"278","D":"C1713","F":"613.53","G":"**"},{"Policy Line":"64101973","B":"Bony Void Filler Grp 3","C":"278","D":"C1713","F":"856.494","G":"**"},{"Policy Line":"64101974","B":"Bony Void Filler Grp 4","C":"278","D":"C1713","F":"1346.094","G":"**"},{"Policy Line":"64101975","B":"Bony Void Filler Grp 5","C":"278","D":"C1713","F":"1624.86","G":"**"},{"Policy Line":"64101976","B":"Bony Void Filler Grp 6","C":"278","D":"C1713","F":"1989.306","G":"**"},{"Policy Line":"64101977","B":"Bony Void Filler Grp 7","C":"278","D":"C1713","F":"3078.972","G":"**"},{"Policy Line":"64101978","B":"Cannula FlwPrt, Hip Arthros","C":"272","F":"628.524","G":"**"},{"Policy Line":"64101979","B":"Impl, Pin Bone Fixation","C":"278","D":"C1713","F":"1974.618","G":"**"},{"Policy Line":"64101980","B":"Valve, Tracheostomy Speaking","C":"274","D":"L8501","F":"69.462"},{"Policy Line":"64101981","B":"IMPLANT HIP HELICAL GRP 3","C":"278","D":"C1713","F":"1446.768"},{"Policy Line":"64101982","B":"Cath Infusion, MidLine","C":"272","D":"C1751","F":"378.828","G":"**"},{"Policy Line":"64101983","B":"Mesh Genl Surg C1781 Grp 3A","C":"278","D":"C1781","F":"549.27","G":"**"},{"Policy Line":"64101987","B":"Mesh Genl Surg C1781 Grp 2A","C":"278","D":"C1781","F":"326.196","G":"**"},{"Policy Line":"64101988","B":"Mesh Genl Surg C1781 Grp 2B","C":"278","D":"C1781","F":"399.636","G":"**"},{"Policy Line":"64101989","B":"Prosthesis Ear GR 2","C":"278","D":"L8613","F":"527.544","G":"**"},{"Policy Line":"64101991","B":"Prosthesis Ear GR 3","C":"278","D":"L8613","F":"644.436","G":"**"},{"Policy Line":"64101992","B":"Impl, Blade, Helical 90-95mm","C":"278","D":"C1713","F":"1443.708","G":"**"},{"Policy Line":"64101993","B":"Sheath, Endograft, Steerable","C":"272","F":"735.93","G":"**"},{"Policy Line":"64101994","B":"Pin Guide Fixation/Temp","C":"272","F":"554.166"},{"Policy Line":"64101996","B":"Restrctr/Spacer Cement","C":"278","F":"96.696","G":"**"},{"Policy Line":"64101997","B":"KIT MENISCAL REPAIR AR-4550","C":"278","F":"1273.572"},{"Policy Line":"64101998","B":"KIT ACCESSORY PENILE PROSTH","C":"272","F":"1073.84142857143","G":"**"},{"Policy Line":"64101999","B":"BonyVoidFiller-Osteosponge10mm","C":"278","D":"C1713","F":"541.314"},{"Policy Line":"64102000","B":"Mesh Genl Surg Marlex 3x6","C":"278","D":"C1781","F":"193.086","G":"**"},{"Policy Line":"64102001","B":"Bony Void Filler Grp 1A","C":"278","D":"C1713","F":"323.136"},{"Policy Line":"64102002","B":"Screw Grp 3B","C":"278","D":"C1713","F":"600.984","G":"**"},{"Policy Line":"64102003","B":"Cath Balloon Dil Non-Vasc Grp3","C":"272","D":"C1726","F":"482.256","G":"**"},{"Policy Line":"64102004","B":"Plate Grp 1A","C":"278","D":"C1713","F":"132.804"},{"Policy Line":"64102005","B":"Plate Grp 1B","C":"278","D":"C1713","F":"162.792"},{"Policy Line":"64102006","B":"Staple Bone Grp 2A","C":"278","D":"C1713","F":"274.788","G":"**"},{"Policy Line":"64102007","B":"Staple Bone Grp 2B","C":"278","D":"C1713","F":"335.682"},{"Policy Line":"64102008","B":"Screw Grp 1A","C":"278","D":"C1713","F":"171.666","G":"**"},{"Policy Line":"64102009","B":"Cable Ortho Grp 4A","C":"278","D":"C1713","F":"930.24"},{"Policy Line":"64102010","B":"CABLE FIXATION W/CLAMP","C":"272","F":"873.936","G":"**"},{"Policy Line":"64102012","B":"Low Cost Screw Grp 11","C":"278","D":"C1713","F":"134.334","G":"**"},{"Policy Line":"64102014","B":"Implant Joint Grp 1","C":"278","D":"C1776","F":"208.08","G":"**"},{"Policy Line":"64102015","B":"Implant Joint Grp 2","C":"278","D":"C1776","F":"309.672","G":"**"},{"Policy Line":"64102016","B":"Implant Joint Grp 3","C":"278","D":"C1776","F":"497.862","G":"**"},{"Policy Line":"64102017","B":"Implant Joint Grp 4","C":"278","D":"C1776","F":"756.432","G":"**"},{"Policy Line":"64102018","B":"Implant Joint Grp 5","C":"278","D":"C1776","F":"965.736","G":"**"},{"Policy Line":"64102019","B":"Implant Joint Grp 6","C":"278","D":"C1776","F":"1265.31","G":"**"},{"Policy Line":"64102020","B":"Implant Joint Grp 7","C":"278","D":"C1776","F":"1782.45","G":"**"},{"Policy Line":"64102021","B":"Implant Joint Grp 8","C":"278","D":"C1776","F":"2029.392","G":"**"},{"Policy Line":"64102022","B":"Implant Joint Grp 9","C":"278","D":"C1776","F":"2896.596","G":"**"},{"Policy Line":"64102023","B":"Implant Joint Grp 10","C":"278","D":"C1776","F":"2950.452","G":"**"},{"Policy Line":"64102024","B":"Implant Joint Grp 11","C":"278","D":"C1776","F":"3272.67","G":"**"},{"Policy Line":"64102025","B":"Implant Joint Grp 12","C":"278","D":"C1776","F":"3791.646","G":"**"},{"Policy Line":"64102026","B":"Implant Joint Grp 13","C":"278","D":"C1776","F":"5157.018","G":"**"},{"Policy Line":"64102028","B":"Pacemaker Sys Enpulse E2Sr01-D","C":"275","F":"0"},{"Policy Line":"64102032","B":"Implant Joint Grp 14","C":"278","D":"C1776","F":"5918.652","G":"**"},{"Policy Line":"64102033","B":"Cath Embolectomy C1757 Grp 1A","C":"272","D":"C1757","F":"144.432"},{"Policy Line":"64102035","B":"Cath Embolectomy C1757 Grp 1B","C":"272","D":"C1757","F":"176.256","G":"**"},{"Policy Line":"64102036","B":"Pin Fixation Hammertoe","C":"278","D":"C1713","F":"1358.946"},{"Policy Line":"64102038","B":"Cath Vascular Bern 4FR","C":"272","D":"C1887","F":"49.266"},{"Policy Line":"64102039","B":"Screw Grp 1B","C":"278","D":"C1713","F":"209.61","G":"**"},{"Policy Line":"64102040","B":"LowCost-Cath Baln Angio Grp 2","C":"272","D":"C1725","F":"104.652"},{"Policy Line":"64102042","B":"Set Colonic Decompression","C":"272","D":"C1769","F":"396.27"},{"Policy Line":"64102044","B":"LowCost-Cath Baln Angio Grp 3","C":"272","D":"C1725","F":"127.908"},{"Policy Line":"64102045","B":"LowCost-Cath Baln Angio Grp 4","C":"272","D":"C1725","F":"157.59"},{"Policy Line":"64102050","B":"Stapler-Reloads Disp. Grp 2A","C":"272","F":"282.438","G":"**"},{"Policy Line":"64102051","B":"Electrode Disposable Grp 2A","C":"272","F":"416.772"},{"Policy Line":"64102052","B":"Electrode Disposable Grp 2B","C":"272","F":"508.878","G":"**"},{"Policy Line":"64102053","B":"Spinal Cage/Spacer Grp 1A","C":"278","F":"839.664","G":"**"},{"Policy Line":"64102054","B":"Spinal Cage/Spacer Grp 1B","C":"278","F":"1026.936","G":"**"},{"Policy Line":"64102056","B":"Screw Grp 2B","C":"278","D":"C1713","F":"369.954","G":"**"},{"Policy Line":"64102057","B":"Anchor Bone Grp 1A","C":"278","D":"C1713","F":"436.968"},{"Policy Line":"64102058","B":"Anchor Bone Grp 1B","C":"278","D":"C1713","F":"533.664","G":"**"},{"Policy Line":"64102059","B":"Spinal Cage/Spacer Grp 3E","C":"278","F":"2823.156"},{"Policy Line":"64102060","B":"Allograft Orth/Neuro Grp 2A","C":"278","F":"716.346","G":"**"},{"Policy Line":"64102061","B":"Nail, Ortho Grp 3A","C":"278","D":"C1713","F":"1310.904","G":"**"},{"Policy Line":"64102062","B":"Sternalock Screw","C":"278","D":"C1713","F":"172.89","G":"**"},{"Policy Line":"64102063","B":"Sternalock Plate GR 2","C":"278","D":"C1713","F":"819.468","G":"**"},{"Policy Line":"64102064","B":"Shears Harmonic 36cm HARHD","C":"272","F":"890.154","G":"**"},{"Policy Line":"64102065","B":"Stapler-Reloads Disp. Grp 3A","C":"272","F":"436.968","G":"**"},{"Policy Line":"64102066","B":"Stapler-Reloads Disp. Grp 3B","C":"272","F":"535.194","G":"**"},{"Policy Line":"64102067","B":"Stapler-Reloads Disp. Grp 3C","C":"272","F":"653.922","G":"**"},{"Policy Line":"64102068","B":"Stapler-Reloads Disp. Grp 1A","C":"272","F":"157.59","G":"**"},{"Policy Line":"64102070","B":"Guidewire Grp 2A","C":"272","D":"C1769","F":"236.538"},{"Policy Line":"64102071","B":"Bit Drill Grp 3A","C":"272","F":"518.058","G":"**"},{"Policy Line":"64102072","B":"RELIEVA SPINPLUS BALLN SYS","C":"278","D":"C1726","F":"2495.43","G":"**"},{"Policy Line":"64102073","B":"Bit Drill Grp 1A","C":"272","F":"198.288","G":"**"},{"Policy Line":"64102074","B":"Tube Trach Cuffless","C":"272","D":"A7520","F":"77.724","G":"**"},{"Policy Line":"64102075","B":"Guidewire Vasc Runthru 300cm","C":"272","D":"C1769","F":"154.836","G":"**"},{"Policy Line":"64102076","B":"Arthowand Group 5","C":"272","F":"698.598"},{"Policy Line":"64102077","B":"Spinal Cage/Spacer Grp 3C","C":"278","F":"1870.884","G":"**"},{"Policy Line":"64102078","B":"Allograft Orth/Neuro Grp 5A","C":"278","F":"1765.314"},{"Policy Line":"64102079","B":"Pacemaker DR MRI Advisa A2DR01","C":"275","D":"C1785","F":"5274.828"},{"Policy Line":"64102081","B":"Screw, Blade Helical 80mm","C":"278","D":"C1713","F":"709.002"},{"Policy Line":"64102084","B":"Guidewire Grp 1C","C":"272","D":"C1769","F":"118.728"},{"Policy Line":"64102085","B":"Nail, Ortho Grp 2A","C":"278","D":"C1713","F":"635.256","G":"**"},{"Policy Line":"64102086","B":"Nail, Ortho Grp 2B","C":"278","D":"C1713","F":"777.24"},{"Policy Line":"64102087","B":"Clip Applier- LAPRA-TY","C":"272","F":"2735.946"},{"Policy Line":"64102088","B":"Coil Embolization Gr 2","C":"278","F":"162.792","G":"**"},{"Policy Line":"64102089","B":"LowCost-Cath Baln Angio Grp 5","C":"272","D":"C1725","F":"192.78"},{"Policy Line":"64102090","B":"StentUretal Temp WODel Sys GrA","C":"278","D":"C2617","F":"181.152","G":"**"},{"Policy Line":"64102091","B":"StentUretal Temp WODel Sys Gr2","C":"278","D":"C2617","F":"283.968","G":"**"},{"Policy Line":"64102092","B":"Washer Grp 2","C":"278","F":"61.506","G":"**"},{"Policy Line":"64102093","B":"Washer Grp 3","C":"278","F":"81.09"},{"Policy Line":"64102094","B":"Washer Grp 4","C":"278","F":"106.182","G":"**"},{"Policy Line":"64102096","B":"Washer Grp 5","C":"278","F":"138.924","G":"**"},{"Policy Line":"64102097","B":"Washer Threaded 3mm","C":"278","F":"356.49"},{"Policy Line":"64102098","B":"Washer STBL LOK NUT 5.0MM","C":"278","F":"576.198"},{"Policy Line":"64102099","B":"Washer Bfly 21.7mm","C":"278","F":"265.302"},{"Policy Line":"64102100","B":"Washer 2mm","C":"278","F":"24.174"},{"Policy Line":"64102101","B":"Allograft Orth/Neuro Grp 4A","C":"278","F":"1500.624","G":"**"},{"Policy Line":"64102102","B":"ALLOGRAFT CEL MTRX-VIVIGEN 5CC","C":"278","F":"2431.476"},{"Policy Line":"64102103","B":"Plate Grp 1C","C":"278","D":"C1713","F":"199.818","G":"**"},{"Policy Line":"64102104","B":"Sizer Mammary Grp 1","C":"272","F":"352.818","G":"**"},{"Policy Line":"64102105","B":"Plate GR 4A","C":"278","D":"C1713","F":"1153.314","G":"**"},{"Policy Line":"64102106","B":"Fascia Lata Tissue Implant GR1","C":"278","D":"C1762","F":"1715.13","G":"**"},{"Policy Line":"64102107","B":"Allograft Orth/Neuro Grp 1A","C":"278","F":"354.348","G":"**"},{"Policy Line":"64102108","B":"Burr Grp 1A","C":"272","F":"176.256","G":"**"},{"Policy Line":"64102109","B":"Burr Grp A","C":"272","F":"98.226","G":"**"},{"Policy Line":"64102110","B":"Guidewire Grp 1A","C":"272","D":"C1769","F":"79.56"},{"Policy Line":"64102111","B":"Cath Brachytherapy Admin Seed","C":"272","D":"C1728","F":"174.114"},{"Policy Line":"64102112","B":"Fixator Finger,BadiaHinge","C":"278","D":"C1713","F":"19.89"},{"Policy Line":"64102114","B":"Prosthesis Penile SPECTRA","C":"278","D":"C2622","F":"8770.572"},{"Policy Line":"64102115","B":"NAIL, ORTHO GRP 10","C":"278","D":"C1713","F":"4007.682","G":"**"},{"Policy Line":"64102116","B":"Plate Grp 8A","C":"278","D":"C1713","F":"2604.672","G":"**"},{"Policy Line":"64102117","B":"Pin Fixation/Temp GR1","C":"272","F":"168.606","G":"**"},{"Policy Line":"64102118","B":"Cath Baln Angio-Sterling GR1","C":"272","D":"C1725","F":"318.24","G":"**"},{"Policy Line":"64102119","B":"Cap Bone/Neuro Grp 2A","C":"278","F":"338.742"},{"Policy Line":"64102120","B":"Cap Bone/Neuro Grp 2B","C":"278","F":"415.242","G":"**"},{"Policy Line":"64102121","B":"Plate Grp 7A","C":"278","D":"C1713","F":"1935.144","G":"**"},{"Policy Line":"64102122","B":"Graft Vascular Grp 6 C","C":"278","D":"C1768","F":"2543.778"},{"Policy Line":"64102124","B":"GRAFT ENDOVASCULAR-EXTENSN GR1","C":"278","F":"2746.656"},{"Policy Line":"64102125","B":"GRAFT ENDOVASCULAR-EXTENSN GR2","C":"278","F":"3359.88"},{"Policy Line":"64102126","B":"Bony Void Filler Grp 2B","C":"278","D":"C1713","F":"749.088","G":"**"},{"Policy Line":"64102127","B":"Screw, Temporary Fixation","C":"278","F":"179.928","G":"**"},{"Policy Line":"64102128","B":"LowCost-Cath Baln Angio Grp 6","C":"272","D":"C1725","F":"231.03"},{"Policy Line":"64102129","B":"Guidewire Grp 1D","C":"272","D":"C1769","F":"143.82"},{"Policy Line":"64102130","B":"Guidewire Grp 1E","C":"272","D":"C1769","F":"175.95","G":"**"},{"Policy Line":"64102131","B":"Implant Joint Grp 16","C":"278","D":"C1776","F":"7479.252"},{"Policy Line":"64102309","B":"IOL - Posterior Chamber-MA6","C":"276","D":"V2632","F":"192"},{"Policy Line":"64102310","B":"IOL - Post Chmbr-ZA,SN,MN,ZCB","C":"276","D":"V2632","F":"228","G":"**"},{"Policy Line":"64102312","B":"IOL - Posterio Chamber- Sensar","C":"276","D":"V2632","F":"267.9"},{"Policy Line":"64102411","B":"GUIDE SZING COMP SPEED IMPLANT","C":"278","F":"94.248"},{"Policy Line":"64102420","B":"Tap Grp 3","C":"272","F":"1017.45"},{"Policy Line":"64102421","B":"Kit Introducer MicroNonL 7272v","C":"272","D":"C1894","F":"47.124","G":"**"},{"Policy Line":"64102431","B":"GUIDEWIRE VASC VIPER","C":"272","D":"C1769","F":"302.634"},{"Policy Line":"64102450","B":"Connector Crosslink Grp 4","C":"278","F":"1981.35"},{"Policy Line":"64102452","B":"Connector Crosslink Grp 5","C":"278","F":"2343.348"},{"Policy Line":"64102466","B":"Valve Csf Grp 3","C":"278","F":"1533.06"},{"Policy Line":"64102467","B":"Programmer Trial Neuro 3510","C":"272","F":"1785.204"},{"Policy Line":"64102488","B":"IOL- ANTERIOR CHAMBER","C":"276","D":"V2630","F":"158.1","G":"**"},{"Policy Line":"64102489","B":"IOL - Posterior Chamber-SN6","C":"276","D":"V2632","F":"161.4","G":"**"},{"Policy Line":"64102710","B":"PEG DISTAL FEM,FIXATN","C":"278","F":"93.636"},{"Policy Line":"64102711","B":"Spacer Cement Restrictor","C":"278","F":"96.696","G":"**"},{"Policy Line":"64102712","B":"Valvulotome EZ Site","C":"272","F":"1086.606"},{"Policy Line":"64102713","B":"Washer Spiked,Ortho 14mm","C":"278","F":"227.664","G":"**"},{"Policy Line":"64102714","B":"Sealant Surg/Closure Dev Grp 3","C":"272","F":"780.3","G":"**"},{"Policy Line":"64102715","B":"Trocar Optical 5mm","C":"272","F":"44.37","G":"**"},{"Policy Line":"64102716","B":"Trocar Optical Airseal","C":"272","F":"169.524"},{"Policy Line":"64102717","B":"Tissue Expander Grp 2A","C":"278","D":"C1789","F":"2340.9","G":"**"},{"Policy Line":"64102718","B":"SysGen,Neurostim MRI Imp-Restr","C":"278","D":"C1820","F":"22113.702"},{"Policy Line":"64102719","B":"Spinal Cage/Spacer Grp 3D","C":"278","F":"2309.688","G":"**"},{"Policy Line":"64102720","B":"Cath Balln Occlusion 26FR","C":"272","D":"C2628","F":"232.254"},{"Policy Line":"64102721","B":"GRAFIX PRIME 3X4CM","C":"278","D":"Q4133","F":"1369.656"},{"Policy Line":"64102722","B":"Clip Suture, Lapra Ty","C":"278","F":"424.422","G":"**"},{"Policy Line":"64102723","B":"Rod, Reaming 2.5mm","C":"272","F":"276.93","G":"**"},{"Policy Line":"64102724","B":"Bone Graft Sub-Formagraft 10CC","C":"278","F":"1329.57","G":"**"},{"Policy Line":"64102725","B":"Bone Grft Sub-Formagraft Block","C":"278","F":"1692.792","G":"**"},{"Policy Line":"64102726","B":"Stapler-Reloads Ech Flx 60mm","C":"272","F":"1627.92"},{"Policy Line":"64102727","B":"Driver Pin/Tap","C":"272","F":"437.58","G":"**"},{"Policy Line":"64102728","B":"Bolt Spinal 5.5x50mm Lrg","C":"278","F":"639.846"},{"Policy Line":"64102729","B":"GEL DBM 10CC XEMPLI","C":"278","F":"1574.064","G":"**"},{"Policy Line":"64102730","B":"Kit Suturetak Disp","C":"272","F":"398.106","G":"**"},{"Policy Line":"64102731","B":"Cath Angio 5FR, Soft-Vu","C":"272","D":"C1887","F":"30.294"},{"Policy Line":"64102732","B":"Central Venous Cath Group 1B","C":"272","D":"C1751","F":"210.834"},{"Policy Line":"64102733","B":"Bony Void Filler Grp 9","C":"278","D":"C1713","F":"3558.168","G":"**"},{"Policy Line":"64102734","B":"Patch Soft Tissue 2mmx15cm","C":"278","D":"C1781","F":"2544.084"},{"Policy Line":"64102735","B":"GUIDE PIN Ti 2mm","C":"272","F":"81.09"},{"Policy Line":"64102736","B":"ARISTA Adhesn Barrier 1 GM","C":"272","F":"167.994","G":"**"},{"Policy Line":"64102737","B":"Introducer/Sheath Grp 2C","C":"272","D":"C1894","F":"307.53","G":"**"},{"Policy Line":"64102738","B":"Cath Bln Occlusion 6 FR","C":"272","D":"C2628","F":"77.418"},{"Policy Line":"64102739","B":"Staple Bone Grp 3E","C":"278","D":"C1713","F":"1560.6","G":"**"},{"Policy Line":"64102740","B":"Stent Aero Tracheobronchial","C":"278","D":"C1874","F":"2536.128"},{"Policy Line":"64102741","B":"Introducer/Sheath NonLsr Grp2A","C":"272","D":"C1894","F":"205.938","G":"**"},{"Policy Line":"64102742","B":"Mesh Genl Sur 30x20cm Symbotex","C":"278","D":"C1781","F":"1623.024","G":"**"},{"Policy Line":"64102743","B":"Cement Bone Group 2A","C":"278","D":"C1713","F":"352.818","G":"**"},{"Policy Line":"64102744","B":"Cement Bone Group 2B","C":"278","D":"C1713","F":"427.482","G":"**"},{"Policy Line":"64102745","B":"Screw Grp 4A","C":"278","D":"C1713","F":"749.088","G":"**"},{"Policy Line":"64102746","B":"Stapler-Reloads Disp. Grp 3F","C":"272","F":"780.3","G":"**"},{"Policy Line":"64102747","B":"Stapler-Reloads Disp. Grp 5","C":"272","F":"1279.692","G":"**"},{"Policy Line":"64102748","B":"Probe Grp A","C":"272","F":"174.114","G":"**"},{"Policy Line":"64102749","B":"Cath Balloon Angioplasty Grp1B","C":"272","D":"C1725","F":"318.24","G":"**"},{"Policy Line":"64102750","B":"Burr Grp 2A","C":"272","F":"265.302","G":"**"},{"Policy Line":"64102751","B":"Laser Fiber Grp 3","C":"272","F":"2216.052"},{"Policy Line":"64102752","B":"Laser Fiber Grp 4","C":"272","F":"2684.232","G":"**"},{"Policy Line":"64102753","B":"Laser Fiber Grp 1A","C":"272","F":"780.3","G":"**"},{"Policy Line":"64102754","B":"Laser Fiber Greenlight","C":"272","F":"1543.158"},{"Policy Line":"64102755","B":"PLATE, STERNAL CABLE","C":"278","D":"C1713","F":"655.452"},{"Policy Line":"64102756","B":"Spinal Cage/Spacer Grp 2A","C":"278","F":"1350.684","G":"**"},{"Policy Line":"64102757","B":"Allogrft Biocartilage Mtrx 1cc","C":"278","D":"C1762","F":"1253.988"},{"Policy Line":"64102758","B":"Cover Screw 3mm-Cochlear Imp","C":"278","D":"L8690","F":"1762.254","G":"**"},{"Policy Line":"64102759","B":"Washer Rnd 12.7mm 71101690","C":"278","F":"178.092"},{"Policy Line":"64102760","B":"Guide Rod Ball Tip 3.0mm","C":"272","F":"306.918","G":"**"},{"Policy Line":"64102761","B":"External Fixator Cmpnts Grp2D","C":"272","F":"686.664","G":"**"},{"Policy Line":"64102762","B":"Laser Fiber Grp 1B","C":"272","F":"951.966"},{"Policy Line":"64102763","B":"Mesh Genl Surg C1781 Grp 7","C":"278","D":"C1781","F":"2528.172","G":"**"},{"Policy Line":"64102764","B":"Suture Anchor SpdbrgeSwvlk4.75","C":"278","D":"C1713","F":"2579.58"},{"Policy Line":"64102765","B":"Wire Spider LRG 6.0 Spd2Us-060","C":"272","D":"C1884","F":"2047.446"},{"Policy Line":"64102766","B":"Implant Joint Grp 2B","C":"278","D":"C1776","F":"374.544","G":"**"},{"Policy Line":"64102767","B":"Screw Grp 4B","C":"278","D":"C1713","F":"913.104","G":"**"},{"Policy Line":"64102768","B":"Custom Cutting Block Low Cost","C":"272","F":"636.786","G":"**"},{"Policy Line":"64102769","B":"Graft Vascular Grp 5A","C":"278","D":"C1768","F":"936.36","G":"**"},{"Policy Line":"64102770","B":"Implant Joint Grp 6A","C":"278","D":"C1776","F":"1529.388","G":"**"},{"Policy Line":"64102771","B":"Allograft Orth/Neuro Grp 6A","C":"278","F":"2426.886","G":"**"},{"Policy Line":"64102772","B":"Cath Hemodialysis LT 43","C":"278","D":"C1750","F":"178.704"},{"Policy Line":"64102774","B":"Rod Polars Pls 8x220","C":"278","D":"C1713","F":"3126.096"},{"Policy Line":"64102775","B":"Cath/Introducer Passiv Stealth","C":"272","F":"726.138","G":"**"},{"Policy Line":"64102776","B":"Tightrope Mini AR 8912/13","C":"278","F":"1154.844"},{"Policy Line":"64102777","B":"Stent Graft Endopros-Endurant","C":"278","F":"6492.096","G":"**"},{"Policy Line":"64102778","B":"Imp Hip-Slv AdaptrC-Taper2.5mm","C":"278","D":"C1776","F":"96.696"},{"Policy Line":"64102779","B":"Cannula OH Dual Lumen 23FR","C":"272","F":"3007.368","G":"**"},{"Policy Line":"64102780","B":"Inflation Device Sinus","C":"272","F":"309.366","G":"**"},{"Policy Line":"64102781","B":"DISSECTOR-SONICISION","C":"272","F":"629.136","G":"**"},{"Policy Line":"64102782","B":"THR Neck Standard","C":"278","D":"C1776","F":"77.418","G":"**"},{"Policy Line":"64102783","B":"Cannula Arterial 16FR","C":"272","F":"341.496"},{"Policy Line":"64102784","B":"Cath: Temporary Pacing","C":"272","F":"278.46"},{"Policy Line":"64102785","B":"Anchor Kit - Neurostim N300","C":"278","F":"242.046"},{"Policy Line":"64102786","B":"Implant Joint Grp 3A","C":"278","D":"C1776","F":"618.12","G":"**"},{"Policy Line":"64102787","B":"Implant Joint Grp 2A","C":"278","D":"C1776","F":"374.544","G":"**"},{"Policy Line":"64102788","B":"Stent Biliary - Express","C":"278","D":"C1876","F":"1215.738","G":"**"},{"Policy Line":"64102789","B":"Lead NeuroStim-Contact 50-70cm","C":"278","D":"C1778","F":"2324.07","G":"**"},{"Policy Line":"64102790","B":"Bony Void Filler Grp 6A","C":"278","D":"C1713","F":"2431.476","G":"**"},{"Policy Line":"64102791","B":"Burr Grp 1A","C":"272","F":"174.726","G":"**"},{"Policy Line":"64102812","B":"Graft Vascular Grp 5 A","C":"278","D":"C1768","F":"847.314"},{"Policy Line":"64102813","B":"Graft Vascular Grp 5 B","C":"278","D":"C1768","F":"932.382","G":"**"},{"Policy Line":"64102814","B":"Graft Vascular Grp 5 C","C":"278","D":"C1768","F":"1025.406"},{"Policy Line":"64102815","B":"Graft Vascular Grp 5 D","C":"278","D":"C1768","F":"1128.222"},{"Policy Line":"64102816","B":"Graft Vascular Grp 5 E","C":"278","D":"C1768","F":"1241.442"},{"Policy Line":"64102817","B":"Graft Vascular Grp 5 F","C":"278","D":"C1768","F":"1365.678","G":"**"},{"Policy Line":"64102818","B":"Graft Vascular Grp 5 G","C":"278","D":"C1768","F":"1502.154"},{"Policy Line":"64102819","B":"Cath Ureteral Wedge 5Fr","C":"272","D":"C1758","F":"28.458","G":"**"},{"Policy Line":"64102820","B":"CATH DRN BIL BALN PROBE 5FR","C":"272","D":"C1729","F":"100.674","G":"**"},{"Policy Line":"64102821","B":"Cath Drainage Thor 24/28Fr","C":"272","D":"C1729","F":"13.464","G":"**"},{"Policy Line":"64102888","B":"ALLGRFT BONE-CANC CHIPS 30CC","C":"278","F":"639.846","G":"**"},{"Policy Line":"64102965","B":"Allograft Orth/Neuro Grp7A","C":"278","F":"3249.108","G":"**"},{"Policy Line":"64102966","B":"Allograft Orth/Neuro Grp7B","C":"278","F":"3573.774","G":"**"},{"Policy Line":"64102967","B":"Allograft Orth/Neuro Grp7C","C":"278","F":"3931.182"},{"Policy Line":"64102968","B":"Stent Endopros AAA-ENDURANT","C":"278","F":"4818.582","G":"**"},{"Policy Line":"64102969","B":"Implant Joint Grp 8 A","C":"278","D":"C1776","F":"2232.576","G":"**"},{"Policy Line":"64102970","B":"Implant Joint Grp 8 B","C":"278","D":"C1776","F":"2455.65","G":"**"},{"Policy Line":"64102971","B":"Implant Joint Grp 8 C","C":"278","D":"C1776","F":"2701.368","G":"**"},{"Policy Line":"64102972","B":"Implant Joint Grp 12 A","C":"278","D":"C1776","F":"4171.086","G":"**"},{"Policy Line":"64102973","B":"Implant Joint Grp 12 B","C":"278","D":"C1776","F":"4588.164","G":"**"},{"Policy Line":"64102974","B":"Implant Joint Grp 12 C","C":"278","D":"C1776","F":"5046.858","G":"**"},{"Policy Line":"64102975","B":"Kit Kyphoplasty VBRX","C":"278","F":"2799.594"},{"Policy Line":"64102982","B":"Cath Infusion Midline 7FR","C":"272","D":"C1751","F":"746.028"},{"Policy Line":"64102983","B":"Cath Infusion Midline 8FR","C":"272","D":"C1751","F":"873.936"},{"Policy Line":"64103000","B":"Washer Grp 6","C":"278","F":"229.5"},{"Policy Line":"64103121","B":"Wire Ortho Supply Grp 4","C":"272","F":"453.492","G":"**"},{"Policy Line":"64103122","B":"Countersink 3 in 1","C":"272","F":"465.732"},{"Policy Line":"64103123","B":"BUTTON CERCLAGE 4.5MM","C":"278","D":"C1713","F":"56.916"},{"Policy Line":"64103124","B":"Wire Ortho Supply Grp 5","C":"272","F":"486.846","G":"**"},{"Policy Line":"64103160","B":"Wire Ortho Bayonet Olive","C":"272","F":"764.694","G":"**"},{"Policy Line":"64103161","B":"Wire Ortho Y,K FC-xxxx","C":"272","F":"767.754"},{"Policy Line":"64103162","B":"Wire Ortho iO-NCW","C":"272","F":"1464.21"},{"Policy Line":"64103163","B":"Prosthesis Ams 800 Balloon GR2","C":"278","D":"C1815","F":"2728.602","G":"**"},{"Policy Line":"64103164","B":"Pin Guide, Tibial PSI","C":"272","F":"636.786","G":"**"},{"Policy Line":"64103165","B":"GRAFT BONE SUB 20CC-KINEX","C":"278","F":"2960.244"},{"Policy Line":"64103166","B":"STENT K WART 6FR","C":"278","D":"C2625","F":"185.742"},{"Policy Line":"64103167","B":"Impl: Cover, Hole for Screw","C":"278","F":"115.974","G":"**"},{"Policy Line":"64103168","B":"Cath: Diagnostic Grp 1","C":"272","F":"19.89","G":"**"},{"Policy Line":"64103169","B":"Cath Baln Angio-Sterling GR2","C":"272","D":"C1725","F":"509.49"},{"Policy Line":"64103170","B":"CathAbla Tiss,XtraVas-Novasure","C":"278","D":"C1886","F":"1401.48","G":"**"},{"Policy Line":"64103171","B":"AnchorSys Implt-AC ReprAR-2271","C":"278","D":"C1713","F":"2057.85","G":"**"},{"Policy Line":"64103172","B":"ALLGRFT AMNIO MEM BIOFIX 2X4CM","C":"278","D":"Q4163","F":"1791.63"},{"Policy Line":"64103188","B":"PLATE STRAIGHT TUBULAR","C":"278","D":"C1713","F":"761.634"},{"Policy Line":"64103189","B":"KIT BIOSUTURE TAK 2.4","C":"272","F":"398.106","G":"**"},{"Policy Line":"64103975","B":"Spinal Cord Stimulator Gen","C":"278","D":"C1820","F":"12043.548"},{"Policy Line":"64103977","B":"PLATE QUARTER TUBULAR W/COLLAR","C":"278","D":"C1713","F":"182.682"},{"Policy Line":"64103978","B":"Cath Guiding-Destination 6x45","C":"272","D":"C1887","F":"169.218"},{"Policy Line":"64104162","B":"Shears Harmonic Endo GR 1","C":"272","F":"635.562","G":"**"},{"Policy Line":"64104163","B":"Shears Harmonic CRVD Blade","C":"272","F":"380.97","G":"**"},{"Policy Line":"64104164","B":"Shears Harmonic ACE 36cm","C":"272","F":"166.77"},{"Policy Line":"64104423","B":"Pleurx Drain Cath Kit 500ml","C":"272","D":"C1729","F":"110.16","G":"**"},{"Policy Line":"64104914","B":"Kit: Post Crani 110-4G","C":"272","F":"1038.258"},{"Policy Line":"64105034","B":"Kit Jejunostomy Ndl 5Fr 071284","C":"272","F":"193.392"},{"Policy Line":"64105533","B":"Kit Venous 19Fr B10 96600-019","C":"272","F":"381.888"},{"Policy Line":"64105883","B":"Endostitch Unit Autosut 173016","C":"272","F":"193.392","G":"**"},{"Policy Line":"64105963","B":"Tunneler: Large 9009-16","C":"272","F":"92.718","G":"**"},{"Policy Line":"64105964","B":"Tunneler: Small 9009-18","C":"272","F":"92.718","G":"**"},{"Policy Line":"64106784","B":"Esu: Argun Handle","C":"272","F":"93.024"},{"Policy Line":"64107787","B":"Anchor Kit Lead - Neurostim","C":"278","F":"242.352"},{"Policy Line":"64107788","B":"Cap Bone Locking - Spine","C":"278","F":"426.87","G":"**"},{"Policy Line":"64107789","B":"SUTURE SPEEDSTITCH OM-8085","C":"278","F":"279.072"},{"Policy Line":"64107790","B":"Cath Ureteral Open End 5Fr","C":"272","D":"C1758","F":"27.234","G":"**"},{"Policy Line":"64107791","B":"Prosthesis Penile Reservoir IZ","C":"278","D":"C1813","F":"2615.688","G":"**"},{"Policy Line":"64108266","B":"Kit: Access 72401850","C":"272","F":"680.85"},{"Policy Line":"64108552","B":"Prosthesis Ams 800 Pump","C":"278","D":"C1815","F":"5036.76","G":"**"},{"Policy Line":"64108944","B":"Sponge: Biocollagen 80-1460","C":"272","F":"182.988","G":"**"},{"Policy Line":"64108951","B":"Kit Accessory Lum Cat 910-121","C":"272","F":"311.508","G":"**"},{"Policy Line":"64109050","B":"Wire: Comp Spring Sys 961499","C":"272","F":"582.012"},{"Policy Line":"64109165","B":"Membrane Sepra Film","C":"272","F":"785.196","G":"**"},{"Policy Line":"64109373","B":"Transfusion Suretrans 8590000","C":"272","F":"204.408","G":"**"},{"Policy Line":"64110238","B":"Kit: Cranioplastic 43-1050","C":"272","F":"821.61","G":"**"},{"Policy Line":"64110379","B":"Drain: Davol Sump 0080450","C":"272","F":"57.528"},{"Policy Line":"64110582","B":"Depuy: Fem Prep 5461-01-000","C":"272","F":"501.534","G":"**"},{"Policy Line":"64111169","B":"Reload Suture Assist Sw120","C":"272","F":"162.486"},{"Policy Line":"64111170","B":"Reload Suture Assist Sw110","C":"272","F":"54.774"},{"Policy Line":"64111171","B":"Unit Suture Assist Sw100","C":"272","F":"795.6"},{"Policy Line":"64111405","B":"Needle: Periuretheral 890-204","C":"272","F":"50.49"},{"Policy Line":"64111723","B":"Scraper: Membrane 20.04","C":"272","F":"214.812","G":"**"},{"Policy Line":"64111828","B":"Implant: Medpore 6322","C":"278","F":"746.64"},{"Policy Line":"64111848","B":"Set: Prostate Stab 500118200","C":"270","F":"74.97","G":"**"},{"Policy Line":"64111882","B":"Interceed Barrier 3X4 4350","C":"278","F":"458.082","G":"**"},{"Policy Line":"64111891","B":"Manipulator: Uterine Tmi1151","C":"272","F":"55.386","G":"**"},{"Policy Line":"64112031","B":"Device: Syr Cook Jlsad060000","C":"272","F":"626.076"},{"Policy Line":"64112195","B":"Medpor Implant Sheet","C":"278","F":"620.874"},{"Policy Line":"64112776","B":"Kit: Cardio Terumo 62432","C":"272","F":"225.828","G":"**"},{"Policy Line":"64113111","B":"Suprafoil: Sjackson Fss04","C":"278","D":"C1781","F":"15.606"},{"Policy Line":"64113228","B":"Neurostim Lead Acc Kit 3550-09","C":"278","D":"C1883","F":"272.34"},{"Policy Line":"64113335","B":"Danek: Biopsy Needle 960-225","C":"272","F":"825.588","G":"**"},{"Policy Line":"64113345","B":"Set: Micro-Puncture 217243","C":"272","F":"73.746"},{"Policy Line":"64114075","B":"Cath Thermachoice Iii Tc003","C":"272","F":"1751.544"},{"Policy Line":"64114161","B":"Suture: Lasso Arthre Ar406590S","C":"272","F":"184.824"},{"Policy Line":"64114334","B":"Avitene: Collagen 1010020","C":"272","F":"310.284","G":"**"},{"Policy Line":"64114560","B":"Tubing Selector Ultra 1517079","C":"272","F":"544.986"},{"Policy Line":"64114812","B":"Splint Nasal 15-24060","C":"272","F":"193.392"},{"Policy Line":"64114964","B":"Drain: Sump Davol 0080420","C":"272","F":"61.812"},{"Policy Line":"64115008","B":"Insert: Octobase Medtron 28707","C":"272","F":"96.696","G":"**"},{"Policy Line":"64115165","B":"Tray: Foley Bard Temp 909116","C":"272","D":"A4314","F":"64.566"},{"Policy Line":"64115243","B":"Gen NeuroStim Non-Rechrg 7426","C":"278","D":"C1767","F":"9566.784"},{"Policy Line":"64115703","B":"Cannula: Terumo 24Fr 13030","C":"272","F":"46.512"},{"Policy Line":"64115841","B":"Stay: Surgical 3311-1G","C":"272","F":"14.688"},{"Policy Line":"64115842","B":"Stay Surgical 3350-8G","C":"272","F":"97.002"},{"Policy Line":"64115850","B":"Delivery Set: Mps Qm 5001102","C":"272","F":"215.73","G":"**"},{"Policy Line":"64115884","B":"Kit Transtibial Ar1897S","C":"272","F":"358.326","G":"**"},{"Policy Line":"64116207","B":"Microtip: Turbos 8065-740837","C":"272","F":"145.044"},{"Policy Line":"64116421","B":"Tip: Smoke Aspiration Se-100","C":"272","F":"24.48"},{"Policy Line":"64116424","B":"Perfusion: Beating Hearts Lv 1","C":"272","F":"2062.44","G":"**"},{"Policy Line":"64117019","B":"Kyphon: Syringe Inflation A08A","C":"272","F":"193.392","G":"**"},{"Policy Line":"64117030","B":"Smith Nephew: Needle 7207877","C":"272","F":"479.196"},{"Policy Line":"64117159","B":"Edwards: Open Heart Disp Pack","C":"272","F":"2628.846"},{"Policy Line":"64117162","B":"Edwards: Non Open Heart Pack","C":"272","F":"852.21"},{"Policy Line":"64117269","B":"Sleeve: Limb Protec 9-7920-003","C":"272","F":"15.912"},{"Policy Line":"64117363","B":"Kit: Groshong Repair 7742000","C":"272","F":"234.702"},{"Policy Line":"64117801","B":"Mender: Meniscus Rich 7209485","C":"272","F":"234.09","G":"**"},{"Policy Line":"64117803","B":"Sholuder Kit: 3583","C":"272","F":"141.984"},{"Policy Line":"64117938","B":"Irrigation: Pert Dial 5B9766","C":"272","F":"15.606"},{"Policy Line":"64118089","B":"Kit Ventricular Drainage","C":"272","F":"322.83","G":"**"},{"Policy Line":"64118291","B":"Pencil Bayonet Elect 9560575","C":"272","F":"133.11","G":"**"},{"Policy Line":"64118447","B":"Tip: Round 30 Degree Alcon","C":"272","F":"157.59"},{"Policy Line":"64118575","B":"Kit: Endo Radial Rad02","C":"272","F":"1103.436"},{"Policy Line":"64118867","B":"Stay Elastic Lonestar 3311-8G","C":"272","F":"114.138"},{"Policy Line":"64118871","B":"Pack: Procedural Acucise Bk004","C":"272","D":"C1726","F":"2203.506"},{"Policy Line":"64119023","B":"Pack: Valve Deroyal 94-0243","C":"272","F":"123.318","G":"**"},{"Policy Line":"64119222","B":"Dressing Acticoat 4X8 20201","C":"272","F":"29.682","G":"**"},{"Policy Line":"64119298","B":"Tip: Forcep Codman 8035070S","C":"272","F":"677.484","G":"**"},{"Policy Line":"64119301","B":"Sphere: Eye 14mm Bausch L1414","C":"272","F":"104.652"},{"Policy Line":"64119302","B":"Sphere: Eye 16mm Bausch L1416","C":"278","F":"104.652"},{"Policy Line":"64119303","B":"Sphere: Eye 18mm Bausch L1418","C":"278","F":"104.652"},{"Policy Line":"64119304","B":"Sphere: Eye 20mm Bausch L1420","C":"272","F":"104.652"},{"Policy Line":"64119305","B":"Sphere: Eye 22mm Sphere L1422","C":"272","F":"75.582"},{"Policy Line":"64119308","B":"Prosthesis Stapes 70145928","C":"278","F":"382.806"},{"Policy Line":"64119482","B":"Kit Ultra Infast 72403885 Ams","C":"278","D":"C2631","F":"1687.896"},{"Policy Line":"64119483","B":"System Tvt Opturator 810081","C":"278","D":"C1771","F":"1675.656","G":"**"},{"Policy Line":"64119490","B":"Kyphon: Mixer Bone Cmt 0033700","C":"272","F":"278.766","G":"**"},{"Policy Line":"64119536","B":"Insert Traction 66Mm N-10122","C":"272","D":"C1713","F":"47.124"},{"Policy Line":"64130148","B":"Implant: Radiesse 1Cc 8044M","C":"278","D":"C1878","F":"795.6","G":"**"},{"Policy Line":"64130229","B":"Electro:Cath Pacin 5Fr 007154P","C":"272","F":"280.296","G":"**"},{"Policy Line":"64130246","B":"Pack Suture Pars AR-8862DS","C":"278","F":"1875.78","G":"**"},{"Policy Line":"64130418","B":"Needle: Deflux 3X23 159042","C":"272","F":"103.734"},{"Policy Line":"64130419","B":"Cath Loop Nephrostomy Drainage","C":"272","D":"C1729","F":"269.28","G":"**"},{"Policy Line":"64130462","B":"Frontalis Suspension 585192","C":"272","F":"193.392","G":"**"},{"Policy Line":"64130564","B":"Drill Guide Kt Disp Ar-1322Ds","C":"272","F":"278.766","G":"**"},{"Policy Line":"64130579","B":"Tubing Pump Arthrex Ar-6410","C":"272","F":"118.116","G":"**"},{"Policy Line":"64130627","B":"Tape Glow N Tell Vas 1100-20","C":"272","F":"104.346","G":"**"},{"Policy Line":"64130679","B":"Suture:Grasper 30 Degr 251721","C":"272","F":"328.338"},{"Policy Line":"64130927","B":"Suture Smartstitch Om-8075","C":"272","F":"167.076"},{"Policy Line":"64131108","B":"Cell Saver Fast Pack 206","C":"272","F":"419.526","G":"**"},{"Policy Line":"64131215","B":"Currette 8.5Mm A11E","C":"272","F":"310.59"},{"Policy Line":"64131252","B":"Smart Stapes Piston 70145926","C":"272","F":"375.156"},{"Policy Line":"64131253","B":"Smart Thermal Tip 7013-1013","C":"272","F":"50.49"},{"Policy Line":"64131281","B":"Micropuncture 4Fr Kit-002-36","C":"272","F":"49.266","G":"**"},{"Policy Line":"64131328","B":"Mixer Cement 606-563","C":"272","F":"263.16"},{"Policy Line":"64131330","B":"Currette 6.5 A11D","C":"272","F":"278.766"},{"Policy Line":"64131458","B":"Greenlt Laser Fiber Next Med","C":"272","F":"1203.804"},{"Policy Line":"64131555","B":"Tube Cuffless Trach Fen 8Cfn","C":"272","D":"A7520","F":"83.538"},{"Policy Line":"64131620","B":"STENT TEMP NON-COR W/O DEL SYS","C":"278","D":"C2617","F":"104.04"},{"Policy Line":"64131621","B":"Cath Angio non laser DCB Grp 3","C":"272","D":"C2623","F":"2496.96"},{"Policy Line":"64131847","B":"Suture Grasper 45 Degre 251722","C":"272","F":"279.072"},{"Policy Line":"64131873","B":"Spray Tip Fan 0210-018-000","C":"272","F":"31.518","G":"**"},{"Policy Line":"64131977","B":"Prosthesis Ams 800 Cuff","C":"278","D":"C1815","F":"3676.59","G":"**"},{"Policy Line":"64131980","B":"Prosthesis Ams 800 Balloon","C":"278","D":"C1815","F":"2295"},{"Policy Line":"64131985","B":"Kit Essentials 04494-10","C":"272","F":"65.79"},{"Policy Line":"64132013","B":"Apogee With Intepro 72404012","C":"278","D":"C1771","F":"1807.236"},{"Policy Line":"64132026","B":"Bone Spike Short 71512449","C":"272","F":"83.844"},{"Policy Line":"64132041","B":"Ams Accessory Kit","C":"272","F":"193.392"},{"Policy Line":"64132061","B":"Occluder Colpo-Pneumo Cpo-6","C":"272","F":"127.296"},{"Policy Line":"64132075","B":"Ams Invance Sling 72403525","C":"278","D":"C1771","F":"3022.974"},{"Policy Line":"64132113","B":"Needle Percutaneous 700-122","C":"272","F":"61.812"},{"Policy Line":"64132152","B":"Valve Strata Ii Regular 42866","C":"278","F":"4303.584","G":"**"},{"Policy Line":"64132162","B":"Manifold Neptune 700-40","C":"272","F":"54.162"},{"Policy Line":"64132177","B":"Essure Birth Control Ess205","C":"278","F":"2367.522"},{"Policy Line":"64132202","B":"Needle 12Gx7.5 Dls-7122-01S","C":"272","F":"103.428"},{"Policy Line":"64132397","B":"Tube Tear Duct Grp","C":"278","F":"127.602"},{"Policy Line":"64132450","B":"Connector Crosslink Grp 4","C":"278","F":"959.922","G":"**"},{"Policy Line":"64132452","B":"Connector Crosslink Grp 5","C":"278","F":"2314.278"},{"Policy Line":"64132495","B":"Drain Hemovac 1/4 542108000","C":"272","F":"100.674"},{"Policy Line":"64132527","B":"Pack Closure Cpp","C":"272","F":"173.196"},{"Policy Line":"64132564","B":"Cath Gde Sos Omni 5Fr 10712005","C":"272","D":"C1887","F":"45.9","G":"**"},{"Policy Line":"64132688","B":"Illuminator W Angle 8065750425","C":"272","F":"179.01"},{"Policy Line":"64132711","B":"Tissue Removal Device-Myosure","C":"272","F":"1447.38","G":"**"},{"Policy Line":"64132755","B":"MATRIX COLLAGEN 12X25CM","C":"278","D":"C9354","F":"9695.61"},{"Policy Line":"64132787","B":"Needle Gripper 20X1 21-276224","C":"272","F":"8.568","G":"**"},{"Policy Line":"64132804","B":"K-Wire 1.0 Wright 4411-2000","C":"272","F":"47.124"},{"Policy Line":"64132858","B":"Plug Anal Fistul C-Afp-0.6X9.5","C":"272","F":"1031.832"},{"Policy Line":"64132873","B":"Kit Accessory","C":"272","F":"222.768","G":"**"},{"Policy Line":"64132972","B":"Valve Adjustable Supa","C":"278","F":"3341.214"},{"Policy Line":"64133002","B":"GUIDE POST 8226-75","C":"278","F":"104.346"},{"Policy Line":"64133023","B":"Arm Sling Shot Medium 08503","C":"272","F":"132.804"},{"Policy Line":"64133040","B":"Prosthesis Penile Grp 1","C":"278","D":"C2622","F":"3185.766"},{"Policy Line":"64133043","B":"Button Septal 1524110","C":"278","F":"375.462","G":"**"},{"Policy Line":"64133069","B":"Reattachment Device 498.807S","C":"278","D":"C1776","F":"3196.17"},{"Policy Line":"64133089","B":"Lead Epicardial 5071-35Cm","C":"278","D":"C1896","F":"794.376"},{"Policy Line":"64133135","B":"CorkScrew, Bone","C":"278","D":"C1713","F":"418.302"},{"Policy Line":"64133136","B":"Wire Ortho Supply Grp 3","C":"272","F":"412.182","G":"**"},{"Policy Line":"64133154","B":"Cap End Lead","C":"272","F":"49.266"},{"Policy Line":"64133192","B":"Handpiece Solo Grip 70537020","C":"272","F":"6040.746"},{"Policy Line":"64133227","B":"Allograft Osteochond Foa20C","C":"278","F":"10139.004"},{"Policy Line":"64133241","B":"Syringe Deflux 1Ml 159034","C":"278","D":"L8606","F":"2430.252"},{"Policy Line":"64133348","B":"Reservoir W/Filter Atr2900Df","C":"272","F":"182.682"},{"Policy Line":"64133428","B":"Cord Stabilizing","C":"278","F":"1269.594"},{"Policy Line":"64134053","B":"Radielle Voice Gel","C":"278","D":"C1878","F":"795.6","G":"**"},{"Policy Line":"64134062","B":"Kit Jejunostomy Laparos 51442","C":"272","F":"246.024"},{"Policy Line":"64134067","B":"Capio Open Access 831-125","C":"272","D":"C2631","F":"718.794","G":"**"},{"Policy Line":"64134085","B":"Maonka 4Mm Wide Fci S1-1630U","C":"272","F":"135.558"},{"Policy Line":"64134091","B":"Needle Interstim 5 041829","C":"272","F":"77.418"},{"Policy Line":"64134102","B":"Tip Uterine Manipulator Umw676","C":"272","F":"84.762"},{"Policy Line":"64134110","B":"Alloderm Tissue 4X16 102082","C":"278","D":"Q4116","F":"2720.952"},{"Policy Line":"64134126","B":"Device Electrosurg 700-103027","C":"272","F":"2969.118"},{"Policy Line":"64134128","B":"System Hta Hydroblation 55016","C":"272","F":"1382.202","G":"**"},{"Policy Line":"64134141","B":"Tray Urologists Bard 123400","C":"272","F":"352.206","G":"**"},{"Policy Line":"64134150","B":"Graft Zenform 6X10 830-245","C":"278","D":"C1763","F":"1404.234"},{"Policy Line":"64134154","B":"System Oats","C":"272","F":"994.806"},{"Policy Line":"64134160","B":"Tray Trach Blue Rhino 263567","C":"272","D":"C1769","F":"746.334","G":"**"},{"Policy Line":"64134182","B":"Electroce Vapor 4.0Mm 225370","C":"272","F":"392.598"},{"Policy Line":"64134199","B":"Implant Medpore Sst 22Mm 80006","C":"278","F":"889.542","G":"**"},{"Policy Line":"64134211","B":"Pak Total Vitrecto 8065-750220","C":"272","F":"754.29"},{"Policy Line":"64134219","B":"Pencil 25Ga Diathermy 14-5011","C":"272","F":"76.806","G":"**"},{"Policy Line":"64134256","B":"Implant Medpor Sst 16Mm 80000","C":"278","F":"889.542","G":"**"},{"Policy Line":"64134257","B":"Implant Medpor SST 18Mm 80002","C":"278","F":"900.864","G":"**"},{"Policy Line":"64134278","B":"Stent Lacrimal Fci S1-1350U","C":"278","F":"217.26"},{"Policy Line":"64134294","B":"Tube Laryngectomy Martin","C":"278","F":"199.206"},{"Policy Line":"64134299","B":"Monoka 3Mm Medium 51-1710U","C":"278","F":"135.558"},{"Policy Line":"64134300","B":"Prosthesis Classic 142104","C":"278","F":"224.298"},{"Policy Line":"64134301","B":"Prosthesis Classic 142105","C":"278","F":"221.238"},{"Policy Line":"64134303","B":"Prosthesis Classic 70142121","C":"278","F":"215.118"},{"Policy Line":"64134304","B":"Prosthesis Classic 4Mm 142100","C":"278","F":"259.488"},{"Policy Line":"64134305","B":"Prosthesis Classic 4Mm 142101","C":"278","F":"348.534"},{"Policy Line":"64134308","B":"Piston Smart Gyrus 70145929","C":"278","F":"382.806"},{"Policy Line":"64134319","B":"Sling Shot Large Breg 08504","C":"274","D":"L3670","F":"120.87","G":"**"},{"Policy Line":"64134327","B":"Versajet 45 Degree/14Mm 50636","C":"272","F":"788.256","G":"**"},{"Policy Line":"64134330","B":"Pericardium 6X8 Bov Pc-0608Sn","C":"278","F":"723.69"},{"Policy Line":"64134340","B":"Tubing Aerosol Spray Has01","C":"272","F":"96.696"},{"Policy Line":"64134341","B":"Lapsac Cook 054800","C":"272","F":"126.378","G":"**"},{"Policy Line":"64134348","B":"Graft Xenform 8X12 830-247","C":"278","F":"1926.882"},{"Policy Line":"64134368","B":"Filter Trap Ease 466-P306Au","C":"278","F":"1023.876"},{"Policy Line":"64134386","B":"Coaptite 1ML SYR M0068903000","C":"278","D":"L8606","F":"544.374","G":"**"},{"Policy Line":"64134389","B":"Implant Subtalar MBA","C":"278","D":"C1713","F":"2910.06","G":"**"},{"Policy Line":"64134403","B":"Prosthesis Urolume 72402015","C":"278","F":"3930.876"},{"Policy Line":"64134408","B":"Forcep Bayonet Disp 20-1420Ki","C":"272","F":"88.128"},{"Policy Line":"64134414","B":"Lead Test Kit Interstim 3057","C":"278","D":"C1897","F":"193.392"},{"Policy Line":"64134415","B":"Tube Baker Jujunst 16F 0042510","C":"278","F":"482.256"},{"Policy Line":"64134417","B":"Needle Soft Tip 25G 8065149525","C":"272","F":"58.14"},{"Policy Line":"64134445","B":"Piston Smart .6X4.25 70145927","C":"278","F":"360.468"},{"Policy Line":"64134446","B":"Piston Smart .6X3.75 70145925","C":"278","F":"375.156"},{"Policy Line":"64134447","B":"Sheet No Channel Ultra 7210","C":"278","F":"577.728"},{"Policy Line":"64134472","B":"Baha Abutment 8.5Mm 90410","C":"278","F":"1992.978"},{"Policy Line":"64134477","B":"Implant Medpor Sst 20Mm 80004","C":"278","F":"945.234"},{"Policy Line":"64134478","B":"Apogee/Intexem Lp 72404089","C":"278","F":"2538.576"},{"Policy Line":"64134518","B":"Kit Procedure Scoop T10Sp9","C":"272","F":"817.02"},{"Policy Line":"64134523","B":"Surgisis 4-Layer Tissue Graft","C":"278","D":"C1763","F":"794.376"},{"Policy Line":"64134532","B":"Generator Ipg Interstim 3058","C":"278","D":"C1767","F":"11386.872","G":"**"},{"Policy Line":"64134533","B":"Patient Programmer Inter 3037","C":"272","D":"C1787","F":"1522.962"},{"Policy Line":"64134534","B":"Peg Smooth 2.3X20 Cos-2320","C":"278","F":"200.736","G":"**"},{"Policy Line":"64134535","B":"Peg Smooth 2.3X18 Cos-2318","C":"278","F":"200.736"},{"Policy Line":"64134536","B":"Peg Smooth 2.3X24 Cos-2324","C":"278","D":"C1713","F":"200.736"},{"Policy Line":"64134537","B":"Peg Smooth 2.3X22 Cos-2322","C":"278","D":"C1713","F":"200.736","G":"**"},{"Policy Line":"64134553","B":"Cavity Evaluation Device 9030","C":"272","F":"274.176"},{"Policy Line":"64134555","B":"Kit Maxcess Disposable 3200060","C":"272","F":"2339.37"},{"Policy Line":"64134557","B":"Gelport 120Mm Applied C8Xx2","C":"272","F":"726.138","G":"**"},{"Policy Line":"64134559","B":"Cable High Freq Mono 277Kb-D10","C":"272","F":"55.386"},{"Policy Line":"64134567","B":"Ultradine Fh 3.5 23101","C":"278","F":"349.146"},{"Policy Line":"64134572","B":"Cuff Nerve Colgn 4.0MMX2.5CM","C":"278","D":"C9355","F":"1983.492"},{"Policy Line":"64134574","B":"Marker Tissue Mt-Nw-887-8Xx","C":"278","D":"A4648","F":"132.192","G":"**"},{"Policy Line":"64134577","B":"Peg Partial Thread Tp20000","C":"278","F":"193.392"},{"Policy Line":"64134578","B":"Kit Tightrope Mini Ar-8911Ds","C":"278","F":"912.186"},{"Policy Line":"64134579","B":"Solution Adept 0600041","C":"272","F":"369.648","G":"**"},{"Policy Line":"64134580","B":"Kit Tipless Irrig 8065741081","C":"278","F":"125.766"},{"Policy Line":"64134588","B":"Dressing Nasal Meropck 1520000","C":"272","F":"138.924","G":"**"},{"Policy Line":"64134600","B":"Kit Flexiflo Gastro 10F 50190","C":"272","F":"320.994","G":"**"},{"Policy Line":"64134602","B":"Needle Side Kick M0068903040","C":"272","F":"82.62","G":"**"},{"Policy Line":"64134604","B":"Alloderm 16X20 X-Thick 982320","C":"278","D":"Q4116","F":"11063.124"},{"Policy Line":"64134609","B":"Battery System 1.5Mm 50-1010","C":"272","F":"193.698"},{"Policy Line":"64134618","B":"Pak Total+Vit 23Ga 8065750828","C":"272","F":"635.562"},{"Policy Line":"64134620","B":"Scraper Tano 23G 20.04.23","C":"272","F":"193.392"},{"Policy Line":"64134623","B":"Sling Advance Male","C":"278","D":"C2631","F":"4680.576"},{"Policy Line":"64134625","B":"System Lactosorb 1.5 915-2816","C":"278","F":"1011.024"},{"Policy Line":"64134636","B":"Ultradine Fh 3.0 23201","C":"278","F":"348.84"},{"Policy Line":"64134638","B":"Graft Gamma 50X62.5 Gg625","C":"278","D":"Q4111","F":"557.226"},{"Policy Line":"64134641","B":"Patch Soft Tissue 1405010010","C":"278","D":"C1781","F":"362.916","G":"**"},{"Policy Line":"64134662","B":"Device Relieva Inflation Bid30","C":"272","F":"144.126","G":"**"},{"Policy Line":"64134678","B":"Allograft L Hamicondyle 268011","C":"278","D":"C1762","F":"10600.452"},{"Policy Line":"64134679","B":"Tissue Strattice 20X20 2020002","C":"278","D":"Q4130","F":"11628.918","G":"**"},{"Policy Line":"64134680","B":"Strattice 16X20","C":"278","D":"Q4130","F":"9303.012","G":"**"},{"Policy Line":"64134683","B":"Sizer Mammary Grp 2","C":"272","F":"431.766","G":"**"},{"Policy Line":"64134690","B":"Paste Dbm 1Cc Trel-Xc Txcpa01","C":"278","F":"344.25"},{"Policy Line":"64134692","B":"Protector Nerve 7X4Cm Nw740","C":"278","D":"C9353","F":"1830.186"},{"Policy Line":"64134693","B":"Ring Malyugin Mal0001","C":"272","F":"217.26"},{"Policy Line":"64134695","B":"Strattice 10 X 16 Cm 1016002","C":"278","D":"Q4130","F":"4516.866","G":"**"},{"Policy Line":"64134697","B":"Elevate Posterior","C":"278","D":"C1781","F":"2229.21"},{"Policy Line":"64134703","B":"System Pinnacle 831705","C":"278","D":"C2631","F":"2365.38"},{"Policy Line":"64134709","B":"Alloderm Tissue 8X16 102128","C":"278","D":"Q4116","F":"4791.654"},{"Policy Line":"64134710","B":"Integra BiWndMtrx 4x5cmBMW4051","C":"278","D":"Q4104","F":"4962.708","G":"**"},{"Policy Line":"64134711","B":"Allograft Femoral 086130-003","C":"278","D":"C1762","F":"10600.452"},{"Policy Line":"64134716","B":"Sys Prolift +M Pfrp02/Pfra02","C":"278","D":"C1781","F":"2566.422"},{"Policy Line":"64134717","B":"System Prolift +M Total Pfrt02","C":"278","D":"C1781","F":"3164.346"},{"Policy Line":"64134719","B":"Dressing Nasopore","C":"272","F":"192.78","G":"**"},{"Policy Line":"64134723","B":"Graft Pegasus 9 X 10Cm Ofx2000","C":"278","F":"3193.11"},{"Policy Line":"64134724","B":"Tray Urologist Disposab 123400","C":"272","F":"216.954"},{"Policy Line":"64134725","B":"Tenoglide 4X5 Tg451","C":"278","D":"C9356","F":"3210.552","G":"**"},{"Policy Line":"64134727","B":"Permacol 20X30Cm 152030","C":"278","D":"C9364","F":"9590.958","G":"**"},{"Policy Line":"64134728","B":"Permacol 15X20Cmx1.5Mm P151520","C":"278","D":"C9364","F":"4984.74"},{"Policy Line":"64134730","B":"Permacol 20X40Cmx1.5Mm 152040","C":"278","D":"C9364","F":"14621.904"},{"Policy Line":"64134734","B":"Permacol 28X40Cmx1.5Mm 152840","C":"278","D":"C9364","F":"25988.886"},{"Policy Line":"64134736","B":"Permacol 10X20Cmx1.5Mm 151020","C":"278","D":"C9364","F":"4218.822","G":"**"},{"Policy Line":"64134737","B":"Integra Wound Matrix 8x10cm","C":"278","D":"Q4108","F":"8735.076"},{"Policy Line":"64134738","B":"Tissue Flexhd 12Cmx24Cm 472224","C":"278","D":"C1762","F":"8994.258"},{"Policy Line":"64134739","B":"Permacol 10X10Cmx1.0Mm 101010","C":"278","D":"C9364","F":"1623.024"},{"Policy Line":"64134740","B":"Pacemaker Accent Rf Dr Pm2210","C":"275","D":"C1785","F":"5783.706"},{"Policy Line":"64134741","B":"Lead Revision Kit 3550-10","C":"272","F":"461.754"},{"Policy Line":"64134742","B":"Permacol 20X50Cmx1.5Mm 152050","C":"278","D":"C9364","F":"18277.38"},{"Policy Line":"64134744","B":"Plug Anal Fistula","C":"278","D":"C1763","F":"1377.306","G":"**"},{"Policy Line":"64134746","B":"Filler Void Otomimix 7014-3266","C":"278","D":"C1763","F":"511.326"},{"Policy Line":"64134747","B":"Lactosorb Template","C":"272","F":"331.092"},{"Policy Line":"64134748","B":"Sling Solyx System 850-700","C":"278","D":"C1763","F":"1602.828"},{"Policy Line":"64134749","B":"System Uphold Vaginal 831-708","C":"278","D":"C1763","F":"2613.546","G":"**"},{"Policy Line":"64134750","B":"Alloderm Tissue 6X12 102071","C":"278","D":"Q4116","F":"2670.768"},{"Policy Line":"64134751","B":"Wound Matrix Integra 10x25CM","C":"278","D":"Q4108","F":"3193.11"},{"Policy Line":"64134752","B":"Tissue Flexhd 12Cmx12Cm 472122","C":"278","D":"C1762","F":"4785.84"},{"Policy Line":"64134754","B":"Alloderm Tissue 4X4 Cm 402025","C":"278","D":"Q4116","F":"760.104"},{"Policy Line":"64134756","B":"Catheter Irrigation","C":"272","F":"246.942"},{"Policy Line":"64134757","B":"Enseal Cautery Device Disp","C":"272","F":"695.232","G":"**"},{"Policy Line":"64134759","B":"Strattice 6X16Cm 0616002","C":"278","D":"Q4130","F":"3193.11"},{"Policy Line":"64134761","B":"Guidewire Relieva Gw35080V","C":"272","F":"246.942"},{"Policy Line":"64134762","B":"Catheter M Sinus Guide Gc110","C":"272","D":"C1887","F":"567.018"},{"Policy Line":"64134764","B":"Pacemaker Zepher Xl Sr 5626","C":"275","F":"4311.234"},{"Policy Line":"64134765","B":"Port Sils 12Mm Silspt12","C":"278","F":"695.538"},{"Policy Line":"64134767","B":"Relieva Luma 20Deg Tip Sis100A","C":"278","F":"835.074"},{"Policy Line":"64134768","B":"Putty Scaffold 2.5Cc Ios10125","C":"278","F":"639.54"},{"Policy Line":"64134769","B":"Tissue Pelvisoft 6X8Cm 481068","C":"278","D":"C1763","F":"1103.436"},{"Policy Line":"64134770","B":"Kit Nasal Epistat Cath 1527030","C":"278","F":"188.19"},{"Policy Line":"64134771","B":"Strattice 20 X 25Cm 2025002","C":"278","D":"Q4130","F":"13728.078","G":"**"},{"Policy Line":"64134772","B":"Strattice 6 X 10Cm 0610008","C":"278","D":"Q4130","F":"2288.268","G":"**"},{"Policy Line":"64134773","B":"Strattice 8 X 16 Cm 0816001","C":"278","D":"Q4130","F":"3533.076"},{"Policy Line":"64134774","B":"Shunt Denver Ascites 42-2050","C":"278","F":"2213.91"},{"Policy Line":"64134776","B":"Expander Tissue Ankle 3614-04","C":"278","F":"1139.544"},{"Policy Line":"64134777","B":"Strattice 10X10Cm 1010002","C":"278","D":"Q4130","F":"3155.778"},{"Policy Line":"64134778","B":"Prosima Mesh Pelvic Rpr Sys","C":"278","D":"C1763","F":"2265.624"},{"Policy Line":"64134779","B":"Seamguard Biosorb Reinforcmnt","C":"278","F":"453.798","G":"**"},{"Policy Line":"64134780","B":"Plasmax Concentrator 800-0516","C":"272","F":"1151.784"},{"Policy Line":"64134781","B":"Sling Male Invance Iz 72403530","C":"278","D":"C1771","F":"4159.152"},{"Policy Line":"64134782","B":"Sling Tvt Exact Tvtrl","C":"278","D":"C1771","F":"1563.354","G":"**"},{"Policy Line":"64134783","B":"Suture Shuttle Lasso","C":"272","F":"325.89","G":"**"},{"Policy Line":"64134784","B":"Endograb Insert Eg000A","C":"272","F":"238.68"},{"Policy Line":"64134785","B":"System Adiana Permanent A6000","C":"278","F":"1834.47"},{"Policy Line":"64134786","B":"Marrowstim Mini Conc 800-0610A","C":"272","F":"2418.624"},{"Policy Line":"64134787","B":"Clip Filshie Avm-851J","C":"272","F":"179.622"},{"Policy Line":"64134790","B":"Sling Abbrevo Tvtoml","C":"278","D":"C1771","F":"1743.588","G":"**"},{"Policy Line":"64134791","B":"Gen Neurostim Non-Rechrg 102","C":"278","D":"C1767","F":"15713.712"},{"Policy Line":"64134793","B":"Staple Calcaneal Barbed","C":"272","F":"1517.454"},{"Policy Line":"64134794","B":"Cath Balloon Karlan Cholang","C":"272","D":"C1726","F":"175.95"},{"Policy Line":"64134795","B":"Integra Mesh Mwm4051 10X12.5CM","C":"278","D":"C9363","F":"4314.6"},{"Policy Line":"64134796","B":"Ent Fusion Sys Disp Tracker","C":"272","F":"260.1","G":"**"},{"Policy Line":"64134797","B":"Implant Chest Wall Right","C":"278","F":"1834.47"},{"Policy Line":"64134804","B":"Integra Wnd Mtrx Mwm2021 2X2","C":"278","D":"Q4104","F":"2945.25","G":"**"},{"Policy Line":"64134805","B":"Reservoir Conceal Iz 720185-01","C":"272","F":"2197.998"},{"Policy Line":"64134806","B":"PM DUAL RR Generator ADDR01","C":"275","D":"C1785","F":"4057.56"},{"Policy Line":"64134807","B":"Bolt Removal Trigen 7163-1278","C":"272","F":"1057.23"},{"Policy Line":"64134811","B":"Sheeting Silastic .020 501-3","C":"278","F":"493.578","G":"**"},{"Policy Line":"64134812","B":"Osteotome 6Mm Flat Ohfo2060Su","C":"272","F":"795.6","G":"**"},{"Policy Line":"64134813","B":"Implant Medpor Titan 81050","C":"278","F":"1407.6"},{"Policy Line":"64134816","B":"Kit Anoscope Sterile Slideone","C":"272","F":"795.6","G":"**"},{"Policy Line":"64134817","B":"Kit Onq Expansion","C":"272","F":"106.488","G":"**"},{"Policy Line":"64134818","B":"Testicular Saline Implant Colo","C":"278","F":"2111.4"},{"Policy Line":"64134819","B":"Tutoplast Fascia 2X14Cm 68021","C":"278","F":"1848.546"},{"Policy Line":"64134820","B":"Device Myosure Trd 10-401","C":"272","F":"1721.25"},{"Policy Line":"64134821","B":"Lead Pacer Isoflex 1948-58","C":"275","D":"C1898","F":"772.038"},{"Policy Line":"64134822","B":"Implant 3 Unilateral Sys Baha","C":"278","D":"L8690","F":"9862.074"},{"Policy Line":"64134823","B":"Reamer Arrowhead 95-3000","C":"272","F":"96.696"},{"Policy Line":"64134824","B":"Reamer 7.0Mm 71674040","C":"272","F":"876.69"},{"Policy Line":"64134825","B":"Implant Speed Forefoot","C":"278","D":"C1713","F":"1167.084"},{"Policy Line":"64134827","B":"RPR Sys Distal Biceps Ar-2260","C":"278","D":"C1713","F":"1555.092","G":"**"},{"Policy Line":"64134828","B":"Sealant Progel 4Ml Pgps002","C":"278","D":"C2615","F":"1194.624"},{"Policy Line":"64134829","B":"System Endo Release 310138","C":"272","F":"1511.64"},{"Policy Line":"64134831","B":"Pump Penile Ms 72404233","C":"278","D":"C1813","F":"7186.716","G":"**"},{"Policy Line":"64134832","B":"Kit Spy Elite Lc 3006","C":"272","F":"795.6","G":"**"},{"Policy Line":"64134833","B":"Tightope Syndemosis Kit","C":"278","D":"C1713","F":"1609.866","G":"**"},{"Policy Line":"64134834","B":"Plasmabutton Electrode","C":"272","F":"763.776","G":"**"},{"Policy Line":"64134835","B":"Vitagel Hemostat","C":"278","F":"376.686"},{"Policy Line":"64134836","B":"Kit V Probe Cryo-206","C":"278","D":"C2618","F":"5291.964","G":"**"},{"Policy Line":"64134837","B":"Frame Ilizaroth F&A 71070395","C":"270","F":"7207.218"},{"Policy Line":"64134838","B":"Alloderm Tissue 6X16 992196","C":"278","D":"Q4116","F":"3161.592"},{"Policy Line":"64134839","B":"Alloderm Rtu 16X20 152032","C":"278","D":"Q4116","F":"10660.122"},{"Policy Line":"64134840","B":"Stent Opth Monoka 4MmW S1-1800","C":"278","F":"180.846","G":"**"},{"Policy Line":"64134841","B":"Alloderm 8 X 16Cm Thin 1516128","C":"278","D":"Q4116","F":"4167.108"},{"Policy Line":"64134842","B":"Alloderm Rtu 4X16Cm 152064","C":"278","F":"2545.308"},{"Policy Line":"64134843","B":"Alloderm Rtu 8X16Cm 1520128","C":"278","D":"Q4116","F":"4020.534","G":"**"},{"Policy Line":"64134844","B":"Synpor Titanium Mesh","C":"278","F":"1690.344"},{"Policy Line":"64134845","B":"Device Fixation Strap25","C":"272","F":"795.6","G":"**"},{"Policy Line":"64134846","B":"System Exair Ant/Posterior","C":"278","D":"C1781","F":"2090.898"},{"Policy Line":"64134847","B":"Penile Prosthesis Titan Colopl","C":"278","D":"C1813","F":"8317.998"},{"Policy Line":"64134848","B":"Strattice 9Cmx18.5Cm Con2006","C":"278","D":"Q4130","F":"3193.11"},{"Policy Line":"64134849","B":"Strattice 10Cmx22Cm Con3006","C":"278","D":"Q4130","F":"3196.17"},{"Policy Line":"64134850","B":"Screw/Kit Mini Scorpion Dx","C":"278","D":"C1713","F":"1737.774"},{"Policy Line":"64134851","B":"RELIEVA SPIN BALLOON SYS","C":"278","D":"C1726","F":"2143.53","G":"**"},{"Policy Line":"64134852","B":"Lead NeurStim Kit Test 3065","C":"278","D":"C1897","F":"485.622"},{"Policy Line":"64134853","B":"Kit Accessory Compon Her01003","C":"272","F":"770.508"},{"Policy Line":"64134854","B":"Nail Panta 10X150Mm 500050Nd","C":"278","F":"3941.586"},{"Policy Line":"64134855","B":"Cath Ureteral Lighted G16747","C":"272","D":"C1758","F":"308.142"},{"Policy Line":"64134856","B":"Kit Speedbridge Ar-8928Bc-Cp","C":"278","D":"C1713","F":"3181.482","G":"**"},{"Policy Line":"64134857","B":"Extractor Stone Saliva","C":"272","F":"557.226","G":"**"},{"Policy Line":"64134858","B":"Set Dilator Salivary G24131","C":"272","F":"193.392"},{"Policy Line":"64134859","B":"Linx Reflux Mgmt System","C":"278","F":"5274.828","G":"**"},{"Policy Line":"64134860","B":"Rod Tendon","C":"278","F":"1904.238"},{"Policy Line":"64134861","B":"Rod Tendon Trial","C":"278","F":"794.682"},{"Policy Line":"64134862","B":"Strattice 25 X 40Cm 2540002","C":"278","D":"Q4130","F":"27584.37"},{"Policy Line":"64134863","B":"Elevate W/Intexen 720129-01","C":"278","D":"C1763","F":"2725.236"},{"Policy Line":"64134864","B":"Nail Valor 11.5X200 415101120R","C":"278","D":"C1713","F":"3761.352"},{"Policy Line":"64134865","B":"Permacol 15X20Cmx1.0Mm P101520","C":"278","D":"C9364","F":"4984.74"},{"Policy Line":"64134866","B":"Grafix Prime 7.5X15 Ps21075","C":"278","D":"Q4133","F":"2538.27"},{"Policy Line":"64134867","B":"Sling Altis","C":"278","D":"C1771","F":"1708.398"},{"Policy Line":"64134868","B":"Abthera Dressing M8275026/5.S","C":"272","F":"585.99","G":"**"},{"Policy Line":"64134869","B":"Allomax Tissue 8X16Cm 1180816","C":"278","D":"Q4100","F":"4136.814"},{"Policy Line":"64134870","B":"Strattice 10 X 20Cm 102000","C":"278","D":"Q4130","F":"5646.312","G":"**"},{"Policy Line":"64134871","B":"IBV Valve Sys Impl Airleak Dev","C":"278","F":"2855.286"},{"Policy Line":"64134872","B":"Balloon Tamponade Bronchii","C":"278","F":"191.25"},{"Policy Line":"64134873","B":"System Implant Ar-2600Sbs-5","C":"278","D":"C1713","F":"3242.682","G":"**"},{"Policy Line":"64134874","B":"Kit Laterjet 285180","C":"278","F":"898.416"},{"Policy Line":"64134875","B":"Cellerate Powder Wci-01-Sacrxp","C":"272","F":"406.062"},{"Policy Line":"64134876","B":"Kit Protoe Inst Disp 45710500","C":"272","F":"238.68","G":"**"},{"Policy Line":"64134877","B":"Dermis Axis 93-9612","C":"278","D":"C1762","F":"2583.864","G":"**"},{"Policy Line":"64134878","B":"Epifix 2X3Cm Gs-5230","C":"278","D":"Q4186","F":"1464.516","G":"**"},{"Policy Line":"64134879","B":"Bone Stimulator/Don Joy","C":"272","F":"3196.17","G":"**"},{"Policy Line":"64134880","B":"Primatrix 6X6Cm Bov 6495-9-116","C":"278","D":"Q4110","F":"2376.396"},{"Policy Line":"64134881","B":"Xenmatrix 20X25Cm Porc 1162025","C":"278","D":"C1781","F":"12861.486"},{"Policy Line":"64134882","B":"Stent, Ureteral Flexima","C":"278","D":"C2625","F":"1316.106","G":"**"},{"Policy Line":"64134883","B":"Flexioflo Gi Tube Kit","C":"272","F":"623.016"},{"Policy Line":"64134884","B":"Nail Panta 13X180Mm 500380Nd","C":"272","F":"4265.334"},{"Policy Line":"64134885","B":"Kit Platelet Abs-10012","C":"272","F":"570.078"},{"Policy Line":"64134886","B":"Tissue Flexhd 16X20Cm Pliable","C":"278","D":"Q4128","F":"10426.644","G":"**"},{"Policy Line":"64134887","B":"Amniofix 1.25 Inject Ai-5125","C":"278","F":"1785.816"},{"Policy Line":"64134888","B":"Stent Esophageal","C":"278","D":"C1874","F":"2965.14"},{"Policy Line":"64134889","B":"Allograft Reset Matri 4X4 Rm44","C":"278","F":"3246.048"},{"Policy Line":"64134890","B":"Liquidgen Allograft Injectable","C":"278","F":"3193.11"},{"Policy Line":"64134891","B":"PICO Wnd Np System","C":"272","F":"795.6","G":"**"},{"Policy Line":"64134892","B":"Alloderm Tissue 4X7","C":"278","D":"Q4116","F":"1117.206"},{"Policy Line":"64134893","B":"Allograft Reset Matri 2X2 Rm22","C":"278","F":"2553.264"},{"Policy Line":"64134894","B":"Hmatrix Dermis 5.0X4.0C","C":"278","D":"Q4134","F":"795.6"},{"Policy Line":"64134895","B":"Strattice 10X16Cm Lap Porcine","C":"278","D":"Q4130","F":"4516.866"},{"Policy Line":"64134896","B":"Alloderm Contour Medium Cm1520","C":"278","F":"4396.608"},{"Policy Line":"64134897","B":"ClarixAdhBar4.0X3.0 Cr10-4030","C":"278","D":"C1765","F":"3196.17"},{"Policy Line":"64134898","B":"Sub Talar Fusion Cup Fixation","C":"278","F":"1529.388","G":"**"},{"Policy Line":"64134899","B":"Pleuristik","C":"278","F":"477.666"},{"Policy Line":"64134900","B":"Alloderm Contour Small Cs1520","C":"278","F":"3196.17"},{"Policy Line":"64134901","B":"Kit Endoscopic Release Ar-8850","C":"272","F":"455.328"},{"Policy Line":"64134902","B":"Axoguard Nerve Protector","C":"278","F":"2761.038","G":"**"},{"Policy Line":"64134903","B":"Avance Nerve Graft 5Cm","C":"272","F":"3037.05","G":"**"},{"Policy Line":"64134904","B":"Implant Midface 5444-0-510","C":"278","F":"15877.116"},{"Policy Line":"64134905","B":"Clarix 6.0X3.0 Cm Cr-10-6030","C":"278","D":"C1765","F":"3246.048"},{"Policy Line":"64134906","B":"Mesh Xenmatrix 10Cmx15 1161015","C":"278","D":"C1781","F":"3880.08"},{"Policy Line":"64134907","B":"Mesh Xenmatrix 15Cmx20 1161520","C":"278","D":"C1781","F":"7761.078"},{"Policy Line":"64134908","B":"Epifix 4X4Cm Gs-5440","C":"278","D":"Q4186","F":"3077.136","G":"**"},{"Policy Line":"64134909","B":"Amniofix 2X3Cm Aps-5230","C":"278","F":"1436.976"},{"Policy Line":"64134910","B":"Amniofix 2.Oml Inject Ai-5200","C":"278","F":"2553.876"},{"Policy Line":"64134911","B":"Clarix Cr-02-4040","C":"278","F":"2668.32"},{"Policy Line":"64134912","B":"Clarix Cr-10-2525","C":"278","F":"2431.476"},{"Policy Line":"64134913","B":"Neox 100 Graft 4.0X3.0","C":"278","D":"Q4156","F":"2803.572"},{"Policy Line":"64134914","B":"Amniofix .5Ml Inject Ai-5050","C":"278","F":"955.944"},{"Policy Line":"64134915","B":"Cath Hemodialysis Short Term","C":"278","D":"C1752","F":"175.95","G":"**"},{"Policy Line":"64134916","B":"Absorba Tack Fixation","C":"278","F":"707.166","G":"**"},{"Policy Line":"64134917","B":"Amniotic Membrane Wound Cover","C":"278","D":"V2790","F":"1599.768"},{"Policy Line":"64134918","B":"Clarix 25Mg","C":"278","F":"1145.358"},{"Policy Line":"64134919","B":"KIT FAST TISSUE REMOVAL","C":"272","F":"979.2","G":"**"},{"Policy Line":"64134920","B":"CLARIX FLO 50MG CR-FL-50","C":"278","D":"Q4155","F":"1913.418"},{"Policy Line":"64134921","B":"XPRESS MULTI SINUS LPLF-10","C":"272","D":"C1726","F":"1919.538","G":"**"},{"Policy Line":"64134922","B":"DERMACLOSE RC 204010","C":"272","F":"1214.514"},{"Policy Line":"64134923","B":"CLARIX CR-10-8030","C":"278","F":"5269.932"},{"Policy Line":"64134924","B":"CLARIX CR-02-2020","C":"278","F":"1619.046"},{"Policy Line":"64134925","B":"TISSUE FLEXHD 16X16CM HP161","C":"278","D":"Q4128","F":"3652.722"},{"Policy Line":"64134926","B":"REVOLVE FAT GRAFT KIT RV0004","C":"272","F":"788.256","G":"**"},{"Policy Line":"64134927","B":"GRAFT ENHANCE 3CMX4CM 322304","C":"278","F":"1535.508"},{"Policy Line":"64134928","B":"OASIS ULTRA 5X7CM 306813000013","C":"278","D":"Q4124","F":"530.91"},{"Policy Line":"64134929","B":"WND MTRX OASIS ULTRA 7X10","C":"278","D":"Q4124","F":"1093.644"},{"Policy Line":"64134930","B":"TISSUE FLEXHD 8X16CM HP1816","C":"278","D":"Q4128","F":"4627.944"},{"Policy Line":"64134931","B":"MATRIX WOUND MESD 8X10 MWM8101","C":"278","D":"C9363","F":"9872.172","G":"**"},{"Policy Line":"64134932","B":"PROPEL SINUS IMPLANT","C":"278","D":"C2625","F":"934.218","G":"**"},{"Policy Line":"64134933","B":"GOLD MARKER QLRAD","C":"278","D":"A4648","F":"199.206","G":"**"},{"Policy Line":"64134934","B":"ALLODERM CONTOUR PERF 132SQCM","C":"278","D":"Q4116","F":"4147.524","G":"**"},{"Policy Line":"64134935","B":"DERMIS ACELLULAR 8X12/1.50MM","C":"278","F":"3196.17"},{"Policy Line":"64134936","B":"VITAGEL 2.0ML SYNTHE 2113-0202","C":"278","F":"397.188"},{"Policy Line":"64134937","B":"DERMIS ACELLULAR 16X20","C":"278","F":"8115.12"},{"Policy Line":"64134938","B":"SYSTEM SHOULDER","C":"278","F":"5411.916"},{"Policy Line":"64134939","B":"ALLODERM RTU 6X16CM 1518616","C":"278","D":"Q4116","F":"3196.17","G":"**"},{"Policy Line":"64134940","B":"DERMIS HMATRIX 5.0X7.0C 208037","C":"278","D":"Q4134","F":"1276.632"},{"Policy Line":"64134941","B":"IMPLANT COCHLEAR C124RE Z60132","C":"278","D":"L8614","F":"12553.956"},{"Policy Line":"64134942","B":"KIT DUAL PROCESSOR DUALN6","C":"278","D":"L8614","F":"13034.988"},{"Policy Line":"64134943","B":"Matristem PSMX 7 x 10 cm","C":"278","F":"2526.03"},{"Policy Line":"64134944","B":"Matristem MicroMatrix 1000mg","C":"278","D":"Q4118","F":"3049.29","G":"**"},{"Policy Line":"64134945","B":"Matristem Psm 5X5CM PSM0505","C":"278","F":"684.522"},{"Policy Line":"64134946","B":"DRILL GUIDE 3MM & 4MM 92139","C":"272","F":"336.294"},{"Policy Line":"64134947","B":"Drill Widening 4MM 92141","C":"272","F":"358.326"},{"Policy Line":"64134948","B":"Processor Cochlear BAHA3 92843","C":"278","D":"L8690","F":"3550.518"},{"Policy Line":"64134949","B":"Implant Baha Grp 2","C":"278","D":"L8690","F":"2880.072","G":"**"},{"Policy Line":"64134952","B":"Matristem PSMX 5x5cm PSMx0505","C":"278","F":"716.346"},{"Policy Line":"64134953","B":"SYSTEM PEAK PLASMA 278001","C":"272","F":"557.226","G":"**"},{"Policy Line":"64134954","B":"Wand Serfas Energy 279-250-101","C":"278","F":"280.908"},{"Policy Line":"64134955","B":"Implant X-fuse Xlarge AXF-XL","C":"278","F":"2166.786"},{"Policy Line":"64134956","B":"Implant X-fuse Large AXF-LO","C":"278","F":"2166.786"},{"Policy Line":"64134957","B":"System Suspension Encore","C":"278","F":"2815.2"},{"Policy Line":"64134958","B":"Fixator Subtalor Frame","C":"272","F":"4971.582"},{"Policy Line":"64134959","B":"Stent Micro Bypass MIGS","C":"278","D":"C1783","F":"2242.98","G":"**"},{"Policy Line":"64134960","B":"Wnd Matrix Matristem 10x15","C":"278","F":"4291.038"},{"Policy Line":"64134961","B":"Matristem Pelvic Floor PFM0912","C":"278","D":"C1781","F":"2266.542","G":"**"},{"Policy Line":"64134962","B":"Implant Alpha Sophono","C":"278","F":"2943.414"},{"Policy Line":"64134963","B":"Kit Processor Alpha 2","C":"272","F":"3646.908"},{"Policy Line":"64134964","B":"Speed Titan Implant 25x20x20","C":"278","D":"C1713","F":"2006.136"},{"Policy Line":"64134965","B":"STENT STOMA 11MM","C":"278","F":"671.058"},{"Policy Line":"64134966","B":"STENT NON-CO/COV PROTEGE","C":"278","D":"C1876","F":"1272.348","G":"**"},{"Policy Line":"64134967","B":"ALLODERM CON LG CL15xxP","C":"278","D":"Q4116","F":"5623.668","G":"**"},{"Policy Line":"64134968","B":"Sound Processor, BAHA BP110","C":"278","D":"L8690","F":"3104.064"},{"Policy Line":"64134969","B":"ALLODERM 2X4CM XThick 982011","C":"278","D":"Q4116","F":"745.722"},{"Policy Line":"64134970","B":"Allograft, Artery","C":"278","F":"6451.398"},{"Policy Line":"64134971","B":"Plating System, Bunion","C":"278","D":"C1776","F":"1022.652"},{"Policy Line":"64134972","B":"STRATTICE 6X8 0608005","C":"278","D":"Q4130","F":"1714.824"},{"Policy Line":"64134973","B":"MATRISTEM PELVIC FLR PFM10X15","C":"278","D":"C1781","F":"4074.084"},{"Policy Line":"64134974","B":"Matristem Matrix Plus MSPL0710","C":"278","D":"C1781","F":"2313.666"},{"Policy Line":"64134975","B":"Stimulator/Locator Nerve 9094","C":"272","F":"794.376","G":"**"},{"Policy Line":"64134976","B":"IMPLNT SYS INT BRACE AR-1688CP","C":"278","F":"1965.744","G":"**"},{"Policy Line":"64134977","B":"IMPLANT SPEED 20X15 SE-2015TI","C":"278","D":"C1713","F":"2175.354"},{"Policy Line":"64134978","B":"Matrix Surg Plus 5x7 MSPL0507","C":"278","D":"C1781","F":"1156.986"},{"Policy Line":"64134979","B":"Integra Derm Reg Te 8x10 38101","C":"278","D":"Q4105","F":"8926.632"},{"Policy Line":"64134980","B":"ALLODERM 3X7 102020","C":"278","F":"1078.65"},{"Policy Line":"64134981","B":"IMPLANT TESTICULAR 450-1329","C":"278","F":"2366.298"},{"Policy Line":"64134982","B":"BONE PUNCH Grp 1","C":"272","F":"171.36"},{"Policy Line":"64134983","B":"BONE PUNCH Grp 2","C":"272","F":"473.994"},{"Policy Line":"64134984","B":"Humeral Fx Shoulder Stem","C":"278","D":"C1776","F":"6277.896"},{"Policy Line":"64134985","B":"AMNIOFIX 2.0X12CM APS-5212","C":"278","F":"1272.654","G":"**"},{"Policy Line":"64134986","B":"Implant BME Speed Grp 1","C":"278","F":"1278.162"},{"Policy Line":"64134987","B":"Implant BME Speed Grp 2","C":"278","F":"2037.348"},{"Policy Line":"64134988","B":"Wedge System, Biofoam","C":"278","F":"2888.334"},{"Policy Line":"64134989","B":"Avance Nerve Graft 30MM","C":"278","D":"C1762","F":"2951.982","G":"**"},{"Policy Line":"64134991","B":"Myosure Lite Tissue Rem 30-401","C":"272","F":"846.09","G":"**"},{"Policy Line":"64134992","B":"Device Myosure XL 50-503XL","C":"272","F":"1481.346","G":"**"},{"Policy Line":"64134993","B":"Matrix Micro 500MG MM0500","C":"278","D":"Q4118","F":"1666.782","G":"**"},{"Policy Line":"64134994","B":"Kit Interphalangeal","C":"272","F":"420.75"},{"Policy Line":"64134995","B":"Human Bone Mimetic, Etex","C":"278","D":"C1713","F":"1991.754"},{"Policy Line":"64134996","B":"Patch,Amniotic 4x4","C":"278","D":"V2790","F":"1836.918"},{"Policy Line":"64134997","B":"Patch,Amniotic 2x2 CYGNUS","C":"278","D":"Q4170","F":"1462.986"},{"Policy Line":"64134998","B":"KIT SM JOINT TAK AR-89434DSC","C":"272","F":"317.934","G":"**"},{"Policy Line":"64134999","B":"Amniotic/Human Tissue Matrix","C":"278","F":"1947.69"},{"Policy Line":"64135083","B":"Tray Lumbar Punc 20X31/2 4301C","C":"272","F":"16.524","G":"**"},{"Policy Line":"64135500","B":"Fibertak Kit","C":"278","D":"C1713","F":"426.564","G":"**"},{"Policy Line":"64135501","B":"Matristem Wnd MatrixPlus 10x10","C":"278","F":"2620.278"},{"Policy Line":"64135502","B":"Kit Template /w K-Wires M225","C":"272","F":"291.006"},{"Policy Line":"64135503","B":"Generator, VNS AspireSR","C":"278","D":"C1767","F":"24356.07"},{"Policy Line":"64135504","B":"Lead, VNS PerennialFlex","C":"278","D":"C1778","F":"5945.886"},{"Policy Line":"64135505","B":"Tunneler for VNS","C":"272","F":"594.558"},{"Policy Line":"64135506","B":"Kit for Tenfuse PIP Fusion","C":"272","F":"670.752","G":"**"},{"Policy Line":"64135507","B":"Patch,Amniotic 2x3","C":"278","F":"1683.306","G":"**"},{"Policy Line":"64135508","B":"Epifix 7x7CM GS-5770","C":"278","D":"Q4186","F":"9428.778","G":"**"},{"Policy Line":"64135509","B":"Protector Nerve 3x40MM AG0340","C":"278","F":"2706.57","G":"**"},{"Policy Line":"64135510","B":"Gen Neurostim Gastric Enterra","C":"278","D":"C1767","F":"8825.346","G":"**"},{"Policy Line":"64135511","B":"Lead Neurostim Enterra 4351","C":"278","D":"C1778","F":"2815.2","G":"**"},{"Policy Line":"64135512","B":"PaliGen Flow 1.00ML PF-010100","C":"278","D":"Q4100","F":"2802.348"},{"Policy Line":"64135513","B":"Matristem Wnd Matrix Pls 10x15","C":"278","F":"3930.264"},{"Policy Line":"64135514","B":"Implant Humeral Stem Elbow","C":"278","D":"C1776","F":"7635.312"},{"Policy Line":"64135515","B":"Cement, Otomimix 2gm","C":"278","F":"511.632","G":"**"},{"Policy Line":"64135516","B":"Tacker, Hernia Fixtn Grp 1","C":"278","F":"499.392","G":"**"},{"Policy Line":"64135517","B":"Tacker, Hernia Fixtn Grp 2","C":"278","F":"717.876","G":"**"},{"Policy Line":"64135518","B":"Abutment BAHA, Aud Device Comp","C":"278","D":"L8690","F":"2361.096","G":"**"},{"Policy Line":"64135519","B":"Sizer Mammary Grp 3","C":"272","F":"624.24"},{"Policy Line":"64135520","B":"Cable, Interstim","C":"272","F":"156.06","G":"**"},{"Policy Line":"64135521","B":"Neurostim Extrnl, Sacrl","C":"272","F":"636.786","G":"**"},{"Policy Line":"64135522","B":"Implant Cochlear CI522 Z382660","C":"278","D":"L8614","F":"12889.944"},{"Policy Line":"64135523","B":"Amniotic Inject Allogen .25ML","C":"278","F":"1913.418"},{"Policy Line":"64135524","B":"AllogrftFlexHD Pliable 6x16cm","C":"278","F":"3762.27"},{"Policy Line":"64135526","B":"Expander Tissue UHP","C":"278","F":"2661.894"},{"Policy Line":"64135527","B":"SLIC Screw Prep Pack","C":"272","F":"1168.308"},{"Policy Line":"64135528","B":"KIT Insert Suprapubic","C":"272","D":"C1769","F":"171.666","G":"**"},{"Policy Line":"64135529","B":"Cannula, Airway L-T","C":"272","F":"184.518"},{"Policy Line":"64135530","B":"Mesh Hernia Phasix","C":"278","D":"C1781","F":"6872.454"},{"Policy Line":"64135531","B":"ABUTMENT BAHA 8.5MM","C":"278","D":"L8690","F":"2096.1"},{"Policy Line":"64135532","B":"BAHA DRILLS","C":"278","F":"304.47","G":"**"},{"Policy Line":"64135533","B":"IMPLANT /C ABUTMENTBAHA","C":"278","D":"L8690","F":"2916.792"},{"Policy Line":"64135534","B":"BAHA IMPLANT GRP 1","C":"278","D":"L8690","F":"1785.204","G":"**"},{"Policy Line":"64135535","B":"CATH BALLOON, DIL-SINUS Grp 1","C":"272","D":"C1726","F":"614.448"},{"Policy Line":"64135536","B":"CATH BALLOON, DIL-SINUS Grp 2","C":"272","D":"C1726","F":"780.3"},{"Policy Line":"64135537","B":"MATRISTEM WND MATRIX PSM 4X12","C":"278","F":"1187.892"},{"Policy Line":"64135538","B":"MESH PHASIX 4X6 1190200","C":"278","D":"C1781","F":"2655.468","G":"**"},{"Policy Line":"64135539","B":"MESH PHASIX 10X12 1190500","C":"278","D":"C1781","F":"10296.288","G":"**"},{"Policy Line":"64135540","B":"ALLOGEN .50ML PO1-AMF-0050","C":"278","F":"2623.338"},{"Policy Line":"64135541","B":"DermaSpan Meshed ACD 4X4","C":"278","F":"1919.538"},{"Policy Line":"64135542","B":"KIT UCL SUTURE PASSER","C":"272","F":"1270.512"},{"Policy Line":"64135543","B":"IMPLANT MAGNET BAHA BIM400","C":"278","D":"L8690","F":"2649.042","G":"**"},{"Policy Line":"64135544","B":"PROCESSOR SOUND BAHA 5","C":"278","D":"L8690","F":"3496.968","G":"**"},{"Policy Line":"64135545","B":"KIT MAGNET BAHA FUZ1078","C":"272","F":"264.996"},{"Policy Line":"64135546","B":"Mesh,Ventralight w/Echo PS4X6","C":"278","D":"C1781","F":"717.876"},{"Policy Line":"64135547","B":"Device Lap Suture Ti Knot","C":"272","F":"358.326"},{"Policy Line":"64135548","B":"TUBE GI GRP 3","C":"272","F":"202.878","G":"**"},{"Policy Line":"64135549","B":"Mesh, Hernia Ventralight 10x13","C":"278","D":"C1781","F":"2902.716","G":"**"},{"Policy Line":"64135550","B":"Tissue Expander Grp 3","C":"278","D":"C1789","F":"2684.232","G":"**"},{"Policy Line":"64135551","B":"Bio-Connekt Wnd Matrix 5x5cm","C":"278","D":"Q4161","F":"1151.784"},{"Policy Line":"64135552","B":"MESH PHASIX ST 6X8 1201520","C":"278","D":"C1781","F":"5239.332"},{"Policy Line":"64135553","B":"HYALOMATRIX, WOUND 5X5CM","C":"278","D":"Q4117","F":"426.564"},{"Policy Line":"64135554","B":"DermaSpan Meshed ACD 5X5","C":"278","F":"1919.538"},{"Policy Line":"64135555","B":"MESH PHASIX 4X4 1201010","C":"278","D":"C1781","F":"2482.578"},{"Policy Line":"64135556","B":"Reform Capsular Tension Ring","C":"278","F":"316.404","G":"**"},{"Policy Line":"64135557","B":"Graft Nerve Avance","C":"278","F":"5198.634","G":"**"},{"Policy Line":"64135558","B":"Protector Nerve AG0540","C":"278","F":"2783.07","G":"**"},{"Policy Line":"64135559","B":"Pacemaker- Dual RR DR GRP A","C":"275","D":"C1785","F":"4057.56"},{"Policy Line":"64135560","B":"Reamer , Crosstie 2.2-2.5","C":"272","F":"159.12","G":"**"},{"Policy Line":"64135561","B":"Alloderm Small Perf 77sqcm","C":"278","D":"Q4116","F":"3047.454"},{"Policy Line":"64135562","B":"COUNTERSINK X POST 118-02077","C":"272","F":"542.844"},{"Policy Line":"64135563","B":"INTERNAL FIXATN POST X MED","C":"278","D":"C1713","F":"2806.326"},{"Policy Line":"64135564","B":"Strattice 6X13cm 0613009","C":"278","D":"Q4130","F":"1995.12"},{"Policy Line":"64135565","B":"Reform Capsular Tension Ring","C":"278","F":"313.65"},{"Policy Line":"64135566","B":"BLADE DISPOSABLE GRP 4","C":"272","F":"624.24","G":"**"},{"Policy Line":"64135567","B":"BLADE DISPOSABLE GRP 5","C":"272","F":"895.662","G":"**"},{"Policy Line":"64135568","B":"BLADE SHAVER iO","C":"272","F":"1988.694"},{"Policy Line":"64135570","B":"IMPLNT-ASSEMBLY TOTAL ELBOW","C":"278","D":"C1776","F":"4564.908"},{"Policy Line":"64135571","B":"Trach System, Scoop Proc","C":"272","F":"380.358"},{"Policy Line":"64135572","B":"Implant Uro System-Urolift","C":"278","D":"L8699","F":"1118.43","G":"**"},{"Policy Line":"64135573","B":"Bony Void Filler Grp 8","C":"278","D":"C1713","F":"3277.26","G":"**"},{"Policy Line":"64135574","B":"Bag, Lap Retrieval Grp1","C":"272","F":"73.746","G":"**"},{"Policy Line":"64135575","B":"Bag, Lap Retrieval Grp2","C":"272","F":"159.12","G":"**"},{"Policy Line":"64135576","B":"Resorb Mrkr Imp-Biozorb; ea","C":"278","D":"A4648","F":"1599.768"},{"Policy Line":"64135577","B":"Rod Spacer, Tendon","C":"278","F":"2293.164"},{"Policy Line":"64135578","B":"Central Venous Cath Group 1A","C":"272","D":"C1751","F":"184.212"},{"Policy Line":"64135579","B":"External Fixator Cmpnts Grp 5","C":"272","F":"2059.992","G":"**"},{"Policy Line":"64135580","B":"External Fixator Cmpnts Grp 6","C":"272","F":"2372.112"},{"Policy Line":"64135581","B":"Implant Joint Grp 15","C":"278","D":"C1776","F":"6304.824","G":"**"},{"Policy Line":"64135582","B":"SPACER, HYDROGEL-SPACEOAR","C":"278","F":"2891.088","G":"**"},{"Policy Line":"64135583","B":"Suture-Arrow Kissloc","C":"278","F":"959.922"},{"Policy Line":"64135584","B":"Fixatn Plate Package-Arrow","C":"278","F":"398.106"},{"Policy Line":"64135585","B":"ALGRFT MEMB AMNIOTC 200MU4X8CM","C":"278","F":"4052.664"},{"Policy Line":"64135586","B":"Sleeve Guide for PLATE P51-950","C":"272","F":"709.002"},{"Policy Line":"64135587","B":"Chisel Bone Fenes P99-150-0035","C":"272","F":"422.586"},{"Policy Line":"64135588","B":"Prosthesis Testicular 450-1329","C":"278","F":"2365.992"},{"Policy Line":"64135590","B":"Tube Biliary 27-260","C":"272","D":"C1729","F":"159.732"},{"Policy Line":"64135591","B":"Cord, Amniotic 2x3 Thick","C":"278","D":"Q4100","F":"2197.998","G":"**"},{"Policy Line":"64135592","B":"Kit-PEEK Tunnel Button Implant","C":"278","D":"C1713","F":"1429.632"},{"Policy Line":"64135593","B":"Kit Elbow, Humeral Screws","C":"278","D":"C1713","F":"381.888","G":"**"},{"Policy Line":"64135594","B":"Kit Elbow, Articulation Size4","C":"278","D":"C1776","F":"1190.034"},{"Policy Line":"64135595","B":"T.Elbow, Comp Humeral PlasmaSp","C":"278","D":"C1776","F":"5071.95"},{"Policy Line":"64135596","B":"T.Elbow, Comp Ulnar PlasmaSp","C":"278","D":"C1776","F":"4564.908"},{"Policy Line":"64135597","B":"Implant Cochlear CI512 Z209051","C":"278","F":"12889.944"},{"Policy Line":"64135598","B":"STAPLER SEPTAL, ENT 601-00100","C":"272","F":"270.504","G":"**"},{"Policy Line":"64135599","B":"DiltnSys-EustachnTube EU061655","C":"272","D":"C1726","F":"1279.692","G":"**"},{"Policy Line":"64135600","B":"Patch,Amniotic 3x4","C":"278","F":"2735.028"},{"Policy Line":"64135601","B":"Kit Pleurx Pat Starter 50-0071","C":"278","F":"455.328","G":"**"},{"Policy Line":"64135602","B":"VPULSE W/COMPRESSION PD C00002","C":"272","F":"388.314","G":"**"},{"Policy Line":"64135603","B":"ALGRFT BONE SCAFFOLD 2.5CC VIA","C":"278","F":"2162.808"},{"Policy Line":"64135605","B":"Patch,Amniotic 2X3 CAM0203","C":"272","F":"2725.848"},{"Policy Line":"64135606","B":"CrossTie Allograft","C":"278","F":"1913.418"},{"Policy Line":"64135607","B":"GRAFT NERVE AVANCE 111250","C":"278","F":"3499.722"},{"Policy Line":"64135608","B":"ALGRFT BONE SCAFFOLD 5CC VIAGR","C":"278","F":"2637.414"},{"Policy Line":"64135609","B":"Allogen 0.5ml Inj Amnion","C":"278","F":"1471.554"},{"Policy Line":"64135610","B":"Allogen 0.25 ml Inj Amnion","C":"278","F":"1151.784"},{"Policy Line":"64135611","B":"Drill Bit/Sonianchor","C":"272","F":"703.8"},{"Policy Line":"64135612","B":"Kit Suture Anchor Sonianchor","C":"278","D":"C1713","F":"739.602"},{"Policy Line":"64135613","B":"IMPL Mesh Phasix 3x4","C":"278","D":"C1781","F":"1823.76","G":"**"},{"Policy Line":"64135614","B":"Allograft PIP 2.8mm","C":"278","F":"2042.55"},{"Policy Line":"64135615","B":"DBM Morsellized Matrix 1cc","C":"278","F":"727.056"},{"Policy Line":"64135616","B":"Reamer 12,15,16mm","C":"272","F":"1113.228","G":"**"},{"Policy Line":"64135617","B":"Plate Fusion Ankle 5920601L","C":"278","D":"C1713","F":"3163.122"},{"Policy Line":"64135618","B":"Rod Grp 7","C":"278","D":"C1713","F":"2059.992","G":"**"},{"Policy Line":"64135619","B":"Drill Bit 1.4x70mm","C":"272","F":"222.768"},{"Policy Line":"64135620","B":"PLANER BONE 8MM","C":"278","F":"375.768","G":"**"},{"Policy Line":"64135621","B":"Plt Rib Biobridge Resorb","C":"278","D":"C1713","F":"1410.354"},{"Policy Line":"64135622","B":"Barrier Avive 2x4CM CA0204","C":"278","F":"2661.894","G":"**"},{"Policy Line":"64135623","B":"Barrier Avive 3x4CM CA0304","C":"278","F":"3043.17","G":"**"},{"Policy Line":"64135624","B":"IMPLANT MTP TOE Polyvinyl","C":"278","D":"C1776","F":"3651.804","G":"**"},{"Policy Line":"64135625","B":"ALGRFT AMNIO MEMB Revita 2x2cm","C":"278","F":"1247.868"},{"Policy Line":"64135627","B":"Algrft Memb Amnio-Revita 2x2cm","C":"278","F":"1247.868"},{"Policy Line":"64135628","B":"GAUGE DEPTH IOL CL1","C":"278","F":"557.226"},{"Policy Line":"64135629","B":"Matrix, Dermal-Dermaspan 4x8","C":"278","D":"Q4126","F":"3388.032"},{"Policy Line":"64135630","B":"Allograft Amniotic 1ml Rheo","C":"278","F":"2879.46","G":"**"},{"Policy Line":"64135631","B":"Pin Fixation/Temp GR2","C":"272","F":"205.326","G":"**"},{"Policy Line":"64135632","B":"Arthroflex Allograft 35x35mm","C":"278","D":"Q4125","F":"2409.75"},{"Policy Line":"64135633","B":"\"MESH PHASIX 6\"\" ROUND 1200015\"","C":"278","D":"C1781","F":"3651.804","G":"**"},{"Policy Line":"64135634","B":"LENS PRESBY-C FNCTN -SND","C":"276","D":"V2788","F":"310.59"},{"Policy Line":"64135635","B":"Passer Suture REV FG0008","C":"272","F":"316.71"},{"Policy Line":"64135636","B":"Graft Porcine, Oto 0.4x0.6cm","C":"278","D":"C1763","F":"215.118","G":"**"},{"Policy Line":"64135637","B":"Graft ENT-TRG-2X3CM","C":"278","D":"C1763","F":"348.534","G":"**"},{"Policy Line":"64135638","B":"Implant Staple Kit-NeoSpan","C":"278","D":"C1713","F":"2182.698"},{"Policy Line":"64135639","B":"Amniofill 500MG AF-0500","C":"278","F":"1471.554","G":"**"},{"Policy Line":"64135640","B":"Graft Porcine, Oto 0.6x0.9cm","C":"278","D":"C1763","F":"294.678","G":"**"},{"Policy Line":"64135641","B":"Algrf Amnio Wet-Palingen 2x6cm","C":"278","D":"Q4173","F":"2149.956"},{"Policy Line":"64135642","B":"Algraft Vendajae 200-008-0204","C":"278","F":"2399.652"},{"Policy Line":"64135644","B":"Implant Tarsi Stent, Size 6,7","C":"278","F":"2047.446","G":"**"},{"Policy Line":"64135645","B":"Algrf Amnio Wet-Palingen 2x4cm","C":"278","D":"Q4173","F":"2399.652"},{"Policy Line":"64135646","B":"ALLOGEN 1.00ML PO1-AMF-0100","C":"278","F":"2994.516","G":"**"},{"Policy Line":"64135647","B":"Prosth Penile Pump Assy Titan","C":"278","D":"C1813","F":"4605.3"},{"Policy Line":"64135648","B":"Kit Biocomposite AR-8928BCJ-CP","C":"278","D":"C1713","F":"2891.088","G":"**"},{"Policy Line":"64135649","B":"Amniotic Placenta Mem 4x4","C":"278","D":"Q4100","F":"2037.96"},{"Policy Line":"64135650","B":"Bone Staple P71-010-1010-S","C":"278","D":"C1713","F":"2247.264","G":"**"},{"Policy Line":"64135651","B":"Cellerate Powder 5gram","C":"272","F":"1913.418"},{"Policy Line":"64135652","B":"KIT COCHLR DUL PROCESSR DUALN7","C":"278","D":"L8614","F":"14680.35"},{"Policy Line":"64135653","B":"Allograft Cellentra 1cc","C":"278","F":"644.742"},{"Policy Line":"64135654","B":"Putty DBM Stagraft 2cc","C":"278","F":"700.434"},{"Policy Line":"64135655","B":"Kit EPFXPRESS ENDOTRAC 3100-D","C":"272","F":"844.56","G":"**"},{"Policy Line":"64135656","B":"ALLODERM LG 164sqcm CL1518P","C":"278","D":"Q4116","F":"5920.488"},{"Policy Line":"64135657","B":"ALLODERM 199.5sqcm CXL1518P","C":"278","D":"Q4116","F":"5729.238","G":"**"},{"Policy Line":"64135658","B":"IMPL Sophono ALPHA2 MPO E++","C":"278","F":"4153.95"},{"Policy Line":"64135659","B":"Kit Implant Sterile, Sophono","C":"278","D":"L8690","F":"2943.414"},{"Policy Line":"64135660","B":"NS Generator, Inspire IV 3028","C":"278","D":"C1767","F":"17346.222","G":"**"},{"Policy Line":"64135661","B":"NS Lead Stimulation 4063","C":"278","D":"C1778","F":"1978.29","G":"**"},{"Policy Line":"64135662","B":"NS Lead Resp Pressr Sens 4323","C":"278","D":"C1778","F":"3093.966","G":"**"},{"Policy Line":"64135663","B":"Remote Sleep Inspire IPG 2500N","C":"272","D":"C1787","F":"1791.63","G":"**"},{"Policy Line":"64135664","B":"Impl Kit StapleInstaFix10x10mm","C":"278","D":"C1713","F":"1542.24"},{"Policy Line":"64135665","B":"InstaFix Accessory Kit 2.0mm","C":"272","F":"692.478"},{"Policy Line":"64135666","B":"Balloon Postpartum-Rapid Instl","C":"272","F":"361.386"},{"Policy Line":"64135667","B":"LEAD PM Tendril MRI","C":"275","D":"C1898","F":"604.962","G":"**"},{"Policy Line":"64135668","B":"PM DRR Gen Assurity MRI","C":"275","D":"C1785","F":"3854.682","G":"**"},{"Policy Line":"64135669","B":"IMPL Button, Biceps","C":"278","D":"C1713","F":"469.71"},{"Policy Line":"64135670","B":"Shunt Glaucoma CYPASS System","C":"278","D":"C1783","F":"2111.4"},{"Policy Line":"64135671","B":"Expander, Tissue Aerofoam 60cc","C":"278","D":"C1789","F":"3123.648"},{"Policy Line":"64135672","B":"Controller Dosage Aeroform","C":"272","F":"555.696"},{"Policy Line":"64135673","B":"AlgrfAmniWet-PalngnXPLUS 2x6cm","C":"278","D":"Q4173","F":"2399.652"},{"Policy Line":"64135674","B":"Epicord 3.0 x 5.0cm","C":"278","D":"Q4187","F":"3169.854","G":"**"},{"Policy Line":"64135675","B":"EpiFix Particulate 100.0mg Inj","C":"278","D":"Q4145","F":"2342.43","G":"**"},{"Policy Line":"64135676","B":"ALLODERM LG 164sqcm CL1519","C":"278","D":"Q4116","F":"4838.472"},{"Policy Line":"64135677","B":"Bit Drill Cannulated 2.7mm","C":"272","F":"986.544","G":"**"},{"Policy Line":"64135678","B":"AmnioFix 4X4cm APS-5440","C":"278","F":"1792.242"},{"Policy Line":"64135679","B":"AmnioFix 6X16cm APS-5616","C":"278","F":"3480.75"},{"Policy Line":"64135680","B":"Hemostat Bone Resorbable HQ6","C":"278","F":"477.666"},{"Policy Line":"64135681","B":"Epifix 4x6 GS-5460","C":"278","D":"Q4186","F":"3854.682","G":"**"},{"Policy Line":"64135682","B":"ALLOGEN 2.00ML P01-AMF-0200","C":"278","F":"2975.544"},{"Policy Line":"64135683","B":"Allogen FZ Liquid XL 2.0ml","C":"278","F":"3853.764"},{"Policy Line":"64135684","B":"Impl HammerTube Sys 3.50x16mm","C":"278","D":"C1713","F":"2197.998","G":"**"},{"Policy Line":"64135685","B":"Syst Endoblade Gastroc Recess","C":"272","F":"1123.02","G":"**"},{"Policy Line":"64135686","B":"TYRX Neuro Absorb Antibac Env","C":"278","F":"1248.48","G":"**"},{"Policy Line":"64135687","B":"Allgrft Amnio Biovance 2x2CM","C":"278","D":"Q4154","F":"752.76"},{"Policy Line":"64135688","B":"Putty Bone Montage 5cc","C":"278","F":"2503.08","G":"**"},{"Policy Line":"64135689","B":"Implant Mandible SD449.510B","C":"278","D":"C1776","F":"7014.132"},{"Policy Line":"64135690","B":"Kit Mandible Reconst SD900.001","C":"278","F":"4784.616"},{"Policy Line":"64135691","B":"Impl Staple DynaNite 13Wx10L","C":"278","D":"C1713","F":"2377.62"},{"Policy Line":"64135692","B":"SET DUAFIT DISP INSTR A0610401","C":"272","F":"1373.94"},{"Policy Line":"64135693","B":"Prosthesis Voice","C":"272","F":"585.378"},{"Policy Line":"64135694","B":"Kit Fusion Motoband","C":"272","F":"998.478","G":"**"},{"Policy Line":"64135695","B":"Graft Jacket 5X5 8600-5X05","C":"278","D":"Q4107","F":"2822.85"},{"Policy Line":"64135697","B":"HANDPIECE TENJET 76000","C":"272","F":"878.22"},{"Policy Line":"64135698","B":"ALLODERM 199.5sqcm CXL1518","C":"278","D":"Q4116","F":"9254.97","G":"**"},{"Policy Line":"64135699","B":"Putty DBM Stagraft Plus","C":"278","F":"1425.348"},{"Policy Line":"64135700","B":"NUCEL .5CC NC-1000","C":"278","F":"829.566","G":"**"},{"Policy Line":"64135701","B":"NuShield 1.6sq cm NO-1160c","C":"278","F":"444.924","G":"**"},{"Policy Line":"64135702","B":"NuShield 2x4sq cm NO-1240","C":"278","F":"1110.474","G":"**"},{"Policy Line":"64135703","B":"NUCEL MEDIUM NC-1001","C":"278","F":"2258.28","G":"**"},{"Policy Line":"64135704","B":"CT LUCIA 602 ++20.5D","C":"276","D":"V2632","F":"273.258"},{"Policy Line":"64135705","B":"Amniofix 16.0mm Disc APS-5160","C":"278","F":"523.566"},{"Policy Line":"64135706","B":"Composite Layer Helx ABS-4050","C":"272","F":"87.21","G":"**"},{"Policy Line":"64135707","B":"SLED MEDIAL 42mm MMSLED-42","C":"278","F":"909.738"},{"Policy Line":"64135708","B":"KIT PRP GENIUS 30ML G20030","C":"272","F":"2697.39","G":"**"},{"Policy Line":"64135709","B":"Reamer Disp 10.5 AR-1410LP-50","C":"272","F":"304.47","G":"**"},{"Policy Line":"64135710","B":"Shunt Pleural Peri 42-9000","C":"278","F":"1835.388"},{"Policy Line":"64135711","B":"Shunt Pleural 42-2020","C":"278","F":"2571.93"},{"Policy Line":"64135712","B":"Impl HammerTube Sys 2.75x14mm","C":"278","D":"C1713","F":"1545.606","G":"**"},{"Policy Line":"64135713","B":"VersaWrap Protector Tendon 2x2","C":"272","F":"2754","G":"**"},{"Policy Line":"64135714","B":"Matrix, Dermal-Dermaspan 4x8","C":"278","D":"Q4126","F":"3490.848"},{"Policy Line":"64135715","B":"Scissor Hyp Disp HYP-ST-DS","C":"272","F":"201.348"},{"Policy Line":"64135716","B":"AmnioFill 2000mg AF-2000","C":"272","F":"4176.9","G":"**"},{"Policy Line":"64135717","B":"NUCEL 2cc NC-1002","C":"278","F":"3182.4","G":"**"},{"Policy Line":"64135718","B":"Kit Interstim Smart TH90G01","C":"272","F":"2446.47","G":"**"},{"Policy Line":"64135719","B":"Device Colpassist 831821","C":"272","F":"656.676","G":"**"},{"Policy Line":"64135720","B":"Imp Sys Lig Deltoid Reconstr","C":"278","D":"C1713","F":"2452.896"},{"Policy Line":"64135721","B":"Impl Staple DynaNite 11Wx10L","C":"278","D":"C1713","F":"1875.78"},{"Policy Line":"64135722","B":"Alloderm CM1516","C":"278","D":"Q4116","F":"3817.962","G":"**"},{"Policy Line":"64135723","B":"Implant Medpor Titan 81032","C":"278","F":"1612.62","G":"**"},{"Policy Line":"64135724","B":"Tissue Patch Cornea GPC-W","C":"278","F":"421.362","G":"**"},{"Policy Line":"64135725","B":"Implant Latera LATSYS","C":"278","F":"1248.48","G":"**"},{"Policy Line":"64135726","B":"Sys Hammertoe Fixation","C":"278","D":"C1713","F":"1499.4","G":"**"},{"Policy Line":"64135727","B":"Alloderm Thick16x20cm 1519320","C":"278","D":"Q4116","F":"9259.866","G":"**"},{"Policy Line":"64135728","B":"INnate Implant 3.6mmx50mm","C":"278","D":"C1713","F":"909.738","G":"**"},{"Policy Line":"64135729","B":"INnate Instrument Kit 4.5mm","C":"272","F":"390.15","G":"**"},{"Policy Line":"64135730","B":"Alloderm Contour XL CXL1519P","C":"278","D":"Q4116","F":"5960.88","G":"**"},{"Policy Line":"64135731","B":"Alloderm Contour Large CL1516","C":"278","D":"Q4116","F":"4743.918","G":"**"},{"Policy Line":"64135732","B":"Matrix Wound PURAPLY 2x2","C":"278","D":"Q4196","F":"940.95","G":"**"},{"Policy Line":"64135733","B":"System Scout Multi Sinus","C":"272","F":"2446.47","G":"**"},{"Policy Line":"64135734","B":"Kit Instr AXI++LINE","C":"272","F":"292.536","G":"**"},{"Policy Line":"64135735","B":"BARRIER AVIVE 3X6CM CA0306","C":"278","F":"3754.314","G":"**"},{"Policy Line":"64135736","B":"GuideWire DigiFuse DW-2590","C":"272","F":"1605.888","G":"**"},{"Policy Line":"64135737","B":"CABLE NAVG TRUDI TDNC001","C":"272","F":"346.392","G":"**"},{"Policy Line":"64135738","B":"TheraSkin XLR 104TSXLR","C":"278","D":"Q4121","F":"3079.89","G":"**"},{"Policy Line":"64135739","B":"VIA Form Moldable, 2.5cc","C":"278","F":"2070.09","G":"**"},{"Policy Line":"64135740","B":"Tissue FlexHD 11x20 SF2002","C":"278","D":"Q4128","F":"3483.504","G":"**"},{"Policy Line":"64135742","B":"Allgrft Amnio Biovance 2x4CM","C":"278","D":"Q4154","F":"2822.85","G":"**"},{"Policy Line":"64135743","B":"Matrix Amnion Patch 4x6","C":"272","F":"2227.068","G":"**"},{"Policy Line":"64135744","B":"Instr Kit Cartiva 10mm MTK-10","C":"272","F":"702.27","G":"**"},{"Policy Line":"64135745","B":"Prosthesis Penile Tactra 11x16","C":"278","D":"C2622","F":"11431.854","G":"**"},{"Policy Line":"64135746","B":"H50 Ablator Aspiration AR-9835","C":"272","F":"310.59","G":"**"},{"Policy Line":"64135747","B":"ALLODERM LG 164sqcm CL1518","C":"278","D":"Q4116","F":"4743.918","G":"**"},{"Policy Line":"64135748","B":"ALLODERM 320sqcm 1518320","C":"278","D":"Q4116","F":"9259.866","G":"**"},{"Policy Line":"64135749","B":"Endoblade System AR-8850DC","C":"272","F":"752.76","G":"**"},{"Policy Line":"64135750","B":"Kit Instrument TH00001","C":"272","F":"390.15","G":"**"},{"Policy Line":"64135751","B":"Zone Navigator AR-7900","C":"272","F":"390.15","G":"**"},{"Policy Line":"64135752","B":"Anterior Cann Zone Nav AR-7905","C":"272","F":"234.09","G":"**"},{"Policy Line":"64135753","B":"Lt Can Mid ZN Navigtr AR-7910L","C":"272","F":"234.09","G":"**"},{"Policy Line":"64135754","B":"Allgrft Amnio Biovance 3x5CM","C":"278","D":"Q4154","F":"1460.232","G":"**"},{"Policy Line":"64135755","B":"Kit Instr STRM-1MPJ-INST-KT","C":"272","F":"661.572","G":"**"},{"Policy Line":"64135756","B":"Kit Tenodesis Graft Sizing","C":"272","F":"460.53","G":"**"},{"Policy Line":"64135757","B":"INBONE Alignment Guide PROPINB","C":"272","F":"1633.428","G":"**"},{"Policy Line":"64135758","B":"Plate Strl Instr Kit 1500-4700","C":"272","F":"622.71","G":"**"},{"Policy Line":"64135759","B":"INBONE Screw Bone Remover","C":"272","F":"257.652","G":"**"},{"Policy Line":"64135760","B":"PuraPlyAM-COM 5x5","C":"278","D":"Q4196","F":"2735.028","G":"**"},{"Policy Line":"64135761","B":"PuraForce 6x3cm 550-004","C":"272","F":"2258.28","G":"**"},{"Policy Line":"64135762","B":"Instr Kit Cartiva 8mm MTK-08","C":"272","F":"702.27","G":"**"},{"Policy Line":"64135763","B":"Alloderm Lg Perforated CL1519P","C":"278","D":"Q4116","F":"4884.984","G":"**"},{"Policy Line":"64135764","B":"Mesh Ovine Poly Perm 10x20cm","C":"278","D":"C1781","F":"4375.8","G":"**"},{"Policy Line":"64135765","B":"PuraForce 6x2cm 550-002","C":"278","F":"1621.8","G":"**"},{"Policy Line":"64135766","B":"PuraForce 8x4cm 550-002","C":"278","F":"2822.85","G":"**"},{"Policy Line":"64135767","B":"TheraSkin 2x3 102TSL","C":"278","D":"Q4121","F":"1526.94","G":"**"},{"Policy Line":"64135768","B":"Neurostimulator Axonics 1101","C":"278","D":"C1820","F":"10144.818","G":"**"},{"Policy Line":"64135769","B":"Remote Control Axonics 2301","C":"278","D":"C1787","F":"1004.904","G":"**"},{"Policy Line":"64135770","B":"Lead Impl Kit Axonics 1801","C":"278","D":"C1894","F":"511.938","G":"**"},{"Policy Line":"64135771","B":"Charging Sys Axonics 1401","C":"278","D":"C1820","F":"1072.836","G":"**"},{"Policy Line":"64136128","B":"Vein Femoral Cryolife V060","C":"278","F":"6593.688"},{"Policy Line":"64136162","B":"Navigus Kit External 9730848","C":"272","F":"1503.684","G":"**"},{"Policy Line":"64136172","B":"Charging System Stim 37752","C":"272","F":"3058.47"},{"Policy Line":"64136175","B":"Antenna Dorsal Stimulat 37092","C":"272","F":"154.836"},{"Policy Line":"64136183","B":"Lead Quattro Sprint 6944-65","C":"278","F":"4870.296"},{"Policy Line":"64136196","B":"Plug Small Bone 6215-5-001","C":"278","F":"134.946","G":"**"},{"Policy Line":"64136220","B":"Tube Humerus T2 1806-0073S","C":"278","F":"329.868","G":"**"},{"Policy Line":"64136259","B":"Stent Graft Endoprosthesis","C":"278","F":"4854.384","G":"**"},{"Policy Line":"64136279","B":"Valve Delta 42824","C":"278","F":"1597.932"},{"Policy Line":"64136280","B":"Valve Delta 42822","C":"278","F":"1590.894"},{"Policy Line":"64136291","B":"Remote Patient Sc-5500-02","C":"272","F":"837.522"},{"Policy Line":"64136292","B":"Generator Pulse Sc-1110","C":"278","D":"C1820","F":"13716.756"},{"Policy Line":"64136293","B":"Charger Patient Sc-6400-02","C":"272","F":"3113.55"},{"Policy Line":"64136295","B":"Kit Patient Trial Sc-6500-02","C":"272","F":"186.66"},{"Policy Line":"64136296","B":"Stylet Enhance 70Cm Sc-4395-70","C":"272","F":"231.03","G":"**"},{"Policy Line":"64136301","B":"Accudrain Csf System Ins-8401","C":"272","F":"405.756","G":"**"},{"Policy Line":"64136302","B":"Cath Ventricular 951-303","C":"272","F":"283.356","G":"**"},{"Policy Line":"64136309","B":"Implant Medpore Micro Plate","C":"278","F":"732.258"},{"Policy Line":"64136312","B":"Stylet Enhanced Sc-4395-50Cm","C":"272","F":"231.03"},{"Policy Line":"64136325","B":"Loop 25Mm Gooseneck Gn2500","C":"272","D":"C1773","F":"509.49","G":"**"},{"Policy Line":"64136338","B":"Plug Port","C":"272","F":"95.778"},{"Policy Line":"64136339","B":"Wrench -Pacer/Neurostim","C":"272","F":"88.128","G":"**"},{"Policy Line":"64136346","B":"Bone Spike 71512450","C":"272","F":"83.844"},{"Policy Line":"64136360","B":"Set Blood Pump 36/42 05050036H","C":"272","F":"18055.224"},{"Policy Line":"64136368","B":"Compressor Open 395.51","C":"278","F":"577.728"},{"Policy Line":"64136377","B":"Valve Holter Med 82-1601","C":"272","F":"437.886"},{"Policy Line":"64136379","B":"Reservoir Nl850-1211","C":"272","F":"553.554"},{"Policy Line":"64136382","B":"Allograft Osteochond Foa30C","C":"278","F":"10043.532"},{"Policy Line":"64136408","B":"Reservoir Csf Nl850","C":"278","F":"512.55"},{"Policy Line":"64136420","B":"Synchro Med Ii Pt Mgr 8832","C":"278","D":"C1772","F":"2900.574"},{"Policy Line":"64136441","B":"Pyramesh 10Mm 905-902","C":"278","F":"7488.738"},{"Policy Line":"64136443","B":"Kit Tool Rotation 6056","C":"272","F":"52.938"},{"Policy Line":"64136444","B":"Mesh Panel Small Neuro 01-7182","C":"278","F":"1314.27","G":"**"},{"Policy Line":"64136451","B":"Module Neurovision Grp 1","C":"272","F":"1151.784","G":"**"},{"Policy Line":"64136453","B":"Fiberloop # 2 Ar-7234","C":"272","F":"193.392"},{"Policy Line":"64136454","B":"System Charging Sc-6412","C":"278","F":"2141.388"},{"Policy Line":"64136470","B":"Defibrillator Dual V-268","C":"278","F":"23658.696"},{"Policy Line":"64136476","B":"Crosslink Bar 6902530","C":"278","F":"170.442"},{"Policy Line":"64136485","B":"Defib Dr-Virtuoso D154Awg","C":"278","D":"C1721","F":"22279.86"},{"Policy Line":"64136490","B":"Cath Suprapubic 12Fr Ac01A","C":"272","F":"309.06"},{"Policy Line":"64136491","B":"Tip Driver 2.5Mm Hpc-0025","C":"272","F":"281.826"},{"Policy Line":"64136503","B":"Clip Stimulation","C":"272","F":"477.666","G":"**"},{"Policy Line":"64136504","B":"Defib. Vr-Virtuoso D154Vwc-Sys","C":"275","F":"0"},{"Policy Line":"64136521","B":"Charge System Ans 3701","C":"278","D":"C1820","F":"1163.106"},{"Policy Line":"64136522","B":"Programmer Patient Ans 3851","C":"272","D":"C1787","F":"892.602"},{"Policy Line":"64136539","B":"Coil Embolization Gr 1","C":"278","F":"97.308"},{"Policy Line":"64136550","B":"Angioseal","C":"278","D":"C1760","F":"330.48","G":"**"},{"Policy Line":"64136554","B":"Extension/Adapter Lead DBS/NS","C":"278","D":"C1883","F":"960.534","G":"**"},{"Policy Line":"64136558","B":"Kit Pleural Cath 50-7000","C":"278","D":"C1729","F":"753.372","G":"**"},{"Policy Line":"64136567","B":"Pacemaker Sys Sensia Sedro1-D","C":"278","F":"0"},{"Policy Line":"64136579","B":"Flexhd 8X16 Derm Tissue 472816","C":"278","D":"Q4128","F":"4044.402"},{"Policy Line":"64136584","B":"NeuroStim Kit Pnt Trial- Grp2","C":"272","F":"187.884"},{"Policy Line":"64136585","B":"Alloderm Tissue 16X20 102320","C":"278","D":"Q4116","F":"10414.098"},{"Policy Line":"64136588","B":"Tenoglide 2X2 Tg221","C":"278","D":"C9356","F":"2715.138","G":"**"},{"Policy Line":"64136591","B":"Allograft Meniscus M040","C":"278","F":"6593.688"},{"Policy Line":"64136601","B":"Clip Aneurysm Group 3","C":"278","F":"604.962","G":"**"},{"Policy Line":"64136608","B":"Lead NS Surgcl 70CM SC-8120-70","C":"278","D":"C1778","F":"2760.12"},{"Policy Line":"64136614","B":"Lead NeurStim SurgKit 2x8-50Cm","C":"278","D":"C1778","F":"2760.12"},{"Policy Line":"64136619","B":"Pacemaker Sr-Sensia Sesro1","C":"275","D":"C1786","F":"4339.998"},{"Policy Line":"64136622","B":"Gen Vagal Nerve Stim 102R","C":"278","D":"C1767","F":"13350.474"},{"Policy Line":"64136631","B":"Spacer Anterior Stt36130-8Lr","C":"278","F":"6694.974"},{"Policy Line":"64136640","B":"Prosthesis Penile Inflatable","C":"278","D":"C1813","F":"5782.176"},{"Policy Line":"64136646","B":"Allograft R Condyle 268012","C":"278","F":"10093.41"},{"Policy Line":"64136649","B":"System Pedicle Access 2010024","C":"272","F":"660.654"},{"Policy Line":"64136655","B":"Kit Dilator Vascular","C":"272","F":"338.436"},{"Policy Line":"64136661","B":"Stent Airway Bifuc M00570680","C":"278","D":"C1874","F":"3631.608"},{"Policy Line":"64136665","B":"Stem Hip L92528","C":"278","F":"8589.726"},{"Policy Line":"64136666","B":"Pump Pain Ap-3000L","C":"278","D":"C1772","F":"6908.256"},{"Policy Line":"64136667","B":"Permacol Tissue 20X30 152030","C":"278","F":"14541.732"},{"Policy Line":"64136669","B":"Dextrus Seal Cap Hap02","C":"272","F":"731.34"},{"Policy Line":"64136671","B":"Kit Maxcess Disp 3200061","C":"272","F":"1380.672"},{"Policy Line":"64136673","B":"Kit Disp Xlif 2010050","C":"272","F":"1270.512"},{"Policy Line":"64136674","B":"Lead Icd Sprint 6947-58Cm","C":"278","D":"C1895","F":"4847.04"},{"Policy Line":"64136675","B":"Generator Primeadvance37702Sys","C":"278","F":"17549.1"},{"Policy Line":"64136678","B":"Stimulator Restor Sys 37711 -D","C":"278","D":"C1820","F":"17549.1"},{"Policy Line":"64136679","B":"Stent Viabahn 7X 10-15 VBH","C":"278","D":"C1874","F":"3655.17","G":"**"},{"Policy Line":"64136680","B":"Kit Restore Tripole 37711Sy","C":"278","D":"C1820","F":"19070.532"},{"Policy Line":"64136681","B":"Valve Aortic Homograft Avoo","C":"278","F":"11710.926"},{"Policy Line":"64136686","B":"Guide Cutting Custom Knee Imp","C":"272","F":"1919.538"},{"Policy Line":"64136688","B":"Tool Tunneling Sc-4254","C":"272","F":"358.326","G":"**"},{"Policy Line":"64136691","B":"Stem Femoral Hip L92522","C":"278","F":"7225.578"},{"Policy Line":"64136699","B":"Kit Electrode Needle 8010040","C":"272","F":"1734.102"},{"Policy Line":"64136708","B":"Pad Pacing Fibrillator 305","C":"272","F":"69.156"},{"Policy Line":"64136711","B":"Prosthesis Penile Pump Grp 2","C":"278","D":"C1813","F":"7384.392"},{"Policy Line":"64136713","B":"Connector Pump 8578","C":"278","F":"238.68","G":"**"},{"Policy Line":"64136714","B":"Handpiece, Bipolar","C":"272","F":"795.6","G":"**"},{"Policy Line":"64136715","B":"Lead Size 20 302-20","C":"278","F":"5073.786"},{"Policy Line":"64136716","B":"Charge System Mini Scs 3721","C":"272","F":"791.928"},{"Policy Line":"64136725","B":"Graftrope Ac Ar-2258","C":"278","F":"1270.512"},{"Policy Line":"64136731","B":"Graft Surgisis C-Sah-8H-13X15","C":"278","D":"C1763","F":"3530.628"},{"Policy Line":"64136733","B":"Integra Bilayer MWD 8x10cm","C":"278","D":"Q4104","F":"4723.722"},{"Policy Line":"64136734","B":"Integra Wnd Matrix 8x10cm","C":"278","D":"Q4108","F":"8115.12"},{"Policy Line":"64136740","B":"Remote Control Scs Sc-5210","C":"272","D":"C1787","F":"837.522"},{"Policy Line":"64136750","B":"Kit Disp Navigation Howmedica","C":"272","F":"794.376","G":"**"},{"Policy Line":"64136754","B":"Dress Acticoat 4X10 66021772","C":"272","F":"90.882","G":"**"},{"Policy Line":"64136756","B":"Coseal 8Ml 934072","C":"272","F":"1155.15","G":"**"},{"Policy Line":"64136759","B":"Graft Acellular Flex 472620","C":"278","F":"9973.152"},{"Policy Line":"64136760","B":"Oxygenator Quadrox Hmod2030","C":"272","F":"1426.878"},{"Policy Line":"64136761","B":"Spool Transition 152.200","C":"278","F":"794.376"},{"Policy Line":"64136762","B":"Bumper 10Mm 452.150S","C":"278","F":"794.376"},{"Policy Line":"64136764","B":"Clip Stimulation 675.700","C":"272","F":"831.708"},{"Policy Line":"64136765","B":"Component Prox Hip 21-108293","C":"278","F":"8179.992"},{"Policy Line":"64136766","B":"Light Source Quadrant 9560658","C":"272","F":"795.6","G":"**"},{"Policy Line":"64136767","B":"Defibrillator Dual 2207-36","C":"275","D":"C1721","F":"17931.294"},{"Policy Line":"64136768","B":"Lead Durata Icd Dual Coil","C":"275","D":"C1895","F":"3935.772"},{"Policy Line":"64136770","B":"Suction Reservior 910500","C":"272","F":"193.392","G":"**"},{"Policy Line":"64136771","B":"Lead Attain 88Cm 4195-88Cm","C":"278","F":"3071.322"},{"Policy Line":"64136772","B":"Sheath Safe Coronary Sinus","C":"278","D":"C1894","F":"2463.606"},{"Policy Line":"64136775","B":"Allograft Talus Human 32647001","C":"278","F":"6492.096"},{"Policy Line":"64136777","B":"Kit Electrode 8050015","C":"272","F":"1343.646","G":"**"},{"Policy Line":"64136778","B":"Kit Dilator 2029950","C":"272","F":"1217.574","G":"**"},{"Policy Line":"64136780","B":"System Harvesting Vh-3000","C":"272","F":"1215.738","G":"**"},{"Policy Line":"64136784","B":"Stent Life Flexstar","C":"278","D":"C1876","F":"2687.292"},{"Policy Line":"64136785","B":"Permacol Collagen P151828","C":"278","F":"7132.248"},{"Policy Line":"64136790","B":"Pak Accessory 502","C":"272","F":"844.866"},{"Policy Line":"64136791","B":"Stem Femoral Grip 1012-04-070","C":"278","D":"C1776","F":"3981.06"},{"Policy Line":"64136792","B":"Lead Extension Neuro 3341/3382","C":"278","D":"C1883","F":"1145.358"},{"Policy Line":"64136793","B":"Filter Fem/Jug Grp 1","C":"278","F":"1896.282"},{"Policy Line":"64136794","B":"Lead Reliance","C":"275","D":"C1895","F":"4564.908"},{"Policy Line":"64136796","B":"Pacer/Defib Cognis N119","C":"275","D":"C1882","F":"23077.602"},{"Policy Line":"64136799","B":"Block Custom System Fem/Tib","C":"272","F":"1919.538"},{"Policy Line":"64136800","B":"Tip Inserter Disp 03.617.902","C":"272","F":"213.588","G":"**"},{"Policy Line":"64136802","B":"Allograft Trinity 10Cc 410110","C":"278","F":"4349.79"},{"Policy Line":"64136806","B":"Stent Trach/Airway","C":"278","D":"C1874","F":"2559.996"},{"Policy Line":"64136808","B":"Adaptor Pocket 1X4 74001","C":"278","F":"788.256"},{"Policy Line":"64136809","B":"Generator Restore 37712-D","C":"278","D":"C1820","F":"18056.142"},{"Policy Line":"64136812","B":"Allograft Osteochond 32147002","C":"278","D":"C1762","F":"10854.126"},{"Policy Line":"64136813","B":"Battery Deep Brain Stim 37601","C":"278","D":"C1767","F":"17817.768","G":"**"},{"Policy Line":"64136814","B":"Defibrillator Concerto D274Trk","C":"275","D":"C1882","F":"24786.612"},{"Policy Line":"64136815","B":"Catheter Guide Attain 6250-Mpr","C":"272","D":"C1887","F":"409.428"},{"Policy Line":"64136816","B":"Kit Accessory Scs 3550-P4","C":"272","F":"398.106","G":"**"},{"Policy Line":"64136817","B":"Plate Spire 45Mm 9240100","C":"278","F":"4057.56","G":"**"},{"Policy Line":"64136818","B":"Dilator Sextant 8675424","C":"272","F":"434.52"},{"Policy Line":"64136819","B":"Scalpel Disp 1001-90112","C":"272","F":"426.87"},{"Policy Line":"64136823","B":"KIT ACCESS PEDICLE 624.027S","C":"272","F":"1477.674"},{"Policy Line":"64136826","B":"Device Synfix Plate","C":"278","F":"6390.81"},{"Policy Line":"64136829","B":"Lead Durata","C":"278","D":"C1895","F":"4590"},{"Policy Line":"64136830","B":"Defib Pro Rf 3207-36","C":"275","F":"23460.714"},{"Policy Line":"64136834","B":"NS Adaptor Pocket Scs 74002","C":"278","D":"C1883","F":"1266.84"},{"Policy Line":"64136835","B":"Pack Custom Ccs Perf Cb6F98R2","C":"272","F":"892.602"},{"Policy Line":"64136836","B":"Tube Delivery Graft 2090-0227","C":"272","F":"716.346"},{"Policy Line":"64136838","B":"Tube Delivery 2090-0216","C":"272","F":"573.138"},{"Policy Line":"64136841","B":"Consulta Crt Bi-V D224Trk","C":"278","D":"C1882","F":"23715.612"},{"Policy Line":"64136842","B":"Occluder Vascular Abd Ocl24Us","C":"278","F":"3193.11"},{"Policy Line":"64137115","B":"Cath: Iabp -Cl","C":"272","F":"1147.806","G":"**"},{"Policy Line":"64137500","B":"Filter Vena Cava","C":"278","D":"C1880","F":"1119.654"},{"Policy Line":"64137563","B":"Guidewire Journey 300cm Strt","C":"272","D":"C1769","F":"312.12","G":"**"},{"Policy Line":"64137790","B":"Tray: Pericardiocentesis","C":"272","D":"C1769","F":"291.006"},{"Policy Line":"64138013","B":"Nail Valor 415101120R","C":"278","D":"C1713","F":"3850.092","G":"**"},{"Policy Line":"64138294","B":"Cath Guid 6FR MultiD, Envoy","C":"272","D":"C1887","F":"686.664"},{"Policy Line":"64138295","B":"Plate Spinal 12X34X24MM","C":"278","D":"C1713","F":"5071.95"},{"Policy Line":"64138296","B":"Graft Vasc, Gortex 8x40","C":"278","D":"C1768","F":"564.876","G":"**"},{"Policy Line":"64138297","B":"Impl Insert Tibia Stab XLK 8MM","C":"278","D":"C1776","F":"831.708"},{"Policy Line":"64138298","B":"GenNeurostim NonHF RchrgBatSys","C":"278","D":"C1820","F":"14258.376"},{"Policy Line":"64138300","B":"Stent, Endopros:7X10MMX120CM","C":"278","D":"C1874","F":"3545.622","G":"**"},{"Policy Line":"64138301","B":"Syst Endoblade Plantr Fasc Rel","C":"272","F":"1636.794","G":"**"},{"Policy Line":"64138302","B":"Arrowlock Fixation System","C":"278","D":"C1713","F":"1631.898"},{"Policy Line":"64138403","B":"Kit Bone Marrow","C":"272","F":"2809.08"},{"Policy Line":"64138407","B":"Sheath Introducer 24Fr Sdv2228","C":"272","F":"513.774"},{"Policy Line":"64138408","B":"Sheath Introducer 12Fr Sdv2228","C":"272","F":"513.774"},{"Policy Line":"64138409","B":"Kit Hip Disposable Ar-6509Dc","C":"272","F":"822.834"},{"Policy Line":"64138410","B":"Light Source Disp 48250210","C":"272","F":"531.522"},{"Policy Line":"64138411","B":"Disposable Extractor 90-5140","C":"272","F":"660.654"},{"Policy Line":"64138412","B":"Kit Platelet 60Ml Apc-60","C":"272","F":"553.554"},{"Policy Line":"64138413","B":"Kit Applicator Spray","C":"272","F":"77.418"},{"Policy Line":"64138414","B":"Filter Co2 Laser Omniguide","C":"272","F":"115.974"},{"Policy Line":"64138415","B":"Kit Navigated Pedicle 9733498","C":"272","F":"733.788"},{"Policy Line":"64138416","B":"Lead Defibrilator Sprint","C":"278","D":"C1895","F":"6530.04"},{"Policy Line":"64138417","B":"Cath Silverhawk","C":"272","D":"C1714","F":"3193.11"},{"Policy Line":"64138418","B":"Tray Tibial 1294-35-415","C":"278","F":"6632.856"},{"Policy Line":"64138420","B":"Fiber Laser Neuro-L","C":"272","F":"2660.364"},{"Policy Line":"64138421","B":"Remote Access 7438","C":"272","F":"793.764"},{"Policy Line":"64138422","B":"Handpiece Solo Grip 705-37020","C":"272","F":"4808.484"},{"Policy Line":"64138423","B":"Kit Dis Mars 3V 698.600S","C":"272","F":"3109.572"},{"Policy Line":"64138424","B":"Remote Access 7438","C":"272","D":"C1787","F":"793.764"},{"Policy Line":"64138425","B":"Rope Tight Acl Ar-1588T","C":"278","D":"C1713","F":"557.226"},{"Policy Line":"64138426","B":"Lead Icd 65Cm 7120-65","C":"278","D":"C1895","F":"4980.762"},{"Policy Line":"64138427","B":"Osteotome Flexible 9986-21-27","C":"272","F":"206.856","G":"**"},{"Policy Line":"64138428","B":"System Disp Joint 904837","C":"272","F":"895.662"},{"Policy Line":"64138429","B":"Wire Ensnare Retrieval","C":"272","F":"557.226","G":"**"},{"Policy Line":"64138430","B":"Kit Platelet Abs-10012","C":"272","F":"425.646"},{"Policy Line":"64138431","B":"Applicator Spray Abs-10051","C":"272","F":"111.996"},{"Policy Line":"64138432","B":"Kit Platelet 20Ml Apc-20","C":"272","F":"375.156"},{"Policy Line":"64138433","B":"Femur Distal L FDF","C":"278","F":"4052.664"},{"Policy Line":"64138434","B":"Stem Hip L92526","C":"272","F":"7952.94"},{"Policy Line":"64138435","B":"Kit Procedure Scoop T10Sp11","C":"272","F":"1120.572"},{"Policy Line":"64138436","B":"Kit Refill Synchrome Pump 8551","C":"272","F":"54.162","G":"**"},{"Policy Line":"64138437","B":"Proxiderm Expander Tissue D460","C":"272","F":"187.578"},{"Policy Line":"64138438","B":"Condyl Hemi Partial 43747002","C":"278","F":"7151.526"},{"Policy Line":"64138440","B":"Applier Atriclip 260066R","C":"272","F":"1913.418"},{"Policy Line":"64138442","B":"Atriclip Occlusion Device","C":"278","F":"1913.418"},{"Policy Line":"64138443","B":"Graft Homograft Aort Av0021","C":"278","F":"10139.004"},{"Policy Line":"64138444","B":"Graft Homograft Aortic Av0025","C":"278","F":"10536.192"},{"Policy Line":"64138445","B":"Knife Metrix Sheath 1571-00","C":"272","F":"622.404"},{"Policy Line":"64138446","B":"Graft Homograft Av10025","C":"278","F":"10139.004"},{"Policy Line":"64138447","B":"MatrixMesh Integra 2X2 Bmw2021","C":"278","D":"Q4104","F":"1844.262","G":"**"},{"Policy Line":"64138448","B":"Graft Iliac Aortic 9X7.3 R010","C":"278","F":"17751.978"},{"Policy Line":"64138449","B":"NuroStm Rechrg Systm SC-6412-3","C":"278","D":"C1820","F":"1947.69","G":"**"},{"Policy Line":"64138450","B":"ICD Singl FortifyVr Cd1231-40Q","C":"278","D":"C1722","F":"15811.632"},{"Policy Line":"64138451","B":"Tube Exchange Monitor 315-0001","C":"272","F":"187.578"},{"Policy Line":"64138452","B":"Filter Laser L-1608R1","C":"272","F":"115.974"},{"Policy Line":"64138453","B":"Gen Deep Brain Activa Sc 37602","C":"278","D":"C1767","F":"9215.802","G":"**"},{"Policy Line":"64138454","B":"Kit Platelet 60Ml Apc-60","C":"272","F":"526.932"},{"Policy Line":"64138455","B":"Battery System 70-1010","C":"272","F":"183.906","G":"**"},{"Policy Line":"64138456","B":"Implant Toe Small 4571-0100","C":"278","D":"C1713","F":"794.376"},{"Policy Line":"64138457","B":"Kit Disp Pro Toe 4571-0300","C":"272","F":"243.576"},{"Policy Line":"64138458","B":"Implant Titan Medpor 81040","C":"278","F":"3193.11"},{"Policy Line":"64138459","B":"Suture Shuttle 45 Right 251004","C":"272","F":"259.488"},{"Policy Line":"64138460","B":"Passer Connector Om-8010","C":"272","F":"206.856","G":"**"},{"Policy Line":"64138461","B":"Needle Ava Flex Afh0011","C":"272","F":"794.376"},{"Policy Line":"64138462","B":"Cath 3Lu 7F 16C Ask-42703-Pcsj","C":"272","F":"225.216","G":"**"},{"Policy Line":"64138463","B":"Device Turbo Hawk Lx-M Th-Lx-M","C":"272","D":"C1714","F":"3196.17"},{"Policy Line":"64138464","B":"Filter Trapease 466-P306Au","C":"278","F":"1781.226"},{"Policy Line":"64138465","B":"Component Art Graft Hero1002","C":"278","F":"1171.062"},{"Policy Line":"64138466","B":"Component Venous Hero1001","C":"278","D":"C1750","F":"3013.488"},{"Policy Line":"64138468","B":"Screw Pedicel Access 3400021","C":"272","F":"1343.646"},{"Policy Line":"64138469","B":"Generator Primeadvanced 37702","C":"278","D":"C1767","F":"15257.466"},{"Policy Line":"64138470","B":"Tool Flexor Tendon T0-Ftrt","C":"272","F":"795.6"},{"Policy Line":"64138471","B":"ICD Sj4 Fort Dua Ch Cd2231-40Q","C":"275","D":"C1721","F":"18946.602"},{"Policy Line":"64138473","B":"Brigade Implant 6941238","C":"278","F":"5071.95"},{"Policy Line":"64138474","B":"Extender Lateral 7756067","C":"278","F":"795.6"},{"Policy Line":"64138475","B":"Guide Cutting Tr7100-L","C":"272","F":"1151.784"},{"Policy Line":"64138476","B":"Wire Spider SM Spd2Us-050","C":"272","D":"C1884","F":"2047.446"},{"Policy Line":"64138477","B":"NS Lead Kit Ext 40Cm 37081-40","C":"278","D":"C1883","F":"889.542"},{"Policy Line":"64138478","B":"Generator Pulse Spine 37713","C":"278","D":"C1820","F":"17549.1"},{"Policy Line":"64138479","B":"Generator Rf Sr Pm1210","C":"275","D":"C1786","F":"4872.132"},{"Policy Line":"64138481","B":"Implant Distal Biceps Ar-2260","C":"278","F":"1707.786"},{"Policy Line":"64138483","B":"Device Reattachment 498.806S","C":"278","F":"2409.138"},{"Policy Line":"64138484","B":"Pack Hip Arthroscopy Ar-6509Ds","C":"272","F":"822.834"},{"Policy Line":"64138485","B":"Shunt Lumbar Strata 44420","C":"278","F":"3938.526"},{"Policy Line":"64138486","B":"Osseoflex Delivery System","C":"278","F":"2015.622"},{"Policy Line":"64138487","B":"Button Patella 7.0 P306-0070-W","C":"278","F":"880.362"},{"Policy Line":"64138488","B":"Botton Ziploop Joint 904834","C":"278","F":"857.412"},{"Policy Line":"64138489","B":"Implant Zero P 9Mm 04.617.139S","C":"278","F":"2910.978","G":"**"},{"Policy Line":"64138490","B":"Kit Cranial Access Ins-Hith","C":"272","F":"597.312","G":"**"},{"Policy Line":"64138491","B":"Set Temp Monitor 1104Hmt","C":"272","F":"1261.944"},{"Policy Line":"64138492","B":"ICP Ventricular 110-4Hmt","C":"272","F":"1046.214"},{"Policy Line":"64138493","B":"Device Synfix 30Mm 08.802.012S","C":"278","F":"6593.688"},{"Policy Line":"64138494","B":"Tissue Ovation 1Cc Ps31001","C":"278","F":"3196.17"},{"Policy Line":"64138495","B":"Cath Crosser 5Fr Cru014S","C":"272","D":"C2628","F":"3193.11"},{"Policy Line":"64138496","B":"Kit Maxcess Disp 324xxxx","C":"272","F":"2047.446","G":"**"},{"Policy Line":"64138497","B":"System Cement Delivery Cds2A","C":"272","F":"788.256","G":"**"},{"Policy Line":"64138498","B":"Cement Mixer Cx01B","C":"272","F":"569.772","G":"**"},{"Policy Line":"64138500","B":"Kit Sheath Laser 14Fr 500-012","C":"272","F":"2828.052"},{"Policy Line":"64138501","B":"Device Lead Lock #2 518-019","C":"272","D":"C1773","F":"773.568"},{"Policy Line":"64138502","B":"Kit Lld Accessory 518-027","C":"272","F":"179.01"},{"Policy Line":"64138503","B":"Kit Maxcess Shim 3240061","C":"272","F":"1380.672"},{"Policy Line":"64138504","B":"Screw Driver Disp 450-0600","C":"272","F":"176.256"},{"Policy Line":"64138506","B":"Cement Gun And Bone Sz3 Cc02A","C":"272","F":"161.874"},{"Policy Line":"64138507","B":"Device Corknot 030800","C":"272","F":"636.786","G":"**"},{"Policy Line":"64138508","B":"Reload Corknot 030850","C":"272","F":"77.724"},{"Policy Line":"64138509","B":"Kit Mixing 417200","C":"272","F":"193.392"},{"Policy Line":"64138510","B":"Slitter Ds2A003","C":"272","F":"96.696"},{"Policy Line":"64138511","B":"Gun Meniscal 228143","C":"272","F":"329.562"},{"Policy Line":"64138512","B":"EP Cath Guid Fxd Crv Intercard","C":"272","D":"C1893","F":"968.49"},{"Policy Line":"64138513","B":"Needle Omnispan","C":"272","F":"525.402"},{"Policy Line":"64138514","B":"ICD Sj4 Unify Crt C Cd3231-40Q","C":"278","F":"22316.58"},{"Policy Line":"64138515","B":"Kit Mdfl Ar-1360B-Cp","C":"278","F":"2521.134"},{"Policy Line":"64138516","B":"Mesh Panel 01-7340","C":"278","F":"795.6"},{"Policy Line":"64138517","B":"Tubing Str Shot To Xps 1895522","C":"272","F":"51.714","G":"**"},{"Policy Line":"64138518","B":"Device Endovascular 300-30159","C":"272","F":"7095.834"},{"Policy Line":"64138519","B":"Stent Tracheal Covrd 9X38","C":"278","D":"C1874","F":"3274.506","G":"**"},{"Policy Line":"64138520","B":"Driver Disp","C":"272","F":"340.272","G":"**"},{"Policy Line":"64138521","B":"Pack Pin 99-35039-00002St10","C":"272","F":"667.08","G":"**"},{"Policy Line":"64138522","B":"Generator Pulse Dbs 37603","C":"278","D":"C1767","F":"9215.802","G":"**"},{"Policy Line":"64138523","B":"Implant Impacted Lg 6713926","C":"278","F":"4057.56"},{"Policy Line":"64138524","B":"Graft Stent Thor Tf4040C159Cp","C":"278","F":"16356.924"},{"Policy Line":"64138525","B":"Graft Stent Tf4242C15Cp","C":"278","F":"17067.15"},{"Policy Line":"64138526","B":"Tack Holding 321-0004","C":"272","F":"48.348"},{"Policy Line":"64138527","B":"Mangifuse 1Cmx10Cm 7509211","C":"278","F":"2958.408"},{"Policy Line":"64138528","B":"Cath Support Crosser Crus6A","C":"272","F":"3193.11"},{"Policy Line":"64138529","B":"Drill Cannulated 338.332","C":"272","F":"2060.604"},{"Policy Line":"64138530","B":"Tubing Selector 5450-850-003","C":"272","F":"629.442","G":"**"},{"Policy Line":"64138531","B":"Lead Tool Epicardial 10626","C":"272","F":"1215.738"},{"Policy Line":"64138532","B":"Vitagel Hemostat 2113-0000","C":"278","F":"709.308"},{"Policy Line":"64138533","B":"Patch Perica 7X15 Cmcv-003-402","C":"278","F":"1657.296"},{"Policy Line":"64138534","B":"Button Retro Ar-1592","C":"272","F":"603.432"},{"Policy Line":"64138535","B":"Tightrope Rt Ar-1588Rt","C":"278","F":"471.24","G":"**"},{"Policy Line":"64138536","B":"Cutter Flip","C":"272","F":"740.214","G":"**"},{"Policy Line":"64138537","B":"Patch Cormatrix Cmcv-006-609","C":"278","F":"648.414","G":"**"},{"Policy Line":"64138538","B":"Tool Tunneling 3655","C":"272","F":"222.768"},{"Policy Line":"64138539","B":"Set Impella Pump 005062","C":"278","F":"28402.92"},{"Policy Line":"64138540","B":"Set Impella Pump Ld A/C 005082","C":"278","F":"28402.92"},{"Policy Line":"64138541","B":"Kit Disp Suture Tak Ar-1322Dsc","C":"278","F":"312.732","G":"**"},{"Policy Line":"64138542","B":"Button Retro 12Mm Ar-1588-60","C":"278","F":"374.238"},{"Policy Line":"64138543","B":"Aigis Pm Abx Env Cmrm3133","C":"278","F":"1197.99"},{"Policy Line":"64138544","B":"System Mobile Charging 3711","C":"272","F":"791.928"},{"Policy Line":"64138545","B":"Wire Reduction 4.3 03.120.023","C":"272","F":"826.812"},{"Policy Line":"64138546","B":"Cutter 2.9 72202403","C":"272","F":"638.316"},{"Policy Line":"64138547","B":"Catheter Scoop 9Cm C-9-2","C":"272","F":"215.118"},{"Policy Line":"64138548","B":"Catheter Balloon Cmd15","C":"272","F":"3196.17"},{"Policy Line":"64138549","B":"Pack Disposable Mcp-Dis-Str","C":"272","F":"591.192"},{"Policy Line":"64138550","B":"Gen AICD Energen VR HE E141","C":"278","D":"C1722","F":"14616.396"},{"Policy Line":"64138551","B":"Powder Absorbable 2114-0003","C":"272","F":"67.932"},{"Policy Line":"64138552","B":"Pack Mpfl Ar-1360-B-Lp","C":"272","F":"2521.134"},{"Policy Line":"64138553","B":"Passer Suture","C":"272","F":"202.266","G":"**"},{"Policy Line":"64138555","B":"Sleeve Inserter 7168-7031","C":"278","F":"264.384"},{"Policy Line":"64138556","B":"Recorder Reveal Xt 9529","C":"278","F":"4514.112"},{"Policy Line":"64138557","B":"Dilator Stimular 945Nsd2750","C":"272","F":"656.676"},{"Policy Line":"64138558","B":"Bipolar Long 1590-00","C":"272","F":"721.242"},{"Policy Line":"64138559","B":"Tip Inserter 03.820.134S","C":"272","F":"198.594","G":"**"},{"Policy Line":"64138560","B":"Cage Plate 26X32 08.802.004S","C":"278","F":"5985.054"},{"Policy Line":"64138562","B":"Drill Step 6.4 7163-1160","C":"272","F":"1158.516"},{"Policy Line":"64138563","B":"Lead Reliance Df4","C":"275","D":"C1895","F":"4960.566"},{"Policy Line":"64138564","B":"Matrix Collagen 5Cm Cnw6050","C":"278","D":"C9361","F":"2137.104"},{"Policy Line":"64138565","B":"Defib Protecta Xt D314Trg","C":"275","D":"C1882","F":"26456.454"},{"Policy Line":"64138566","B":"Lead Pacemaker 4296-88Cm","C":"275","D":"C1898","F":"3401.802"},{"Policy Line":"64138567","B":"Cage T-Lif 12Mm 08.812.212","C":"278","F":"5858.064","G":"**"},{"Policy Line":"64138568","B":"Device Synfic 08.802.019S","C":"278","F":"6390.81"},{"Policy Line":"64138569","B":"Monopolar Hook Ar-6528-02","C":"272","F":"906.066"},{"Policy Line":"64138570","B":"Ovation Small .3Cc Ps31030","C":"278","F":"2041.326"},{"Policy Line":"64138571","B":"Kit Magellan Mar01","C":"272","F":"2367.522"},{"Policy Line":"64138572","B":"Graft Grafix Core 5X5 Ps22055","C":"278","D":"Q4132","F":"2209.626"},{"Policy Line":"64138573","B":"Graft L Medial Menisca 2822502","C":"278","F":"4818.582"},{"Policy Line":"64138574","B":"Grafix Prime 5X5 Ps21055","C":"278","D":"Q4133","F":"3093.966"},{"Policy Line":"64138575","B":"System Charging 3722","C":"272","F":"791.928"},{"Policy Line":"64138576","B":"Set Disp Juggerknot 912041","C":"278","D":"C1713","F":"582.318"},{"Policy Line":"64138577","B":"Cage Peek Xlif 6210160","C":"278","F":"5579.298"},{"Policy Line":"64138578","B":"Disc Artifcl 5-6MM 09.820.0XXS","C":"278","F":"4893.552","G":"**"},{"Policy Line":"64138579","B":"Kit W Syringe 03.702.215S","C":"272","F":"237.15"},{"Policy Line":"64138580","B":"Kit Access 03.804.512S","C":"272","F":"615.978"},{"Policy Line":"64138581","B":"Spacer Peek 10X22Mm 193.101","C":"278","F":"5868.162","G":"**"},{"Policy Line":"64138582","B":"Anchor Peek Xc-201-01","C":"278","D":"C1713","F":"2042.55"},{"Policy Line":"64138583","B":"Gen NS Pulse Sc-1132","C":"278","D":"C1820","F":"16534.71"},{"Policy Line":"64138584","B":"NSKit Remote Control SC-5532-1","C":"272","D":"C1787","F":"1349.154","G":"**"},{"Policy Line":"64138585","B":"Pack Hip Scope Ar-6526S","C":"272","F":"822.834"},{"Policy Line":"64138586","B":"Cage Peek 10X26Mm 193.102","C":"278","F":"5868.162","G":"**"},{"Policy Line":"64138587","B":"Screw Driver Lag 71674068","C":"272","F":"794.376"},{"Policy Line":"64138588","B":"Spacer 10X30Cm 193.113","C":"278","F":"6492.096"},{"Policy Line":"64138589","B":"Implant Brigade 6941234","C":"278","F":"5071.95"},{"Policy Line":"64138590","B":"Anchor System Implt","C":"278","D":"C1713","F":"2880.99","G":"**"},{"Policy Line":"64138591","B":"Kit 3-Arm Disp Davinci 420290","C":"272","F":"318.24"},{"Policy Line":"64138592","B":"Permacol 10X15Cmx1.5Mm P151015","C":"278","F":"3144.15"},{"Policy Line":"64138594","B":"Cage Peek 7-14Mmx30Mm 193.103","C":"278","F":"6492.096","G":"**"},{"Policy Line":"64138595","B":"System Delivery Ar-2268","C":"278","D":"C1713","F":"2157.606"},{"Policy Line":"64138596","B":"Kit Protoe Inst Disp 45710500","C":"272","F":"419.526"},{"Policy Line":"64138597","B":"Sheath Laser","C":"272","D":"C2629","F":"3121.506"},{"Policy Line":"64138598","B":"Countersink","C":"272","F":"398.106","G":"**"},{"Policy Line":"64138599","B":"Spacer 10X26Mm 193.112","C":"278","F":"6492.096"},{"Policy Line":"64138600","B":"Scalpel Plasma Aw-422552/3.Om","C":"272","F":"682.992","G":"**"},{"Policy Line":"64138602","B":"Filter Meridian Femoral Md800F","C":"278","F":"1401.786"},{"Policy Line":"64138603","B":"Cone Body 11-301302","C":"278","F":"6217.002"},{"Policy Line":"64138604","B":"Graft Stent Thoracic Vamf","C":"278","F":"19775.556","G":"**"},{"Policy Line":"64138605","B":"Anchor Sys Implant Ar-1360C-Cp","C":"278","D":"C1713","F":"1865.682","G":"**"},{"Policy Line":"64138606","B":"Perclose Proglide 12673","C":"272","F":"354.96"},{"Policy Line":"64138607","B":"Chargng Sys Int/Ext-Repl 37754","C":"274","D":"L8689","F":"3058.47"},{"Policy Line":"64138608","B":"Remote Patient Sc-15532-1","C":"272","F":"1349.154"},{"Policy Line":"64138609","B":"Plate Sup/Inf End Pdl-M-Sp06S","C":"278","D":"C1713","F":"4564.908"},{"Policy Line":"64138610","B":"Marker Meduim 10Mm Pdl-M-T10S","C":"278","F":"1330.794"},{"Policy Line":"64138611","B":"Custom Cutting Block","C":"272","F":"1151.784","G":"**"},{"Policy Line":"64138612","B":"Alloderm Rtu 16X20Cm 1520320","C":"278","D":"Q4116","F":"10571.382","G":"**"},{"Policy Line":"64138614","B":"Graft Stent Vam3232C150Tu","C":"278","F":"18761.166","G":"**"},{"Policy Line":"64138615","B":"Alloderm Tissue Contour CL1520","C":"278","D":"Q4116","F":"5461.488"},{"Policy Line":"64138616","B":"Graft 32147001","C":"278","F":"11107.8"},{"Policy Line":"64138617","B":"NS Kit Lead Trial SC-2316-50E","C":"278","D":"C1778","F":"2694.942","G":"**"},{"Policy Line":"64138618","B":"Lead Targeting 66-It-Ar4P","C":"272","F":"206.856","G":"**"},{"Policy Line":"64138619","B":"Splint Nasal Posisep X 9210584","C":"272","F":"203.49","G":"**"},{"Policy Line":"64138620","B":"Kit Access 8700-9112","C":"272","F":"1791.63"},{"Policy Line":"64138621","B":"Kit Monitor 8700-9122","C":"272","F":"1151.784"},{"Policy Line":"64138622","B":"Cage Latis 10X32Mm 181.210","C":"278","F":"5071.95"},{"Policy Line":"64138623","B":"Screw Cap Head Tulip 1119-0100","C":"278","F":"795.6","G":"**"},{"Policy Line":"64138624","B":"Patch Tissue 4X7 Cmcv-004-404","C":"278","F":"1017.45"},{"Policy Line":"64138625","B":"Illuminator 38-Light-1","C":"272","F":"483.786"},{"Policy Line":"64138627","B":"Cage Latis 10X32Mm 181.209","C":"278","F":"5980.158"},{"Policy Line":"64138628","B":"Device Anchor Band Fb-201-01","C":"278","F":"1023.876","G":"**"},{"Policy Line":"64138629","B":"TAVR VALVE","C":"278","F":"32967.828","G":"**"},{"Policy Line":"64138630","B":"CLAMP BAND 1754-55-055","C":"272","F":"1197.99"},{"Policy Line":"64138631","B":"IMPLANTABLE DOPPLER PROBE","C":"278","F":"1195.236"},{"Policy Line":"64138632","B":"DIALATOR ENDOVAS","C":"272","F":"278.766","G":"**"},{"Policy Line":"64138633","B":"Heart-Lung Dispo Kit - ECMO","C":"272","F":"13313.754","G":"**"},{"Policy Line":"64138635","B":"STARFIX PLATFORM UNILATERAL","C":"272","F":"3168.018"},{"Policy Line":"64138636","B":"STARFIX PLATFORM BILATERAL","C":"272","F":"4564.908"},{"Policy Line":"64138639","B":"TRAY PLATFORM SZ 3 1294-35-315","C":"278","F":"7169.58"},{"Policy Line":"64138640","B":"Iovera System Disp Tip","C":"272","F":"702.27","G":"**"},{"Policy Line":"64138641","B":"KIT DISP TOGGLEL WASHER 909846","C":"272","F":"1058.454"},{"Policy Line":"64138642","B":"KIT T3AMZ DISPOSABLE AR-13217","C":"272","F":"899.946","G":"**"},{"Policy Line":"64138644","B":"BOLT EXTRACTION 71631320","C":"272","F":"495.108","G":"**"},{"Policy Line":"64138645","B":"TRAY CHEST TUBE 16FR G05462","C":"272","D":"C1729","F":"271.728"},{"Policy Line":"64138646","B":"SPACER RISE 10X30MM 193.123","C":"278","F":"6492.096"},{"Policy Line":"64138647","B":"OSTEOTOME FLEXIBLE","C":"272","F":"929.322"},{"Policy Line":"64138648","B":"SYRINGE VASOSHIELD VH5001","C":"272","F":"308.754","G":"**"},{"Policy Line":"64138649","B":"DEVICE SYNFIX 32MM 08.802.001S","C":"278","F":"6390.81"},{"Policy Line":"64138650","B":"ADAPTER ENDO III 139249","C":"278","F":"281.826"},{"Policy Line":"64138651","B":"AWL DISPOSABLE 3608-90035","C":"272","F":"334.152"},{"Policy Line":"64138652","B":"KIT CATH INSERTION VP-211","C":"272","F":"308.754"},{"Policy Line":"64138653","B":"SYSTEM SHOULDER 10MX83M 113630","C":"278","F":"6041.97"},{"Policy Line":"64138654","B":"HANDLE DISTAL iO-DH","C":"272","F":"398.106"},{"Policy Line":"64138656","B":"SPLITTER FASCIAL 8801279","C":"278","F":"795.6"},{"Policy Line":"64138657","B":"TUBE SET COMBO 905103","C":"272","F":"959.922"},{"Policy Line":"64138658","B":"CATHETER CORONARY SINUS PR9","C":"272","F":"2546.226"},{"Policy Line":"64138659","B":"CAGE BRIGADE 7502075","C":"278","F":"5579.298"},{"Policy Line":"64138666","B":"TIP YANK WAVEGUIDE","C":"272","F":"410.652"},{"Policy Line":"64138667","B":"STIMULATOR 39286-65CM","C":"278","F":"6289.218"},{"Policy Line":"64138668","B":"NAIL VALOR 11.5X200 415101120L","C":"278","D":"C1713","F":"3911.598"},{"Policy Line":"64138669","B":"SPACER 8-15MM (26MM) 193.122","C":"278","F":"6492.096"},{"Policy Line":"64138670","B":"AVS ARIA NEURO PROBE DILATOR","C":"272","F":"1151.784"},{"Policy Line":"64138671","B":"CORENT CAGE","C":"278","F":"5579.298","G":"**"},{"Policy Line":"64138672","B":"OSTEOTOME 6MM SERRA OHSO2060SU","C":"272","F":"795.6","G":"**"},{"Policy Line":"64138673","B":"KIT PLATELET ABS-10011","C":"272","F":"261.63"},{"Policy Line":"64138674","B":"KIT SHOULDER SPS0121K","C":"278","F":"4058.172"},{"Policy Line":"64138675","B":"TRAIL SPS971","C":"278","F":"604.044"},{"Policy Line":"64138676","B":"Kit Platelet","C":"272","F":"261.63"},{"Policy Line":"64138677","B":"Device Fusion","C":"278","F":"6773.004"},{"Policy Line":"64138678","B":"Nail Valor 415101125R","C":"278","D":"C1713","F":"3911.598","G":"**"},{"Policy Line":"64138679","B":"WAND APOLLO LG AP9","C":"272","F":"5675.688"},{"Policy Line":"64138680","B":"Cath Pulmonary Endovent EV","C":"272","F":"1817.028","G":"**"},{"Policy Line":"64138681","B":"Kit EMG Module 8050315","C":"272","F":"1151.784","G":"**"},{"Policy Line":"64138682","B":"KIT PROC XLIF PRECEPT 8027088","C":"278","F":"11055.168"},{"Policy Line":"64138683","B":"Davinci Forcep 428080","C":"272","F":"1799.586"},{"Policy Line":"64138684","B":"COUPLER GEM VAS W/PROBE","C":"278","F":"1106.496"},{"Policy Line":"64138685","B":"CAGE CORVENT 10MM 1663012","C":"278","F":"6847.362"},{"Policy Line":"64138686","B":"Mesh Panel Lactosorb 915-2412","C":"278","F":"1083.852"},{"Policy Line":"64138687","B":"WIRE MOD J TIP 260CM WWIJ35260","C":"272","F":"483.786"},{"Policy Line":"64138688","B":"Integra DRT 8x10 38101","C":"278","D":"Q4105","F":"7198.344"},{"Policy Line":"64138689","B":"Stem Shoulder 12x83mm 113632","C":"278","D":"C1776","F":"3905.172"},{"Policy Line":"64138690","B":"Imp Spine Dev Interlam 14-16MM","C":"278","D":"C1821","F":"5901.21","G":"**"},{"Policy Line":"64138691","B":"ANCHOR BUMPY 97791","C":"272","F":"318.24","G":"**"},{"Policy Line":"64138692","B":"Plate Spinal Process 121316","C":"278","D":"C1713","F":"5832.972"},{"Policy Line":"64138693","B":"Pusher Kit 2.9 AR-2923DS","C":"272","F":"398.106"},{"Policy Line":"64138694","B":"COMPONENT FEMORAL 71461016","C":"278","D":"C1776","F":"7902.144"},{"Policy Line":"64138695","B":"KIT PREP FEMORAL SZ6 5555-2256","C":"272","F":"306.612","G":"**"},{"Policy Line":"64138696","B":"KIT PREP TIBIAL SZ6 5555-2326","C":"272","F":"218.79"},{"Policy Line":"64138697","B":"Cable Trial","C":"272","F":"318.24"},{"Policy Line":"64138698","B":"BUTTON RIGIDLOOP 25MM 232014","C":"272","F":"703.494","G":"**"},{"Policy Line":"64138699","B":"KIT RIDGIDLOOP","C":"272","F":"795.6","G":"**"},{"Policy Line":"64138700","B":"MESH MALLEABLE LG 53-00486","C":"278","F":"1130.976"},{"Policy Line":"64138701","B":"Genratr Neuro Rechg SC-1032A/B","C":"278","D":"C1820","F":"17549.1"},{"Policy Line":"64138702","B":"Blade Shaver Micro iO-MBS5.5","C":"272","F":"1967.274"},{"Policy Line":"64138704","B":"Femoral Component 150351","C":"278","D":"C1776","F":"6379.182"},{"Policy Line":"64138705","B":"DISK ARTIFICIAL CORE ASSEMBLY","C":"278","F":"2343.348"},{"Policy Line":"64138706","B":"DISK ARTIFICIAL END PLATE","C":"278","F":"5055.732"},{"Policy Line":"64138707","B":"GRAFT MITROFLOW CONDUIT MVC030","C":"278","F":"2811.834"},{"Policy Line":"64138708","B":"HANDLE DISTAL","C":"272","F":"450.432"},{"Policy Line":"64138709","B":"CAGE FUSION 10X26MM 1124.1011","C":"278","F":"6492.096","G":"**"},{"Policy Line":"64138710","B":"GRAFT GRAFIX XC 7.5X15 PS24075","C":"278","D":"Q4133","F":"6238.728"},{"Policy Line":"64138711","B":"KIT PORTAL ENTRY","C":"272","F":"523.566"},{"Policy Line":"64138712","B":"LEVEL BUBBLE DISP","C":"272","F":"323.136"},{"Policy Line":"64138713","B":"DISC CERVICAL","C":"278","F":"4564.908"},{"Policy Line":"64138714","B":"CAGE LUMBAR 8-12MM 1124.1111","C":"278","F":"6492.096","G":"**"},{"Policy Line":"64138715","B":"CAGE 10MMX50MMX6 2968050","C":"278","F":"6289.218"},{"Policy Line":"64138716","B":"CAGE 10X31MM 1124.1013","C":"278","F":"6492.096"},{"Policy Line":"64138717","B":"ANCHOR SUTURE","C":"278","D":"C1713","F":"573.138","G":"**"},{"Policy Line":"64138718","B":"DILATOR 4.75MM 72203951","C":"278","F":"310.59"},{"Policy Line":"64138719","B":"KIT PORTAL ENTRY","C":"272","F":"523.872","G":"**"},{"Policy Line":"64138720","B":"PASSER SUTURE 02590","C":"272","F":"555.696","G":"**"},{"Policy Line":"64138721","B":"PORTAL ENTRY KIT 00241","C":"272","F":"523.872"},{"Policy Line":"64138722","B":"LEAD RA 1944-52","C":"278","F":"816.102"},{"Policy Line":"64138724","B":"WRAPSURGI BIORESORB 27204","C":"278","F":"392.904"},{"Policy Line":"64138725","B":"KIT LEAD NEUROSTIMULATOR","C":"278","D":"C1778","F":"4590","G":"**"},{"Policy Line":"64138726","B":"KIT ACCESS PEDICLE","C":"272","F":"1174.734","G":"**"},{"Policy Line":"64138728","B":"CAGE LORDOTIC 194.945","C":"278","F":"6086.34"},{"Policy Line":"64138729","B":"BULLET ENDO 698.135S","C":"272","F":"1142.604"},{"Policy Line":"64138730","B":"DISC PCM MEDIUM 6.5MM 7680365","C":"278","F":"4564.908"},{"Policy Line":"64138732","B":"CAGE FUSION 2926250","C":"278","F":"6918.048"},{"Policy Line":"64138733","B":"REDUCTION DEVICE","C":"272","F":"450.432"},{"Policy Line":"64138734","B":"EPIPHYSIS MODULAR 130720101","C":"278","D":"C1776","F":"6056.964"},{"Policy Line":"64138735","B":"SYSTEM OATS 10MM AR-1981-10S","C":"272","F":"950.742","G":"**"},{"Policy Line":"64138736","B":"BAR 10.5X250MM 71062250","C":"272","F":"379.134"},{"Policy Line":"64138737","B":"CLAMP 6 H MULTIPIN 71067376","C":"272","F":"1330.794","G":"**"},{"Policy Line":"64138738","B":"GUIDEWIRE GROUP 3","C":"272","F":"389.538","G":"**"},{"Policy Line":"64138739","B":"KIT PROC XLIF PRECEPT 8200265","C":"278","F":"13694.418"},{"Policy Line":"64138740","B":"CAGE TLIF 9-13MM 1124.1112","C":"278","F":"6492.096"},{"Policy Line":"64138741","B":"STENT VIABAHN","C":"278","D":"C1874","F":"3193.11","G":"**"},{"Policy Line":"64138748","B":"GRAFT STENT","C":"278","F":"16103.556"},{"Policy Line":"64138749","B":"PUSHER KNOT AR-4515","C":"272","F":"284.886","G":"**"},{"Policy Line":"64138750","B":"DEVICE INTERLLAMINER UQ100010","C":"278","D":"C1821","F":"5900.598"},{"Policy Line":"64138751","B":"CAGE LUMBAR 1124.1113","C":"278","F":"6492.096"},{"Policy Line":"64138752","B":"KIT ACCESSORY KYPHO","C":"272","F":"2670.462"},{"Policy Line":"64138753","B":"MIXER INJECTION SYS TO60415","C":"272","F":"573.138"},{"Policy Line":"64138754","B":"BIPOLAR ELLMAN 4793.692","C":"272","F":"740.826"},{"Policy Line":"64138755","B":"STEM FEMORAL 1572-02-195","C":"278","F":"6251.886"},{"Policy Line":"64138756","B":"BIPOLAR TRIGGER 40990.0031","C":"272","F":"794.376"},{"Policy Line":"64138757","B":"SYSTEM ENDO RELEASE 310040","C":"272","F":"1511.64"},{"Policy Line":"64138758","B":"ROD LENGHTEN 5.5 MS1-5590S","C":"278","D":"C1713","F":"17751.978"},{"Policy Line":"64138759","B":"CATH VISION 88901","C":"272","D":"C1753","F":"1278.162"},{"Policy Line":"64138760","B":"DISSECTOR","C":"272","F":"2605.59"},{"Policy Line":"64138761","B":"KIT ACCESS 210CM 701063540","C":"272","F":"231.03","G":"**"},{"Policy Line":"64138762","B":"HIPGRID 1015-012-121","C":"272","F":"358.326"},{"Policy Line":"64138763","B":"IRRIGATOR ENDOWRIST 410299","C":"272","F":"350.064"},{"Policy Line":"64138764","B":"TIP YANK ES3Y","C":"272","F":"437.886","G":"**"},{"Policy Line":"64138765","B":"DEVICE RETRIEVAL 4200-20","C":"272","F":"2681.172"},{"Policy Line":"64138766","B":"AWL STARTER DISP","C":"272","F":"1023.876"},{"Policy Line":"64138767","B":"DISC CERVICAL MB3355","C":"278","F":"4564.908"},{"Policy Line":"64138768","B":"KIT ACL DISP 232300","C":"272","F":"794.376","G":"**"},{"Policy Line":"64138769","B":"PLUG 14-524038","C":"278","F":"96.696"},{"Policy Line":"64138770","B":"KIT PUSHLOCK 3.5 AR-1926DS","C":"272","F":"278.766"},{"Policy Line":"64138771","B":"BATTERY RESTORE SENSOR 97714","C":"278","D":"C1820","F":"19020.042","G":"**"},{"Policy Line":"64138772","B":"PIP ASCENSION PACK PIP-DIS-STR","C":"272","F":"612.918"},{"Policy Line":"64138773","B":"DEVICE COR KNOT MINI 031350","C":"272","F":"895.662","G":"**"},{"Policy Line":"64138774","B":"CAGE PLATE 13MM 376.413","C":"278","D":"C1713","F":"5071.95"},{"Policy Line":"64138775","B":"COMPONENT FEMORAL PX02-0855-W","C":"278","F":"7351.344"},{"Policy Line":"64138776","B":"SCREW MARKER FIDUCIAL 019006","C":"278","D":"A4648","F":"128.826"},{"Policy Line":"64138777","B":"LEAD ICD LDA220Q-58","C":"278","D":"C1895","F":"3935.772"},{"Policy Line":"64138778","B":"LEAD RA TENDRIL ICD 2088TC-46","C":"275","D":"C1898","F":"794.376"},{"Policy Line":"64138779","B":"ELLIPSE DR ICD DUEL CD2411-36Q","C":"278","D":"C1721","F":"12680.028"},{"Policy Line":"64138780","B":"MESH XENMATRIX 10X15CM 1151015","C":"278","D":"C1781","F":"4001.562"},{"Policy Line":"64138781","B":"KIT CENTRIFUGE GSBMA-60","C":"272","F":"2367.522","G":"**"},{"Policy Line":"64138782","B":"CAGE VBR","C":"278","F":"6390.81"},{"Policy Line":"64138783","B":"BOLT ILIAC 8.5X70MM 8438570","C":"278","D":"C1713","F":"1407.6"},{"Policy Line":"64138784","B":"SPACER CERVICAL RISE 193.121","C":"278","F":"6492.096","G":"**"},{"Policy Line":"64138785","B":"TAPE FIBER COLLAGEN COATED","C":"272","F":"193.392"},{"Policy Line":"64138786","B":"PUNCH 5.5 AR-1927PBS","C":"272","F":"175.644","G":"**"},{"Policy Line":"64138787","B":"CAGE LUMBAR 10X36 1124.1211","C":"278","F":"6492.096"},{"Policy Line":"64138788","B":"KIT DILATOR AR-1923PK","C":"272","F":"350.064"},{"Policy Line":"64138790","B":"PLATFORM BIL MP-KIT-02D","C":"272","F":"3398.436"},{"Policy Line":"64138792","B":"ENDOWRIST VESSEL SEALER 410322","C":"272","F":"795.6","G":"**"},{"Policy Line":"64138793","B":"GUIDE/SHEATH HELI-FX","C":"272","F":"2253.384","G":"**"},{"Policy Line":"64138794","B":"ENDOANCHOR HELI FX SA-85","C":"278","F":"4818.582","G":"**"},{"Policy Line":"64138795","B":"Endoprosthesis VBJR061502A","C":"278","D":"C1874","F":"3963.924","G":"**"},{"Policy Line":"64138796","B":"REAMER DHS TRIPLE 338.13","C":"272","F":"1906.074"},{"Policy Line":"64138797","B":"XLIF 2-LEVEL W/PLATE 8027025","C":"278","D":"C1713","F":"10159.506"},{"Policy Line":"64138798","B":"CERVICAL FUSION KIT 8027189","C":"278","F":"4634.676"},{"Policy Line":"64138799","B":"LUMBAR FUSION KIT","C":"278","F":"10933.686"},{"Policy Line":"64138800","B":"ANTERIOR/POSTERIOR FUSION KIT","C":"278","F":"17163.54"},{"Policy Line":"64138801","B":"GUIDE SUTURE 3.7 AR-1906","C":"272","F":"782.442"},{"Policy Line":"64138802","B":"FILLER BONE 90-300-251008","C":"278","D":"C1713","F":"4194.342"},{"Policy Line":"64138803","B":"WITTMAN PATCH EWP2040","C":"278","D":"C1781","F":"2943.414"},{"Policy Line":"64138804","B":"SPINAL CORD STIMULATOR KIT","C":"278","F":"20406.222","G":"**"},{"Policy Line":"64138805","B":"CAGE RISE 10X22MM 193.141","C":"278","F":"6192.522"},{"Policy Line":"64138806","B":"Access Platform Gelpoint Advan","C":"272","F":"821.916","G":"**"},{"Policy Line":"64138807","B":"Access Platform Gelpoint Mini","C":"272","F":"726.75","G":"**"},{"Policy Line":"64138808","B":"Access Platform Gelpnt Transan","C":"272","F":"906.984","G":"**"},{"Policy Line":"64138809","B":"EXPANDER TISSUE TEXP120RH","C":"278","F":"2531.844"},{"Policy Line":"64138810","B":"KIT QUICKSET 16CC ABS-3016","C":"278","F":"4136.202"},{"Policy Line":"64138811","B":"CAGE PEEK 1124.1232","C":"278","F":"6192.522"},{"Policy Line":"64138812","B":"CAGE PEEK 10X36MM 1124.1212","C":"278","F":"6192.522"},{"Policy Line":"64138813","B":"BUTTON TIGHTROPE AR-1588TB","C":"278","F":"313.344"},{"Policy Line":"64138814","B":"VALVE HEART SOLO 21MM ICV1247","C":"278","F":"5612.04"},{"Policy Line":"64138815","B":"CABLE MONITORING 38-STIM","C":"272","F":"414.936"},{"Policy Line":"64138816","B":"LIGHTSOURCE DISPO 38-LIGHT-1","C":"272","F":"458.694"},{"Policy Line":"64138817","B":"TIGHTROPE KNOTLESS AR-8926SS","C":"278","F":"1531.224"},{"Policy Line":"64138818","B":"KIT SUTURE APEX AR-7298","C":"278","F":"696.15","G":"**"},{"Policy Line":"64138819","B":"STEM HUMERAL AR-9100-07S","C":"278","D":"C1776","F":"5771.466"},{"Policy Line":"64138820","B":"CAGE PEEK 10X26MM 1124.1033","C":"278","F":"6192.522"},{"Policy Line":"64138821","B":"EPIFIX 6.0X16.0CM XL-5616","C":"278","D":"Q4186","F":"7571.052"},{"Policy Line":"64138822","B":"TSH MOLD,CEMENT SPACER","C":"272","F":"1399.95"},{"Policy Line":"64138823","B":"CAGE EXPANDABLE","C":"278","F":"5612.04"},{"Policy Line":"64138824","B":"CAGE CERVICAL 1124.1032","C":"278","F":"6192.522"},{"Policy Line":"64138825","B":"PROBE CRYO-ABLATION CRY03","C":"272","F":"2815.2","G":"**"},{"Policy Line":"64138826","B":"CAGE 10X31MM 9-13MM 1124.1132","C":"278","F":"6492.096","G":"**"},{"Policy Line":"64138827","B":"GRAFT NERVE AVANCE 411270","C":"278","F":"4564.908","G":"**"},{"Policy Line":"64138828","B":"CABLE 1X16 OR SC-4116","C":"272","F":"477.666","G":"**"},{"Policy Line":"64138829","B":"ALLODERM 9.6X19.3CM CM1516","C":"278","D":"Q4116","F":"4396.302","G":"**"},{"Policy Line":"64138830","B":"Generator,NeurostimMRI Implan","C":"278","D":"C1820","F":"13694.418"},{"Policy Line":"64138832","B":"DEVICE SUTURING FB-101-01","C":"272","F":"636.786"},{"Policy Line":"64138833","B":"PROGRAMMER PNT NEUROSTIM 3853","C":"272","D":"C1787","F":"891.684"},{"Policy Line":"64138836","B":"VALVE, SAPIEN TAVR","C":"278","F":"32967.828","G":"**"},{"Policy Line":"64138837","B":"GUIDEWIRE, WIRE Y","C":"272","F":"477.666"},{"Policy Line":"64138838","B":"GRAFT ENDOVASCULAR AAA GRP2","C":"278","F":"10924.2","G":"**"},{"Policy Line":"64138839","B":"GEN NEUROST RECHRG DBS ACTIVA","C":"278","D":"C1820","F":"22316.58","G":"**"},{"Policy Line":"64138840","B":"BIPOLAR TRIGGER 130401019A","C":"272","F":"1023.876"},{"Policy Line":"64138841","B":"COMPONENT HUMERAL 130720103","C":"278","D":"C1776","F":"5777.28"},{"Policy Line":"64138842","B":"CAGE CERVICAL 10X22MM 193.111","C":"278","F":"6192.522"},{"Policy Line":"64138843","B":"CATH GUIDE 8F 54CM ACUITY 7069","C":"272","D":"C1887","F":"566.712"},{"Policy Line":"64138844","B":"COVER, LOCK SPINE","C":"278","F":"281.52"},{"Policy Line":"64138845","B":"CAP,PIN","C":"272","F":"78.336"},{"Policy Line":"64138846","B":"KIT REVISION, INTRATHECAL CATH","C":"272","F":"639.846"},{"Policy Line":"64138847","B":"PUMP BALLOON, FIBER OPTIC","C":"272","F":"1324.98","G":"**"},{"Policy Line":"64138848","B":"LOOP RETRO BUTTON FIXATN DEV","C":"278","F":"534.582"},{"Policy Line":"64138849","B":"REAMER, CANNULATED GRP 1","C":"272","F":"312.12","G":"**"},{"Policy Line":"64138850","B":"ENDO PROSTHESIS COVRD W/ DEL V","C":"278","D":"C1874","F":"3444.03","G":"**"},{"Policy Line":"64138851","B":"CATHETER ANGIOGRAPHIC MUSTANG","C":"272","D":"C1725","F":"390.15","G":"**"},{"Policy Line":"64138852","B":"AAA Endoprosthesis Excluder","C":"278","F":"10904.922","G":"**"},{"Policy Line":"64138853","B":"CLIP,RAVINE LAT ACCESS SYS","C":"272","F":"724.302","G":"**"},{"Policy Line":"64138854","B":"Screw Spine,Pedicle 6.0","C":"278","D":"C1713","F":"2700.144"},{"Policy Line":"64138855","B":"Blade, Helical TFN","C":"278","D":"C1713","F":"1117.818","G":"**"},{"Policy Line":"64138856","B":"REAMER, CANNULATED GRP 2","C":"272","F":"740.214","G":"**"},{"Policy Line":"64138857","B":"Sealant, Progel","C":"272","F":"1087.83","G":"**"},{"Policy Line":"64138858","B":"Screw Grp 9","C":"278","D":"C1713","F":"2091.204","G":"**"},{"Policy Line":"64138859","B":"Screw Grp 10","C":"278","D":"C1713","F":"2340.9","G":"**"},{"Policy Line":"64138860","B":"Screw Grp 11","C":"278","D":"C1713","F":"2715.444","G":"**"},{"Policy Line":"64138861","B":"Screw Grp 12","C":"278","D":"C1713","F":"2965.14"},{"Policy Line":"64138862","B":"Screw Grp 13","C":"278","D":"C1713","F":"3277.26"},{"Policy Line":"64138863","B":"CONNECTOR,NERVE PORCINE ECM","C":"278","F":"1631.898","G":"**"},{"Policy Line":"64138864","B":"PIN,STEINMAN","C":"272","F":"14.382","G":"**"},{"Policy Line":"64138865","B":"GUIDE,NERVE INTEGRA","C":"278","D":"C9352","F":"1725.228"},{"Policy Line":"64138866","B":"STEM,HUMERAL ARTHREX","C":"278","D":"C1776","F":"6055.128"},{"Policy Line":"64138867","B":"KIT ACCESS. RP BOOTS DBS","C":"272","F":"174.726"},{"Policy Line":"64138868","B":"KIT COMPLEX FUSION,SPINE","C":"278","D":"C1713","F":"2592.738"},{"Policy Line":"64138869","B":"GUIDE PIN","C":"272","F":"124.848","G":"**"},{"Policy Line":"64138870","B":"NAIL, VALOR 10X150","C":"278","D":"C1713","F":"4150.89"},{"Policy Line":"64138871","B":"WAND,TURBO,REDUCTION ENT","C":"272","F":"323.442","G":"**"},{"Policy Line":"64138872","B":"STEM HUMERAL ARTHREX UNIVERSE","C":"278","D":"C1776","F":"6055.128"},{"Policy Line":"64138873","B":"CATH -OFF-ROAD REENTRY","C":"272","D":"C1725","F":"2739.006"},{"Policy Line":"64138874","B":"NEEDLE CURVED,SPEED CINCH","C":"272","F":"723.078"},{"Policy Line":"64138875","B":"ABS,IMPLANT,TIGHTRPE AR-1588TN","C":"278","F":"418.608"},{"Policy Line":"64138876","B":"GUIDE PIN W/REAMERS","C":"272","F":"739.908","G":"**"},{"Policy Line":"64138877","B":"INTERLLAMINER IMPLANT","C":"278","D":"C1821","F":"5901.21"},{"Policy Line":"64138878","B":"KIT OCTAPOLAR, DBS","C":"272","F":"238.68"},{"Policy Line":"64138879","B":"IMPLANT SHOULDER REVERSE","C":"278","D":"C1776","F":"7100.73","G":"**"},{"Policy Line":"64138880","B":"ELECTRODE DISP GRP 3","C":"272","F":"780.3"},{"Policy Line":"64138881","B":"LEAD,EXTNSN, NEUROSTIM","C":"278","D":"C1883","F":"1084.77"},{"Policy Line":"64138882","B":"WAND, MULTIVAC ENT","C":"272","F":"412.182"},{"Policy Line":"64138883","B":"NEEDLE GRP 3","C":"272","F":"749.088","G":"**"},{"Policy Line":"64138884","B":"STENT BILIARY GRP 2","C":"278","D":"C1876","F":"1872.72"},{"Policy Line":"64138885","B":"STENT BILIARY GRP 4","C":"278","D":"C1876","F":"3121.2"},{"Policy Line":"64138886","B":"STENT BILIARY GRP 3","C":"278","D":"C1876","F":"2340.9"},{"Policy Line":"64138887","B":"FUSION,CERVICAL CONSTRUCT","C":"278","D":"C1713","F":"4666.194"},{"Policy Line":"64138888","B":"Non-Charge Surg Supply","C":"270","F":"0"},{"Policy Line":"64138889","B":"REAMER ORTHO GRP 2","C":"272","F":"780.3","G":"**"},{"Policy Line":"64138890","B":"IMPNT-BLADE,HELICAL TFN","C":"278","D":"C1713","F":"1117.818"},{"Policy Line":"64138891","B":"KIT,ACL ALL INSIDE ARTHREX","C":"272","F":"873.936"},{"Policy Line":"64138893","B":"Cath Angio non laser DCB Grp 1","C":"278","D":"C2623","F":"1906.686","G":"**"},{"Policy Line":"64138894","B":"Cath Angio non laser DCB Grp 2","C":"272","D":"C2623","F":"2184.84"},{"Policy Line":"64138895","B":"Epifix 6.5x16","C":"278","D":"Q4186","F":"8057.592"},{"Policy Line":"64138896","B":"KIT,KYPHON,BILAT DIR","C":"278","F":"2809.08"},{"Policy Line":"64138897","B":"Stem, Femoral Depuy","C":"278","D":"C1776","F":"7927.848"},{"Policy Line":"64138898","B":"Graft Bone Substitute 16cc","C":"278","D":"C1713","F":"5381.622"},{"Policy Line":"64138900","B":"Pack,Cath/Sheath ClosureFast","C":"272","F":"927.792","G":"**"},{"Policy Line":"64138901","B":"Stent nonCoa/Cov w/del GRP I","C":"278","D":"C1876","F":"1337.832","G":"**"},{"Policy Line":"64138902","B":"Kit Vertebroplasty","C":"272","F":"1663.722"},{"Policy Line":"64138903","B":"Nail, Ortho Grp 8","C":"278","D":"C1713","F":"2809.08","G":"**"},{"Policy Line":"64138905","B":"Inserter Tip Articular Surface","C":"272","F":"248.472"},{"Policy Line":"64138906","B":"System Illumination, Spine","C":"272","F":"2116.908","G":"**"},{"Policy Line":"64138907","B":"Bit Drill Grp","C":"272","F":"39.168","G":"**"},{"Policy Line":"64138908","B":"PUNCH DISP","C":"272","F":"432.99"},{"Policy Line":"64138909","B":"Bone Graft Sub Bead Kit 25cc","C":"278","D":"C1713","F":"1324.674"},{"Policy Line":"64138910","B":"Valve Heart Perceval LRG","C":"278","F":"9941.022"},{"Policy Line":"64138911","B":"Stent Trachea Coated w/Del Sys","C":"278","D":"C1874","F":"3130.686"},{"Policy Line":"64138912","B":"Endopros AAA, Excluder","C":"278","F":"11142.684","G":"**"},{"Policy Line":"64138913","B":"Fixation Device grp 2","C":"278","F":"738.684","G":"**"},{"Policy Line":"64138914","B":"Introducer/Sheath Grp 5","C":"272","D":"C1894","F":"1092.42"},{"Policy Line":"64138915","B":"Guidewire, Vascular","C":"272","D":"C1769","F":"25.704","G":"**"},{"Policy Line":"64138916","B":"VAD Catheter, Impella CP","C":"278","F":"25359.75","G":"**"},{"Policy Line":"64138917","B":"Arthroflex Allograft 4x7cm","C":"278","D":"Q4125","F":"3945.258","G":"**"},{"Policy Line":"64138918","B":"Cage Spinal Interbody Synfix","C":"278","F":"5874.282","G":"**"},{"Policy Line":"64138919","B":"Kit Maxcess4 XLIFT","C":"272","F":"2929.644"},{"Policy Line":"64138920","B":"Cage Spine Expandable","C":"278","F":"5021.46","G":"**"},{"Policy Line":"64138921","B":"Injector Graft/ Luna 360 Cage","C":"272","F":"573.138","G":"**"},{"Policy Line":"64138922","B":"Kit Accessory Benvenue Spine","C":"272","F":"1996.344"},{"Policy Line":"64138923","B":"Paste DBM Orthoblast","C":"278","D":"C1713","F":"289.17","G":"**"},{"Policy Line":"64138925","B":"Surgicel Snow Dressing","C":"272","F":"201.96","G":"**"},{"Policy Line":"64138926","B":"Cage Cervical Amendia","C":"278","F":"5579.298"},{"Policy Line":"64138927","B":"Fiberloop w/Fiber Tag&Needle","C":"272","F":"284.58"},{"Policy Line":"64138928","B":"Intralaminar Fusion Device sz8","C":"278","F":"6086.34"},{"Policy Line":"64138929","B":"Stent Innova Nonct/cv w/del","C":"278","D":"C1876","F":"2753.694"},{"Policy Line":"64138930","B":"Cage FlxFit 9mm AT0909","C":"278","F":"5883.462"},{"Policy Line":"64138931","B":"Adherus Dural Sealant","C":"272","F":"959.922","G":"**"},{"Policy Line":"64138932","B":"Drill Bit 2.4mm NAV2075","C":"272","F":"1663.722","G":"**"},{"Policy Line":"64138933","B":"Kit Dilators - Spine","C":"272","F":"695.844","G":"**"},{"Policy Line":"64138934","B":"Stent Coated W/Deliv Grp 1","C":"278","D":"C1874","F":"2296.836"},{"Policy Line":"64138935","B":"Stent Coated w/Del Sys Grp 2","C":"278","D":"C1874","F":"2552.958"},{"Policy Line":"64138936","B":"NAIL VALOR 150 to 200MM","C":"278","D":"C1713","F":"4151.196","G":"**"},{"Policy Line":"64138937","B":"Spacer,Global Shou Monoblock","C":"278","D":"C1776","F":"1648.422"},{"Policy Line":"64138938","B":"Putty Human Tissue - Propel","C":"278","F":"1593.036"},{"Policy Line":"64138939","B":"Dialysis Access Sys Implant","C":"278","D":"C1881","F":"477.666"},{"Policy Line":"64138940","B":"THR-Taper Adapt Fem","C":"278","D":"C1776","F":"77.418"},{"Policy Line":"64138941","B":"Endoprosthesis AAA,Thorac Prox","C":"278","F":"18761.166"},{"Policy Line":"64138942","B":"Stent Ncoa/Ncov w/Del Grp 2","C":"278","D":"C1876","F":"1695.546"},{"Policy Line":"64138943","B":"Segment Fibula Allograft","C":"278","F":"863.532"},{"Policy Line":"64138945","B":"Spinal Cage Expandable","C":"278","F":"5883.462","G":"**"},{"Policy Line":"64138946","B":"Spinal Cage/Spacer Grp 9","C":"278","F":"5118.768","G":"**"},{"Policy Line":"64138947","B":"GRAFT MITROFLOW CONDUIT 28MM","C":"278","F":"2687.292"},{"Policy Line":"64138948","B":"Cannula, Spine Precis","C":"272","F":"636.786"},{"Policy Line":"64138949","B":"BLADE DISPOSABLE GRP 3","C":"272","F":"468.18","G":"**"},{"Policy Line":"64138950","B":"NAIL, ORTHO GRP 9","C":"278","D":"C1713","F":"3277.26","G":"**"},{"Policy Line":"64138951","B":"Manual Distractor MMD-003","C":"272","F":"639.846"},{"Policy Line":"64138952","B":"Guide Cath Omni Flush","C":"272","D":"C1887","F":"24.786","G":"**"},{"Policy Line":"64138953","B":"Fiberloop #4 Ar-7229","C":"272","F":"96.696"},{"Policy Line":"64138954","B":"Lead Extension Neurostim 55cm","C":"278","D":"C1883","F":"1113.228"},{"Policy Line":"64138955","B":"Plate 10mm 2 hole","C":"278","D":"C1713","F":"5376.42","G":"**"},{"Policy Line":"64138956","B":"Low Cost Screw Grp - 1","C":"278","D":"C1713","F":"17.136"},{"Policy Line":"64138957","B":"Low Cost Screw Grp - 2","C":"278","D":"C1713","F":"29.682"},{"Policy Line":"64138958","B":"Low Cost Screw Grp - 3","C":"278","D":"C1713","F":"35.802","G":"**"},{"Policy Line":"64138959","B":"Low Cost Screw Grp - 4","C":"278","D":"C1713","F":"43.758","G":"**"},{"Policy Line":"64138960","B":"Low Cost Screw Grp 5","C":"278","D":"C1713","F":"52.938","G":"**"},{"Policy Line":"64138961","B":"Low Cost Screw Grp 6","C":"278","D":"C1713","F":"62.424","G":"**"},{"Policy Line":"64138962","B":"Low Cost Screw Grp 7","C":"278","D":"C1713","F":"74.97","G":"**"},{"Policy Line":"64138963","B":"Low Cost Screw Grp 8","C":"278","D":"C1713","F":"84.15","G":"**"},{"Policy Line":"64138964","B":"Low Cost Screw Grp 9","C":"278","D":"C1713","F":"96.696","G":"**"},{"Policy Line":"64138965","B":"Low Cost Screw Grp 10","C":"278","D":"C1713","F":"109.242","G":"**"},{"Policy Line":"64138966","B":"Device Interllaminer Grp 1","C":"278","D":"C1821","F":"3178.116"},{"Policy Line":"64138967","B":"Component Femoral 71421165","C":"278","D":"C1776","F":"7016.58"},{"Policy Line":"64138968","B":"Pin Guide 98-8500-000-01","C":"272","F":"1215.738","G":"**"},{"Policy Line":"64138969","B":"Button insert AR-2262","C":"272","F":"222.768"},{"Policy Line":"64138970","B":"Stratafix Knotless Device","C":"272","F":"53.856","G":"**"},{"Policy Line":"64138971","B":"Dermabond/Prineo","C":"272","F":"146.88"},{"Policy Line":"64138972","B":"Plug Rod 5.5 2000-1005","C":"278","F":"96.696"},{"Policy Line":"64138973","B":"Algrft Amniotic Fluid 1.0ml","C":"278","F":"2637.414"},{"Policy Line":"64138975","B":"Neurostim Lead Kit CoveredgeX","C":"278","D":"C1778","F":"4590.306","G":"**"},{"Policy Line":"64138976","B":"Shunt Valve Adjust","C":"278","F":"5111.73"},{"Policy Line":"64138977","B":"Router Str 1.1mm","C":"272","F":"184.212"},{"Policy Line":"64138978","B":"Wand Lapro 90 Right","C":"272","F":"262.548"},{"Policy Line":"64138979","B":"Wound Retractor Grp 1","C":"272","F":"109.242","G":"**"},{"Policy Line":"64138980","B":"Wound Retractor Grp 2","C":"272","F":"171.666","G":"**"},{"Policy Line":"64138981","B":"Device Secure Safeguard 82000","C":"278","F":"135.558"},{"Policy Line":"64138982","B":"Tip Yankauer Vue","C":"272","F":"308.754","G":"**"},{"Policy Line":"64138983","B":"Knot Pusher MI-KP-001","C":"272","F":"398.106"},{"Policy Line":"64138984","B":"Prosthesis Breast Implnt Grp 5","C":"278","D":"C1789","F":"1966.356"},{"Policy Line":"64138985","B":"Prosthesis Breast Implnt Grp 6","C":"278","D":"C1789","F":"2559.384"},{"Policy Line":"64138986","B":"Suture Belt MI-ISBA-001","C":"272","F":"159.12","G":"**"},{"Policy Line":"64138987","B":"Cage Peek 10MM AT0910","C":"278","F":"5883.462"},{"Policy Line":"64138988","B":"Tot Shoulder Cap Price Depuy","C":"278","D":"C1776","F":"5782.176"},{"Policy Line":"64138989","B":"Spine-Cage Lock","C":"278","F":"1599.768"},{"Policy Line":"64138990","B":"Cage ALIF","C":"278","F":"6380.406"},{"Policy Line":"64138991","B":"Kit Endo Pushlok","C":"272","F":"451.044","G":"**"},{"Policy Line":"64138992","B":"Cannula Split","C":"272","F":"414.018"},{"Policy Line":"64138993","B":"Pusher Knot Curved","C":"272","F":"247.248"},{"Policy Line":"64138994","B":"Tube GI Grp 3","C":"278","F":"268.362","G":"**"},{"Policy Line":"64138995","B":"Tube GI Grp 4","C":"278","F":"299.574","G":"**"},{"Policy Line":"64138996","B":"Tube Esophageal,Blakemore","C":"278","F":"593.028"},{"Policy Line":"64138997","B":"Kit Disp Instru PFF0001","C":"272","D":"C1769","F":"2536.128"},{"Policy Line":"64138998","B":"Skin Sub - Amniotic Cord 3x6","C":"278","D":"Q4100","F":"3159.45","G":"**"},{"Policy Line":"64138999","B":"Adapter Hip Mold 431188","C":"272","F":"676.26"},{"Policy Line":"64139000","B":"Bowl Mixing w/ del sys","C":"272","F":"373.932","G":"**"},{"Policy Line":"64139001","B":"Spacer Mold 431181","C":"272","F":"2158.524","G":"**"},{"Policy Line":"64139002","B":"STENT PROMUS PREMIER","C":"278","D":"C1874","F":"1599.768"},{"Policy Line":"64139004","B":"Gen NeurostimNoRechrg Proclaim","C":"278","D":"C1767","F":"14460.03","G":"**"},{"Policy Line":"64139005","B":"GRAFT ENDOVASCULAR AAA GRP1","C":"278","F":"10118.196","G":"**"},{"Policy Line":"64139006","B":"IMPL JT:HeadRadial ALN-RHI-220","C":"278","D":"C1776","F":"3007.368","G":"**"},{"Policy Line":"64139007","B":"PATCH TUTO 8x14cm","C":"278","F":"390.15","G":"**"},{"Policy Line":"64139008","B":"KIT SCP KNEE","C":"278","D":"C1713","F":"3828.978","G":"**"},{"Policy Line":"64139009","B":"IMPLANTABLE RECHARGE NEUROSTIM","C":"278","D":"C1820","F":"19019.736"},{"Policy Line":"64139010","B":"STERNALOCK SYSTEM","C":"278","D":"C1713","F":"4294.71"},{"Policy Line":"64139011","B":"Kit Accessory Luna 3D Spine","C":"272","F":"1996.344","G":"**"},{"Policy Line":"64139012","B":"CATHETER IVUS Eagle Eye","C":"272","D":"C1753","F":"1087.83"},{"Policy Line":"64139013","B":"Graft Vascular Grp 6 B","C":"278","D":"C1768","F":"1716.66"},{"Policy Line":"64139014","B":"Graft Vascular Grp 10","C":"278","D":"C1768","F":"2809.08"},{"Policy Line":"64139015","B":"Graft Vascular Grp 11","C":"278","D":"C1768","F":"3121.2"},{"Policy Line":"64139016","B":"Graft Vascular Grp 12","C":"278","D":"C1768","F":"3433.32"},{"Policy Line":"64139017","B":"Wire Ortho Low Cost Grp 1","C":"272","F":"55.692","G":"**"},{"Policy Line":"64139018","B":"Bolt Iliac","C":"278","F":"1791.63"},{"Policy Line":"64139019","B":"Wrap Amniofix TN-5220","C":"278","F":"872.406"},{"Policy Line":"64139020","B":"Spine Pedicle Access Kit","C":"272","F":"373.932","G":"**"},{"Policy Line":"64139021","B":"Pin Guide; Femoral","C":"272","F":"636.786","G":"**"},{"Policy Line":"64139022","B":"Generator CRT-D Dynagen G151","C":"275","D":"C1882","F":"19780.758"},{"Policy Line":"64139023","B":"Suture Anchor Speedbridge","C":"278","D":"C1713","F":"1220.328","G":"**"},{"Policy Line":"64139024","B":"Button Tightrope; Anchor","C":"278","D":"C1713","F":"509.49","G":"**"},{"Policy Line":"64139025","B":"KIT PNT TRIAL,NEUROSTIM GRP 1","C":"272","F":"135.558"},{"Policy Line":"64139026","B":"Pack ACL Autogrft,Graftlink","C":"278","D":"C1713","F":"1547.136","G":"**"},{"Policy Line":"64139027","B":"Sys Spine Fusion/Fixxatn","C":"278","F":"2552.958"},{"Policy Line":"64139028","B":"AICD, Single Emblem","C":"275","D":"C1722","F":"20287.8"},{"Policy Line":"64139029","B":"Lead S-ICD Emblem","C":"275","D":"C1896","F":"4057.56"},{"Policy Line":"64139030","B":"Cap for Screw","C":"278","D":"C1713","F":"477.666"},{"Policy Line":"64139031","B":"Spine Cage Lateral","C":"278","F":"7608.078"},{"Policy Line":"64139032","B":"Spine Shim Lateral","C":"278","F":"238.68"},{"Policy Line":"64139033","B":"Drill Bit Lag Screw","C":"272","F":"1023.876","G":"**"},{"Policy Line":"64139034","B":"Pin Guide","C":"272","F":"376.992","G":"**"},{"Policy Line":"64139035","B":"Gen NeuroStim NonRechr Prime","C":"278","D":"C1767","F":"13187.376"},{"Policy Line":"64139036","B":"PLATE OCCIPITAL ADJ","C":"278","D":"C1713","F":"5467.302"},{"Policy Line":"64139037","B":"Valve Aortic Supra Annular","C":"278","F":"3854.682"},{"Policy Line":"64139038","B":"Tap, Spine Vertex","C":"272","F":"1919.538"},{"Policy Line":"64139039","B":"Kit Spinal Fusion Dtrax","C":"272","F":"1087.83"},{"Policy Line":"64139040","B":"Videoscpe, Disposable","C":"272","F":"450.738","G":"**"},{"Policy Line":"64139041","B":"External Fixator Cmpnts Grp 7","C":"272","F":"2059.992"},{"Policy Line":"64139042","B":"External Fixator Cmpnts Grp 8","C":"272","F":"2372.112"},{"Policy Line":"64139043","B":"Fixator External","C":"272","F":"3413.736"},{"Policy Line":"64139044","B":"Ext Fixn Implants Grp1","C":"278","D":"C1713","F":"62.424"},{"Policy Line":"64139045","B":"Ext Fixn Implants Grp 2","C":"278","D":"C1713","F":"174.726","G":"**"},{"Policy Line":"64139046","B":"Ext Fixn Implants Grp 3","C":"278","D":"C1713","F":"218.484"},{"Policy Line":"64139047","B":"Ext Fixn Implants Grp 4","C":"278","D":"C1713","F":"280.908"},{"Policy Line":"64139048","B":"Ext Fixn Implants Grp 5","C":"278","D":"C1713","F":"374.544","G":"**"},{"Policy Line":"64139049","B":"Ext Fixn Implants Grp 6","C":"278","D":"C1713","F":"468.18"},{"Policy Line":"64139050","B":"Ext Fixn Implants Grp 7","C":"278","D":"C1713","F":"624.24"},{"Policy Line":"64139051","B":"Ext Fixn Implants Grp 8","C":"278","D":"C1713","F":"936.36"},{"Policy Line":"64139052","B":"Ext Fixn Implants Grp 9","C":"278","D":"C1713","F":"1248.48"},{"Policy Line":"64139053","B":"Ext Fixn Implants Grp 10","C":"278","D":"C1713","F":"1560.6","G":"**"},{"Policy Line":"64139054","B":"Ext Fixn Implants Grp 11","C":"278","D":"C1713","F":"1872.72"},{"Policy Line":"64139055","B":"Gen Neuro nonHF Recharge","C":"278","D":"C1820","F":"17549.1","G":"**"},{"Policy Line":"64139056","B":"Anchor Spine Coalition","C":"278","F":"636.786"},{"Policy Line":"64139057","B":"SUTURE SPEEDSTITCH","C":"272","F":"154.836","G":"**"},{"Policy Line":"64139058","B":"KIT CHARGE","C":"272","F":"1616.292","G":"**"},{"Policy Line":"64139059","B":"KIT IPG","C":"278","D":"C1822","F":"16916.904","G":"**"},{"Policy Line":"64139060","B":"VALVE HEART AORTIC MED PVS23","C":"278","F":"9941.022"},{"Policy Line":"64139061","B":"STENT INNOVA","C":"278","D":"C1876","F":"3135.276"},{"Policy Line":"64139062","B":"PIN REDUCTION","C":"272","F":"671.976"},{"Policy Line":"64139063","B":"Algrft Memb Amniotic 4x8cm","C":"278","F":"4052.358"},{"Policy Line":"64139064","B":"Algrft Memb Amniotic 2x4cm","C":"278","F":"3192.804"},{"Policy Line":"64139065","B":"Tiss Transfer Sys Lipogem","C":"272","F":"2552.958"},{"Policy Line":"64139066","B":"Primatrix Meshed Implant","C":"278","D":"Q4110","F":"11863.62"},{"Policy Line":"64139067","B":"Balloon Solopath Access","C":"272","D":"C1894","F":"985.32"},{"Policy Line":"64139068","B":"VASC CLSR-Perclose A-T","C":"278","D":"C1760","F":"363.528","G":"**"},{"Policy Line":"64139069","B":"Valve Heart Grp 4","C":"278","F":"6999.444","G":"**"},{"Policy Line":"64139070","B":"Plug Vascular","C":"278","F":"1064.574"},{"Policy Line":"64139071","B":"Graft Nerve Avanc 70MM","C":"278","F":"4894.47","G":"**"},{"Policy Line":"64139072","B":"Clamp Trauma Fixation","C":"272","F":"925.344"},{"Policy Line":"64139073","B":"Clip Aneurysm Grp 4","C":"278","F":"764.082"},{"Policy Line":"64139074","B":"Pin External Fixatn 150,250MM","C":"278","D":"C1713","F":"174.42","G":"**"},{"Policy Line":"64139075","B":"Fixation Device Post 30Deg","C":"278","D":"C1713","F":"175.338"},{"Policy Line":"64139076","B":"Graft Nerve Repair","C":"278","F":"2459.934"},{"Policy Line":"64139077","B":"Pin External Fixation 300MM","C":"278","D":"C1713","F":"183.294","G":"**"},{"Policy Line":"64139078","B":"Strut Cortical 1.5x10.0cm","C":"278","F":"799.578"},{"Policy Line":"64139079","B":"Plasma Scalpel 85MM","C":"272","F":"698.598"},{"Policy Line":"64139080","B":"System Oscar Cement Removal","C":"272","F":"1919.538","G":"**"},{"Policy Line":"64139081","B":"Kit Prevena Incision Mgmt Sys","C":"278","F":"787.644","G":"**"},{"Policy Line":"64139082","B":"Ablator Aspiration AR-9811","C":"272","F":"372.708","G":"**"},{"Policy Line":"64139083","B":"Pin Exchange 3.2MM 500375","C":"272","F":"164.016","G":"**"},{"Policy Line":"64139084","B":"Implant Ifuse SI JOINT FUSN","C":"278","D":"C1713","F":"3079.584","G":"**"},{"Policy Line":"64139086","B":"IMPLANT MXL 8083424","C":"278","F":"6847.056"},{"Policy Line":"64139087","B":"STEM FEMORAL","C":"278","D":"C1776","F":"6501.582"},{"Policy Line":"64139088","B":"Algrft Valv Pulm Conduit6-32mm","C":"278","F":"19562.58"},{"Policy Line":"64139089","B":"Filter, Vena Cava-Cook","C":"278","D":"C1880","F":"1663.722"},{"Policy Line":"64139090","B":"Graft Endo TGU282810","C":"278","F":"16483.608"},{"Policy Line":"64139091","B":"Retriever Vascular Vrs-6.0-90","C":"272","D":"C1773","F":"754.902","G":"**"},{"Policy Line":"64139092","B":"Implant Crani Custom","C":"278","F":"15898.536"},{"Policy Line":"64139093","B":"Drill Bit Cannulated","C":"272","F":"1261.638","G":"**"},{"Policy Line":"64139094","B":"Cath Angio VTEK","C":"272","F":"40.392","G":"**"},{"Policy Line":"64139095","B":"Snare En 18-30","C":"278","D":"C1773","F":"596.7","G":"**"},{"Policy Line":"64139096","B":"Stent Self Expand 1012529-80","C":"278","D":"C1876","F":"927.486"},{"Policy Line":"64139097","B":"Ring Annuloplasty Tricuspidl","C":"278","F":"2789.496","G":"**"},{"Policy Line":"64139098","B":"End Cap,VBR Spacer","C":"278","F":"3094.578"},{"Policy Line":"64139099","B":"Cap Certex Spinal Screw","C":"278","F":"703.8"},{"Policy Line":"64139100","B":"Kit Swivelock Disp","C":"272","F":"625.464","G":"**"},{"Policy Line":"64139101","B":"CAGE EXPANDABLE","C":"278","F":"10708.776","G":"**"},{"Policy Line":"64139102","B":"Cage 3D expandalbe 14mm8degree","C":"278","F":"5021.154"},{"Policy Line":"64139103","B":"Valve Aortic PTFE ONXAAP-2_","C":"278","F":"7608.078"},{"Policy Line":"64139104","B":"Probe Neuro","C":"272","F":"477.666"},{"Policy Line":"64139105","B":"IMPL NS Kit Lead Adaptor 25cm","C":"278","D":"C1883","F":"642.906"},{"Policy Line":"64139106","B":"Sealant Dural w/Appl","C":"272","F":"1017.144","G":"**"},{"Policy Line":"64139107","B":"Implant NS Lead Attain","C":"278","D":"C1778","F":"6603.48","G":"**"},{"Policy Line":"64139108","B":"Wand Hipvac 50","C":"272","F":"1022.346","G":"**"},{"Policy Line":"64139109","B":"Flowport CAT01549","C":"272","F":"628.524"},{"Policy Line":"64139110","B":"Stent Endopros Tracheobronch","C":"278","D":"C1876","F":"1215.738"},{"Policy Line":"64139111","B":"Stent Endopros Wall","C":"278","D":"C1876","F":"1215.432"},{"Policy Line":"64139112","B":"IMPLANT HIP HELICAL GRP 2","C":"278","D":"C1713","F":"1183.608"},{"Policy Line":"64139113","B":"NS Lead Penta 3mm 60cm","C":"278","D":"C1778","F":"6847.056"},{"Policy Line":"64139114","B":"Probe, Cautery Spine","C":"272","F":"596.7"},{"Policy Line":"64139117","B":"Cage Corpectomy","C":"278","F":"6350.112"},{"Policy Line":"64139118","B":"Cinch Meniscal","C":"272","F":"649.332","G":"**"},{"Policy Line":"64139119","B":"Clamp External Fixator","C":"272","F":"746.028","G":"**"},{"Policy Line":"64139120","B":"Stent Periph wDel 6x40x125","C":"278","D":"C1874","F":"1503.378"},{"Policy Line":"64139121","B":"Microcath Supercross 5303","C":"272","D":"C1887","F":"708.084"},{"Policy Line":"64139122","B":"Kit Cranial Access INS-HITH","C":"272","F":"597.312"},{"Policy Line":"64139123","B":"GudeWire Viper VPR-GW-FT14","C":"272","D":"C1769","F":"302.328","G":"**"},{"Policy Line":"64139124","B":"Wireguide Micro G50793","C":"272","D":"C1769","F":"257.958"},{"Policy Line":"64139125","B":"Guidewire Hydro HMW14300ST","C":"272","D":"C1769","F":"299.268"},{"Policy Line":"64139126","B":"Cath Vision IVUS 88901","C":"272","D":"C1753","F":"1471.554","G":"**"},{"Policy Line":"64139127","B":"Insert Lock 370002","C":"278","F":"78.642"},{"Policy Line":"64139128","B":"GuideWire Viper VPR-GW-200","C":"272","D":"C1769","F":"302.328"},{"Policy Line":"64139129","B":"Cement Spacer, Knee SPK0122","C":"278","F":"3487.176"},{"Policy Line":"64139130","B":"Wrap Amniofix TN-5460","C":"278","F":"2813.67"},{"Policy Line":"64139131","B":"Stent Endo AAA INT Iliac","C":"278","F":"3119.058"},{"Policy Line":"64139132","B":"VASC CLOSURE DEV-MYNX MX6721","C":"278","D":"C1760","F":"321.606","G":"**"},{"Policy Line":"64139133","B":"Shaft Driver Disp 7480741t","C":"272","F":"230.724","G":"**"},{"Policy Line":"64139134","B":"Stent Covered I-Cast","C":"278","D":"C1874","F":"3057.246"},{"Policy Line":"64139135","B":"STENT COVERED 85455","C":"278","D":"C1874","F":"3057.246"},{"Policy Line":"64139136","B":"Kit Access, Nuvasive","C":"272","F":"3550.518"},{"Policy Line":"64139137","B":"Kit Needle Spine 5001-90009-G1","C":"272","F":"477.666"},{"Policy Line":"64139138","B":"GRAFT LINK ACL FGL","C":"278","F":"2780.622","G":"**"},{"Policy Line":"64139140","B":"Drill Guide/Sleeve","C":"272","F":"178.398","G":"**"},{"Policy Line":"64139141","B":"Pack Graft Link AR-1588AL-CP","C":"278","D":"C1713","F":"1718.496","G":"**"},{"Policy Line":"64139142","B":"Interspace, Shoulder w/cement","C":"278","F":"4057.866"},{"Policy Line":"64139143","B":"PLUG CABLE 370004","C":"278","F":"82.926"},{"Policy Line":"64139144","B":"IMPL PIN DRILL 4.0 5023-6-150","C":"272","F":"158.202"},{"Policy Line":"64139145","B":"IMPL PIN DRILL 5.0 5018-5-250","C":"272","F":"179.01"},{"Policy Line":"64139146","B":"Endobutton 72202799","C":"278","F":"566.406","G":"**"},{"Policy Line":"64139147","B":"Tendon Gracilis 1976-39","C":"278","F":"2495.43","G":"**"},{"Policy Line":"64139148","B":"ScrewCann 12.5mm 10-P-12550-01","C":"278","D":"C1713","F":"6593.688"},{"Policy Line":"64139149","B":"ScrewCann 8.5mm 10-S08545-01","C":"278","D":"C1713","F":"4057.56"},{"Policy Line":"64139150","B":"Pin Fixatn Provisionl 71173585","C":"272","F":"807.534"},{"Policy Line":"64139151","B":"Cath Endovascular","C":"272","D":"C1757","F":"3037.968"},{"Policy Line":"64139152","B":"NS Tool Tunneling","C":"272","F":"160.65","G":"**"},{"Policy Line":"64139153","B":"Mesh Hernia, Parietex","C":"278","D":"C1751","F":"367.2"},{"Policy Line":"64139154","B":"Cath Dialys Chronc Sport Pack","C":"278","D":"C1750","F":"485.316","G":"**"},{"Policy Line":"64139155","B":"Implant Joint Grp 8A","C":"278","D":"C1776","F":"2216.052","G":"**"},{"Policy Line":"64139156","B":"Implant Joint Grp 8B","C":"278","D":"C1776","F":"2437.596","G":"**"},{"Policy Line":"64139157","B":"Implant Joint Grp 8C","C":"278","D":"C1776","F":"2684.232","G":"**"},{"Policy Line":"64139158","B":"JOINT STABILIZN SYS-PLATE BASE","C":"278","D":"C1713","F":"7445.592","G":"**"},{"Policy Line":"64139159","B":"PIN AXIS IJS-EAP-25452","C":"278","D":"C1713","F":"469.404","G":"**"},{"Policy Line":"64139160","B":"Cage Peek 9x26x11 5891255","C":"278","F":"6086.34","G":"**"},{"Policy Line":"64139161","B":"Dvice Occlsn Intraortic ICF100","C":"278","F":"3211.47","G":"**"},{"Policy Line":"64139162","B":"Intro Sheath 9FR IS19A","C":"272","F":"557.226","G":"**"},{"Policy Line":"64139163","B":"TKR-H Comp Fem Assem","C":"278","D":"C1776","F":"10079.946"},{"Policy Line":"64139164","B":"CHRGE SYSTM DBS Activa RC37651","C":"278","D":"C1820","F":"2687.292","G":"**"},{"Policy Line":"64139165","B":"CAGE VBR CS2250-12-16","C":"278","F":"9538.938"},{"Policy Line":"64139166","B":"Spine Clamp Lock","C":"278","F":"2536.128"},{"Policy Line":"64139167","B":"Spine Device Stable","C":"278","F":"3448.926"},{"Policy Line":"64139168","B":"Kypho Balln Cath INTVM","C":"272","F":"2799.594","G":"**"},{"Policy Line":"64139169","B":"ACID_GEN Dynagen VR Singl","C":"278","D":"C1722","F":"13389.948"},{"Policy Line":"64139170","B":"TSR Glenosphere ECC 42MM","C":"278","D":"C1776","F":"2268.684","G":"**"},{"Policy Line":"64139171","B":"PACK EPI-SENSE CDP-4330-5","C":"272","F":"12680.028","G":"**"},{"Policy Line":"64139172","B":"HANDPIECE EVS MICRO 23-121-1","C":"272","F":"850.986","G":"**"},{"Policy Line":"64139173","B":"CATH PORT GRP 3","C":"278","D":"C1788","F":"604.962","G":"**"},{"Policy Line":"64139174","B":"TUBE DRAINAGE CHEST PLEURA","C":"272","D":"C1729","F":"628.524","G":"**"},{"Policy Line":"64139175","B":"PLATELET PLASMA KIT AMS310","C":"272","F":"612.612","G":"**"},{"Policy Line":"64139176","B":"Trephine Extractor","C":"272","F":"1376.694"},{"Policy Line":"64139177","B":"SCS-Kit Trial 977DS26SYS","C":"278","F":"1407.6"},{"Policy Line":"64139178","B":"Latitude NXT Adapter Cellular","C":"272","F":"557.226"},{"Policy Line":"64139179","B":"VIVA CRT-P C6TR01","C":"275","D":"C2621","F":"8013.834"},{"Policy Line":"64139180","B":"CUSTOM IMP-iTotal Knee TPS","C":"278","D":"C1776","F":"5070.726"},{"Policy Line":"64139181","B":"VAD-Head Pump Blood","C":"272","F":"297.432"},{"Policy Line":"64139182","B":"Alloderm Tiss 2x4 Thick 102012","C":"278","D":"Q4116","F":"700.434"},{"Policy Line":"64139183","B":"Stent Polaris M00619214202","C":"278","D":"C2617","F":"280.602"},{"Policy Line":"64139184","B":"Cannula Ang H965251920","C":"272","F":"13187.07"},{"Policy Line":"64139185","B":"Thoracic Stent Graft","C":"278","F":"18760.86","G":"**"},{"Policy Line":"64139186","B":"Pacemaker DR Advisa A2DR01SYS","C":"275","D":"C1785","F":"5999.436"},{"Policy Line":"64139189","B":"BALLOON VIABAHN VBX 6X19MM","C":"278","F":"2594.574","G":"**"},{"Policy Line":"64139190","B":"SPACER ALIF SYNFIX EVOLUTION","C":"278","F":"5579.298","G":"**"},{"Policy Line":"64139191","B":"STENT BILIARY GPS MINI","C":"278","D":"C1876","F":"1087.83"},{"Policy Line":"64139192","B":"GUIDEWIRE VASC, TRANSEND","C":"272","D":"C1769","F":"787.644"},{"Policy Line":"64139193","B":"WAND COBLATION","C":"272","F":"768.978"},{"Policy Line":"64139194","B":"LEAD NEUROSTIM LINEAR","C":"278","D":"C1778","F":"2323.764"},{"Policy Line":"64139195","B":"BALLOON EXP VIABAHN VBX","C":"278","D":"C1874","F":"3621.204","G":"**"},{"Policy Line":"64139196","B":"Graft Stent Valiant Thoracic","C":"278","F":"18760.86"},{"Policy Line":"64139209","B":"Blade Disposable Grp 2","C":"272","F":"389.538","G":"**"},{"Policy Line":"64139210","B":"Stapler-Reloads Disp. Grp 1","C":"272","F":"128.826","G":"**"},{"Policy Line":"64139211","B":"Stapler-Reloads Disp. Grp 2","C":"272","F":"231.03","G":"**"},{"Policy Line":"64139212","B":"Stapler-Reloads Disp. Grp 3","C":"272","F":"357.408","G":"**"},{"Policy Line":"64139213","B":"Stapler-Reloads Disp. Grp 4","C":"272","F":"1026.018","G":"**"},{"Policy Line":"64139214","B":"Blade Disposable Grp 1","C":"272","F":"147.492","G":"**"},{"Policy Line":"64139215","B":"Plate Grp 7","C":"278","D":"C1713","F":"1713.294","G":"**"},{"Policy Line":"64139216","B":"Plate Grp 6","C":"278","D":"C1713","F":"1600.992","G":"**"},{"Policy Line":"64139217","B":"Probe Grp 1","C":"272","F":"332.01","G":"**"},{"Policy Line":"64139218","B":"Probe Grp 2","C":"272","F":"323.442","G":"**"},{"Policy Line":"64139219","B":"Probe Grp 3","C":"272","F":"761.634","G":"**"},{"Policy Line":"64139220","B":"Probe Grp 4","C":"272","F":"835.38","G":"**"},{"Policy Line":"64139238","B":"Cap Bone/Neuro Grp 1","C":"278","F":"161.568","G":"**"},{"Policy Line":"64139239","B":"Cap Bone/Neuro Grp 2","C":"278","F":"276.93","G":"**"},{"Policy Line":"64139240","B":"Cap Bone/Neuro Grp 3","C":"278","F":"286.11","G":"**"},{"Policy Line":"64139248","B":"Tissue Expander Grp 1","C":"278","D":"C1789","F":"809.37","G":"**"},{"Policy Line":"64139250","B":"Burr Hole Cover Grp 2","C":"278","F":"375.768","G":"**"},{"Policy Line":"64139251","B":"Aortic/Cardio Punch Grp 1","C":"272","F":"59.67"},{"Policy Line":"64139252","B":"Stent Endoprosthes Fluency Grp","C":"278","D":"C1874","F":"2994.21","G":"**"},{"Policy Line":"64139255","B":"Nail, Ortho Grp 1","C":"278","D":"C1713","F":"146.574"},{"Policy Line":"64139256","B":"Nail, Ortho Grp 2","C":"278","D":"C1713","F":"519.282","G":"**"},{"Policy Line":"64139257","B":"Nail, Ortho Grp 3","C":"278","D":"C1713","F":"1123.02","G":"**"},{"Policy Line":"64139258","B":"Nail, Ortho Grp 4","C":"278","D":"C1713","F":"1440.036","G":"**"},{"Policy Line":"64139259","B":"Nail, Ortho Grp 5","C":"278","D":"C1713","F":"1843.956","G":"**"},{"Policy Line":"64139260","B":"Tube Gi Grp 2","C":"278","F":"184.518","G":"**"},{"Policy Line":"64139265","B":"Ablator Grp","C":"272","F":"674.118"},{"Policy Line":"64139274","B":"Adapter","C":"272","F":"235.926","G":"**"},{"Policy Line":"64139275","B":"Adapter Grp 1","C":"272","F":"112.914"},{"Policy Line":"64139279","B":"Allograft Eye C1762 Grp 2","C":"278","D":"C1762","F":"893.52"},{"Policy Line":"64139280","B":"Tutoplast Pericardium 68250","C":"278","F":"437.886","G":"**"},{"Policy Line":"64139281","B":"Tissue Amniotic-per procedure","C":"278","D":"V2790","F":"949.824","G":"**"},{"Policy Line":"64139284","B":"Cath Central Venous Grp 2","C":"278","D":"C1751","F":"504.288","G":"**"},{"Policy Line":"64139286","B":"Allograft Orth/Neuro Grp 6","C":"278","F":"2004.912","G":"**"},{"Policy Line":"64139287","B":"Allograft Orth/Neuro Grp 5","C":"278","F":"1569.78","G":"**"},{"Policy Line":"64139288","B":"Allograft Orth/Neuro Grp 4","C":"278","F":"1227.672","G":"**"},{"Policy Line":"64139289","B":"Allograft Orth/Neuro Grp 3","C":"278","F":"813.348","G":"**"},{"Policy Line":"64139290","B":"Allograft Orth/Neuro Grp 2","C":"278","F":"585.684","G":"**"},{"Policy Line":"64139291","B":"Allograft Orth/Neuro Grp 1","C":"278","F":"291.924","G":"**"},{"Policy Line":"64139301","B":"Anchor Bone Grp 3","C":"278","D":"C1713","F":"612.306","G":"**"},{"Policy Line":"64139302","B":"Anchor Bone Grp 2","C":"278","D":"C1713","F":"581.4","G":"**"},{"Policy Line":"64139303","B":"Anchor Bone Grp 1","C":"278","D":"C1713","F":"357.102","G":"**"},{"Policy Line":"64139305","B":"Arthowand Group 1","C":"272","F":"340.578","G":"**"},{"Policy Line":"64139309","B":"Balloon Kyphoplasty","C":"272","F":"1471.554","G":"**"},{"Policy Line":"64139311","B":"Barrier Sheet Grp 1","C":"278","F":"620.874","G":"**"},{"Policy Line":"64139313","B":"Bit Drill Grp 4","C":"272","F":"674.424","G":"**"},{"Policy Line":"64139314","B":"Bit Drill Grp 3","C":"272","F":"423.198","G":"**"},{"Policy Line":"64139315","B":"Bit Drill Grp 2","C":"272","F":"260.1","G":"**"},{"Policy Line":"64139316","B":"Bit Drill Grp 1","C":"272","F":"161.874","G":"**"},{"Policy Line":"64139322","B":"Implant Hip Helical Grp 1","C":"278","D":"C1713","F":"835.992"},{"Policy Line":"64139327","B":"Blower Mister Off Pump","C":"272","F":"96.696"},{"Policy Line":"64139328","B":"Bolt Locking Grp 2","C":"278","D":"C1713","F":"500.31"},{"Policy Line":"64139329","B":"Bolt Locking Grp 1","C":"278","D":"C1713","F":"113.526"},{"Policy Line":"64139330","B":"Bolt Spinal Pedicle Grp 2","C":"278","F":"1024.488"},{"Policy Line":"64139331","B":"Bolt Spinal Pedicle Grp 1","C":"278","F":"783.972","G":"**"},{"Policy Line":"64139334","B":"Burr Grp 3","C":"272","F":"481.032","G":"**"},{"Policy Line":"64139335","B":"Burr Grp 2","C":"272","F":"217.566","G":"**"},{"Policy Line":"64139336","B":"Burr Grp 1","C":"272","F":"143.82","G":"**"},{"Policy Line":"64139337","B":"Cable Ortho Grp 2","C":"278","D":"C1713","F":"275.094"},{"Policy Line":"64139338","B":"Cable Ortho Grp 1","C":"278","D":"C1713","F":"97.614"},{"Policy Line":"64139339","B":"Cable Ortho Grp 5","C":"278","D":"C1713","F":"1142.91","G":"**"},{"Policy Line":"64139340","B":"Cable Ortho Grp 4","C":"278","D":"C1713","F":"761.634","G":"**"},{"Policy Line":"64139341","B":"Cable Ortho Grp 3","C":"278","D":"C1713","F":"471.24","G":"**"},{"Policy Line":"64139345","B":"Cage High Cost","C":"278","F":"5141.412","G":"**"},{"Policy Line":"64139346","B":"Cannula Coronary Grp 2","C":"272","F":"794.988","G":"**"},{"Policy Line":"64139347","B":"Cannula Coronary Grp 1","C":"272","F":"83.538","G":"**"},{"Policy Line":"64139349","B":"Cannula Ortho/Neuro","C":"272","F":"67.626","G":"**"},{"Policy Line":"64139360","B":"Catch Endo","C":"272","F":"188.19","G":"**"},{"Policy Line":"64139364","B":"Cath Angiographic","C":"272","F":"198.9"},{"Policy Line":"64139369","B":"Cath Balloon Dil Non-Vasc Grp2","C":"272","D":"C1726","F":"394.434","G":"**"},{"Policy Line":"64139370","B":"Cath Balloon Dil Non-Vasc Grp1","C":"272","D":"C1726","F":"286.416"},{"Policy Line":"64139371","B":"Cath Balloon Angioplasty Grp 3","C":"272","D":"C1725","F":"901.782","G":"**"},{"Policy Line":"64139372","B":"Cath Balloon Angioplasty Grp 2","C":"272","D":"C1725","F":"639.54","G":"**"},{"Policy Line":"64139373","B":"Cath Spinal Neuro Grp 2","C":"272","D":"C1755","F":"1228.59","G":"**"},{"Policy Line":"64139374","B":"Cath Balloon Angioplasty Grp 1","C":"272","D":"C1725","F":"258.264","G":"**"},{"Policy Line":"64139377","B":"Cath Biliary Cholangiogram","C":"272","F":"145.656","G":"**"},{"Policy Line":"64139379","B":"Cath Central Venous Grp 1","C":"272","D":"C1751","F":"65.79","G":"**"},{"Policy Line":"64139382","B":"Cath Csf Grp 2","C":"272","F":"227.358","G":"**"},{"Policy Line":"64139383","B":"Cath Csf Grp 1","C":"272","F":"191.862","G":"**"},{"Policy Line":"64139386","B":"Cath Embolectomy C1757 Grp 2","C":"272","D":"C1757","F":"409.122"},{"Policy Line":"64139387","B":"Cath Embolectomy C1757 Grp 1","C":"272","D":"C1757","F":"118.422","G":"**"},{"Policy Line":"64139388","B":"Cath Indwelling, 3way-Foley","C":"272","D":"A4346","F":"100.674","G":"**"},{"Policy Line":"64139389","B":"Cath Guiding Grp 1","C":"272","D":"C1887","F":"116.586","G":"**"},{"Policy Line":"64139390","B":"Cath Hemodialysis C1750 Grp 2","C":"278","D":"C1750","F":"728.586","G":"**"},{"Policy Line":"64139391","B":"Cath Hemodialysis C1750 Grp 1","C":"278","D":"C1750","F":"361.998","G":"**"},{"Policy Line":"64139395","B":"Sling Urology C1771 Grp 1","C":"278","D":"C1771","F":"1294.38","G":"**"},{"Policy Line":"64139400","B":"Cath Port C1788 Grp 2","C":"278","D":"C1788","F":"476.748","G":"**"},{"Policy Line":"64139401","B":"Cath Port C1788 Grp 1","C":"278","D":"C1788","F":"447.984","G":"**"},{"Policy Line":"64139403","B":"Cath Spinal Neuro Grp 1","C":"272","D":"C1755","F":"636.786"},{"Policy Line":"64139404","B":"Cath Suprapubic","C":"272","D":"A4335","F":"152.082"},{"Policy Line":"64139405","B":"Cath Ureteral","C":"272","D":"C1758","F":"129.438","G":"**"},{"Policy Line":"64139408","B":"LowCost-Cath Baln Angio Grp 1","C":"272","D":"C1725","F":"84.762"},{"Policy Line":"64139410","B":"Cath Vascular Bern","C":"272","D":"C1887","F":"34.884","G":"**"},{"Policy Line":"64139411","B":"Cath Closure Vnus","C":"272","D":"C1888","F":"1135.566"},{"Policy Line":"64139412","B":"Cautery Endo","C":"272","F":"103.734","G":"**"},{"Policy Line":"64139413","B":"Cement Bone Grp 5","C":"278","D":"C1713","F":"2831.724","G":"**"},{"Policy Line":"64139414","B":"Cement Bone Grp 4","C":"278","D":"C1713","F":"1773.27"},{"Policy Line":"64139415","B":"Cement Bone Grp 1","C":"278","D":"C1713","F":"111.384","G":"**"},{"Policy Line":"64139422","B":"Cement Spinal Kit 283910000","C":"278","F":"2933.01","G":"**"},{"Policy Line":"64139424","B":"Cement Bone Restrictor Grp 1","C":"278","F":"307.53","G":"**"},{"Policy Line":"64139427","B":"Clamp External Fixator Grp 3","C":"272","F":"1114.452"},{"Policy Line":"64139430","B":"Clip Aneurysm Grp 2","C":"278","F":"406.674"},{"Policy Line":"64139431","B":"Clip Aneurysm Grp 1","C":"278","F":"92.718"},{"Policy Line":"64139434","B":"Clip Applier Grp 3","C":"272","F":"792.234","G":"**"},{"Policy Line":"64139435","B":"Clip Applier Grp 2","C":"272","F":"246.024","G":"**"},{"Policy Line":"64139436","B":"Clip Applier Grp 1","C":"272","F":"151.776","G":"**"},{"Policy Line":"64139437","B":"Clip Craniofix","C":"278","F":"180.234","G":"**"},{"Policy Line":"64139438","B":"Clip Raney Gun","C":"272","F":"117.198","G":"**"},{"Policy Line":"64139453","B":"Connector Crosslink Grp 3","C":"278","F":"928.098","G":"**"},{"Policy Line":"64139454","B":"Connector Crosslink Grp 2","C":"278","F":"929.016","G":"**"},{"Policy Line":"64139455","B":"Connector Crosslink Grp 1","C":"278","F":"629.748","G":"**"},{"Policy Line":"64139456","B":"Connector Csf","C":"278","F":"123.93"},{"Policy Line":"64139457","B":"Connector Orth/Neuro Grp 5","C":"278","F":"5764.122"},{"Policy Line":"64139458","B":"Connector Orth/Neuro Grp 4","C":"278","F":"1344.564","G":"**"},{"Policy Line":"64139459","B":"Connector Orth/Neuro Grp 3","C":"278","F":"920.142","G":"**"},{"Policy Line":"64139460","B":"Connector Orth/Neuro Grp 2","C":"278","F":"667.386","G":"**"},{"Policy Line":"64139461","B":"Connector Orth/Neuro Grp 1","C":"278","F":"241.128"},{"Policy Line":"64139466","B":"Cutter Suture / Knot 72201537","C":"272","F":"148.716","G":"**"},{"Policy Line":"64139471","B":"Derma Skin Carrier","C":"270","F":"65.178","G":"**"},{"Policy Line":"64139475","B":"Dura Subtitute Grp 4","C":"278","F":"2024.802","G":"**"},{"Policy Line":"64139476","B":"Dura Subtitute Grp 3","C":"278","F":"1046.52","G":"**"},{"Policy Line":"64139477","B":"Dura Subtitute Grp 2","C":"278","F":"795.6","G":"**"},{"Policy Line":"64139478","B":"Dura Subtitute Grp 1","C":"278","F":"268.668"},{"Policy Line":"64139481","B":"Electrode Disposable Grp 1","C":"272","F":"225.216","G":"**"},{"Policy Line":"64139483","B":"Electrode Disposable Grp 2","C":"272","F":"341.496","G":"**"},{"Policy Line":"64139487","B":"External Fixator Cmpnts Grp 4","C":"272","F":"1748.484","G":"**"},{"Policy Line":"64139488","B":"External Fixator Cmpnts Grp 3","C":"272","F":"958.086","G":"**"},{"Policy Line":"64139489","B":"External Fixator Cmpnts Grp 2","C":"272","F":"319.158","G":"**"},{"Policy Line":"64139490","B":"External Fixator Cmpnts Grp1","C":"272","F":"103.734","G":"**"},{"Policy Line":"64139491","B":"Graft Felt Teflon Vascular","C":"278","D":"C1768","F":"181.764","G":"**"},{"Policy Line":"64139502","B":"Fixation Device grp 1","C":"278","F":"547.434","G":"**"},{"Policy Line":"64139505","B":"Forcep Grp 2","C":"272","F":"719.406","G":"**"},{"Policy Line":"64139506","B":"Forcep Grp 1","C":"272","F":"257.958","G":"**"},{"Policy Line":"64139509","B":"Generator Icd","C":"275","D":"C1721","F":"13948.092"},{"Policy Line":"64139510","B":"Pacemaker, Gen, Dual Grp1","C":"275","D":"C1785","F":"4528.188"},{"Policy Line":"64139524","B":"Graft Patch Grp 1","C":"278","D":"C1768","F":"197.676"},{"Policy Line":"64139547","B":"Grasper Endo","C":"272","F":"379.44","G":"**"},{"Policy Line":"64139548","B":"Guidewire Grp 1","C":"272","D":"C1769","F":"64.872","G":"**"},{"Policy Line":"64139549","B":"Guidewire Ortho Grp 1","C":"272","F":"118.422","G":"**"},{"Policy Line":"64139550","B":"Guidewire Ortho Grp 2","C":"272","F":"286.11","G":"**"},{"Policy Line":"64139559","B":"Hook Spinal/Pedicle Disp Grp 5","C":"278","F":"1414.332"},{"Policy Line":"64139560","B":"Hook Spinal/Pedicle Disp Grp 4","C":"278","F":"921.672"},{"Policy Line":"64139561","B":"Hook Spinal/Pedicle Disp Grp 3","C":"278","F":"691.866","G":"**"},{"Policy Line":"64139562","B":"Hook Spinal/Pedicle Disp Grp 2","C":"278","F":"371.79"},{"Policy Line":"64139563","B":"Hook Spinal/Pedicle Disp Grp 1","C":"278","F":"195.534"},{"Policy Line":"64139571","B":"Implant Cornea","C":"278","D":"V2785","F":"3193.11"},{"Policy Line":"64139573","B":"Implant Eyelid","C":"278","F":"432.684","G":"**"},{"Policy Line":"64139576","B":"Implant Forehead","C":"278","F":"421.974"},{"Policy Line":"64139578","B":"Implant Glaucoma Grp 1","C":"278","D":"C1783","F":"795.6","G":"**"},{"Policy Line":"64139589","B":"Implant Orbital","C":"278","F":"1096.704"},{"Policy Line":"64139590","B":"Implant Sclera Labtician","C":"278","F":"25.704","G":"**"},{"Policy Line":"64139591","B":"Implant Sclera Tutoplast Grp 2","C":"278","D":"C1762","F":"861.696"},{"Policy Line":"64139592","B":"Implant Sclera Tutoplast Grp 1","C":"278","D":"C1762","F":"437.886","G":"**"},{"Policy Line":"64139593","B":"Implant Thyroplasty","C":"278","D":"C1878","F":"576.81"},{"Policy Line":"64139600","B":"Implant Jnt Toe Grp 2","C":"278","D":"C1776","F":"2016.234"},{"Policy Line":"64139605","B":"Inflation Device Vascular","C":"272","F":"65.79","G":"**"},{"Policy Line":"64139606","B":"Introducer/Sheath Grp 3","C":"272","D":"C1894","F":"437.886","G":"**"},{"Policy Line":"64139609","B":"Introducer/Sheath Grp 4","C":"272","D":"C1894","F":"713.898","G":"**"},{"Policy Line":"64139610","B":"IOL Grp 2","C":"276","F":"240.516"},{"Policy Line":"64139611","B":"IOL Grp 1","C":"276","F":"232.254","G":"**"},{"Policy Line":"64139613","B":"Kit / System Harvesting","C":"272","F":"212.058","G":"**"},{"Policy Line":"64139614","B":"Kit Arterial","C":"272","F":"383.418"},{"Policy Line":"64139615","B":"Kit Aspirator Ortho","C":"272","F":"340.272"},{"Policy Line":"64139616","B":"Prosthesis Kit Penile/Uri GR1","C":"278","D":"C1815","F":"726.444","G":"**"},{"Policy Line":"64139617","B":"Kit Bead Grp 2","C":"278","F":"1977.372"},{"Policy Line":"64139618","B":"Kit Bead Grp 1","C":"278","F":"838.44"},{"Policy Line":"64139619","B":"Kit Thyroplasty","C":"272","F":"193.392","G":"**"},{"Policy Line":"64139621","B":"Knife","C":"272","F":"451.962","G":"**"},{"Policy Line":"64139623","B":"Knife Eye","C":"272","F":"73.746"},{"Policy Line":"64139624","B":"Kypho Add'L Fracture Tray","C":"272","F":"2980.44","G":"**"},{"Policy Line":"64139625","B":"Kypho Bx Device Not Implant","C":"272","F":"192.78","G":"**"},{"Policy Line":"64139626","B":"Kypho First Fracture Kit/Tray","C":"278","F":"3275.118","G":"**"},{"Policy Line":"64139628","B":"Kypho Introducer Kit","C":"272","F":"1906.074"},{"Policy Line":"64139630","B":"Lacrimal Intubation","C":"272","F":"162.486","G":"**"},{"Policy Line":"64139637","B":"Laser Fiber Trimedyne","C":"272","F":"222.768","G":"**"},{"Policy Line":"64139638","B":"Laser Fiber Grp 2","C":"272","F":"1829.574","G":"**"},{"Policy Line":"64139639","B":"Laser Fiber Grp 1","C":"272","F":"605.268","G":"**"},{"Policy Line":"64139640","B":"Lead Pacemaker","C":"275","D":"C1898","F":"636.786","G":"**"},{"Policy Line":"64139641","B":"Lead Neuro C1778 Grp 4","C":"278","D":"C1778","F":"3231.054","G":"**"},{"Policy Line":"64139642","B":"Lead Neuro C1778 Grp 3","C":"278","D":"C1778","F":"2637.108","G":"**"},{"Policy Line":"64139643","B":"Lead Neuro C1778 Grp 2","C":"278","D":"C1778","F":"1044.684"},{"Policy Line":"64139644","B":"Lead Neuro C1778 Grp 1","C":"278","D":"C1778","F":"794.682"},{"Policy Line":"64139645","B":"Ligasure Handpiece Grp 1","C":"272","F":"771.12","G":"**"},{"Policy Line":"64139646","B":"Ligasure Handpiece Grp 2","C":"272","F":"904.23","G":"**"},{"Policy Line":"64139649","B":"Mesh Genl Surg C1781 Grp 6","C":"278","D":"C1781","F":"2087.226","G":"**"},{"Policy Line":"64139650","B":"Mesh Genl Surg C1781 Grp 5","C":"278","D":"C1781","F":"1242.972","G":"**"},{"Policy Line":"64139651","B":"Mesh Genl Surg C1781 Grp 4","C":"278","D":"C1781","F":"808.758","G":"**"},{"Policy Line":"64139652","B":"Mesh Genl Surg C1781 Grp 3","C":"278","D":"C1781","F":"464.202","G":"**"},{"Policy Line":"64139653","B":"Mesh Genl Surg C1781 Grp 2","C":"278","D":"C1781","F":"266.526","G":"**"},{"Policy Line":"64139654","B":"Mesh Genl Surg C1781 Grp 1","C":"278","D":"C1781","F":"94.86","G":"**"},{"Policy Line":"64139655","B":"Optimesh","C":"278","D":"C1781","F":"4498.812"},{"Policy Line":"64139656","B":"Microtip Neuro","C":"272","F":"885.564","G":"**"},{"Policy Line":"64139669","B":"Needle Grp 2","C":"272","F":"273.564","G":"**"},{"Policy Line":"64139670","B":"Needle Grp 1","C":"272","F":"136.17","G":"**"},{"Policy Line":"64139671","B":"Nut","C":"278","F":"187.272","G":"**"},{"Policy Line":"64139673","B":"On-Q Soaker Pain Pump Grp 2","C":"272","F":"518.058","G":"**"},{"Policy Line":"64139674","B":"On-Q Soaker Pain Pump Grp 1","C":"272","F":"286.416"},{"Policy Line":"64139680","B":"Perforator Cranial","C":"272","F":"276.012","G":"**"},{"Policy Line":"64139682","B":"Peristrip Grp 1","C":"278","F":"311.814","G":"**"},{"Policy Line":"64139683","B":"Pin Grp 3","C":"278","D":"C1713","F":"407.898","G":"**"},{"Policy Line":"64139684","B":"Pin Grp 2","C":"278","D":"C1713","F":"253.98","G":"**"},{"Policy Line":"64139685","B":"Pin Grp 1","C":"278","D":"C1713","F":"94.248","G":"**"},{"Policy Line":"64139694","B":"Plate Grp 5","C":"278","D":"C1713","F":"1222.164","G":"**"},{"Policy Line":"64139695","B":"Plate Grp 4","C":"278","D":"C1713","F":"943.092","G":"**"},{"Policy Line":"64139696","B":"Plate Grp 3","C":"278","D":"C1713","F":"327.726","G":"**"},{"Policy Line":"64139697","B":"Plate Grp 2","C":"278","D":"C1713","F":"272.034","G":"**"},{"Policy Line":"64139698","B":"Plate Grp 1","C":"278","D":"C1713","F":"108.018","G":"**"},{"Policy Line":"64139699","B":"Plate End - Artificial Disk","C":"278","F":"5985.054"},{"Policy Line":"64139700","B":"Polar Care","C":"272","F":"227.97","G":"**"},{"Policy Line":"64139708","B":"Programmer Neuro","C":"272","D":"C1787","F":"1406.988","G":"**"},{"Policy Line":"64139709","B":"Prosthesis Breast Grp 3","C":"278","D":"C1789","F":"1380.06","G":"**"},{"Policy Line":"64139710","B":"Prosthesis Breast Grp 2","C":"278","D":"C1789","F":"1063.656","G":"**"},{"Policy Line":"64139711","B":"Prosthesis Breast Grp 1","C":"278","D":"C1789","F":"769.896","G":"**"},{"Policy Line":"64139712","B":"Prosthesis Ear GR1","C":"278","D":"L8613","F":"431.46","G":"**"},{"Policy Line":"64139716","B":"Prosthesis Penile C1813 Grp 2","C":"278","D":"C1813","F":"6015.654","G":"**"},{"Policy Line":"64139718","B":"Prosthesis Penile Pump Grp 1","C":"278","D":"C1813","F":"5231.682"},{"Policy Line":"64139719","B":"Prosthesis Penile Reservoir","C":"278","D":"C1813","F":"1868.742"},{"Policy Line":"64139726","B":"Pump Neuro","C":"278","D":"C1772","F":"11236.32","G":"**"},{"Policy Line":"64139729","B":"Reamer Ortho Grp 1","C":"272","F":"492.048","G":"**"},{"Policy Line":"64139730","B":"Retractor Grp 1","C":"272","F":"440.028","G":"**"},{"Policy Line":"64139734","B":"Retractor Grp 2","C":"272","F":"892.296","G":"**"},{"Policy Line":"64139740","B":"Ring Mitral","C":"278","F":"2969.424","G":"**"},{"Policy Line":"64139745","B":"Rod Grp 4","C":"278","F":"609.858","G":"**"},{"Policy Line":"64139746","B":"Rod Grp 3","C":"278","D":"C1713","F":"498.78","G":"**"},{"Policy Line":"64139747","B":"Rod Grp 2","C":"278","D":"C1713","F":"337.824","G":"**"},{"Policy Line":"64139748","B":"Rod Grp 1","C":"278","D":"C1713","F":"211.752","G":"**"},{"Policy Line":"64139750","B":"Scissor Endo","C":"272","F":"308.448","G":"**"},{"Policy Line":"64139753","B":"Screw Grp 5","C":"278","D":"C1713","F":"1119.96","G":"**"},{"Policy Line":"64139754","B":"Screw Grp 4","C":"278","D":"C1713","F":"617.202","G":"**"},{"Policy Line":"64139755","B":"Screw Grp 3","C":"278","D":"C1713","F":"403.002","G":"**"},{"Policy Line":"64139756","B":"Screw Grp 2","C":"278","D":"C1713","F":"247.554","G":"**"},{"Policy Line":"64139757","B":"Screw Grp 1","C":"278","D":"C1713","F":"139.842","G":"**"},{"Policy Line":"64139767","B":"Screw Grp 6","C":"278","D":"C1713","F":"1290.708","G":"**"},{"Policy Line":"64139773","B":"Shears Harmonic Endo GR 2","C":"272","F":"736.236","G":"**"},{"Policy Line":"64139774","B":"Introducer/Sheath Grp 2","C":"272","D":"C1894","F":"167.994","G":"**"},{"Policy Line":"64139775","B":"Introducer/Sheath Grp 1","C":"272","D":"C1894","F":"34.884","G":"**"},{"Policy Line":"64139776","B":"Sheeting Silastic Neuro","C":"278","F":"173.808","G":"**"},{"Policy Line":"64139779","B":"Shunt Carotid","C":"272","F":"640.152","G":"**"},{"Policy Line":"64139781","B":"Shunt Coronary","C":"278","F":"85.068","G":"**"},{"Policy Line":"64139784","B":"Skin Adhesive Grp 2","C":"272","F":"522.036"},{"Policy Line":"64139785","B":"Skin Adhesive Grp 1","C":"272","F":"41.31","G":"**"},{"Policy Line":"64139791","B":"Sling Urology C1771 Grp 2","C":"278","D":"C1771","F":"1507.968","G":"**"},{"Policy Line":"64139795","B":"Spacer Tapered Grp 2","C":"278","F":"280.908"},{"Policy Line":"64139796","B":"Spacer Tapered Grp 1","C":"278","F":"187.272","G":"**"},{"Policy Line":"64139798","B":"Stabilizer Cv Sternal Grp 2","C":"278","F":"1407.6","G":"**"},{"Policy Line":"64139799","B":"Stabilizer Cv Grp 1","C":"278","F":"795.6","G":"**"},{"Policy Line":"64139800","B":"Staple Bone Grp 4","C":"278","D":"C1713","F":"1788.876","G":"**"},{"Policy Line":"64139801","B":"Staple Bone Grp 3","C":"278","D":"C1713","F":"824.67"},{"Policy Line":"64139802","B":"Staple Bone Grp 2","C":"278","D":"C1713","F":"224.298","G":"**"},{"Policy Line":"64139803","B":"Staple Bone Grp 1","C":"278","D":"C1713","F":"151.47"},{"Policy Line":"64139804","B":"Staple Bone Grp 5","C":"278","D":"C1713","F":"2066.724","G":"**"},{"Policy Line":"64139820","B":"Stent Biliary C1876","C":"278","D":"C1876","F":"1533.06","G":"**"},{"Policy Line":"64139821","B":"StentUretal Temp WODel Sys Gr1","C":"278","D":"C2617","F":"220.014","G":"**"},{"Policy Line":"64139823","B":"Stent Vascular Grp 2","C":"278","F":"2016.234"},{"Policy Line":"64139825","B":"Stimulator Bone","C":"278","F":"5021.46","G":"**"},{"Policy Line":"64139829","B":"Stone Basket Grp 2","C":"272","F":"309.672","G":"**"},{"Policy Line":"64139830","B":"Stone Basket Grp 1","C":"272","F":"150.858","G":"**"},{"Policy Line":"64139831","B":"Stylet","C":"272","F":"95.166"},{"Policy Line":"64139832","B":"Surgicel","C":"272","F":"148.716","G":"**"},{"Policy Line":"64139834","B":"Suture Retriever 71111579","C":"272","F":"239.904","G":"**"},{"Policy Line":"64139835","B":"Syringe Bio Glue","C":"272","F":"1065.798","G":"**"},{"Policy Line":"64139837","B":"Tap Grp 2","C":"272","F":"358.326","G":"**"},{"Policy Line":"64139838","B":"Tap Grp 1","C":"272","F":"192.78","G":"**"},{"Policy Line":"64139840","B":"Template","C":"272","F":"112.302","G":"**"},{"Policy Line":"64139842","B":"Tissue Expander Grp 2","C":"278","D":"C1789","F":"1918.314","G":"**"},{"Policy Line":"64139843","B":"Tray Applicator Mammosite","C":"272","F":"3259.512"},{"Policy Line":"64139844","B":"Trocar Grp 1","C":"272","F":"78.642","G":"**"},{"Policy Line":"64139845","B":"Trocar Grp 2","C":"272","F":"283.662","G":"**"},{"Policy Line":"64139846","B":"Trocar Grp 3","C":"272","F":"636.786","G":"**"},{"Policy Line":"64139848","B":"Tube Gi Grp 1","C":"272","F":"59.976","G":"**"},{"Policy Line":"64139850","B":"Tube Myringotomy","C":"278","F":"73.746","G":"**"},{"Policy Line":"64139852","B":"Tube Trach Grp 2","C":"272","F":"470.016","G":"**"},{"Policy Line":"64139853","B":"Tube Trach Cuffed Grp1","C":"272","D":"A7521","F":"77.724","G":"**"},{"Policy Line":"64139855","B":"Tunneling Tool","C":"272","F":"953.802"},{"Policy Line":"64139856","B":"Uterine Manipulator","C":"272","F":"148.716","G":"**"},{"Policy Line":"64139858","B":"Valve Heart Aortic W/Graft","C":"278","F":"5478.012"},{"Policy Line":"64139859","B":"Valve Csf Grp 2","C":"278","F":"1273.878","G":"**"},{"Policy Line":"64139860","B":"Valve Csf Grp 1","C":"278","F":"461.142"},{"Policy Line":"64139861","B":"Valve Lumbar","C":"278","F":"1686.672","G":"**"},{"Policy Line":"64139864","B":"Valve Heart Grp 1","C":"278","F":"4964.85"},{"Policy Line":"64139865","B":"Valve Heart Grp 2","C":"278","F":"5482.602","G":"**"},{"Policy Line":"64139866","B":"Valve Heart Grp 3","C":"278","F":"5889.582"},{"Policy Line":"64139867","B":"Valvulotome","C":"272","F":"2404.548"},{"Policy Line":"64139873","B":"Washer Grp 2","C":"278","F":"724.302"},{"Policy Line":"64139874","B":"Washer Grp 1","C":"278","F":"61.506","G":"**"},{"Policy Line":"64139876","B":"Wire Ortho Supply Grp 2","C":"272","F":"253.368","G":"**"},{"Policy Line":"64139878","B":"Wire Ortho Supply Grp 1","C":"272","F":"113.22","G":"**"},{"Policy Line":"64139912","B":"URO Open Major Supply Charge","C":"272","F":"756.432"},{"Policy Line":"64139913","B":"URO Intermediate Supply Charg","C":"272","F":"335.682"},{"Policy Line":"64139914","B":"URO Open Minor Supply Charge","C":"272","F":"262.242"},{"Policy Line":"64139996","B":"Lens Presby Correcting Functn","C":"276","D":"V2788","F":"298.5","G":"**"},{"Policy Line":"64139997","B":"Restor Conventional Iol","C":"276","F":"261.63"},{"Policy Line":"64139998","B":"Restor Lens -D","C":"276","F":"0"},{"Policy Line":"64140000","B":"Neurostim Kit Anchor","C":"272","F":"242.046","G":"**"},{"Policy Line":"64140001","B":"Insert Trial Lgn POLY PS SZ5-6","C":"278","F":"385.254"},{"Policy Line":"64140002","B":"NS Gen Precsn HF Rechg SC-1200","C":"278","D":"C1820","F":"16534.71","G":"**"},{"Policy Line":"64140003","B":"External Fixator Cmpnts Grp 2A","C":"272","F":"390.15","G":"**"},{"Policy Line":"64140004","B":"External Fixator Cmpnts Grp 2B","C":"272","F":"477.666","G":"**"},{"Policy Line":"64140005","B":"Kit Accessory ACL/PCL 014725","C":"272","F":"440.946","G":"**"},{"Policy Line":"64140006","B":"Shaft Drive Seal 351.718S","C":"272","F":"63.342","G":"**"},{"Policy Line":"64140007","B":"Clip Lock 352.260S","C":"272","F":"170.136","G":"**"},{"Policy Line":"64140008","B":"Tube Assembly 314.746S","C":"272","F":"820.386","G":"**"},{"Policy Line":"64140009","B":"Filter Graft RTA 352.229S","C":"272","F":"764.082","G":"**"},{"Policy Line":"64140011","B":"CAGE PEEK XL 6200445","C":"278","F":"5832.666"},{"Policy Line":"64140012","B":"OH VALV SUTERE CHORD-X 1/2CIR","C":"278","F":"2536.128","G":"**"},{"Policy Line":"64140013","B":"OH VALV-SIZER CHORD-X CXCS","C":"278","F":"398.106"},{"Policy Line":"64140014","B":"Probe Ablation XL90 Ar-9821","C":"272","F":"272.034","G":"**"},{"Policy Line":"64140015","B":"Stent Biliary Visi Pro","C":"278","D":"C1876","F":"1087.83"},{"Policy Line":"64140016","B":"KIT SNARE RETRIEVAL SRK30","C":"272","D":"C1773","F":"469.404"},{"Policy Line":"64140017","B":"Collagen Scaffold LG 2169-3","C":"278","F":"2571.318"},{"Policy Line":"64140018","B":"Lead AICD SGL Reliance 0293","C":"275","D":"C1777","F":"3803.886"},{"Policy Line":"64140019","B":"CAP DEPUY CEMENTED KNEE","C":"278","D":"C1776","F":"3651.804","G":"**"},{"Policy Line":"64140020","B":"CAP DEPUY HIP UNI-BIPOLAR","C":"278","D":"C1776","F":"3144.762","G":"**"},{"Policy Line":"64140021","B":"CAP TORNIER SHOULDER TOTAL","C":"278","D":"C1776","F":"5071.95","G":"**"},{"Policy Line":"64140022","B":"CAP DEPUY T SHOULDER REVERSE","C":"278","D":"C1776","F":"8622.468","G":"**"},{"Policy Line":"64140023","B":"CAP HIP UNI-BIPOLAR S/N","C":"278","D":"C1776","F":"3144.762","G":"**"},{"Policy Line":"64140024","B":"Graft Stent Thor 30MM","C":"278","F":"17239.428"},{"Policy Line":"64140025","B":"Graft Stent Thor 38MM","C":"278","F":"16478.406"},{"Policy Line":"64140026","B":"Cath Distal Shunt Progav","C":"278","F":"3088.152"},{"Policy Line":"64140027","B":"Valve,Shunt Adj Prosa","C":"278","F":"3648.744"},{"Policy Line":"64140028","B":"CAP UPCHRG-HIP TOTAL DEPUY","C":"278","D":"C1776","F":"4919.562","G":"**"},{"Policy Line":"64140029","B":"CAP-KNEE TOTAL JOURNEY S/N","C":"278","D":"C1776","F":"4833.576","G":"**"},{"Policy Line":"64140030","B":"CAP- HIP TOTAL OXI S/N","C":"278","D":"C1776","F":"5071.95","G":"**"},{"Policy Line":"64140031","B":"NS Genr Precision SC-1140sys","C":"278","D":"C1767","F":"17549.1"},{"Policy Line":"64140032","B":"EPIFIX 18 MM DISK GS-5180","C":"278","D":"Q4186","F":"534.582","G":"**"},{"Policy Line":"64140033","B":"CAP DEPUY T SHOULDER","C":"278","D":"C1776","F":"5071.95"},{"Policy Line":"64140034","B":"CAP T KNEE HI DEMND-INSERT S/N","C":"278","D":"C1776","F":"4326.228","G":"**"},{"Policy Line":"64140035","B":"STENT INNOVA 39293-07103","C":"278","D":"C1876","F":"1215.738","G":"**"},{"Policy Line":"64140036","B":"TOE FUSN SYSTEM PIP; 1PP-ON","C":"278","D":"C1713","F":"1151.784"},{"Policy Line":"64140037","B":"CAP, END X CORE","C":"278","F":"1279.692"},{"Policy Line":"64140038","B":"IM HIP-SLEEVE/DRILL GUIDE","C":"272","F":"358.632"},{"Policy Line":"64140039","B":"SPINAL SET SCREW BLOCKER GR1","C":"278","F":"96.696"},{"Policy Line":"64140040","B":"SPINAL SET SCREW BLOCKER GR2","C":"278","F":"199.206"},{"Policy Line":"64140041","B":"CAP MIS FOR SET SCREW 16A034","C":"278","F":"477.666"},{"Policy Line":"64140042","B":"GENERATOR MONTAGE SC-1210A","C":"278","D":"C1820","F":"17549.1"},{"Policy Line":"64140043","B":"CAP-TORNIER SHOULDER REVERSE","C":"278","D":"C1776","F":"8622.468","G":"**"},{"Policy Line":"64140044","B":"SHEATH SAFE 10.5 FR 667466-001","C":"272","D":"C1892","F":"96.696"},{"Policy Line":"64140045","B":"CAP KNEE T CEMENTED NK-ZIMMER","C":"278","D":"C1776","F":"3651.804","G":"**"},{"Policy Line":"64140046","B":"STYLET MRI 9735566","C":"272","F":"863.532"},{"Policy Line":"64140047","B":"TIP LASER DIFF MRI 400-T10","C":"272","F":"14196.258","G":"**"},{"Policy Line":"64140048","B":"CUTTER FLIP AR-1204AF-80","C":"272","F":"517.14"},{"Policy Line":"64140049","B":"NEEDLE SCORPION AR-13991N","C":"272","F":"222.768"},{"Policy Line":"64140050","B":"SUTURE LASSO 90 AR-6069-90","C":"272","F":"254.592"},{"Policy Line":"64140051","B":"SOLN WOUND LAVAGE-BACTISURE","C":"272","F":"767.754","G":"**"},{"Policy Line":"64140052","B":"Sys LAA-ATRICLIP PROV 35-50MM","C":"278","F":"5579.298","G":"**"},{"Policy Line":"64140053","B":"FEMO STOP COMPRES++SYS C11165","C":"272","F":"167.076","G":"**"},{"Policy Line":"64140054","B":"FORCEP BIPOLAR BAYONET TIP","C":"272","F":"1538.262","G":"**"},{"Policy Line":"64140055","B":"DRILL GUIDE PROBE","C":"272","F":"2543.166"},{"Policy Line":"64140058","B":"Cap K3 Knee Uni Partl-Zuk S/N","C":"278","D":"C1776","F":"3246.048","G":"**"},{"Policy Line":"64140059","B":"Cath CFS Ventricular INS-4500","C":"278","F":"202.266","G":"**"},{"Policy Line":"64140060","B":"Allograft Spacer BALM0007 7mm","C":"278","F":"1279.692"},{"Policy Line":"64140061","B":"CAP-T KNEE CEMNTLES HYBRID ZIM","C":"278","D":"C1776","F":"4792.878","G":"**"},{"Policy Line":"64140062","B":"Syst Delivery Osseoflx OF-0348","C":"272","F":"831.708"},{"Policy Line":"64140063","B":"Balln Steer Osseoflx OF-0224","C":"272","F":"1004.292"},{"Policy Line":"64140064","B":"Drill Hand Osseoflx OF-0217","C":"272","F":"310.284"},{"Policy Line":"64140065","B":"Kit Acc Vclas Neur-Anchr/sty","C":"272","F":"3043.17","G":"**"},{"Policy Line":"64140066","B":"CAP-T. Knee Cemented-Consensus","C":"278","D":"C1776","F":"3651.804"},{"Policy Line":"64140067","B":"Trephine Extractor 18- 18.5m","C":"272","F":"391.068"},{"Policy Line":"64140068","B":"T KNEE CEMENTLESS DEPUY PATELA","C":"278","D":"C1776","F":"4564.908","G":"**"},{"Policy Line":"64140069","B":"ANCHOR-KNEE LIGAMNT AUGMNT RPR","C":"278","D":"C1713","F":"1529.388","G":"**"},{"Policy Line":"64140070","B":"REAMER 9.5MM, AR-1409LP-50","C":"272","F":"310.284","G":"**"},{"Policy Line":"64140071","B":"SHIMM 10,14MM; SP INTERBDY CG","C":"278","F":"2879.46"},{"Policy Line":"64140072","B":"SHELL SHORT 2PART CAGE","C":"278","F":"2879.46","G":"**"},{"Policy Line":"64140073","B":"SHELL ASSY 27MM-SP INTERBDY CG","C":"278","F":"2879.46"},{"Policy Line":"64140074","B":"CAP-HIP TOTAL RESURFC S/N","C":"278","D":"C1776","F":"8115.12"},{"Policy Line":"64140075","B":"STENT PERIPH OTW - SUPERA","C":"278","D":"C1876","F":"2041.326","G":"**"},{"Policy Line":"64140076","B":"CATH,BALLN EVERCROSS","C":"272","D":"C1725","F":"190.944"},{"Policy Line":"64140077","B":"CATH ATHERECTOMY,HAWKONE","C":"272","D":"C1714","F":"3144.762","G":"**"},{"Policy Line":"64140078","B":"CATH THROMB SET ANGIOJET 6FR","C":"272","D":"C1757","F":"2182.086"},{"Policy Line":"64140079","B":"PM GEN 1 CHMBR SR-MRI ACCOLADE","C":"275","D":"C1786","F":"3651.804"},{"Policy Line":"64140080","B":"Kit Baloon Strt 10GA Vertebrex","C":"272","F":"1446.156","G":"**"},{"Policy Line":"64140081","B":"Allograft Spacer 018406 6MM","C":"278","F":"2134.35"},{"Policy Line":"64140082","B":"Cerv Disc Pros MB3575","C":"278","F":"6086.34"},{"Policy Line":"64140083","B":"NS Cable Ext Trial Intellis","C":"272","F":"1663.722","G":"**"},{"Policy Line":"64140084","B":"Stent Innova 7mmx60mmx130cm","C":"278","D":"C1876","F":"927.486","G":"**"},{"Policy Line":"64140085","B":"Guide Sheath Steerable","C":"272","D":"C1887","F":"735.624"},{"Policy Line":"64140087","B":"Needle Disp Reline","C":"272","F":"2611.71"},{"Policy Line":"64140088","B":"Device Inflation, Osseon","C":"272","F":"159.12"},{"Policy Line":"64140089","B":"Blade Helical-80,100MM","C":"278","D":"C1713","F":"1204.416","G":"**"},{"Policy Line":"64140090","B":"Catheter Passer Tunneler 38cm","C":"272","F":"189.72","G":"**"},{"Policy Line":"64140091","B":"Filter Vena Cava","C":"278","D":"C1880","F":"1328.346"},{"Policy Line":"64140092","B":"T Knee Cemented Stnd Insrt SN","C":"278","D":"C1776","F":"3651.804","G":"**"},{"Policy Line":"64140093","B":"Imp Del Biocomp AR-2260BC","C":"278","D":"C1713","F":"1407.6","G":"**"},{"Policy Line":"64140094","B":"AMNIOFILL 100MG","C":"278","F":"2879.46","G":"**"},{"Policy Line":"64140095","B":"EPIFIX XL 9.0CMX15CM","C":"278","D":"Q4186","F":"9987.228"},{"Policy Line":"64140096","B":"ANCHOR SUTURE GR1","C":"278","D":"C1713","F":"358.326","G":"**"},{"Policy Line":"64140097","B":"DEVICE SPINE DISCECTOMY","C":"278","F":"1251.54"},{"Policy Line":"64140098","B":"KIT HIP DISP W/DRILL GUID","C":"278","F":"863.838","G":"**"},{"Policy Line":"64140099","B":"CAP T KNEE JOURNEY OXINIUM S&N","C":"278","D":"C1776","F":"3753.396","G":"**"},{"Policy Line":"64140100","B":"CAP TKNEE LEGION OXINUM GII SN","C":"278","D":"C1776","F":"4159.152","G":"**"},{"Policy Line":"64140102","B":"SUTURE MITRAL 2-0 CHORD-X","C":"272","F":"639.846"},{"Policy Line":"64140103","B":"NS KIT ++ LEADS 9771 ISYS","C":"278","D":"C1820","F":"25160.85"},{"Policy Line":"64140104","B":"AICD Unify Assura CRT-D","C":"275","D":"C1882","F":"17491.266"},{"Policy Line":"64140105","B":"SIZER TLIF LUNA LUN3501-08","C":"272","F":"752.76"},{"Policy Line":"64140106","B":"Cap TKnee W/Vit E Ploy","C":"278","D":"C1776","F":"4574.7","G":"**"},{"Policy Line":"64140109","B":"EPIFIX Fenestrated 9x9cm","C":"278","D":"Q4186","F":"5904.882","G":"**"},{"Policy Line":"64140110","B":"SYSTEM DELIVERY CEMENT","C":"272","F":"468.18","G":"**"},{"Policy Line":"64140111","B":"End Plate Assy","C":"278","F":"4723.722","G":"**"},{"Policy Line":"64140112","B":"BOLT PEDICAL","C":"278","F":"336.6"},{"Policy Line":"64140113","B":"REAMER PASSING PIN 4.5MM","C":"278","F":"115.668"},{"Policy Line":"64140114","B":"CAP SHOULDER HEMI FLEX TORNIER","C":"278","D":"C1776","F":"4176.9","G":"**"},{"Policy Line":"64140115","B":"CAP T SHOULDER TORNIER SIMPL","C":"278","D":"C1776","F":"5469.75","G":"**"},{"Policy Line":"64140116","B":"Sys Flex LAA Excl Vclip 45mm","C":"272","F":"2509.2"},{"Policy Line":"64140117","B":"Custom TMJ Bilateral Bundle","C":"278","D":"C1776","F":"16409.25"},{"Policy Line":"64140118","B":"ATRICLIP FLEX","C":"272","F":"2509.2","G":"**"},{"Policy Line":"64140119","B":"DRILL BIT CANN 16MM 03.037.104","C":"272","F":"1568.862"},{"Policy Line":"64140120","B":"IMPLANT COCHLEAR CI532 Z285654","C":"278","D":"L8614","F":"14348.952"},{"Policy Line":"64140121","B":"ROD CIRCULAR 4922-7-220","C":"278","F":"612.612"},{"Policy Line":"64140122","B":"ROD GUIDE 2.0 71751146","C":"272","F":"350.064","G":"**"},{"Policy Line":"64140123","B":"TEMPLATE SIZING 15MM 329.932","C":"272","F":"1722.474"},{"Policy Line":"64140124","B":"TISSUE DERMA MATRIX PDMW-4X8","C":"278","D":"Q4100","F":"2742.984"},{"Policy Line":"64140125","B":"CAP T. Hip Porous Fem S&N","C":"278","D":"C1776","F":"4475.25"},{"Policy Line":"64140126","B":"Cable Stern TIw/ndl 3TPR 1 cut","C":"278","F":"713.592","G":"**"},{"Policy Line":"64140127","B":"AICD DYNAGEN MINI DF4 VR","C":"278","D":"C1722","F":"10740.6"},{"Policy Line":"64140128","B":"IPG W/CHARGE SYST","C":"278","D":"C1820","F":"18199.35","G":"**"},{"Policy Line":"64140129","B":"LEAD SPRINT QUATTRO","C":"278","D":"C1895","F":"4375.8"},{"Policy Line":"64140130","B":"PATCH BOVINE PERICARDIAL","C":"278","F":"265.302","G":"**"},{"Policy Line":"64140131","B":"ACL BACKUP FIXATION SYS","C":"278","F":"752.76","G":"**"},{"Policy Line":"64140132","B":"ZIMMER TOTAL KNEE VITAMIN","C":"278","D":"C1776","F":"4375.8"},{"Policy Line":"64140133","B":"TMJ FOSSA & MANDI COMP","C":"272","F":"9447.75"},{"Policy Line":"64140134","B":"STENT GRAFT","C":"278","F":"16901.298"},{"Policy Line":"64140135","B":"HEAD REDUCTION","C":"272","F":"702.27","G":"**"},{"Policy Line":"64140136","B":"CAP SET","C":"272","F":"94.86"},{"Policy Line":"64140137","B":"HIP HEMI S&N","C":"278","F":"3580.2","G":"**"},{"Policy Line":"64140138","B":"NEEDLE DELIVERY DLS-7126-05S","C":"272","F":"509.184","G":"**"},{"Policy Line":"64140139","B":"Algrft Amniotic Mem Fen 9x20cm","C":"278","D":"Q4100","F":"11750.4","G":"**"},{"Policy Line":"64140140","B":"LEAD TRIAL INFINION 1X16 70CM","C":"278","D":"C1897","F":"940.95"},{"Policy Line":"64140141","B":"TORQUE WRENCH KIT","C":"272","F":"157.59"},{"Policy Line":"64140142","B":"PASSER SUT LASSO CRVD","C":"272","F":"202.878"},{"Policy Line":"64140143","B":"Syndesmosis Repair Implant Sys","C":"278","D":"C1713","F":"1875.474","G":"**"},{"Policy Line":"64140144","B":"BONE GRAFT SUBSTITUTE PUTTY","C":"278","D":"C1713","F":"647.802"},{"Policy Line":"64140145","B":"KNEE TOTAL PERSONA HYBRID CAP","C":"278","D":"C1776","F":"4375.8","G":"**"},{"Policy Line":"64140146","B":"KNEE TOTAL AESCULAP CAP","C":"278","D":"C1776","F":"5917.122","G":"**"},{"Policy Line":"64140147","B":"CAP END","C":"278","F":"1254.6"},{"Policy Line":"64140148","B":"Omni Robot Knee Cap","C":"278","F":"3580.2"},{"Policy Line":"64140149","B":"Kit Cement","C":"278","F":"847.008"},{"Policy Line":"64140150","B":"Balloon Kyho","C":"272","F":"1881.9"},{"Policy Line":"64140151","B":"drill hand","C":"272","F":"167.076"},{"Policy Line":"64140152","B":"Needle Biopsy 13G","C":"272","F":"167.076"},{"Policy Line":"64140153","B":"BALLOON EXPAND BXAL083902A","C":"278","F":"3077.748","G":"**"},{"Policy Line":"64140154","B":"Lactosorb system","C":"278","F":"1387.404","G":"**"},{"Policy Line":"64140155","B":"Powder Surg Collagen","C":"272","D":"A6010","F":"1875.474","G":"**"},{"Policy Line":"64140156","B":"SYS HERO HERO1000","C":"272","F":"3978","G":"**"},{"Policy Line":"64140157","B":"KIT COMP AR-7297","C":"272","F":"752.76"},{"Policy Line":"64140158","B":"KIT TORQUE","C":"272","F":"627.606"},{"Policy Line":"64140159","B":"Implant Crani PK621318","C":"278","F":"9746.1"},{"Policy Line":"64140160","B":"Implant Crani 4350","C":"278","F":"7359.3"},{"Policy Line":"64140161","B":"Plate Cerv Dual 1174.1001","C":"278","D":"C1713","F":"5469.75"},{"Policy Line":"64140162","B":"Stimulator Neuro 37703","C":"278","D":"C1820","F":"8453.25"},{"Policy Line":"64140163","B":"Header 2 Port 3032","C":"272","F":"690.03"},{"Policy Line":"64140164","B":"GRAFT ENDOVASCULAR AAA GRP4","C":"278","F":"13921.776","G":"**"},{"Policy Line":"64140165","B":"KIT CARTILAGE BIOPSY 80006","C":"272","F":"712.368"},{"Policy Line":"64140166","B":"CUFF INFRARENAL A28-28/C75V","C":"272","F":"5269.626"},{"Policy Line":"64140167","B":"Spinal Cage Expandable Grp 1A","C":"278","F":"6464.25"},{"Policy Line":"64140168","B":"Plug Graft Cont 1676817","C":"278","F":"139.842"},{"Policy Line":"64140169","B":"SHIM DISC","C":"272","F":"663.408","G":"**"},{"Policy Line":"64140170","B":"MODEL BONE 3D FF-PSG-0003","C":"272","F":"2132.82"},{"Policy Line":"64140171","B":"KIT TRACKER RM-1000","C":"272","F":"627.3"},{"Policy Line":"64140172","B":"Extractor Nail","C":"272","F":"350.982","G":"**"},{"Policy Line":"64140173","B":"Spacer Nail GA04041","C":"272","F":"11075.67","G":"**"},{"Policy Line":"64140174","B":"Anchor Ligament Fiber Tak","C":"278","D":"C1713","F":"616.284","G":"**"},{"Policy Line":"64140175","B":"KIT ACCESS TDAK0021","C":"272","F":"934.524","G":"**"},{"Policy Line":"64140176","B":"Bolt Locking Grp 4","C":"278","D":"C1713","F":"1928.106"},{"Policy Line":"64140177","B":"SPINAL CORD STIMULATOR KIT","C":"278","F":"25160.85"},{"Policy Line":"64140178","B":"CAP-KNEE LGN GII PS OXI","C":"278","F":"4077.45"},{"Policy Line":"64140179","B":"INLAY 8.5mm","C":"278","F":"1380.06","G":"**"},{"Policy Line":"64140180","B":"PACEMAKER PRODIGY MRI","C":"278","F":"16075.098","G":"**"},{"Policy Line":"64140181","B":"Cannula Ortho/Neuro Grp 4","C":"272","F":"772.344","G":"**"},{"Policy Line":"64140182","B":"Cap knee Modular Vega","C":"278","D":"C1776","F":"5917.122","G":"**"},{"Policy Line":"64140183","B":"DISC CERVICAL MB3597","C":"278","F":"5967","G":"**"},{"Policy Line":"64140184","B":"Controller Patient","C":"272","F":"1499.094","G":"**"},{"Policy Line":"64140185","B":"Spine Cage Lateral GRP 1","C":"278","F":"5967","G":"**"},{"Policy Line":"64140186","B":"Thoracic Stent Graft GRP 2","C":"278","F":"21376.548","G":"**"},{"Policy Line":"64140187","B":"Stent Graft Endopros-Endurant","C":"278","F":"9919.908","G":"**"},{"Policy Line":"64140188","B":"KIT INTELIS TRIAL","C":"278","D":"C1897","F":"2256.75","G":"**"},{"Policy Line":"64140189","B":"BALLOON CATH INTV-15-DDK","C":"278","D":"C1726","F":"2774.502","G":"**"},{"Policy Line":"64140190","B":"Aortic Annuloplasty","C":"278","F":"5967","G":"**"},{"Policy Line":"64140191","B":"SHOULDER TOTAL DJ","C":"278","F":"5469.75","G":"**"},{"Policy Line":"64140192","B":"STAPLES TENDON","C":"272","F":"390.15","G":"**"},{"Policy Line":"64140193","B":"NAIL FUSION 71931590","C":"272","F":"6484.14","G":"**"},{"Policy Line":"64140194","B":"REBEL H7493927432350","C":"272","F":"702.27","G":"**"},{"Policy Line":"64140195","B":"STENT H7493926038400","C":"272","F":"1119.042","G":"**"},{"Policy Line":"64140196","B":"KYPHO BONE ACCESS KIT","C":"272","F":"546.21","G":"**"},{"Policy Line":"64140197","B":"RF DUAL PROBE KIT","C":"272","F":"4176.9","G":"**"},{"Policy Line":"64140198","B":"IMPLANT FUSION SI","C":"278","F":"8453.25","G":"**"},{"Policy Line":"64140200","B":"IMPLANT SEROSAFUSE","C":"278","F":"4950.468"},{"Policy Line":"64140201","B":"PLATE DISTAL RAD KIT","C":"278","D":"C1713","F":"4972.5","G":"**"},{"Policy Line":"64140202","B":"KIT GRAFT SIZING AR-1676ST","C":"272","F":"460.224","G":"**"},{"Policy Line":"64140203","B":"SPINE ROD GRP","C":"272","F":"4405.482","G":"**"},{"Policy Line":"64140205","B":"KIT INSTRU DISP","C":"272","F":"624.24","G":"**"},{"Policy Line":"64141948","B":"Mesh Genl Surg C1781 Grp 3B","C":"278","D":"C1781","F":"694.62","G":"**"},{"Policy Line":"64142021","B":"Implant Joint Grp 8","C":"278","D":"C1776","F":"2029.392","G":"**"},{"Policy Line":"64142746","B":"Stapler-Reloads Disp. Grp 3F","C":"272","F":"780.3","G":"**"},{"Policy Line":"64144433","B":"Endotine Implant","C":"278","F":"408.816","G":"**"},{"Policy Line":"64145640","B":"Graft Porcine, Oto 0.6x0.9cm","C":"278","D":"C1763","F":"294.678","G":"**"},{"Policy Line":"64148863","B":"CONNECTOR,NERVE PORCINE ECM","C":"278","F":"1631.898"},{"Policy Line":"64149211","B":"Stapler-Reloads Disp. Grp 2","C":"272","F":"231.03","G":"**"},{"Policy Line":"64149216","B":"Plate Grp 6","C":"278","D":"C1713","F":"1600.992","G":"**"},{"Policy Line":"64149301","B":"Anchor Bone Grp 3","C":"278","D":"C1713","F":"612.306","G":"**"},{"Policy Line":"64149313","B":"Bit Drill Grp 4","C":"272","F":"674.424","G":"**"},{"Policy Line":"64149315","B":"Bit Drill Grp 2","C":"272","F":"260.1","G":"**"},{"Policy Line":"64149754","B":"Screw Grp 4","C":"278","D":"C1713","F":"617.202","G":"**"},{"Policy Line":"64149756","B":"Screw Grp 2","C":"278","D":"C1713","F":"247.554","G":"**"},{"Policy Line":"64149757","B":"Screw Grp 1","C":"278","D":"C1713","F":"139.842","G":"**"},{"Policy Line":"64149878","B":"Wire Ortho Supply Grp 1","C":"272","F":"113.22","G":"**"},{"Policy Line":"64407030","B":"Sys Fix Ultrafast Crv 72201491","C":"278","D":"C1713","F":"513.468"},{"Policy Line":"64408888","B":"Non-Charge Anes Supply","C":"270","F":"0"},{"Policy Line":"64500002","B":"Clip OTSC System 220 cm","C":"272","F":"661.1436","G":"**"},{"Policy Line":"64500014","B":"Anchor TT 220 cm Colon","C":"272","F":"661.2354"},{"Policy Line":"64500015","B":"OTSC Anchor 165 CM","C":"272","F":"661.2354"},{"Policy Line":"64500020","B":"Twin Grasper 220 CM","C":"272","F":"738.7146","G":"**"},{"Policy Line":"64500021","B":"Implantable Fastener Kit","C":"272","F":"4722.1308","G":"**"},{"Policy Line":"64500070","B":"Grasper/Retriever","C":"272","F":"183.906"},{"Policy Line":"64500071","B":"RETRIEVER ENDO HRD WIR","C":"272","F":"670.14","G":"**"},{"Policy Line":"64500218","B":"Ebus Fna/Biopsy Needle","C":"272","F":"175.032"},{"Policy Line":"64501022","B":"CATH BALLOON EXTRACTION PRORX","C":"272","F":"231.03","G":"**"},{"Policy Line":"64501170","B":"Blood Trans: 1 Unit-D","C":"270","F":"0"},{"Policy Line":"64501175","B":"Blood Trans: Add'L Units-D","C":"270","F":"0"},{"Policy Line":"64502012","B":"Bravo Capsule","C":"278","F":"345.474","G":"**"},{"Policy Line":"64502030","B":"Cath Spyscope","C":"272","F":"1011.024"},{"Policy Line":"64502031","B":"Forceps Disp Spybite Bx","C":"272","F":"795.6","G":"**"},{"Policy Line":"64502032","B":"Set Colonic Decompression","C":"272","D":"C1769","F":"272.34","G":"**"},{"Policy Line":"64502033","B":"Fiapc Probe Disp","C":"272","F":"343.026","G":"**"},{"Policy Line":"64502035","B":"Stent Advanix","C":"278","D":"C2617","F":"217.26","G":"**"},{"Policy Line":"64502036","B":"Stent Advanix Pigtail","C":"278","D":"C2617","F":"105.57","G":"**"},{"Policy Line":"64502037","B":"Rx Needleknife","C":"272","F":"308.754","G":"**"},{"Policy Line":"64502038","B":"Naviflex Stent Delivery Sys","C":"272","F":"163.098"},{"Policy Line":"64502039","B":"Guidewire Dreamwire","C":"272","D":"C1769","F":"298.35","G":"**"},{"Policy Line":"64502040","B":"Jagwire Hydra","C":"272","D":"C1769","F":"298.35","G":"**"},{"Policy Line":"64502041","B":"Guidewire Pathfinder","C":"272","D":"C1769","F":"390.15"},{"Policy Line":"64502042","B":"CATH BALLOON EXTRACTION HURCN","C":"272","D":"C1726","F":"397.188","G":"**"},{"Policy Line":"64502043","B":"Gastric Lavage Sys","C":"272","F":"367.506"},{"Policy Line":"64502044","B":"Cath Balloon Quantum Billiary","C":"272","D":"C1726","F":"312.12"},{"Policy Line":"64502045","B":"Cath Dilation Graduated Cook","C":"272","F":"123.93"},{"Policy Line":"64502046","B":"Cath Balloon Dil Non-Vascular","C":"272","D":"C1726","F":"733.788","G":"**"},{"Policy Line":"64502051","B":"3-LUMEN EXTRACTION BALLOON V","C":"272","D":"C1726","F":"191.556"},{"Policy Line":"64502052","B":"GUIDEWIRE VISIGLIDE","C":"272","D":"C1769","F":"231.03"},{"Policy Line":"64502053","B":"DUETTE MUCOSECTOMY","C":"272","F":"461.754"},{"Policy Line":"64502056","B":"CATH ACCESS/DEL SPY SCOPE","C":"272","F":"3135.276","G":"**"},{"Policy Line":"64502057","B":"PROBE EHL, AUTOLITH","C":"272","F":"682.686","G":"**"},{"Policy Line":"64502058","B":"Cath Balloon Non-Vasc-MaxFrce","C":"272","D":"C1726","F":"352.206"},{"Policy Line":"64502091","B":"StentFlex/PlasticW/ODelSys GR2","C":"278","D":"C2617","F":"143.514"},{"Policy Line":"64502092","B":"StentFlex/PlasticW/ODelSys GR3","C":"278","D":"C2617","F":"176.256","G":"**"},{"Policy Line":"64505006","B":"SphinctertomeHydrotomw/Guidewi","C":"272","D":"C1769","F":"676.566","G":"**"},{"Policy Line":"64505007","B":"Sphincterotome Autotome","C":"272","F":"349.146","G":"**"},{"Policy Line":"64505008","B":"Sphincterotome","C":"272","F":"268.974","G":"**"},{"Policy Line":"64505009","B":"Cath Gold Probe","C":"272","F":"294.678","G":"**"},{"Policy Line":"64505010","B":"Cath Esophogeal Dilatation","C":"272","D":"C1729","F":"363.528","G":"**"},{"Policy Line":"64505011","B":"Cath Ercp Balloon","C":"272","D":"C1726","F":"239.598","G":"**"},{"Policy Line":"64505012","B":"Cath Esophogeal Ph Monitoring","C":"272","F":"145.656"},{"Policy Line":"64505014","B":"G / J Tube","C":"272","F":"106.794"},{"Policy Line":"64505015","B":"Needle Eus Biopsy","C":"272","F":"407.898","G":"**"},{"Policy Line":"64505016","B":"Basket Stone Retreival","C":"272","F":"448.29","G":"**"},{"Policy Line":"64505017","B":"Guidewire / Jagwire","C":"272","D":"C1769","F":"361.08","G":"**"},{"Policy Line":"64505018","B":"Clip Resolution","C":"272","F":"273.87","G":"**"},{"Policy Line":"64505019","B":"Gdewre-Sphincterotome Jagtome","C":"272","D":"C1769","F":"488.682","G":"**"},{"Policy Line":"64505020","B":"Stent Non-Cov W/Delivery Sys","C":"278","D":"C1876","F":"3196.17","G":"**"},{"Policy Line":"64505021","B":"Stent Covered W/Delivery Sys","C":"278","D":"C1874","F":"2989.62","G":"**"},{"Policy Line":"64505022","B":"Stent Flexi/Plas W/Del Gr2","C":"278","D":"C2625","F":"221.85"},{"Policy Line":"64505023","B":"Feeding Tube Grp 2","C":"272","F":"175.95","G":"**"},{"Policy Line":"64505024","B":"Stent Flex/Plastic W/O Del Sys","C":"278","D":"C2617","F":"134.334"},{"Policy Line":"64505025","B":"G Tube Grp 1","C":"272","F":"83.844","G":"**"},{"Policy Line":"64505026","B":"Stent,Non-cor, temp w/del sys","C":"278","D":"C2625","F":"214.2","G":"**"},{"Policy Line":"64505027","B":"Alliance Ii Cre Syringe Disp","C":"272","F":"61.2"},{"Policy Line":"64505028","B":"Cytology Brush","C":"272","F":"193.392","G":"**"},{"Policy Line":"64505029","B":"Cath Ercp/Biliary","C":"272","F":"120.564","G":"**"},{"Policy Line":"64505031","B":"Needle Sclerotherapy","C":"272","F":"57.528","G":"**"},{"Policy Line":"64505032","B":"Breeze Rx Inflation Device","C":"272","F":"141.984","G":"**"},{"Policy Line":"64505034","B":"Cannula","C":"272","F":"99.144","G":"**"},{"Policy Line":"64505035","B":"Cath Ano-Rectal Manometry","C":"272","F":"92.106","G":"**"},{"Policy Line":"64505041","B":"Cath Ablation Halo 360","C":"272","D":"C1726","F":"1700.136"},{"Policy Line":"64505042","B":"Cath Ablation Halo 90","C":"272","F":"1513.782","G":"**"},{"Policy Line":"64505043","B":"Balloon Sizing Halo","C":"272","F":"595.17"},{"Policy Line":"64505044","B":"Cath Ablation Halo-Express","C":"272","F":"3160.98"},{"Policy Line":"64505048","B":"Gastric Lavage System Easi-Lav","C":"272","F":"428.4","G":"**"},{"Policy Line":"64505049","B":"Stent Cov W/Deliv Grp 2","C":"278","D":"C1874","F":"3178.116","G":"**"},{"Policy Line":"64505056","B":"Feeding Set Jejunal Pegj-12-24","C":"272","F":"371.178"},{"Policy Line":"64505083","B":"Probe Ph","C":"272","F":"125.766","G":"**"},{"Policy Line":"64505084","B":"Overtube Endoscopic; Esoph","C":"272","F":"310.59"},{"Policy Line":"64505085","B":"Ligator Polyloop","C":"272","F":"164.016"},{"Policy Line":"64505087","B":"Nasobiliary Drainage Set","C":"272","F":"222.768"},{"Policy Line":"64505088","B":"Ligator Speedband","C":"272","F":"55.386","G":"**"},{"Policy Line":"64505133","B":"Stent Flexi/Plas W/Del Gr1","C":"278","D":"C2625","F":"181.152"},{"Policy Line":"64505134","B":"Stent Flexi/Plas W/Del Gr2","C":"278","D":"C2625","F":"271.422"},{"Policy Line":"64505231","B":"Device Retrieval Spec Endo","C":"272","F":"190.944","G":"**"},{"Policy Line":"64505500","B":"Ligator: Multiband","C":"272","F":"425.646","G":"**"},{"Policy Line":"64505788","B":"Retrieval Net","C":"272","F":"182.07","G":"**"},{"Policy Line":"64505888","B":"Tube: Blakemore","C":"272","F":"401.778","G":"**"},{"Policy Line":"64508888","B":"Cdd Non-Chargeable Supplies","C":"270","F":"0"},{"Policy Line":"64509548","B":"Guidewire Grp 1","C":"272","D":"C1769","F":"94.86","G":"**"},{"Policy Line":"64600006","B":"Stent: Fluency Grp 2","C":"278","D":"C1874","F":"2936.682"},{"Policy Line":"64600014","B":"Probe Ablation XL90 Ar-9821","C":"272","F":"272.034"},{"Policy Line":"64600068","B":"IOL-Posterior Chamber SOFTECHD","C":"276","D":"V2632","F":"159.12"},{"Policy Line":"64600069","B":"IOL- POSTERIOR CHAMBER","C":"276","D":"V2632","F":"279.378"},{"Policy Line":"64600070","B":"Rezoom Conventional Lens","C":"276","F":"261.63"},{"Policy Line":"64600071","B":"Rezoom Lens -D","C":"276","F":"0"},{"Policy Line":"64600076","B":"Tecnis Conventional Lens","C":"276","D":"V2632","F":"261.63","G":"**"},{"Policy Line":"64600077","B":"Toric A-C Lens ZCT, SN6AT","C":"276","D":"V2787","F":"177.3","G":"**"},{"Policy Line":"64600078","B":"Crystalens -D","C":"276","F":"0"},{"Policy Line":"64600079","B":"Crystalens Conventional Lens","C":"276","F":"249.084"},{"Policy Line":"64600080","B":"Crystalens A-C Functionality","C":"276","D":"V2787","F":"390.456"},{"Policy Line":"64600081","B":"Peg P-K Socket System","C":"278","F":"423.198"},{"Policy Line":"64600100","B":"Cuff Nerve Colgn 2.0MMX2.5CM","C":"278","D":"C9355","F":"1889.244"},{"Policy Line":"64600101","B":"Enduragen","C":"278","D":"C1763","F":"1056.006"},{"Policy Line":"64600102","B":"Inforce Matrix-CnTiss Nonhuman","C":"278","D":"C1763","F":"375.462"},{"Policy Line":"64600103","B":"Tightrope Knotless Ar-8926Ss","C":"278","D":"C1713","F":"1622.106"},{"Policy Line":"64600104","B":"Epifix 4X4Cm Gs-5440","C":"278","D":"Q4186","F":"3198.924"},{"Policy Line":"64600105","B":"Epifix 2X3Cm Gs-5230","C":"278","D":"Q4186","F":"1697.076","G":"**"},{"Policy Line":"64600106","B":"Amniofix 1.25Cc Inject Ai-5125","C":"278","F":"2129.148"},{"Policy Line":"64600107","B":"Implant X-Fuse Large Axf-Xlo","C":"278","F":"2070.702"},{"Policy Line":"64600108","B":"Allograft Epi 14Mmx2Cm Gs-5140","C":"278","D":"Q4186","F":"476.748"},{"Policy Line":"64600109","B":"Kit Acl Disposable Ar-1898S","C":"272","F":"231.03"},{"Policy Line":"64600110","B":"Guide Nerve Png630","C":"278","D":"C9352","F":"1311.822"},{"Policy Line":"64600111","B":"Amniofix .5Ml Inject Ai-5050","C":"278","F":"997.254"},{"Policy Line":"64600112","B":"Bone Stimulator 01-203-0001","C":"278","F":"2571.624"},{"Policy Line":"64600113","B":"Impl I-Stent Micro AquesDrnag","C":"278","D":"C1783","F":"2143.53","G":"**"},{"Policy Line":"64600116","B":"Kit Mini Osteoset 5Cc 84000611","C":"278","F":"874.548"},{"Policy Line":"64600117","B":"Kit Fast Rem Tx-1 554-1003-001","C":"272","F":"965.43"},{"Policy Line":"64600118","B":"Implant Cornea","C":"278","F":"3499.722","G":"**"},{"Policy Line":"64600120","B":"COUNTERSINK FINE DISP","C":"272","F":"384.03"},{"Policy Line":"64600121","B":"CUSTOM BONE WEDGE PMTP-21008","C":"278","F":"2404.242"},{"Policy Line":"64600122","B":"KIT CARPAL TUNNEL 4116","C":"272","F":"383.724"},{"Policy Line":"64600124","B":"GUIDE NERVE INTEGRA 2mmX3CM","C":"278","D":"C9352","F":"2234.718"},{"Policy Line":"64600125","B":"COUNTERSINK DISP","C":"272","F":"446.454","G":"**"},{"Policy Line":"64600128","B":"Alloderm 6x16CM 1520616","C":"278","D":"Q4116","F":"2962.998"},{"Policy Line":"64600129","B":"SYSTEM ENDO RELEASE 310138","C":"272","F":"1380.366"},{"Policy Line":"64600130","B":"PACK PROC HAT-TRICK","C":"272","F":"2239.614"},{"Policy Line":"64600131","B":"PROTECTOR NERVE 7MMX4CM","C":"278","D":"C9353","F":"1738.998"},{"Policy Line":"64600132","B":"Stylet Vasc Closure 6FR","C":"272","F":"850.986"},{"Policy Line":"64600139","B":"Algrft Amniotic Mem Fen 9x20cm","C":"278","D":"Q4100","F":"11750.4"},{"Policy Line":"64600150","B":"PIP ASCENSION PACK PIP-DIS-STR","C":"272","F":"612.918"},{"Policy Line":"64600151","B":"PROTECTOR NERVE 40MM AG0XXX","C":"278","F":"2683.62","G":"**"},{"Policy Line":"64600152","B":"ORTHOPAK 2 EXTERNAL 1067718","C":"272","F":"5021.46"},{"Policy Line":"64600153","B":"EPIFIX 9.0 X 9.0 CM","C":"278","D":"Q4186","F":"6022.998"},{"Policy Line":"64600155","B":"EPIFIX 5X6CM GS-5560","C":"278","D":"Q4186","F":"5510.142"},{"Policy Line":"64600156","B":"CONNECTOR, NERVE, PORCINE ECM","C":"278","F":"1631.898","G":"**"},{"Policy Line":"64600161","B":"Set Disp Jugger Knot","C":"278","D":"C1713","F":"739.602"},{"Policy Line":"64600162","B":"Pack, Finger Implant","C":"272","F":"560.286"},{"Policy Line":"64600163","B":"Countersink","C":"272","F":"358.02"},{"Policy Line":"64600164","B":"Tissue Patch Cornea GPC-W","C":"278","F":"429.93","G":"**"},{"Policy Line":"64600166","B":"Epifix Powder/Inj 160mg","C":"278","D":"Q4145","F":"2942.19"},{"Policy Line":"64600167","B":"Lens Sensar","C":"276","D":"V2632","F":"278.46"},{"Policy Line":"64600168","B":"ALLOGEN .1.0ML PO1-AMF-0100","C":"278","F":"2994.516"},{"Policy Line":"64600169","B":"Epifix 100MG EI-5125","C":"278","D":"Q4145","F":"2342.43","G":"**"},{"Policy Line":"64600170","B":"ARROWLOK FIXATION SYSTEM","C":"278","D":"C1713","F":"1631.592"},{"Policy Line":"64600171","B":"Suture Anchor Speedbridge","C":"278","D":"C1713","F":"1782.45"},{"Policy Line":"64600172","B":"Button Tightrope; Anchor","C":"278","D":"C1713","F":"509.49"},{"Policy Line":"64600174","B":"Integra MatrxWnd BilyrMesh 2x2","C":"278","F":"2844.882","G":"**"},{"Policy Line":"64600175","B":"Kit Suturetak Disp","C":"272","F":"398.106"},{"Policy Line":"64600176","B":"Kit Swivelock Disp","C":"272","F":"625.464","G":"**"},{"Policy Line":"64600177","B":"Kit Fusion Motoband","C":"272","F":"1018.368"},{"Policy Line":"64600178","B":"Staple Fsn Motoclip","C":"278","D":"C1713","F":"2349.468"},{"Policy Line":"64600179","B":"PEG SMOOTH","C":"278","D":"C1713","F":"171.666"},{"Policy Line":"64600180","B":"Pars Achilles JIG Suture Kit","C":"278","F":"771.426"},{"Policy Line":"64600181","B":"Peg Partial Threaded-Wrist","C":"278","D":"C1713","F":"206.856"},{"Policy Line":"64600183","B":"Axogard Nerve Protector AG0340","C":"278","F":"2552.958"},{"Policy Line":"64600184","B":"Screw Tenodesis","C":"278","D":"C1713","F":"444.006"},{"Policy Line":"64600185","B":"Stent Visi Pro","C":"278","D":"C1876","F":"1087.83"},{"Policy Line":"64600186","B":"Cath Guide Omni Flush","C":"272","D":"C1887","F":"24.786"},{"Policy Line":"64600187","B":"Coil Helical","C":"278","F":"144.126"},{"Policy Line":"64600188","B":"Cinch Meniscal","C":"272","F":"649.332"},{"Policy Line":"64600189","B":"ORTHOCORD","C":"272","F":"52.938"},{"Policy Line":"64600190","B":"STENT 8X80X80 VIUS08080","C":"278","D":"C1876","F":"767.754"},{"Policy Line":"64600191","B":"WIRE GD J 0.035X180 49-167","C":"272","D":"C1769","F":"40.392"},{"Policy Line":"64600192","B":"WIRE BENTSON .035X180 49-177","C":"272","D":"C1769","F":"44.37"},{"Policy Line":"64600193","B":"WIRE TIP V-14 39216-91821","C":"272","D":"C1769","F":"311.508"},{"Policy Line":"64600194","B":"WIRE GUIDE","C":"272","D":"C1769","F":"76.806","G":"**"},{"Policy Line":"64600195","B":"TRAY TRACH BLU RHINO G13166","C":"272","D":"C1769","F":"691.56"},{"Policy Line":"64600196","B":"KIT SNARE RETRIEVAL SRK30","C":"272","D":"C1773","F":"469.404"},{"Policy Line":"64600198","B":"CATH SEEKER 5FR 150CM SK15035M","C":"272","D":"C1887","F":"641.376"},{"Policy Line":"64600199","B":"CATH 4FR 65 STRT SEL 10731402","C":"272","D":"C1887","F":"66.402"},{"Policy Line":"64600200","B":"CATH GUIDE STR 5F 65CM CG505","C":"272","D":"C1887","F":"103.122"},{"Policy Line":"64600201","B":"CATH 4FR 150C STRT SEL11731507","C":"272","D":"C1887","F":"194.004"},{"Policy Line":"64600202","B":"QUICK CLOT 183","C":"272","F":"70.38","G":"**"},{"Policy Line":"64600203","B":"SURGICLIP PREM TITANIUM","C":"272","F":"124.236","G":"**"},{"Policy Line":"64600204","B":"CUTTER SUTURE/PUSHER 72202674","C":"272","F":"232.254"},{"Policy Line":"64600205","B":"ADHESIVE CLOSURE SKIN CLR222US","C":"272","F":"147.798"},{"Policy Line":"64600206","B":"WAND ARTHRO SERFA 0279-351-400","C":"272","F":"285.498"},{"Policy Line":"64600207","B":"SYS FIX ULTRAFAST CRV 72201491","C":"278","F":"503.064"},{"Policy Line":"64600208","B":"RETRACTOR CAPSULE MCR-0001","C":"272","F":"52.938"},{"Policy Line":"64600209","B":"DERMACARRIER II 00-2195-012-00","C":"272","F":"66.402","G":"**"},{"Policy Line":"64600210","B":"EXPANDER PUPIL I RING 58700","C":"272","F":"208.08","G":"**"},{"Policy Line":"64600211","B":"PASSER SUTURE CHIA PERC 214101","C":"272","F":"253.062","G":"**"},{"Policy Line":"64600212","B":"PROBE ANTERIOR VIT 8065752134","C":"272","F":"302.328","G":"**"},{"Policy Line":"64600213","B":"IOL Restor Alcon Multi SV25TO","C":"276","D":"V2788","F":"310.59","G":"**"},{"Policy Line":"64600215","B":"Stent Bil GPS Mini Paramount","C":"278","D":"C1876","F":"1087.83"},{"Policy Line":"64600216","B":"KIT PUSHLOK AR-1926DS","C":"272","F":"278.46"},{"Policy Line":"64600217","B":"GRAFT Vascular Hemoshield","C":"278","D":"C1768","F":"900.864"},{"Policy Line":"64600218","B":"Graft Gamma 8x9 GG625","C":"278","D":"Q4111","F":"557.226"},{"Policy Line":"64600219","B":"Support BK++TLSO UPT2633-15","C":"274","D":"L0456","F":"476.748"},{"Policy Line":"64600220","B":"Endotine Mini CFD-22202","C":"278","F":"670.446","G":"**"},{"Policy Line":"64600221","B":"Stylet Endovenos RFS2-6-12","C":"272","F":"850.986"},{"Policy Line":"64600222","B":"Kit Prevena PRE1001US","C":"272","F":"787.644"},{"Policy Line":"64600223","B":"CathAngioNon-LsrTranslum Grp A","C":"272","D":"C1725","F":"167.076"},{"Policy Line":"64600224","B":"Kit BoneFiller Synth-Foot/Ankl","C":"278","D":"C1713","F":"3828.978"},{"Policy Line":"64600225","B":"Wrap Amniofix 2.0x2.0cmTN-5220","C":"278","F":"928.71"},{"Policy Line":"64600226","B":"Kit Biocomposite AR-8928BC-CP","C":"278","D":"C1713","F":"3181.176"},{"Policy Line":"64600227","B":"Implt Sys MPFL Bio AR-1360C-CP","C":"278","D":"C1713","F":"1865.682"},{"Policy Line":"64600228","B":"Implt Sys ACL AR-1360CST-CP","C":"278","D":"C1713","F":"3084.174"},{"Policy Line":"64600229","B":"Implt Sys ANKL AR-1675BC-CP","C":"278","D":"C1713","F":"2239.614"},{"Policy Line":"64600230","B":"Imp Del Biocomp AR-2260BC","C":"278","D":"C1713","F":"2011.644","G":"**"},{"Policy Line":"64600231","B":"Sys Imp Bioc Swivlck AR2600SBS","C":"278","D":"C1713","F":"3181.176"},{"Policy Line":"64600232","B":"Fibrtape Collgn Coat AR-7237-7","C":"272","F":"145.044"},{"Policy Line":"64600233","B":"Guidewire 1.3MM AR-5050-01","C":"272","F":"261.018"},{"Policy Line":"64600234","B":"Epifix 40mg Inject EI-5050","C":"278","D":"Q4145","F":"928.098"},{"Policy Line":"64600235","B":"Amniofill 500MG AF-0500","C":"278","F":"1471.554"},{"Policy Line":"64600236","B":"DRILL KIT RETROFSN AR-4157DS","C":"272","F":"822.834"},{"Policy Line":"64600237","B":"PACK GRAFT LINK AR-1588AL-CP","C":"278","F":"1718.496"},{"Policy Line":"64600238","B":"Kit Drill BME 3.0MM DK-300","C":"272","F":"787.644"},{"Policy Line":"64600239","B":"Template Drilling BME EL-DTS","C":"272","F":"175.032"},{"Policy Line":"64600240","B":"Imp Strght Bridge 4Leg","C":"278","D":"C1713","F":"2713.302"},{"Policy Line":"64600241","B":"Imp Strght Bridge 2Leg","C":"278","D":"C1713","F":"3071.322"},{"Policy Line":"64600242","B":"ALLOGRAFT BIOFIX FLOW 1CC BFA","C":"278","D":"Q4162","F":"3530.016","G":"**"},{"Policy Line":"64600243","B":"Kit Biocomposite AR-8928BCJ-CP","C":"278","D":"C1713","F":"2485.332"},{"Policy Line":"64600244","B":"Epifix 2x3cm ES-2300","C":"278","D":"Q4186","F":"1464.516"},{"Policy Line":"64600245","B":"BARRIER AVIVE 3X6CM CA0306","C":"278","F":"3742.992","G":"**"},{"Policy Line":"64600246","B":"Pack Suture Pars AR-8862DS","C":"278","F":"1247.562"},{"Policy Line":"64600247","B":"CUTTER FLIP 8.5MM AR-1204AF-85","C":"272","F":"517.14"},{"Policy Line":"64600248","B":"BUTTON TIGHTROPE AR-1588TB-4","C":"278","D":"C1713","F":"356.49"},{"Policy Line":"64600249","B":"COUNTERSINK 4.0 P20-915-4000","C":"272","F":"305.082"},{"Policy Line":"64600250","B":"IMPNT TOE JNT MTP, CARTIVA","C":"278","D":"C1776","F":"3651.804"},{"Policy Line":"64600251","B":"STNT OCULR-XEN SFT GEL 0449T","C":"278","D":"C1783","F":"1574.064","G":"**"},{"Policy Line":"64600252","B":"Fixator Kit, Hand-Digit Widget","C":"272","F":"1983.492"},{"Policy Line":"64600253","B":"Epicord 3.0 x 5.0CM","C":"278","D":"Q4187","F":"3169.854"},{"Policy Line":"64600254","B":"Graft Vascular GRP 6","C":"278","D":"C1768","F":"1214.514"},{"Policy Line":"64600255","B":"Cath Atherectomy, 1.25","C":"272","D":"C1724","F":"3443.724"},{"Policy Line":"64600256","B":"Ring, Capsular TNSN EyeJet","C":"272","F":"278.766"},{"Policy Line":"64600257","B":"Graft,Nerve Avance 3-4mm","C":"278","F":"5071.95"},{"Policy Line":"64600258","B":"GRAFT VASCULAR GRP 8","C":"278","D":"C1768","F":"2994.516"},{"Policy Line":"64600259","B":"Syndesmosis Repair Implant Sys","C":"278","D":"C1713","F":"1875.474"},{"Policy Line":"64600260","B":"NUCEL 2cc NC-1002","C":"278","F":"3182.4","G":"**"},{"Policy Line":"64600261","B":"STAPLES TENDON","C":"272","F":"390.15"},{"Policy Line":"64600262","B":"Reamer , Crosstie","C":"272","F":"159.12"},{"Policy Line":"64600263","B":"PriMatrix 8X8 Sq Cm AG meshed","C":"278","D":"Q4110","F":"4784.31","G":"**"},{"Policy Line":"64600264","B":"Closure Device Mynx","C":"278","D":"C1760","F":"321.606"},{"Policy Line":"64600265","B":"Staple Bone Grp 5","C":"278","D":"C1713","F":"2066.724","G":"**"},{"Policy Line":"64600266","B":"DEVICE CATH MICRO","C":"272","F":"2007.36","G":"**"},{"Policy Line":"64600273","B":"Implant Eyelid","C":"278","F":"432.684"},{"Policy Line":"64600279","B":"Rod Grp 6","C":"278","F":"1850.688"},{"Policy Line":"64600280","B":"SIZER MAMMARY GRP 1","C":"272","F":"83.538"},{"Policy Line":"64600281","B":"Cath,Translum Angioplast Grp1A","C":"272","D":"C1725","F":"218.484"},{"Policy Line":"64600282","B":"Cath,Translum Angioplast Grp1B","C":"272","D":"C1725","F":"265.302"},{"Policy Line":"64600389","B":"CEMENT BONE GRP 3","C":"278","D":"C1713","F":"464.814"},{"Policy Line":"64600579","B":"Plate Grp 10","C":"278","D":"C1713","F":"4506.768","G":"**"},{"Policy Line":"64600595","B":"Plate Grp 8","C":"278","D":"C1713","F":"2496.654","G":"**"},{"Policy Line":"64600596","B":"Plate Grp 9","C":"278","D":"C1713","F":"2602.224"},{"Policy Line":"64600798","B":"BLADE DISPOSABLE GRP 6","C":"272","F":"1092.42"},{"Policy Line":"64600839","B":"Epicord 2X3Cm","C":"278","D":"Q4186","F":"1604.664","G":"**"},{"Policy Line":"64600876","B":"Anchor Bone Grp 4","C":"278","D":"C1713","F":"770.202","G":"**"},{"Policy Line":"64601249","B":"Guidewire Grp 2","C":"272","F":"193.086"},{"Policy Line":"64601251","B":"SCREW GRP 7","C":"278","D":"C1713","F":"1463.292"},{"Policy Line":"64601270","B":"Allograft Ort/Neu Human Grp7","C":"278","F":"2655.468","G":"**"},{"Policy Line":"64601271","B":"ALLOGRAFT ORTH/NEUR HUMAN GRP8","C":"278","F":"6022.998"},{"Policy Line":"64601356","B":"Cath Guiding Low Cost Grp 4","C":"272","D":"C1887","F":"44.982"},{"Policy Line":"64601531","B":"TranslumAther Dir Cath-Hawkone","C":"272","F":"3144.762"},{"Policy Line":"64601549","B":"FLEXHD 6X12 CM","C":"278","D":"Q4128","F":"2028.78"},{"Policy Line":"64601687","B":"GUIDE PIN, NON IMPLNT GR 3","C":"272","F":"895.662"},{"Policy Line":"64601689","B":"Allograft BiofixFlow 0.5CC","C":"278","D":"Q4162","F":"3071.322"},{"Policy Line":"64601691","B":"ALLGRFT AMNIO MEM BIOFIX 4X4CM","C":"278","D":"Q4163","F":"3164.958"},{"Policy Line":"64601703","B":"Plate Grp 9A","C":"278","D":"C1713","F":"3295.926"},{"Policy Line":"64601746","B":"Neurawrap Nrv Protectr 5mmx2cm","C":"278","D":"C9353","F":"2081.412"},{"Policy Line":"64601747","B":"Neuragen Nerve Guide 2 Cm","C":"278","D":"C9352","F":"1828.35"},{"Policy Line":"64601748","B":"Neuragen Nerve Guide 3 Cm","C":"278","D":"C9352","F":"2409.75"},{"Policy Line":"64601750","B":"Tap 5.5mm","C":"272","F":"787.644"},{"Policy Line":"64601836","B":"Screw Grp 2A","C":"278","D":"C1713","F":"287.028","G":"**"},{"Policy Line":"64601838","B":"Screw Grp 3A","C":"278","D":"C1713","F":"491.742"},{"Policy Line":"64601865","B":"Bit Drill Grp 2A","C":"272","F":"279.378"},{"Policy Line":"64601866","B":"Bit Drill Grp 2B","C":"272","F":"341.802","G":"**"},{"Policy Line":"64601868","B":"Implant Hammerlock 20mm","C":"278","D":"C1713","F":"1439.424"},{"Policy Line":"64601879","B":"KIT JUGGER KNOT SZ1 OR 2","C":"278","D":"C1713","F":"818.856"},{"Policy Line":"64601883","B":"Plate Grp 3 B","C":"278","D":"C1713","F":"489.906"},{"Policy Line":"64601885","B":"Plate Grp 3 C","C":"278","D":"C1713","F":"597.618"},{"Policy Line":"64601887","B":"Plate Grp 3 D","C":"278","D":"C1713","F":"730.422","G":"**"},{"Policy Line":"64601913","B":"SCREW GRP 6 A","C":"278","D":"C1713","F":"1223.388"},{"Policy Line":"64601929","B":"Bit Drill Grp 4 A","C":"272","F":"824.058","G":"**"},{"Policy Line":"64601947","B":"Mesh Genl Surg C1781 Grp 3A","C":"278","D":"C1781","F":"567.936"},{"Policy Line":"64601967","B":"Bony Void Filler Grp 1","C":"278","D":"C1713","F":"316.71","G":"**"},{"Policy Line":"64601972","B":"Bony Void Filler Grp 2","C":"278","D":"C1713","F":"631.278","G":"**"},{"Policy Line":"64601973","B":"BONY VOID FILLER GRP3","C":"278","D":"C1713","F":"828.342","G":"**"},{"Policy Line":"64601974","B":"Bony Void Filler Grp 4","C":"278","D":"C1713","F":"1346.094"},{"Policy Line":"64601975","B":"Bony Void Filler Grp 5","C":"278","D":"C1713","F":"1624.86"},{"Policy Line":"64601977","B":"BONY VOID FILLER GRP 7","C":"278","F":"2854.062"},{"Policy Line":"64601997","B":"KIT MENISCAL REPAIR AR-4550","C":"278","F":"1273.572"},{"Policy Line":"64602008","B":"Screw Grp 1A","C":"278","D":"C1713","F":"171.666","G":"**"},{"Policy Line":"64602016","B":"Implant Joint Grp 3","C":"278","F":"546.21"},{"Policy Line":"64602017","B":"IMPLANT JOINT GRP 4","C":"278","D":"C1776","F":"620.262","G":"**"},{"Policy Line":"64602018","B":"Implant Joint Grp 5","C":"278","D":"C1776","F":"911.268"},{"Policy Line":"64602019","B":"Implant Joint Group 6","C":"278","D":"C1776","F":"1437.588","G":"**"},{"Policy Line":"64602020","B":"Implant Joint Grp 7","C":"278","F":"1782.45"},{"Policy Line":"64602021","B":"IMPLANT JOINT GRP 8","C":"278","D":"C1776","F":"2011.032","G":"**"},{"Policy Line":"64602022","B":"IMPLANT JOINT GRP 9","C":"278","D":"C1776","F":"2496.96"},{"Policy Line":"64602023","B":"IMPLANT JOINT GRP 10","C":"278","D":"C1776","F":"2653.02"},{"Policy Line":"64602024","B":"IMPLANT JOINT GRP 11","C":"278","D":"C1776","F":"2902.716"},{"Policy Line":"64602025","B":"Implant Joint Grp 12","C":"278","D":"C1776","F":"3978"},{"Policy Line":"64602036","B":"Pin Fixation Hammertoe","C":"278","D":"C1713","F":"1358.946"},{"Policy Line":"64602039","B":"Screw Grp 1B","C":"278","D":"C1713","F":"209.61","G":"**"},{"Policy Line":"64602056","B":"Screw Grp 2B","C":"278","D":"C1713","F":"369.954"},{"Policy Line":"64602085","B":"Nail, Ortho Grp 2A","C":"278","D":"C1713","F":"622.71"},{"Policy Line":"64602397","B":"Tube Tear Duct","C":"278","F":"127.602"},{"Policy Line":"64602509","B":"Stent,Peripheral SE","C":"278","D":"C1876","F":"959.922"},{"Policy Line":"64602527","B":"Pack Closure Cpp","C":"272","F":"173.196"},{"Policy Line":"64602612","B":"Cath Thrombec/Embolec","C":"272","F":"174.42"},{"Policy Line":"64602619","B":"Dermabond, per vial","C":"272","F":"41.004"},{"Policy Line":"64602713","B":"Washer Spiked,Ortho 14mm","C":"278","F":"227.664"},{"Policy Line":"64602731","B":"Cath Angio 5FR, Soft-Vu","C":"272","D":"C1887","F":"30.294"},{"Policy Line":"64602735","B":"GUIDE PIN Ti 2mm","C":"272","F":"81.09"},{"Policy Line":"64602745","B":"Screw Grp 4A","C":"278","D":"C1713","F":"749.088","G":"**"},{"Policy Line":"64602788","B":"Stent Biliary - Express","C":"278","D":"C1876","F":"1215.738"},{"Policy Line":"64602790","B":"Bony Void Filler Grp 6A","C":"278","D":"C1713","F":"2431.476","G":"**"},{"Policy Line":"64603171","B":"AnchorSys Implt-AC ReprAR-2271","C":"278","D":"C1713","F":"2057.85"},{"Policy Line":"64603172","B":"ALLGRFT AMNIO MEM BIOFIX 2X4CM","C":"278","D":"Q4163","F":"1791.63"},{"Policy Line":"64603189","B":"KIT BIOSUTURE TAK","C":"272","F":"254.592","G":"**"},{"Policy Line":"64603328","B":"Tutoplast Pericardium 68250","C":"278","F":"469.098","G":"**"},{"Policy Line":"64603336","B":"Set Frontalis Suspension Bd","C":"278","F":"86.904"},{"Policy Line":"64604008","B":"Eye Sphere Implantable","C":"278","F":"40.392"},{"Policy Line":"64604085","B":"Stent Opth Monoka 4MmW S1-1630","C":"278","F":"135.558"},{"Policy Line":"64604160","B":"Tray Trach Blue Rhino 263567","C":"272","D":"C1769","F":"766.836"},{"Policy Line":"64604202","B":"Stent Lacriminal","C":"278","F":"156.06"},{"Policy Line":"64604319","B":"Sling Shot Large Breg 08504","C":"274","D":"L3670","F":"88.434","G":"**"},{"Policy Line":"64604327","B":"Versajet II 45/14MM","C":"272","F":"788.256"},{"Policy Line":"64604365","B":"Closure Device Angioseal","C":"278","D":"C1760","F":"334.152"},{"Policy Line":"64604389","B":"Implant Subtalar MBA","C":"278","D":"C1713","F":"2686.374"},{"Policy Line":"64604407","B":"Eye Sphere Implant Gulden","C":"278","F":"104.652"},{"Policy Line":"64604408","B":"Screw Cannulated Synthes","C":"278","D":"C1713","F":"237.15"},{"Policy Line":"64604409","B":"Alloderm 2X4 cm","C":"278","D":"Q4116","F":"700.434"},{"Policy Line":"64604410","B":"Corneal Tissue Mt#0015042","C":"278","D":"V2785","F":"4011.966","G":"**"},{"Policy Line":"64604411","B":"Corneal Tissue Mt#0019054","C":"278","D":"V2785","F":"4052.664"},{"Policy Line":"64604419","B":"Eyelid Implant","C":"278","F":"1189.422"},{"Policy Line":"64604420","B":"Fibrin Sealant","C":"272","F":"447.372"},{"Policy Line":"64604421","B":"Enduragen Collagen","C":"278","D":"C1763","F":"1056.006"},{"Policy Line":"64604422","B":"Graft Ambio-Dry Ad-5230","C":"278","D":"V2790","F":"855.576","G":"**"},{"Policy Line":"64604424","B":"Symblepharon Ring","C":"272","F":"122.094"},{"Policy Line":"64604425","B":"Ring Malyugin Mal0001","C":"272","F":"199.206","G":"**"},{"Policy Line":"64604426","B":"Impl Screw","C":"278","F":"119.34"},{"Policy Line":"64604428","B":"Implant Eyelid Gold","C":"278","F":"505.206"},{"Policy Line":"64604429","B":"Tutoplast Sclera Whole","C":"278","D":"C1762","F":"889.542"},{"Policy Line":"64604430","B":"Tutoplast Sclera 5X8","C":"278","D":"C1762","F":"469.098","G":"**"},{"Policy Line":"64604431","B":"Tutoplast Fascia Lata","C":"278","D":"C1762","F":"1683"},{"Policy Line":"64604433","B":"Endotine Implant","C":"278","F":"316.71"},{"Policy Line":"64604435","B":"Cath Balloon Lacriminal Duct","C":"272","D":"C1726","F":"531.522"},{"Policy Line":"64604437","B":"PTOSE Up Implant","C":"278","F":"115.668"},{"Policy Line":"64604438","B":"Set Lacriminal Intubation","C":"272","F":"174.114"},{"Policy Line":"64604439","B":"Shunt Ex-Press Mini Glaucoma","C":"278","D":"C1783","F":"1273.572"},{"Policy Line":"64604440","B":"Baervelt Glaucoma Implant","C":"278","F":"884.34","G":"**"},{"Policy Line":"64604442","B":"Malar Implant Medpor","C":"278","F":"339.66"},{"Policy Line":"64604444","B":"Nasal Arch","C":"278","F":"358.02"},{"Policy Line":"64604445","B":"Surgicel","C":"272","F":"66.096"},{"Policy Line":"64604446","B":"Dermabond","C":"272","F":"56.916"},{"Policy Line":"64604447","B":"Sheet Barrier","C":"278","F":"794.376"},{"Policy Line":"64604448","B":"Implant Flexblock","C":"278","F":"724.302"},{"Policy Line":"64604449","B":"Reform Capsular Tension Ring","C":"278","F":"343.332","G":"**"},{"Policy Line":"64604451","B":"Amniograft","C":"278","D":"V2790","F":"1017.45"},{"Policy Line":"64604453","B":"Graft Ambio Dry Af1230","C":"278","D":"V2790","F":"918.306"},{"Policy Line":"64604454","B":"Lens Tecnis Ntiol","C":"276","D":"C1780","F":"270.504"},{"Policy Line":"64604455","B":"Screw; Implant","C":"278","D":"C1713","F":"99.45"},{"Policy Line":"64604456","B":"Plate Eyectr Grp 1","C":"278","D":"C1713","F":"208.386"},{"Policy Line":"64604457","B":"Plate Eyectr Grp 2","C":"278","F":"267.444"},{"Policy Line":"64604468","B":"Pac Ant Vitrectomy","C":"272","F":"288.864"},{"Policy Line":"64604469","B":"Drain Tube Extender Glcma Vlv","C":"272","F":"199.206","G":"**"},{"Policy Line":"64604470","B":"Bladeless Cataract Sur Imaging","C":"279","F":"229.5","G":"**"},{"Policy Line":"64604477","B":"Medpor SST Implant","C":"278","F":"660.348"},{"Policy Line":"64604478","B":"Implant Chaineyelid Platinum","C":"278","F":"1151.478"},{"Policy Line":"64604479","B":"Zmaoo Tecnis P-C Iol -D","C":"276","F":"1145.358"},{"Policy Line":"64604481","B":"Lens Presby-C Fnctn Multifocal","C":"276","D":"V2788","F":"298.5","G":"**"},{"Policy Line":"64604482","B":"Corneal Tissue Impl Mm#0080844","C":"278","D":"V2785","F":"4140.792"},{"Policy Line":"64604483","B":"Corneal Tissue Imp Mt#0080853","C":"278","D":"V2785","F":"4564.908","G":"**"},{"Policy Line":"64604572","B":"Cuff Nerve Collagen","C":"278","D":"C9355","F":"1811.52"},{"Policy Line":"64604710","B":"Integra BiWndMtrx 4x5cmBMW4051","C":"278","D":"Q4104","F":"4962.708"},{"Policy Line":"64604737","B":"Wound Matrix Restrata","C":"623","D":"A6460","F":"4475.25","G":"**"},{"Policy Line":"64604750","B":"Alloderm 6x12","C":"278","D":"Q4116","F":"2536.434"},{"Policy Line":"64604783","B":"Suture Shuttle","C":"272","F":"287.028"},{"Policy Line":"64604833","B":"Tightrope Syndemosis Kit","C":"278","F":"1104.048"},{"Policy Line":"64604835","B":"Vitagel Hemostat","C":"278","F":"397.188"},{"Policy Line":"64604840","B":"Stent Opth Monoka 4MmW S1-1800","C":"278","F":"187.272"},{"Policy Line":"64604850","B":"Screw/Kit Mini Scorpion","C":"278","D":"C1713","F":"1215.738"},{"Policy Line":"64604903","B":"AVANCE NERVE GRAFT 5CM","C":"272","F":"3037.05"},{"Policy Line":"64604922","B":"Dermaclose RC 204010-K","C":"272","F":"1214.208"},{"Policy Line":"64604953","B":"SYSTEM PEAK PLASMA 278001","C":"272","F":"535.194"},{"Policy Line":"64604976","B":"Imp Lig AugmRpr Sys AR-1688-CP","C":"278","D":"C1713","F":"1965.438"},{"Policy Line":"64604977","B":"IMPLANT SPEED 20X15 SE-2015TI","C":"278","D":"C1713","F":"2069.478"},{"Policy Line":"64604989","B":"Avance Nerve Graft 30MM","C":"278","F":"2894.148","G":"**"},{"Policy Line":"64605548","B":"TUBE GI GRP 3","C":"278","F":"212.67"},{"Policy Line":"64605557","B":"Graft Nerve Avance","C":"278","F":"6314.922","G":"**"},{"Policy Line":"64605566","B":"BLADE DISPOSABLE GRP 4","C":"272","F":"624.24","G":"**"},{"Policy Line":"64605569","B":"ALLOGRFT BIOFIX FLOW 2CC BFA2","C":"278","D":"Q4162","F":"6289.218"},{"Policy Line":"64605577","B":"Rod Spacer, Tendon","C":"278","F":"2293.164"},{"Policy Line":"64605622","B":"Barrier Avive 2x4CM CAO204","C":"278","F":"2661.894","G":"**"},{"Policy Line":"64605623","B":"Barrier Avive 3x4cm CA0304","C":"278","F":"3043.17"},{"Policy Line":"64605758","B":"Plate Strl Instr Kit 1500-4700","C":"272","F":"622.71","G":"**"},{"Policy Line":"64605884","B":"Kit Transtibial Acl Ar-1897S","C":"272","F":"362.916"},{"Policy Line":"64606539","B":"Coil Embolization","C":"278","F":"108.936"},{"Policy Line":"64606588","B":"Tenoglide 2X2 Tg221","C":"278","D":"C9356","F":"2386.8","G":"**"},{"Policy Line":"64606679","B":"Stent Viabahn 7X 10-15 VBH","C":"278","D":"C1874","F":"3580.2"},{"Policy Line":"64606793","B":"Filter Fem/Jug Grp 1","C":"278","D":"C1880","F":"1896.282"},{"Policy Line":"64607220","B":"Balloon Inflation Device","C":"272","F":"65.79"},{"Policy Line":"64607500","B":"Filter Vena Cava","C":"278","D":"C1880","F":"1119.654"},{"Policy Line":"64607501","B":"GD Cath/Sheath - Pinnacle","C":"272","D":"C1887","F":"169.218"},{"Policy Line":"64607502","B":"GD Cath/Sheath - Pinnacle Gr2","C":"272","D":"C1887","F":"192.168"},{"Policy Line":"64607503","B":"Guide Cath Support - Rubicon","C":"272","D":"C1887","F":"249.696"},{"Policy Line":"64607504","B":"Cath Endovenous RF","C":"272","D":"C1888","F":"1135.26"},{"Policy Line":"64607505","B":"Sheath/Introducr - Destination","C":"272","D":"C1894","F":"152.694"},{"Policy Line":"64607506","B":"Glidesheath, Slendor","C":"272","D":"C1894","F":"198.9"},{"Policy Line":"64607507","B":"Vascular Coil, Vortx","C":"278","F":"144.432"},{"Policy Line":"64607563","B":"Guidewire Journey","C":"272","D":"C1769","F":"311.508"},{"Policy Line":"64607564","B":"Stent Fluency Grp 1","C":"278","D":"C1874","F":"2680.866"},{"Policy Line":"64608301","B":"Syst Endoblade Plantr Fasc Rel","C":"272","F":"1604.664"},{"Policy Line":"64608481","B":"Implant Distal Biceps Ar-2260","C":"278","D":"C1713","F":"1608.642"},{"Policy Line":"64608520","B":"Driver Disp","C":"272","F":"333.54"},{"Policy Line":"64608532","B":"Vitagel Hemostat 2113-0000","C":"278","F":"647.802"},{"Policy Line":"64608536","B":"Cutter Flip","C":"272","F":"740.214"},{"Policy Line":"64608749","B":"PUSHER KNOT AR-4515","C":"272","F":"284.886"},{"Policy Line":"64608765","B":"Ahmed Valve","C":"272","F":"788.562"},{"Policy Line":"64608786","B":"PUNCH 5.5 AR-1927PBS","C":"272","F":"171.972","G":"**"},{"Policy Line":"64608859","B":"Screw Grp 10","C":"278","D":"C1713","F":"2340.9"},{"Policy Line":"64608863","B":"CONNECTOR,NERVE PORCINE ECM","C":"278","F":"1567.638"},{"Policy Line":"64608888","B":"Eye/Surg Center Non Chargeable","C":"270","F":"0"},{"Policy Line":"64608889","B":"REAMER ORTHO GRP 2","C":"272","F":"780.3","G":"**"},{"Policy Line":"64608892","B":"Alloderm LG 164SQCM CL1516","C":"278","D":"Q4116","F":"5462.1"},{"Policy Line":"64608900","B":"Pack,Cath/Sheath ClosureFast","C":"272","F":"927.792"},{"Policy Line":"64608949","B":"BLADE DISPOSABLE GRP 3","C":"272","F":"343.332","G":"**"},{"Policy Line":"64608961","B":"SCREW LOW COST GRP 6","C":"278","D":"C1713","F":"60.894","G":"**"},{"Policy Line":"64608963","B":"Low Cost Screw Grp 8","C":"278","F":"84.15","G":"**"},{"Policy Line":"64608964","B":"Low Cost Screw Grp 9","C":"278","D":"C1713","F":"96.696"},{"Policy Line":"64609026","B":"PACK GRAFT LINK AR-1588AU-CP","C":"278","D":"C1713","F":"870.264"},{"Policy Line":"64609028","B":"DRILL BIT, TWIST","C":"272","F":"782.136"},{"Policy Line":"64609082","B":"Ablator Aspiration AR-9811","C":"272","F":"272.034","G":"**"},{"Policy Line":"64609128","B":"GuideWire Viper VPR-GW-200","C":"272","D":"C1769","F":"302.328"},{"Policy Line":"64609147","B":"Tendon Gracilis 1976-39","C":"278","F":"2495.43"},{"Policy Line":"64609159","B":"PIN AXIS IJS-EAP-25452","C":"278","D":"C1713","F":"460.224"},{"Policy Line":"64609209","B":"BLADE DISPOSABLE GRP2","C":"272","F":"283.662","G":"**"},{"Policy Line":"64609214","B":"BLADE DISPOSABLE GRP 1","C":"272","F":"181.764","G":"**"},{"Policy Line":"64609215","B":"PLATE GRP 7","C":"278","D":"C1713","F":"1844.262","G":"**"},{"Policy Line":"64609216","B":"Plate Grp 6 Surg Ctr","C":"278","D":"C1713","F":"1591.812","G":"**"},{"Policy Line":"64609256","B":"System Fixation Bone SBFS062","C":"278","D":"C1713","F":"678.096"},{"Policy Line":"64609279","B":"ALLOGRAFT EYE HUMAN GRP 2","C":"278","F":"708.084"},{"Policy Line":"64609281","B":"Graft Amnio Wet AG-2015","C":"278","D":"V2790","F":"786.726","G":"**"},{"Policy Line":"64609286","B":"Allograft Ort/Neu Human Grp6","C":"278","F":"2141.082","G":"**"},{"Policy Line":"64609287","B":"Allograft Ort/Neu Human Grp5","C":"278","F":"1704.726","G":"**"},{"Policy Line":"64609288","B":"Allograft Orth/Neur Grp4","C":"278","F":"1290.708","G":"**"},{"Policy Line":"64609289","B":"Allograft Orth/Neur Human Grp3","C":"278","F":"999.09","G":"**"},{"Policy Line":"64609290","B":"ALLOGRAFT ORTH/NEUR HUMAN GRP2","C":"278","F":"483.786","G":"**"},{"Policy Line":"64609291","B":"Allograft Orth/Neur Human GRP1","C":"278","F":"279.684"},{"Policy Line":"64609301","B":"Anchor Bone Grp 3","C":"278","D":"C1713","F":"645.66","G":"**"},{"Policy Line":"64609302","B":"Anchor Bone Grp 2","C":"278","D":"C1713","F":"534.888","G":"**"},{"Policy Line":"64609305","B":"Arthrowand GRP","C":"272","F":"239.598"},{"Policy Line":"64609313","B":"DRILL BIT GRP 4","C":"272","F":"525.402","G":"**"},{"Policy Line":"64609314","B":"Bit Drill Grp 3","C":"272","F":"417.078","G":"**"},{"Policy Line":"64609315","B":"Bit Drill Grp 2","C":"272","F":"229.5","G":"**"},{"Policy Line":"64609316","B":"Bit Drill Grp 1","C":"272","F":"208.386","G":"**"},{"Policy Line":"64609317","B":"IOL- ANTERIOR CHAMBER","C":"276","D":"V2630","F":"158.1","G":"**"},{"Policy Line":"64609318","B":"IOL A-C Symfony ZXT","C":"276","D":"V2787","F":"325.5","G":"**"},{"Policy Line":"64609336","B":"Burr Grp 1","C":"272","F":"146.268","G":"**"},{"Policy Line":"64609349","B":"Cannula Ortho/Neuro","C":"272","F":"48.348","G":"**"},{"Policy Line":"64609374","B":"Cath Balloon Angioplasty Grp 1","C":"272","D":"C1725","F":"350.064","G":"**"},{"Policy Line":"64609398","B":"Wedge Enophthalmos Implant","C":"278","F":"540.09"},{"Policy Line":"64609413","B":"Cement Bone GRP 5","C":"278","D":"C1713","F":"2818.26"},{"Policy Line":"64609434","B":"Clip Applier Grp 3","C":"272","F":"792.234"},{"Policy Line":"64609435","B":"Clip Applier Grp 2","C":"272","F":"265.302"},{"Policy Line":"64609436","B":"Clip Applier Grp 1","C":"272","F":"151.776"},{"Policy Line":"64609483","B":"Electrode Disp Grp 2","C":"272","F":"285.498"},{"Policy Line":"64609490","B":"External Fixator Cmpnts Grp1","C":"272","F":"175.032"},{"Policy Line":"64609502","B":"FIXATION DEVICE","C":"278","F":"1145.358"},{"Policy Line":"64609548","B":"Guide Wire Ortho C1769 Grp 1","C":"272","D":"C1769","F":"62.424","G":"**"},{"Policy Line":"64609549","B":"GUIDEWIRE ORTHO GRP 2","C":"272","F":"118.422","G":"**"},{"Policy Line":"64609550","B":"Guide Wire Endo Dbl End C1769","C":"272","D":"C1769","F":"31.212"},{"Policy Line":"64609551","B":"GUIDEWIRE ORTHO 0.62 AR-8941KT","C":"272","F":"60.894"},{"Policy Line":"64609578","B":"Implant Glaucoma Grp 1","C":"278","D":"C1783","F":"778.77","G":"**"},{"Policy Line":"64609589","B":"Orbital Sphere Medpor Implant","C":"278","F":"845.172"},{"Policy Line":"64609611","B":"IOL - Posterior Chamber","C":"276","D":"V2632","F":"227.7","G":"**"},{"Policy Line":"64609621","B":"Knife","C":"272","F":"184.824"},{"Policy Line":"64609630","B":"Lacrimal Intubation","C":"272","F":"162.486"},{"Policy Line":"64609651","B":"MESH GENL SURG C1781 GRP 4","C":"278","F":"654.228"},{"Policy Line":"64609669","B":"Needle Grp 2","C":"272","F":"367.506","G":"**"},{"Policy Line":"64609670","B":"Needle Grp 1","C":"272","F":"136.17"},{"Policy Line":"64609683","B":"PIN, BONE AXIS 2.5 X 5.5","C":"278","D":"C1713","F":"469.71"},{"Policy Line":"64609685","B":"PIN GRP1 IMPLANTABLE","C":"278","D":"C1713","F":"94.248"},{"Policy Line":"64609694","B":"Plate Grp 5","C":"278","D":"C1713","F":"1266.534","G":"**"},{"Policy Line":"64609695","B":"Plate Grp 4","C":"278","D":"C1713","F":"900.864","G":"**"},{"Policy Line":"64609696","B":"Plate GRP 3","C":"278","D":"C1713","F":"600.372"},{"Policy Line":"64609697","B":"Plate Grp 2","C":"278","D":"C1713","F":"300.798"},{"Policy Line":"64609698","B":"Plate Grp 1","C":"278","D":"C1713","F":"143.208"},{"Policy Line":"64609700","B":"Polar Care","C":"272","F":"227.97"},{"Policy Line":"64609709","B":"PROSTHESIS BREAST GRP 3","C":"278","D":"C1789","F":"1096.704"},{"Policy Line":"64609710","B":"Prosthesis Breast Grp 2","C":"278","D":"C1789","F":"1042.848"},{"Policy Line":"64609711","B":"PROSTHESIS BREAST GRP 1","C":"278","D":"C1789","F":"769.896","G":"**"},{"Policy Line":"64609729","B":"Reamer Ortho","C":"272","F":"373.32","G":"**"},{"Policy Line":"64609730","B":"Cath, Translum Angioplast Grp1","C":"272","D":"C1725","F":"199.818"},{"Policy Line":"64609731","B":"Cath, Translum Angioplast Grp2","C":"272","D":"C1725","F":"310.59"},{"Policy Line":"64609732","B":"Cath, Translum Angioplast Grp3","C":"272","D":"C1725","F":"351.288"},{"Policy Line":"64609733","B":"Cath Translum Angioplast Gr4","C":"272","D":"C1725","F":"390.15"},{"Policy Line":"64609734","B":"Cath, Translum Angioplast Grp5","C":"272","D":"C1725","F":"430.848"},{"Policy Line":"64609735","B":"Cath, Translum Angioplast Grp6","C":"272","D":"C1725","F":"462.06"},{"Policy Line":"64609736","B":"Cath, Translum Angioplast Grp7","C":"272","D":"C1725","F":"469.71"},{"Policy Line":"64609737","B":"Cath, Translum Antioplast Gr8","C":"272","D":"C1725","F":"502.452"},{"Policy Line":"64609740","B":"Cath,Translum Angioplast Grp10","C":"272","D":"C1725","F":"728.892"},{"Policy Line":"64609746","B":"ROD GRP 3","C":"278","F":"406.062"},{"Policy Line":"64609748","B":"Rod Grp 1","C":"278","D":"C1713","F":"211.752"},{"Policy Line":"64609753","B":"Screw Grp 5","C":"278","D":"C1713","F":"773.874","G":"**"},{"Policy Line":"64609754","B":"Screw Grp 4","C":"278","D":"C1713","F":"578.952","G":"**"},{"Policy Line":"64609755","B":"Screw Grp 3","C":"278","D":"C1713","F":"411.876","G":"**"},{"Policy Line":"64609756","B":"Screw Grp 2","C":"278","D":"C1713","F":"233.172","G":"**"},{"Policy Line":"64609757","B":"Screw Grp 1","C":"278","D":"C1713","F":"139.842","G":"**"},{"Policy Line":"64609767","B":"SCREW GRP 6","C":"278","F":"1003.986"},{"Policy Line":"64609770","B":"Stent Non-Coa/Non-Cov WDel Gr1","C":"278","D":"C1876","F":"1089.36"},{"Policy Line":"64609771","B":"Stent Non-Coa/Non-Cov WDel Gr2","C":"278","D":"C1876","F":"1217.268"},{"Policy Line":"64609772","B":"Stent Non-Coa/Non-Cov WDel Gr3","C":"278","D":"C1876","F":"1312.434"},{"Policy Line":"64609773","B":"Stent Non-Coa/Non-Cov WDel Gr4","C":"278","D":"C1876","F":"1407.6"},{"Policy Line":"64609775","B":"Introducer/Sheath Non-Lsr Grp1","C":"272","D":"C1894","F":"34.884"},{"Policy Line":"64609776","B":"Stent Non-Coa/Non-Cov WDel Gr7","C":"278","D":"C1876","F":"1872.72"},{"Policy Line":"64609790","B":"Stent Coa/Cov WDel Sys Gr1","C":"278","D":"C1874","F":"2684.232"},{"Policy Line":"64609792","B":"Stent Coa/Cov WDel Sys Gr2","C":"278","D":"C1874","F":"2936.988"},{"Policy Line":"64609800","B":"Staple Bone Grp 4","C":"278","D":"C1713","F":"884.34","G":"**"},{"Policy Line":"64609802","B":"Staple Bone Grp 2","C":"278","D":"C1713","F":"263.466"},{"Policy Line":"64609820","B":"Stent Biliary","C":"278","D":"C1876","F":"1533.06"},{"Policy Line":"64609834","B":"SUTURE RETRIEVER","C":"272","F":"123.93","G":"**"},{"Policy Line":"64609838","B":"TAP GRP 1","C":"272","F":"166.464","G":"**"},{"Policy Line":"64609842","B":"Tissue Expander Grp 2","C":"278","D":"C1789","F":"1918.314","G":"**"},{"Policy Line":"64609874","B":"Washer Grp 1","C":"278","F":"60.282"},{"Policy Line":"64609876","B":"Wire Ortho Supply Grp 2","C":"272","F":"204.408","G":"**"},{"Policy Line":"64609878","B":"WIRE ORTHO SUPPLY GRP 1","C":"272","F":"37.944","G":"**"},{"Policy Line":"64609996","B":"Lens Presby-C Fnctn ZXR SV25T0","C":"276","D":"V2788","F":"296.7","G":"**"},{"Policy Line":"64609997","B":"Restor Conventional Lens","C":"276","D":"V2632","F":"279.378"},{"Policy Line":"65102403","B":"Kit: Gastrostomy Tube Replace","C":"272","F":"102.204","G":"**"},{"Policy Line":"65102874","B":"Tray: Paracentesis","C":"272","F":"59.058","G":"**"},{"Policy Line":"65102876","B":"Tray: Vaginal Delivery","C":"272","F":"83.232"},{"Policy Line":"65106360","B":"Tray: Er Chest Tube Insertion","C":"272","F":"86.292","G":"**"},{"Policy Line":"68252507","B":"Sponsor supplied Study Drug","C":"624","F":"0"},{"Policy Line":"68259000","B":"Carfilzomib 60mg-study drug","C":"624","F":"0"},{"Policy Line":"68259001","B":"IMMU-114-Study drug","C":"624","F":"0"},{"Policy Line":"68259002","B":"Ipilimumab 200mg/40ml Study dr","C":"624","F":"0"},{"Policy Line":"68259003","B":"Ipilimumab 50mg/10ml Study drg","C":"624","F":"0"},{"Policy Line":"68259004","B":"Nivolumab 100mg/10ml Study drg","C":"624","F":"0"},{"Policy Line":"68259005","B":"Nivolumab 40mg/4ml Study drug","C":"624","F":"0"},{"Policy Line":"68259006","B":"Nivlumb/Plcbo100mg/10mlStdyDrg","C":"624","F":"0"},{"Policy Line":"68259007","B":"Panitumumab 100mg/5ml Stdy Drg","C":"624","F":"0"},{"Policy Line":"68259008","B":"Panitumumab 400mg/20ml Stdy Dr","C":"624","F":"0"},{"Policy Line":"68259009","B":"Pembrolizumab100mg/4ml StdyDrg","C":"624","F":"0"},{"Policy Line":"68259010","B":"Pembrolizumab 50mg/2ml StdyDrg","C":"624","F":"0"},{"Policy Line":"68260120","B":"Onc Central Line Dressing","C":"272","F":"21.114"},{"Policy Line":"68262507","B":"Sponsor supplied Study Drug","C":"624","F":"0"},{"Policy Line":"68269000","B":"Carfilzomib 60mg-study drug","C":"624","F":"0"},{"Policy Line":"68269001","B":"IMMU-114-Study drug","C":"624","F":"0"},{"Policy Line":"68269002","B":"Ipilimumab 200mg/40ml Study dr","C":"624","F":"0"},{"Policy Line":"68269003","B":"Ipilimumab 50mg/10ml Study drg","C":"624","F":"0"},{"Policy Line":"68269004","B":"Nivolumab 100mg/10ml Study drg","C":"624","F":"0"},{"Policy Line":"68269005","B":"Nivolumab 40mg/4ml Study drug","C":"624","F":"0"},{"Policy Line":"68269006","B":"Nivlumb/Plcbo100mg/10mlStdyDrg","C":"624","F":"0"},{"Policy Line":"68269007","B":"Panitumumab 100mg/5ml Stdy Drg","C":"624","F":"0"},{"Policy Line":"68269008","B":"Panitumumab 400mg/20ml Stdy Dr","C":"624","F":"0"},{"Policy Line":"68269009","B":"Pembrolizumab100mg/4ml StdyDrg","C":"624","F":"0"},{"Policy Line":"68269010","B":"Pembrolizumab 50mg/2ml StdyDrg","C":"624","F":"0"},{"Policy Line":"68300250","B":"Brachymesh 6720-Mesh/Per Seed","C":"278","D":"C2642","F":"129.438"},{"Policy Line":"68300252","B":"Cesium 131 Per Seed","C":"278","D":"C2643","F":"141.678","G":"**"},{"Policy Line":"68300253","B":"Brachy Cesium-131Chlor per mCi","C":"278","D":"C2644","F":"143.514"},{"Policy Line":"68300256","B":"I-125 Each Seed","C":"278","D":"C2639","F":"61.506"},{"Policy Line":"68300258","B":"Fiducial Marker","C":"278","D":"A4648","F":"355.266","G":"**"},{"Policy Line":"68300264","B":"CATH, BRACHYTHER SEED ADMIN","C":"272","D":"C1728","F":"89.352"},{"Policy Line":"68300265","B":"BRACHYTX, NON STR, HDR IR-192","C":"278","D":"C1717","F":"433.296","G":"**"},{"Policy Line":"71101440","B":"Pack: Hystosalpingogram","C":"272","F":"109.854"},{"Policy Line":"71101760","B":"Pack: Sialogram","C":"272","F":"83.844"},{"Policy Line":"71127064","B":"Clip: Stereotactic","C":"278","D":"A4648","F":"152.388"},{"Policy Line":"71180063","B":"Needle Marker Supply","C":"272","F":"49.878"},{"Policy Line":"71300159","B":"Cath Drainage","C":"272","D":"C1729","F":"188.19"},{"Policy Line":"71300160","B":"Needle Biopsy","C":"272","F":"79.56"},{"Policy Line":"71301100","B":"Needle: Yvecentesis","C":"272","F":"55.386"},{"Policy Line":"71301105","B":"Needle: Co-Axial Intro","C":"272","F":"30.294"},{"Policy Line":"71301110","B":"Probe Cover: Ultrasound","C":"272","F":"28.152"},{"Policy Line":"71301120","B":"Needle: Tru Core 18G","C":"272","F":"67.626"},{"Policy Line":"71301490","B":"Pack: Localization","C":"272","F":"80.478"},{"Policy Line":"71302145","B":"Biopsy: Liver-D","C":"272","F":"0"},{"Policy Line":"71302566","B":"Probe Needle Guide Kit","C":"270","F":"31.824"},{"Policy Line":"71304050","B":"Pack: Amniocentesis - Us","C":"272","F":"47.736"},{"Policy Line":"71304075","B":"Pack: Aspiration","C":"272","F":"82.926","G":"**"},{"Policy Line":"71304150","B":"Pack: Biopsy","C":"272","F":"114.444","G":"**"},{"Policy Line":"71304155","B":"Pack: Biopsy Renal","C":"272","F":"101.898"},{"Policy Line":"71304660","B":"Pack: Psac Pseudo Aneurysm","C":"272","F":"10.404"},{"Policy Line":"71304750","B":"Pack: Sonohystogram","C":"272","F":"145.962"},{"Policy Line":"71304885","B":"Pack: Thoracentesis","C":"272","F":"96.084"},{"Policy Line":"71304930","B":"Pack: Vaginal","C":"272","F":"26.622"},{"Policy Line":"71307018","B":"Needle: Homer Mammalok","C":"272","F":"64.26"},{"Policy Line":"71307019","B":"Needle: Biopsy Temno","C":"272","F":"80.478"},{"Policy Line":"71307026","B":"Needle: Biopsy Bard","C":"272","F":"56.304"},{"Policy Line":"71307027","B":"Cath: Drain Set Flexima 8Fr","C":"272","F":"176.868"},{"Policy Line":"71307028","B":"Cath: Drain Set Flexima 6F","C":"272","F":"188.802"},{"Policy Line":"71307038","B":"Needle: Biopsy Coax Temno","C":"272","F":"127.602"},{"Policy Line":"71307044","B":"Needle: Spinal","C":"272","F":"15.912"},{"Policy Line":"71307064","B":"Clip: Stereotactic","C":"278","D":"A4648","F":"176.256"},{"Policy Line":"71307074","B":"Tray: Hsg","C":"272","F":"102.204"},{"Policy Line":"71307085","B":"Set: Navarre Perc Access","C":"272","F":"143.82"},{"Policy Line":"71307090","B":"Cath: Abcession Drainage","C":"272","D":"C1729","F":"177.174"},{"Policy Line":"71308888","B":"Biopsy Results Letter","C":"270","F":"0"},{"Policy Line":"71400082","B":"Brachymesh 6720-Mesh/Per Seed","C":"278","D":"C2642","F":"129.438"},{"Policy Line":"71402105","B":"90-Yttrium Spheres Per Vial","C":"278","D":"C2616","F":"24116.778","G":"**"},{"Policy Line":"71404962","B":"I 125 Seed","C":"278","D":"C2639","F":"103.122"},{"Policy Line":"71404963","B":"Cesium 131 Stranded/ Per Seed","C":"278","D":"C2642","F":"129.438"},{"Policy Line":"71405308","B":"Xenon Kit/Xe 133 (20Mci)-D","C":"272","F":"0"},{"Policy Line":"71500150","B":"Fast Find Grid","C":"270","F":"12.24"},{"Policy Line":"71502500","B":"Tru-Core Ii Biopsy Needle","C":"272","F":"64.872"},{"Policy Line":"71502800","B":"Stereotaxis-D","C":"272","F":"0"},{"Policy Line":"71504600","B":"Pack: Aspiration","C":"272","F":"79.56"},{"Policy Line":"71504620","B":"Pack: Biopsy","C":"272","F":"109.854"},{"Policy Line":"71504680","B":"Pack: Sterotaxis","C":"272","F":"12.24"},{"Policy Line":"71506009","B":"Electrode: 4.0 Cm-Leveen Needl","C":"272","F":"1211.76"},{"Policy Line":"71506100","B":"Cath: Drainage All Purpose","C":"272","D":"C1729","F":"163.404","G":"**"},{"Policy Line":"71506120","B":"Cath: Locking Pigtail Drain","C":"272","D":"C1729","F":"149.94"},{"Policy Line":"71506450","B":"Co-Axial Intro Needle","C":"272","F":"29.07"},{"Policy Line":"71506600","B":"Needle: Biopsy Adj Throw Temno","C":"272","F":"90.27"},{"Policy Line":"71506610","B":"Needle: Chiba","C":"272","F":"22.338"},{"Policy Line":"71506620","B":"Needle: Biopsy Coaxial Temno","C":"272","F":"105.57"},{"Policy Line":"71506700","B":"Set: Coaxial Aspiration","C":"272","F":"60.282"},{"Policy Line":"71506731","B":"ApplicatrThermo Ablatn-ACCULIS","C":"272","F":"2551.122"},{"Policy Line":"71507730","B":"Drain Set: Biliary/Nephro","C":"272","F":"255.816"},{"Policy Line":"71608102","B":"Suros Handpiece 20 Mr (Access)","C":"272","F":"609.246"},{"Policy Line":"71608103","B":"Suros Localization Set 12 (Acc","C":"272","F":"339.048"},{"Policy Line":"71608104","B":"Suros Localization Set 20 (Acc","C":"272","F":"339.048"},{"Policy Line":"71700003","B":"Trufill Liquid Embolization Sy","C":"278","F":"6673.554","G":"**"},{"Policy Line":"71700006","B":"Stent: Fluency","C":"278","D":"C1874","F":"2813.364","G":"**"},{"Policy Line":"71700007","B":"Coil Emb Xtrasoft Orbit Glxy","C":"278","F":"2341.512","G":"**"},{"Policy Line":"71700008","B":"Power PICC","C":"278","D":"C1751","F":"193.392","G":"**"},{"Policy Line":"71700009","B":"Power PICC - Triple Lumen","C":"278","D":"C1751","F":"224.298"},{"Policy Line":"71700032","B":"Stent Cov W/Deliv No Cost","C":"278","D":"C1874","F":"0.306"},{"Policy Line":"71700033","B":"Osteocool Bone Access Kit","C":"272","F":"524.79","G":"**"},{"Policy Line":"71700034","B":"Osteocool RF Single Probe Kit","C":"278","D":"C1886","F":"3092.436"},{"Policy Line":"71700037","B":"Osteocool RF Dual Probe Kit","C":"278","D":"C1886","F":"3984.12","G":"**"},{"Policy Line":"71700038","B":"STENT WINGSPAN NEUROVASCULAR","C":"278","F":"6051.762"},{"Policy Line":"71700039","B":"BALLOON GATEWAY","C":"272","D":"C1725","F":"1291.932"},{"Policy Line":"71700040","B":"POWER PICC LEVEL 1","C":"272","D":"C1751","F":"346.086","G":"**"},{"Policy Line":"71700041","B":"CATH, PICC 1LUM BIOFLO","C":"272","D":"C1751","F":"238.68"},{"Policy Line":"71700042","B":"Osteocool Introduce Bevel Kit","C":"272","F":"954.72"},{"Policy Line":"71700050","B":"Penumbra Microcoil Cath","C":"278","D":"C1887","F":"1190.034"},{"Policy Line":"71700052","B":"Kit Kyphon First Fracture","C":"272","F":"3575.304"},{"Policy Line":"71700060","B":"Penumbra Sheath","C":"272","F":"628.83"},{"Policy Line":"71700061","B":"SHEATH, STEERABLE 7FR","C":"272","F":"735.93"},{"Policy Line":"71700062","B":"Stent: Fluency 9 X 80","C":"278","D":"C1874","F":"2367.522","G":"**"},{"Policy Line":"71700067","B":"Introducer Sheath Grp 3 E","C":"272","D":"C1894","F":"156.06","G":"**"},{"Policy Line":"71700068","B":"Introducer Sheath Grp 3 F","C":"272","D":"C1894","F":"171.666","G":"**"},{"Policy Line":"71700074","B":"Cath Guiding Grp 1 E","C":"272","D":"C1887","F":"202.878","G":"**"},{"Policy Line":"71700075","B":"Cath Guiding Grp 2 B","C":"272","D":"C1887","F":"234.09"},{"Policy Line":"71700076","B":"Cath Guiding Grp 2 C","C":"272","D":"C1887","F":"257.652","G":"**"},{"Policy Line":"71700077","B":"Cath Guiding Grp 2 D","C":"272","D":"C1887","F":"283.968","G":"**"},{"Policy Line":"71700078","B":"GDE SHEATH, STEERABLE 7FR","C":"272","D":"C1887","F":"735.93","G":"**"},{"Policy Line":"71700100","B":"Kyphoplasty Kit Ivas","C":"278","F":"1450.44"},{"Policy Line":"71700101","B":"Cement Stryker Autoplex","C":"278","D":"C1713","F":"1023.876"},{"Policy Line":"71700104","B":"Cement Cannula","C":"272","F":"142.29"},{"Policy Line":"71700105","B":"Bone Biopsy Kit Stryker","C":"272","F":"188.802"},{"Policy Line":"71700106","B":"CORTOSS RESIN/CEMENT CARTRIDGE","C":"278","F":"865.062"},{"Policy Line":"71700107","B":"BONE TAMP KYPHOPLASTY","C":"272","F":"1168.614"},{"Policy Line":"71700108","B":"KYPHON BALLOON TRAY, 1st FRACT","C":"272","F":"2890.782","G":"**"},{"Policy Line":"71700159","B":"TRAY-PARACENTESIS 3-WAY","C":"272","D":"C1729","F":"49.878"},{"Policy Line":"71700169","B":"Stent Wallflex","C":"278","D":"C1876","F":"3193.11"},{"Policy Line":"71700170","B":"STENT VASC,SELF EXPANDIN","C":"278","D":"C1876","F":"927.486","G":"**"},{"Policy Line":"71700177","B":"Trellis Infusion Cath System","C":"272","D":"C1751","F":"2814.588"},{"Policy Line":"71700178","B":"Cath Stabilizer Neuroform3","C":"272","F":"1573.452"},{"Policy Line":"71700179","B":"Renegade Cath Preld Coils Neur","C":"272","D":"C1887","F":"931.158"},{"Policy Line":"71700184","B":"Stent Enterprise","C":"278","D":"C1876","F":"6608.376","G":"**"},{"Policy Line":"71700185","B":"Stent Protege GRP 2","C":"278","D":"C1876","F":"1393.83","G":"**"},{"Policy Line":"71700186","B":"Tray Cath Drnage Thoracic Vent","C":"272","D":"C1729","F":"338.436"},{"Policy Line":"71700188","B":"Cone Recovery Bard Fbrc","C":"272","F":"795.6"},{"Policy Line":"71700190","B":"Cath Triple Lumen","C":"272","F":"139.842","G":"**"},{"Policy Line":"71700191","B":"Coil Interlock Fibered Idc","C":"278","F":"505.512","G":"**"},{"Policy Line":"71700192","B":"Vascular Plug Amplatz","C":"278","D":"C1768","F":"1046.214","G":"**"},{"Policy Line":"71700197","B":"Penumbra Delivery Cath","C":"272","F":"788.256"},{"Policy Line":"71700198","B":"Penumbra Cath Select Neuron","C":"272","F":"199.206"},{"Policy Line":"71700199","B":"Penumbra Reperfusion Cath","C":"278","D":"C1757","F":"3033.072"},{"Policy Line":"71700200","B":"Penumbra Seperator Cath","C":"278","F":"2415.564"},{"Policy Line":"71700201","B":"Penumbra Aspiration Tubing Sys","C":"272","F":"589.05","G":"**"},{"Policy Line":"71700202","B":"Penumbra- Pump/Canister/Filter","C":"270","F":"318.24"},{"Policy Line":"71700208","B":"Closure Device","C":"278","D":"C1760","F":"327.726","G":"**"},{"Policy Line":"71700209","B":"Kit Angiojet Power Pulse Deliv","C":"272","F":"66.402"},{"Policy Line":"71700210","B":"Tube Gastrostomy","C":"272","F":"70.686","G":"**"},{"Policy Line":"71700212","B":"Cath Guiding Grp 1","C":"278","D":"C1887","F":"128.826","G":"**"},{"Policy Line":"71700213","B":"Cath Dialysis Long Term Grp1","C":"278","D":"C1750","F":"201.042","G":"**"},{"Policy Line":"71700217","B":"Cath Infusion","C":"272","D":"C1751","F":"215.424","G":"**"},{"Policy Line":"71700218","B":"Cath Occlusion","C":"272","D":"C2628","F":"463.284"},{"Policy Line":"71700219","B":"Embosphere Microspheres S410Gh","C":"272","F":"393.21","G":"**"},{"Policy Line":"71700220","B":"Wire Coil Pusher","C":"272","F":"287.334","G":"**"},{"Policy Line":"71700222","B":"Cath Dialysis Long Term Grp2","C":"278","D":"C1750","F":"360.468","G":"**"},{"Policy Line":"71700223","B":"Cath Dialysis Short Term","C":"278","D":"C1752","F":"172.278","G":"**"},{"Policy Line":"71700225","B":"Cath Excelsior Micro","C":"272","F":"886.482"},{"Policy Line":"71700226","B":"Stent Covered W/Delivery Sys","C":"278","D":"C1874","F":"2028.78","G":"**"},{"Policy Line":"71700227","B":"Stent Non-Cov w/Del LVL 1","C":"278","D":"C1876","F":"1342.116","G":"**"},{"Policy Line":"71700228","B":"Stent Graft Endoprosthesis","C":"278","D":"C1874","F":"4366.926","G":"**"},{"Policy Line":"71700230","B":"Set Haskal Portal Access","C":"272","D":"C1894","F":"855.27"},{"Policy Line":"71700231","B":"Cath Peripheral Ivus","C":"272","D":"C1753","F":"3196.17"},{"Policy Line":"71700232","B":"Cath Guiding Grp 3","C":"272","D":"C1887","F":"613.224","G":"**"},{"Policy Line":"71700233","B":"Cath Guiding Grp 4","C":"272","D":"C1887","F":"982.26","G":"**"},{"Policy Line":"71700234","B":"Embospheres Micro 820Gh/S620Gh","C":"272","F":"278.766","G":"**"},{"Policy Line":"71700237","B":"Cath Balloon Grp 2","C":"272","D":"C1725","F":"427.176","G":"**"},{"Policy Line":"71700238","B":"Cath Balloon Grp 3","C":"272","D":"C1725","F":"530.604","G":"**"},{"Policy Line":"71700240","B":"Cath Dialysis Duraflow","C":"278","D":"C1750","F":"504.9"},{"Policy Line":"71700243","B":"MIC Tube Jejunal","C":"272","F":"358.938","G":"**"},{"Policy Line":"71700244","B":"Kyphon Express Trocar T24/34B","C":"272","F":"636.786"},{"Policy Line":"71700245","B":"Kyphon Bone Filler Device F06A","C":"272","F":"193.392"},{"Policy Line":"71700246","B":"Kyphon Bone Biopsy Dev F07/05A","C":"272","F":"205.326","G":"**"},{"Policy Line":"71700248","B":"Bone Cement W/Mixer Kypho _01B","C":"272","F":"384.642","G":"**"},{"Policy Line":"71700249","B":"Kyphon Tray Kpt1505/2005","C":"272","F":"2715.444"},{"Policy Line":"71700250","B":"Stent Vascular Comlete Se","C":"278","D":"C1876","F":"1904.544"},{"Policy Line":"71700251","B":"Kyphon Kyphx Latitude Curette","C":"272","F":"297.738"},{"Policy Line":"71700252","B":"Cath Trifusion Bard Hickman","C":"272","D":"C1751","F":"788.256"},{"Policy Line":"71700253","B":"Cath Balloon Gateway","C":"272","D":"C1725","F":"1250.928"},{"Policy Line":"71700254","B":"Stent Covrd W/Delivry Sys Grp2","C":"278","D":"C1874","F":"2671.38","G":"**"},{"Policy Line":"71700255","B":"Cath Atherectomy","C":"272","D":"C1724","F":"3288.888","G":"**"},{"Policy Line":"71700256","B":"Viper Guidewire","C":"272","D":"C1769","F":"302.328","G":"**"},{"Policy Line":"71700258","B":"Pleurx Cath Kit","C":"272","D":"C1729","F":"795.6","G":"**"},{"Policy Line":"71700260","B":"Cath Vascu Trak","C":"272","D":"C1725","F":"992.664"},{"Policy Line":"71700261","B":"Cath Eagle Eye Vasc Us","C":"272","D":"C1753","F":"959.922"},{"Policy Line":"71700262","B":"Cath Balloon Grp 4A","C":"272","D":"C1725","F":"780.3","G":"**"},{"Policy Line":"71700264","B":"Mynx Closure System","C":"278","D":"C1760","F":"337.518","G":"**"},{"Policy Line":"71700265","B":"FBRC Recovery Cone Removal Sys","C":"278","D":"C1773","F":"843.336","G":"**"},{"Policy Line":"71700266","B":"MIC Introducer Kit","C":"272","F":"327.726","G":"**"},{"Policy Line":"71700267","B":"Vertaplex Hv Cement +Kit","C":"278","D":"C1713","F":"1098.234"},{"Policy Line":"71700268","B":"Button Gastrostomy Tube","C":"272","F":"199.206"},{"Policy Line":"71700269","B":"IVC Filter Jugular","C":"278","D":"C1880","F":"1531.53"},{"Policy Line":"71700270","B":"Jejunostomy Cath Set","C":"272","F":"235.62"},{"Policy Line":"71700271","B":"Gastrostomy Cath Set","C":"272","F":"204.714","G":"**"},{"Policy Line":"71700272","B":"Stent Covered W/Deliv Sys Grp3","C":"278","D":"C1874","F":"3261.654","G":"**"},{"Policy Line":"71700273","B":"Stent Covrd W/Delivry Sys Grp4","C":"278","D":"C1874","F":"3558.168","G":"**"},{"Policy Line":"71700275","B":"Sheath Grp 1","C":"272","D":"C1894","F":"20.502","G":"**"},{"Policy Line":"71700276","B":"Introducer Grp 2","C":"272","D":"C1894","F":"62.424","G":"**"},{"Policy Line":"71700277","B":"Introducer Sheath Grp 3","C":"272","D":"C1894","F":"84.456","G":"**"},{"Policy Line":"71700278","B":"Introducer Sheath Grp 4","C":"272","D":"C1894","F":"193.698","G":"**"},{"Policy Line":"71700279","B":"Vascutrak Balloon Cath","C":"272","D":"C1725","F":"959.922"},{"Policy Line":"71700280","B":"Stent Cov W/Delivery","C":"278","D":"C1874","F":"1300.194"},{"Policy Line":"71700281","B":"Pleurx Cath Kit 50-7000B","C":"272","D":"C1729","F":"703.8","G":"**"},{"Policy Line":"71700282","B":"Cath Atherectomy Lvl 1","C":"272","D":"C1724","F":"3193.11"},{"Policy Line":"71700283","B":"Retrieval Device, Insertable","C":"272","D":"C1773","F":"445.842","G":"**"},{"Policy Line":"71700284","B":"Catheter, Extraction","C":"272","D":"C1757","F":"469.71","G":"**"},{"Policy Line":"71700285","B":"Stent Non-Covw/Deliv Sys Lvl2","C":"278","D":"C1876","F":"1785.204"},{"Policy Line":"71700286","B":"Renegade Cath Neuro Emboliz","C":"272","F":"703.8"},{"Policy Line":"71700287","B":"Cath Infusion Thrombolysis","C":"278","D":"C1751","F":"254.592"},{"Policy Line":"71700290","B":"Cath Guiding Grp 2","C":"272","D":"C1887","F":"222.156","G":"**"},{"Policy Line":"71700291","B":"Cath Guiding Softvu","C":"278","D":"C1887","F":"34.884","G":"**"},{"Policy Line":"71700292","B":"Pacemaker Gen Pm1210","C":"275","D":"C1786","F":"4224.942"},{"Policy Line":"71700293","B":"Cath Temp Pacing (401760/7)","C":"272","F":"193.392"},{"Policy Line":"71700294","B":"Cath Spinal","C":"272","D":"C1755","F":"164.016"},{"Policy Line":"71700295","B":"Cement Tray Vmx00CT Carefusion","C":"278","D":"C1713","F":"901.17"},{"Policy Line":"71700296","B":"Avamax Vertebral Balloon","C":"278","F":"1535.202"},{"Policy Line":"71700297","B":"Catheter, IVUS Levl 1","C":"272","D":"C1753","F":"1199.826","G":"**"},{"Policy Line":"71700298","B":"Catheter Guiding - Grp 5","C":"272","D":"C1887","F":"1039.788","G":"**"},{"Policy Line":"71700299","B":"CathAngio Translum Coated Grp1","C":"278","D":"C2623","F":"2069.478","G":"**"},{"Policy Line":"71700300","B":"Pacemaker Sensia Dr Sedr01","C":"275","D":"C1785","F":"3679.344"},{"Policy Line":"71700301","B":"Accent Pm1110 Pacemaker","C":"275","D":"C1786","F":"4427.82"},{"Policy Line":"71700302","B":"Sensia Sesr01 Pacemaker","C":"275","D":"C1786","F":"3196.17"},{"Policy Line":"71700304","B":"Revo Rvdr01 Pacemaker","C":"275","D":"C1785","F":"5560.938"},{"Policy Line":"71700305","B":"Intro/Sheath,Fixed,Peel-Away","C":"272","D":"C1892","F":"125.766"},{"Policy Line":"71700306","B":"Distaflo Stent Graft","C":"278","D":"C1768","F":"2789.802"},{"Policy Line":"71700307","B":"Stent Graft Grp 1","C":"278","D":"C1768","F":"693.09"},{"Policy Line":"71700308","B":"Stent Graft Grp 2","C":"278","D":"C1768","F":"1026.018"},{"Policy Line":"71700309","B":"Stent Graft Grp 3","C":"278","D":"C1768","F":"1794.384"},{"Policy Line":"71700310","B":"Kyphon Addl Kit Kpe1001/1002","C":"278","F":"2961.774","G":"**"},{"Policy Line":"71700311","B":"Kit Kyphon First Fracture","C":"278","F":"3064.896","G":"**"},{"Policy Line":"71700312","B":"Barricade Coil","C":"278","F":"884.34"},{"Policy Line":"71700313","B":"Penumbra Coil Embolization","C":"278","F":"2751.552"},{"Policy Line":"71700314","B":"Coil, Embolization Soft","C":"278","F":"2290.716","G":"**"},{"Policy Line":"71700315","B":"Coil, Embolizn Xtra Soft","C":"278","F":"1522.962","G":"**"},{"Policy Line":"71700316","B":"Introducer Sheath Grp 5","C":"272","D":"C1894","F":"237.15","G":"**"},{"Policy Line":"71700355","B":"Cath Surefire Angiographic","C":"272","F":"341.496"},{"Policy Line":"71700356","B":"Surefire Infusion Cath System","C":"272","F":"3193.11"},{"Policy Line":"71700357","B":"IMPL PACEMKR ASSURITY MRI-DC","C":"275","D":"C1785","F":"3854.682"},{"Policy Line":"71700360","B":"Coil Gdc Neurovascular","C":"278","F":"1615.986"},{"Policy Line":"71700361","B":"Coil Cerecyte","C":"278","F":"1002.762","G":"**"},{"Policy Line":"71700363","B":"Microsnare Kit/Retrieval Dev","C":"272","D":"C1773","F":"795.906","G":"**"},{"Policy Line":"71700366","B":"Pleurx Kit Pt Starter 50-0071","C":"272","F":"434.52","G":"**"},{"Policy Line":"71700367","B":"CEMENT BONE KPE1003","C":"278","F":"4153.95","G":"**"},{"Policy Line":"71700368","B":"PACEMAKER ZEPHYR 5820","C":"275","D":"C1785","F":"4427.82"},{"Policy Line":"71700369","B":"IVAS STRYKER CURETTE","C":"272","F":"652.698"},{"Policy Line":"71700370","B":"SPHENOCATH","C":"272","F":"238.68"},{"Policy Line":"71700371","B":"Kit Cath Midline w/GW 5FR","C":"272","D":"C1751","F":"188.802"},{"Policy Line":"71700372","B":"Stent,Biliary Vis Pro","C":"278","D":"C1876","F":"1087.83","G":"**"},{"Policy Line":"71700373","B":"Introducer Sheath 14FR X 28CM","C":"272","D":"C1894","F":"318.24"},{"Policy Line":"71700374","B":"Catheter Guiding 8FR","C":"278","D":"C1887","F":"106.488"},{"Policy Line":"71700375","B":"Controller Coil Detach-Azur","C":"272","F":"284.886"},{"Policy Line":"71700376","B":"Stent,Peripheral OTW-SUPERA","C":"278","D":"C1876","F":"2041.326","G":"**"},{"Policy Line":"71700377","B":"Synergy Coronary Stent","C":"278","D":"C1874","F":"1119.042"},{"Policy Line":"71700508","B":"Lead Neurostimulator SC-2316","C":"278","D":"C1778","F":"3246.048"},{"Policy Line":"71700509","B":"Kit Patient Trial - Neurostim","C":"272","F":"145.044"},{"Policy Line":"71700510","B":"Neuromod Cable w/ Tray","C":"272","F":"795.6"},{"Policy Line":"71700511","B":"Cath GD Softvu - Braided","C":"272","D":"C1887","F":"70.686"},{"Policy Line":"71701051","B":"EmbosphereMicroSyr2ml700-900UM","C":"272","F":"393.21"},{"Policy Line":"71701202","B":"Power Port","C":"278","D":"C1788","F":"663.714","G":"**"},{"Policy Line":"71701210","B":"Carey-Alzate-Coons Gastro Jeju","C":"278","D":"C1769","F":"449.208"},{"Policy Line":"71701211","B":"Carey-Alzate-Coons Gastro Jeju","C":"278","D":"C1729","F":"617.814"},{"Policy Line":"71701212","B":"Gastrostomy Tube","C":"272","F":"59.67","G":"**"},{"Policy Line":"71701213","B":"Liver Access Bx Set","C":"278","F":"761.022"},{"Policy Line":"71701215","B":"MIC Gastrostomy Tube","C":"272","F":"46.206","G":"**"},{"Policy Line":"71701218","B":"Re-Entry Cath Endov Outback","C":"272","F":"2303.568"},{"Policy Line":"71701220","B":"Catheter 4F Metal Tip 150cm","C":"272","D":"C1728","F":"165.852"},{"Policy Line":"71701221","B":"Guidewire Vasc, Control V18","C":"272","D":"C1769","F":"181.458","G":"**"},{"Policy Line":"71701222","B":"CATH SUPPORT TRAILBLZR ANG","C":"272","D":"C1887","F":"1279.386","G":"**"},{"Policy Line":"71701353","B":"Cath Guiding Low Cost Grp 1","C":"272","D":"C1887","F":"21.726","G":"**"},{"Policy Line":"71701354","B":"Cath Guiding Low Cost Grp 2","C":"272","D":"C1887","F":"28.152","G":"**"},{"Policy Line":"71701355","B":"Cath Guiding Low Cost Grp 3","C":"272","D":"C1887","F":"34.272"},{"Policy Line":"71701356","B":"Cath Guiding Low Cost Grp 4","C":"272","D":"C1887","F":"43.758","G":"**"},{"Policy Line":"71701357","B":"Cath Guiding Low Cost Grp 5","C":"272","D":"C1887","F":"68.544"},{"Policy Line":"71701358","B":"Introducer Sheath Grp 3A","C":"272","D":"C1894","F":"104.652","G":"**"},{"Policy Line":"71701441","B":"Patch: Topical","C":"272","F":"50.49","G":"**"},{"Policy Line":"71701443","B":"SNARE SYSTEM ENDOVASCULAR 7FR","C":"272","D":"C1773","F":"573.138","G":"**"},{"Policy Line":"71701444","B":"Cath PTCA MR Push 15x Emerge","C":"272","D":"C1725","F":"215.424","G":"**"},{"Policy Line":"71701445","B":"Cath Central Venous 1 Lumen","C":"272","D":"C1751","F":"49.572"},{"Policy Line":"71701504","B":"Cath - Silver Hawk","C":"272","D":"C1714","F":"2375.172"},{"Policy Line":"71701505","B":"Filterwire Es","C":"272","D":"C1884","F":"1575.288","G":"**"},{"Policy Line":"71701508","B":"Sychro 0.14 Guidewire","C":"278","D":"C1769","F":"467.568","G":"**"},{"Policy Line":"71701509","B":"Transend Ex Guidewire","C":"278","D":"C1769","F":"750.618","G":"**"},{"Policy Line":"71701512","B":"Ultipaq Microcoil","C":"278","F":"1258.884"},{"Policy Line":"71701526","B":"Complex Fill Detachable Coils","C":"278","F":"2391.696","G":"**"},{"Policy Line":"71701531","B":"Cath Turbohawk Atherectomy","C":"272","D":"C1714","F":"3193.11"},{"Policy Line":"71701532","B":"Coil Detachable Target 360","C":"278","F":"2418.318"},{"Policy Line":"71701533","B":"Coil Detach Sys Inzone/Target","C":"278","F":"463.284","G":"**"},{"Policy Line":"71701534","B":"CathAngio Translum Coated Grp2","C":"278","D":"C2623","F":"1906.686","G":"**"},{"Policy Line":"71701535","B":"Cath Atherectomy Dir-HawkOne","C":"278","D":"C1714","F":"3144.762","G":"**"},{"Policy Line":"71701536","B":"Stent Protege GRP 1","C":"278","D":"C1876","F":"1140.768","G":"**"},{"Policy Line":"71701537","B":"Filterwire Spider FX V04","C":"272","D":"C1884","F":"2047.446","G":"**"},{"Policy Line":"71701538","B":"Stent Cor DES MR-Synergy","C":"278","D":"C1874","F":"1141.686","G":"**"},{"Policy Line":"71701708","B":"Cytology Brush Sheathed","C":"272","F":"213.894"},{"Policy Line":"71701806","B":"NS Kit PatientTrial SC-6500-32","C":"272","F":"135.558"},{"Policy Line":"71701814","B":"CATH CV-TRIPLE LUMEN GRP 2","C":"272","D":"C1751","F":"522.036","G":"**"},{"Policy Line":"71701815","B":"Guidewire FFR, COMET","C":"272","D":"C1769","F":"799.884"},{"Policy Line":"71701888","B":"Port Power 8FR SGL","C":"278","D":"C1788","F":"373.932","G":"**"},{"Policy Line":"71702038","B":"Cath Vascular Bern 4FR","C":"278","D":"C1887","F":"49.266","G":"**"},{"Policy Line":"71702221","B":"Stylet Endovenos RFS2-6-12","C":"272","F":"851.292","G":"**"},{"Policy Line":"71702369","B":"Cath/Sheath Guid Pinnacle","C":"272","D":"C1887","F":"191.556","G":"**"},{"Policy Line":"71702506","B":"Neuroform Stent","C":"278","D":"C1874","F":"4481.982"},{"Policy Line":"71702507","B":"Acculink Carotid Stent","C":"278","D":"C1874","F":"2952.594"},{"Policy Line":"71702508","B":"Stent,Biliary Absolute Pro lv2","C":"278","D":"C1876","F":"1343.952"},{"Policy Line":"71702509","B":"Stent,Peripheral SE","C":"278","D":"C1876","F":"959.922","G":"**"},{"Policy Line":"71702552","B":"Impl NS Lead Test Kit","C":"278","D":"C1897","F":"2303.568"},{"Policy Line":"71702553","B":"Impl NS Lead Octrode Trial60cm","C":"278","D":"C1897","F":"3071.322"},{"Policy Line":"71702611","B":"Renegade Cath W/Coils Periph","C":"278","D":"C1887","F":"841.806"},{"Policy Line":"71702612","B":"Fogerty Catheter","C":"272","D":"C1757","F":"174.42","G":"**"},{"Policy Line":"71702613","B":"Viatorr Endoprosthesis","C":"278","D":"C1874","F":"3540.42","G":"**"},{"Policy Line":"71702623","B":"Cath DX ADVANCE TORCON","C":"272","F":"141.984"},{"Policy Line":"71702624","B":"Cath Balloon PTA PE ADVANCE","C":"272","D":"C1725","F":"238.68"},{"Policy Line":"71702631","B":"Dermabond Advanced .7ml","C":"272","F":"46.818"},{"Policy Line":"71702731","B":"Cath Angio 5FR, Soft-Vu","C":"272","D":"C1887","F":"30.294","G":"**"},{"Policy Line":"71702788","B":"Stent Biliary - Express","C":"278","D":"C1876","F":"1215.738","G":"**"},{"Policy Line":"71704058","B":"Cath: Thrombectomy Trerotola","C":"272","D":"C1757","F":"729.504"},{"Policy Line":"71704061","B":"Cath: Thrombectormy","C":"278","D":"C1757","F":"3038.274"},{"Policy Line":"71704062","B":"Cath: Thrombectormy 6FR","C":"278","D":"C1757","F":"2309.688","G":"**"},{"Policy Line":"71704161","B":"Tray Trach Blue Rhino 263567","C":"272","D":"C1769","F":"679.32"},{"Policy Line":"71704208","B":"Shortstop","C":"272","F":"13.77"},{"Policy Line":"71704225","B":"Port: Implantable","C":"278","D":"C1788","F":"705.636"},{"Policy Line":"71704231","B":"CATH THROMB SET 8FR ANGIOJET","C":"278","D":"C1757","F":"3448.926","G":"**"},{"Policy Line":"71704365","B":"Angioseal Sp","C":"278","D":"C1760","F":"433.296"},{"Policy Line":"71704370","B":"Cath: Angiojet 60Cm","C":"272","D":"C1757","F":"947.07","G":"**"},{"Policy Line":"71704375","B":"Cath: Angiojet 100Cm","C":"272","D":"C1757","F":"1925.964"},{"Policy Line":"71704380","B":"Cath: Angiojet","C":"272","D":"C1757","F":"2026.026","G":"**"},{"Policy Line":"71704423","B":"Pleurx Drain Kit","C":"272","D":"C1729","F":"119.952","G":"**"},{"Policy Line":"71704550","B":"Microspheres","C":"272","F":"318.24"},{"Policy Line":"71704552","B":"BEADS EMBOLIZN 100-300UM 2ML","C":"272","F":"2687.292"},{"Policy Line":"71704553","B":"BEADS EMBOLIZN 30-60UM 0.25MG","C":"272","F":"1919.538"},{"Policy Line":"71704829","B":"Microcatheter Group 2","C":"278","D":"C1887","F":"593.028"},{"Policy Line":"71704830","B":"Microcatheter Group 1","C":"272","D":"C1887","F":"187.272"},{"Policy Line":"71704831","B":"Microcatheter Grp 3","C":"272","D":"C1887","F":"936.36"},{"Policy Line":"71704840","B":"Cath EP DX/ABL 3D Map","C":"278","D":"C1732","F":"2424.744"},{"Policy Line":"71705028","B":"Brush, Cytology","C":"272","F":"173.502","G":"**"},{"Policy Line":"71705207","B":"Cath Guiding-Prowler Micro","C":"278","D":"C1887","F":"1256.742","G":"**"},{"Policy Line":"71705210","B":"Cutting Ballon","C":"272","D":"C1725","F":"1023.876"},{"Policy Line":"71705222","B":"Lead Anchoring Sleeve","C":"272","F":"62.73"},{"Policy Line":"71705223","B":"Stylet","C":"272","F":"115.974"},{"Policy Line":"71705226","B":"Tunneling Tool Disp","C":"272","F":"687.582"},{"Policy Line":"71705460","B":"Catheter, Guiding Perfusion","C":"272","D":"C1887","F":"3186.378","G":"**"},{"Policy Line":"71705461","B":"Catheter 3 MAX","C":"272","F":"2162.808","G":"**"},{"Policy Line":"71705462","B":"Catheter, Micro Vel","C":"272","F":"1394.748"},{"Policy Line":"71705463","B":"Catheter Indigo","C":"272","F":"1650.87"},{"Policy Line":"71705464","B":"Separator Indigo","C":"272","F":"1017.45"},{"Policy Line":"71705563","B":"Guidewire Grp 3","C":"272","D":"C1769","F":"227.358","G":"**"},{"Policy Line":"71705566","B":"Pacemaker Adapta Addr01 Sys -D","C":"275","F":"0"},{"Policy Line":"71705567","B":"Pacemaker Generator Addr01","C":"275","D":"C1785","F":"4245.138"},{"Policy Line":"71705568","B":"PM Lead Ra","C":"275","D":"C1898","F":"236.232"},{"Policy Line":"71705569","B":"PM Lead Rv","C":"275","D":"C1898","F":"236.232"},{"Policy Line":"71705570","B":"Pacemaker Single Chamber","C":"275","D":"C1786","F":"4543.794"},{"Policy Line":"71705571","B":"Pacemaker Dual Chamber","C":"275","D":"C1785","F":"4427.82"},{"Policy Line":"71705572","B":"Lead Pacemaker","C":"275","D":"C1898","F":"795.6"},{"Policy Line":"71705573","B":"Pacemaker Dual Revo Mri","C":"275","D":"C1785","F":"6498.216"},{"Policy Line":"71705574","B":"Lead Revo Mri","C":"275","D":"C1898","F":"951.966"},{"Policy Line":"71705575","B":"Lead Adapter","C":"272","F":"313.65"},{"Policy Line":"71705576","B":"Lead Connector","C":"272","F":"384.642"},{"Policy Line":"71705578","B":"Wrench Pacemaker Disp","C":"272","F":"91.494"},{"Policy Line":"71705580","B":"Lead Tendril","C":"275","D":"C1898","F":"636.786"},{"Policy Line":"71705581","B":"Pacemaker Gen Accent Pm2210","C":"275","D":"C1785","F":"4666.194"},{"Policy Line":"71705582","B":"PACER GEN ADDRS1","C":"275","D":"C1785","F":"3880.08"},{"Policy Line":"71705602","B":"Cath Guiding Grp 1A","C":"272","D":"C1887","F":"157.59","G":"**"},{"Policy Line":"71705611","B":"Quickcross GuideCatheter","C":"272","D":"C1887","F":"295.902","G":"**"},{"Policy Line":"71705633","B":"Lead Pacng/Sensng MRI-Ingevity","C":"275","D":"C1898","F":"636.786"},{"Policy Line":"71705695","B":"EP INTRACRD FIX GUID INRO/SHTH","C":"272","D":"C1893","F":"231.03"},{"Policy Line":"71706001","B":"Pacemaker Gen Dual Rr Grp 2","C":"275","D":"C1785","F":"4057.56"},{"Policy Line":"71706100","B":"Flexima Biliary Drain Cath","C":"272","D":"C1729","F":"159.732","G":"**"},{"Policy Line":"71706714","B":"Handpiece, Bipolar Aquamantys","C":"272","F":"639.846"},{"Policy Line":"71706784","B":"Stent Life Flexstar","C":"278","D":"C1876","F":"1407.6","G":"**"},{"Policy Line":"71706816","B":"NS Kit Accessory - Cable","C":"278","F":"165.546"},{"Policy Line":"71707003","B":"Port,Indwelling Power Slim","C":"278","D":"C1788","F":"398.106","G":"**"},{"Policy Line":"71707005","B":"Cath Infusion, Central Venous","C":"272","D":"C1751","F":"410.652","G":"**"},{"Policy Line":"71707006","B":"Power PICC - Single Lumen","C":"278","D":"C1751","F":"165.546","G":"**"},{"Policy Line":"71707008","B":"Power PICC - Dual Lumen","C":"278","D":"C1751","F":"214.2"},{"Policy Line":"71707009","B":"Handle, Detachment for Coil","C":"272","F":"382.5","G":"**"},{"Policy Line":"71707010","B":"Coil, Complex Soft","C":"278","F":"2970.036"},{"Policy Line":"71707011","B":"Coil, Curve ES 8cm","C":"278","F":"2982.276"},{"Policy Line":"71707012","B":"Coil, Curve ES 4cm","C":"278","F":"2470.95"},{"Policy Line":"71707013","B":"Coil, Complex ES 2mmx4cm","C":"278","F":"2592.738"},{"Policy Line":"71707014","B":"Catheter, Delivery for Coil","C":"272","D":"C1887","F":"1211.454","G":"**"},{"Policy Line":"71707021","B":"Cath Occlusion, Balloon, XC","C":"272","D":"C2628","F":"2175.354"},{"Policy Line":"71707100","B":"PICC Set: Double Lumen","C":"278","D":"C1751","F":"205.02"},{"Policy Line":"71707106","B":"Kit: Neff","C":"272","F":"210.222"},{"Policy Line":"71707109","B":"Perc-U-Stay","C":"272","D":"A5200","F":"29.376"},{"Policy Line":"71707110","B":"Cath Balloon Low Cost GR 1","C":"272","D":"C1725","F":"159.12","G":"**"},{"Policy Line":"71707115","B":"Cath Balloon Grp 1","C":"272","D":"C1725","F":"323.748","G":"**"},{"Policy Line":"71707150","B":"Kit Biopsy Bone, Medtronic","C":"272","F":"477.666"},{"Policy Line":"71707151","B":"Currette, Kyphon","C":"272","F":"788.256"},{"Policy Line":"71707152","B":"Syringe Inflation, Kyphon","C":"272","F":"206.856"},{"Policy Line":"71707153","B":"Cath Balloon Low Cost GR 2","C":"272","D":"C1725","F":"193.392","G":"**"},{"Policy Line":"71707154","B":"Cath Balloon Low Cost GR 3","C":"272","D":"C1725","F":"235.62","G":"**"},{"Policy Line":"71707155","B":"Cath Balloon Low Cost GR 4","C":"272","D":"C1725","F":"287.028","G":"**"},{"Policy Line":"71707220","B":"Balloon Inflation Device","C":"272","F":"59.058","G":"**"},{"Policy Line":"71707230","B":"Cath: Drainage","C":"272","D":"C1729","F":"149.022","G":"**"},{"Policy Line":"71707231","B":"Cath: Drainage Centesis Yueh","C":"272","D":"C1729","F":"47.736","G":"**"},{"Policy Line":"71707250","B":"Cath: Diagnostic","C":"272","F":"50.184","G":"**"},{"Policy Line":"71707251","B":"Cath: Diagnostic GRP 2","C":"272","F":"56.304","G":"**"},{"Policy Line":"71707252","B":"Cath: Diagnostic GRP 3","C":"272","F":"62.424"},{"Policy Line":"71707253","B":"Cath: Diagnostic GRP 4","C":"272","F":"68.544"},{"Policy Line":"71707254","B":"Cath: Diagnostic GRP 5","C":"272","F":"78.03","G":"**"},{"Policy Line":"71707255","B":"Cath: Diagnostic GRP 6","C":"272","F":"85.986"},{"Policy Line":"71707256","B":"Cath: Diagnostic GRP 7","C":"272","F":"93.636","G":"**"},{"Policy Line":"71707257","B":"Cath: Diagnostic GRP 8","C":"272","F":"103.122"},{"Policy Line":"71707258","B":"Cath: Diagnostic 4FR STRT","C":"272","F":"25.092"},{"Policy Line":"71707278","B":"Cath Balloon Grp 4","C":"272","D":"C1725","F":"624.24","G":"**"},{"Policy Line":"71707279","B":"Cath Balloon Grp 5","C":"272","D":"C1725","F":"717.876","G":"**"},{"Policy Line":"71707280","B":"Cath Balloon Evercross 9x40cm","C":"272","D":"C1725","F":"215.424"},{"Policy Line":"71707350","B":"Cath: Nephrostomy Drain","C":"272","D":"C1729","F":"193.698","G":"**"},{"Policy Line":"71707420","B":"Coil: Embolization","C":"278","F":"177.48","G":"**"},{"Policy Line":"71707421","B":"Coil: Helical Filling","C":"278","F":"889.542","G":"**"},{"Policy Line":"71707422","B":"Coil: Vascular Grp 1","C":"278","F":"109.242","G":"**"},{"Policy Line":"71707423","B":"Coil: Vascular Grp 2","C":"278","F":"124.848","G":"**"},{"Policy Line":"71707424","B":"Coil: Vascular Grp 3","C":"278","F":"140.454"},{"Policy Line":"71707425","B":"Coil Vascular Detach-Azur","C":"278","F":"1154.844","G":"**"},{"Policy Line":"71707500","B":"Filter Vena Cava","C":"278","D":"C1880","F":"1299.276","G":"**"},{"Policy Line":"71707501","B":"Filter Vena Cava-Jugular","C":"278","D":"C1880","F":"1119.96","G":"**"},{"Policy Line":"71707502","B":"Filter Vena Cava-Group 2","C":"278","D":"C1880","F":"1560.6"},{"Policy Line":"71707527","B":"Pack Fast Closure CFP","C":"272","F":"173.196","G":"**"},{"Policy Line":"71707559","B":"Guidewire Grp 1","C":"272","D":"C1769","F":"40.086","G":"**"},{"Policy Line":"71707560","B":"Guidewire Grp 2","C":"272","D":"C1769","F":"113.832","G":"**"},{"Policy Line":"71707561","B":"Guidewire Grp 4","C":"272","D":"C1769","F":"541.62","G":"**"},{"Policy Line":"71707562","B":"Guidewire Hydro","C":"272","D":"C1769","F":"240.822"},{"Policy Line":"71707563","B":"Guidewire Journey","C":"272","D":"C1769","F":"283.356"},{"Policy Line":"71707564","B":"Guidewire Grp 2B","C":"272","D":"C1769","F":"170.136","G":"**"},{"Policy Line":"71707566","B":"Guidewire Grp 2C","C":"272","D":"C1769","F":"167.688","G":"**"},{"Policy Line":"71707591","B":"GuideWire Synchro10 300cm/50cm","C":"278","D":"C1769","F":"863.838","G":"**"},{"Policy Line":"71707596","B":"Guidewire Grp 3A","C":"272","D":"C1769","F":"280.908","G":"**"},{"Policy Line":"71707597","B":"Guidewire Grp 3B","C":"272","D":"C1769","F":"343.332"},{"Policy Line":"71707598","B":"Guidewire Grp 3C","C":"272","D":"C1769","F":"419.832","G":"**"},{"Policy Line":"71707599","B":"Guidewire Grp 2A","C":"272","D":"C1769","F":"138.924","G":"**"},{"Policy Line":"71707825","B":"Particles: Pva Emboli","C":"278","F":"236.538"},{"Policy Line":"71707900","B":"Sheath Introducer Grp 1","C":"272","D":"C1894","F":"35.496","G":"**"},{"Policy Line":"71707901","B":"Sheath Introducer Grp 2","C":"272","D":"C1894","F":"50.184","G":"**"},{"Policy Line":"71707902","B":"SheathIntroducer- TRIFORCE 5FR","C":"272","D":"C1894","F":"571.608"},{"Policy Line":"71707925","B":"Snare Intravascular","C":"272","D":"C1773","F":"652.698","G":"**"},{"Policy Line":"71707926","B":"Snare Gooseneck","C":"272","D":"C1773","F":"509.49","G":"**"},{"Policy Line":"71707950","B":"Stent: Ureteral Percuflex","C":"278","D":"C2617","F":"200.124","G":"**"},{"Policy Line":"71708268","B":"AMNIOFIX SHEET 6.0X16CM","C":"278","F":"3319.794"},{"Policy Line":"71708462","B":"Cath 3Lu 7F 16C Ask-42703-Pcsj","C":"272","F":"225.216"},{"Policy Line":"71708645","B":"TRAY CHEST TUBE DRNG 16FR,20FR","C":"272","D":"C1729","F":"308.142"},{"Policy Line":"71708646","B":"StentEndopros Viabahn 6x25 6Fr","C":"278","D":"C1874","F":"6487.2","G":"**"},{"Policy Line":"71708746","B":"D-STAT Flowable Hemostat","C":"272","F":"218.178","G":"**"},{"Policy Line":"71708846","B":"Cath Balloon Grp 1 A","C":"272","D":"C1725","F":"356.184","G":"**"},{"Policy Line":"71708847","B":"Cath Balloon Grp 1 B","C":"272","D":"C1725","F":"391.68","G":"**"},{"Policy Line":"71708848","B":"Cath Balloon 5X135- CHARGER","C":"272","D":"C1725","F":"262.854"},{"Policy Line":"71708881","B":"Guidewire Zipwire Stiff 180","C":"272","D":"C1769","F":"75.582","G":"**"},{"Policy Line":"71708888","B":"Non-Charge Surg Supply","C":"270","F":"0"},{"Policy Line":"71708893","B":"Optiflow Tunneled Catheter","C":"278","D":"C1750","F":"783.054"},{"Policy Line":"71708896","B":"Disposable: Needle Holder","C":"272","F":"13.464"},{"Policy Line":"71708898","B":"Cath Dialysis ShrtTrm-Niagra","C":"278","D":"C1752","F":"226.746"},{"Policy Line":"71708900","B":"Cath: Triple Lumen","C":"272","D":"C1751","F":"155.142"},{"Policy Line":"71708901","B":"Biopsy Set: Liver","C":"272","D":"C1887","F":"766.53","G":"**"},{"Policy Line":"71708907","B":"Cath,Infusion,Midline Non-Dial","C":"272","D":"C1751","F":"3444.03"},{"Policy Line":"71708934","B":"Stent Coated W/Deliv Grp 1","C":"278","D":"C1874","F":"2297.142"},{"Policy Line":"71708952","B":"Guide Cath Omni Flush","C":"278","D":"C1887","F":"26.01","G":"**"},{"Policy Line":"71708988","B":"Coil Emboliz -Free Sample","C":"278","F":"0"},{"Policy Line":"71708995","B":"Request For Special Procedures","C":"270","F":"0"},{"Policy Line":"71709061","B":"STENT INNOVA","C":"278","D":"C1876","F":"3135.276"},{"Policy Line":"71709091","B":"Retriever Vascular Vrs-6.0-90","C":"272","D":"C1773","F":"767.754","G":"**"},{"Policy Line":"71709120","B":"Stent Periph wDel 6x40x125","C":"278","D":"C1874","F":"1503.684"},{"Policy Line":"71709154","B":"Cath Dialys Chronc Sport Pack","C":"278","D":"C1750","F":"459.918"},{"Policy Line":"71709191","B":"STENT BILIARY GPS MINI","C":"278","D":"C1876","F":"1087.83","G":"**"},{"Policy Line":"71709294","B":"Cath Guid 6FR MultiD, Envoy","C":"272","D":"C1887","F":"686.664","G":"**"},{"Policy Line":"71709389","B":"Cath Guiding Grp 1","C":"272","D":"C1887","F":"116.586","G":"**"},{"Policy Line":"71709410","B":"Cath Vascular Bern","C":"278","D":"C1887","F":"34.884","G":"**"},{"Policy Line":"71709411","B":"Cath Closure Fast Vnus","C":"278","D":"C1888","F":"1343.646","G":"**"},{"Policy Line":"71709456","B":"Cath Infsn, EKOS Thrombolytic","C":"272","D":"C1757","F":"3040.11"},{"Policy Line":"71709490","B":"Cement/Bone Filler","C":"278","D":"C1713","F":"193.392"},{"Policy Line":"71709491","B":"Precise Carotid Stent","C":"278","D":"C1876","F":"2621.808","G":"**"},{"Policy Line":"71709492","B":"Pinnacle Long Sheath","C":"272","F":"190.026"},{"Policy Line":"71709493","B":"Angioguard Filterwire","C":"272","D":"C1884","F":"2405.772"},{"Policy Line":"71709494","B":"Endurant Stent Graft System","C":"278","F":"4897.836"},{"Policy Line":"71709626","B":"Kypho First Fracture Kit/Tray","C":"278","F":"3287.664"},{"Policy Line":"71709627","B":"Kyphoplasty Tray","C":"278","F":"3646.908"},{"Policy Line":"71709628","B":"VCF Treatment System, KIVA","C":"278","F":"3647.826"},{"Policy Line":"71709642","B":"Lead, Neurostimulator Grp 5","C":"278","D":"C1778","F":"4057.56"},{"Policy Line":"71709669","B":"Needle Grp 2","C":"272","F":"273.564"},{"Policy Line":"71709785","B":"Skin Adhesive Grp 1","C":"272","F":"41.31"},{"Policy Line":"7205","B":"HBO IMAGE TO PACS","C":"270","F":"0"},{"Policy Line":"72100010","B":"Stent Viabahn Gore 8x7.5 0.018","C":"278","D":"C1874","F":"3315.357","G":"**"},{"Policy Line":"72100012","B":"Atherect System Rotapro 1.25mm","C":"278","D":"C1724","F":"2297.295","G":"**"},{"Policy Line":"72100014","B":"Patch Bovine 0.8 X 8 cm","C":"272","F":"254.898"},{"Policy Line":"72100015","B":"BIOTRONIK STENT 2.5X15 434887","C":"278","D":"C1874","F":"2561.22"},{"Policy Line":"72100018","B":"BIOTRONIK STENT 3.5X15 434889","C":"278","D":"C1874","F":"2561.22"},{"Policy Line":"72100021","B":"Stent Complete Se","C":"278","D":"C1876","F":"1813.968"},{"Policy Line":"72100022","B":"BIOTRONIK STENT 4X15 434890","C":"278","D":"C1874","F":"2561.22"},{"Policy Line":"72100023","B":"BIOTRONIK STENT 2.5X20 734893","C":"278","D":"C1874","F":"2561.22"},{"Policy Line":"72100026","B":"BIOTRONIK STENT 3.5X20 434895","C":"278","D":"C1874","F":"2561.22"},{"Policy Line":"72100028","B":"BIOTRONIK STENT 4X20 434896","C":"278","D":"C1874","F":"2561.22","G":"**"},{"Policy Line":"72100032","B":"BIOTRONIK STENT 3X26 434899","C":"278","D":"C1874","F":"2561.22"},{"Policy Line":"72100033","B":"BIOTRONIK STENT 3.5X26 434900","C":"278","D":"C1874","F":"2561.22"},{"Policy Line":"72100040","B":"In/Pact Admiral Balloon 0.035","C":"278","D":"C2623","F":"2625.48","G":"**"},{"Policy Line":"72100045","B":"Graft Vascular 10mmX30cm","C":"278","D":"C1768","F":"586.50408","G":"**"},{"Policy Line":"72100063","B":"CATH/SHEATH GUIDING 8FR","C":"272","D":"C1887","F":"169.218"},{"Policy Line":"72100205","B":"Cryoplasty Inflation Unit","C":"272","F":"1331.712"},{"Policy Line":"72100206","B":"Cryoplasty (N20) Cartridge","C":"272","F":"108.018"},{"Policy Line":"72100208","B":"Cryoplasty Ballon .035","C":"278","D":"C1725","F":"890.154"},{"Policy Line":"72100209","B":"Cryoplasty Ballon .014","C":"278","D":"C1725","F":"1185.75"},{"Policy Line":"72100211","B":"Cath C7 Dragonfly","C":"272","D":"C1753","F":"1230.12"},{"Policy Line":"72100212","B":"Catheter Set Impella CP VAD","C":"278","F":"25785.09","G":"**"},{"Policy Line":"72100213","B":"Cath Balloon Zmed","C":"278","D":"C1725","F":"852.21","G":"**"},{"Policy Line":"72100214","B":"Asahi Tornus Balloon Cath","C":"278","D":"C1725","F":"959.922"},{"Policy Line":"72100215","B":"Asahi Corsair Microcath Csw135","C":"278","D":"C1887","F":"1215.738","G":"**"},{"Policy Line":"72100216","B":"Asahi Corsair Microcath Csw150","C":"278","D":"C1887","F":"1215.738"},{"Policy Line":"72100217","B":"ENSNARE EN2007030","C":"272","D":"C1773","F":"522.954"},{"Policy Line":"72100218","B":"CATH-TRANSLUM-COATD-NONLASR","C":"278","D":"C2623","F":"2312.748","G":"**"},{"Policy Line":"72100219","B":"PM Generator - Single-Assurity","C":"275","D":"C1786","F":"4030.02"},{"Policy Line":"72100220","B":"Septal Occluder, Amplatzer","C":"278","D":"C1817","F":"6408.558","G":"**"},{"Policy Line":"72100221","B":"Balloon,Sizing - Amplatzer","C":"272","F":"498.78","G":"**"},{"Policy Line":"72100222","B":"Guidewire, Amplatzer","C":"272","D":"C1769","F":"103.122","G":"**"},{"Policy Line":"72100223","B":"Delivery Sys, TorqVue, Amplatz","C":"272","F":"940.644","G":"**"},{"Policy Line":"72100224","B":"Catheter Impella 2.5 VAD","C":"278","F":"20287.8","G":"**"},{"Policy Line":"72100225","B":"PM Gen RR - Single-Zephyr 5620","C":"275","D":"C1786","F":"2536.128"},{"Policy Line":"72100226","B":"Cath Balloon PTA MR","C":"278","D":"C1725","F":"509.49"},{"Policy Line":"72100227","B":"Evercross Balloon 6x60x135","C":"278","D":"C1725","F":"180.846"},{"Policy Line":"72100228","B":"Visi-Pro Stent 7x37x80","C":"275","D":"C1786","F":"1003.68"},{"Policy Line":"72100229","B":"Everflex Stent 7x80x120","C":"275","D":"C1786","F":"1129.14"},{"Policy Line":"72100238","B":"Cath: Balloon Angio Level 3","C":"278","D":"C1725","F":"480.726"},{"Policy Line":"72100239","B":"Cath Balloon: COR CTO Stingray","C":"278","D":"C1725","F":"1956.87"},{"Policy Line":"72100270","B":"Cath Balloon PTA MR Quantum","C":"278","D":"C1725","F":"199.206","G":"**"},{"Policy Line":"72100290","B":"Cath Guiding Grp 2","C":"272","D":"C1887","F":"192.474"},{"Policy Line":"72100297","B":"Catheter, IVUS Levl 1","C":"272","D":"C1753","F":"1199.826"},{"Policy Line":"72100299","B":"CathAngio Translum Coated Grp1","C":"278","F":"1906.686","G":"**"},{"Policy Line":"72100376","B":"Stent,Peripheral OTW-SUPERA","C":"278","D":"C1876","F":"1750.32"},{"Policy Line":"72100400","B":"Triever Asp Cath Guide 20Fr","C":"272","F":"11383.2"},{"Policy Line":"72100401","B":"Triever Asp Cath Guide 24Fr","C":"272","F":"11383.2"},{"Policy Line":"72100402","B":"Triever Asp Cath Guide 16Fr","C":"272","F":"11383.2"},{"Policy Line":"72101001","B":"Lunderquist Wire Exchange","C":"272","D":"C1769","F":"252.45","G":"**"},{"Policy Line":"72101008","B":"Cath Balloon: Cutting / Cryo","C":"278","D":"C1725","F":"1075.896","G":"**"},{"Policy Line":"72101010","B":"Cath Cto","C":"272","D":"C1725","F":"268.056"},{"Policy Line":"72101011","B":"Catheter Crossing Occlusion","C":"278","D":"C1725","F":"1157.904"},{"Policy Line":"72101025","B":"Stent Cor Cvrd w/Del Sys Grp 1","C":"278","D":"C1874","F":"936.36","G":"**"},{"Policy Line":"72101027","B":"Stent Cor Cvrd w/Del Sys Grp 2","C":"278","D":"C1874","F":"1872.72"},{"Policy Line":"72101028","B":"Stent Trach Bronc Cvrd 8x59","C":"278","D":"C1874","F":"2674.746"},{"Policy Line":"72101029","B":"Stent Cvrd w/Del Sys-Synergy","C":"278","D":"C1874","F":"1535.508","G":"**"},{"Policy Line":"72101036","B":"OCCLUDER PFO AMPLATZER","C":"278","F":"10139.004","G":"**"},{"Policy Line":"72101110","B":"Stent Cor NoncovWDlvry GRP A","C":"278","D":"C1876","F":"655.452","G":"**"},{"Policy Line":"72101128","B":"EP Intro/Sheath-SafeSheath 7Fr","C":"272","D":"C1892","F":"71.604"},{"Policy Line":"72101195","B":"KIT ARTERIAL FEMORAL","C":"272","F":"358.632"},{"Policy Line":"72101441","B":"Patch: Topical","C":"272","F":"58.14"},{"Policy Line":"72101443","B":"SNARE SYSTEM ENDOVASCULAR 7FR","C":"272","D":"C1773","F":"573.138"},{"Policy Line":"72101498","B":"Sheath Introducer Grp 3","C":"272","D":"C1894","F":"205.326","G":"**"},{"Policy Line":"72101499","B":"Guidewire Grp 2","C":"272","D":"C1769","F":"106.794","G":"**"},{"Policy Line":"72101500","B":"Lead Ruler Tape","C":"272","F":"67.626"},{"Policy Line":"72101505","B":"Sheath Introducer Grp 4","C":"272","D":"C1894","F":"227.97","G":"**"},{"Policy Line":"72101535","B":"Cath Atherectomy Dir-HawkOne","C":"278","D":"C1714","F":"3144.762","G":"**"},{"Policy Line":"72101707","B":"DEVICE,INFLATION-ENCORE 26","C":"272","F":"138.924"},{"Policy Line":"72102026","B":"Cath Balloon: Valvuloplasty","C":"278","D":"C1725","F":"992.052"},{"Policy Line":"72102305","B":"Guidewire FFR, COMET","C":"272","D":"C1769","F":"799.884"},{"Policy Line":"72102369","B":"Cath/Sheath Guid Pinnacle","C":"272","D":"C1887","F":"169.218"},{"Policy Line":"72102732","B":"Central Venous Cath Group 1B","C":"272","D":"C1751","F":"210.834","G":"**"},{"Policy Line":"72102788","B":"Stent Biliary - Express","C":"278","D":"C1876","F":"1215.738"},{"Policy Line":"72102930","B":"Aigis Antibx Pm/Icd Envelope","C":"278","F":"927.792"},{"Policy Line":"72104684","B":"Cath: Silverhawk Atherectomy","C":"278","D":"C1724","F":"2657.61","G":"**"},{"Policy Line":"72105243","B":"Cath Intra Cardiac US 8FR","C":"278","D":"C1759","F":"3080.196","G":"**"},{"Policy Line":"72105356","B":"Pack: Cath Lab Diagnostic","C":"272","F":"143.208"},{"Policy Line":"72105493","B":"Guidewire, Low Cost","C":"272","D":"C1769","F":"14.994"},{"Policy Line":"72105604","B":"Closure Device","C":"278","D":"C1760","F":"317.016","G":"**"},{"Policy Line":"72105611","B":"Quickcross Catheter","C":"272","D":"C1887","F":"265.914","G":"**"},{"Policy Line":"72105612","B":"Cath Laser Turbo","C":"272","D":"C1885","F":"685.134"},{"Policy Line":"72105613","B":"Cath Guide TaperTip 5FR GR2","C":"272","D":"C1887","F":"889.542","G":"**"},{"Policy Line":"72105614","B":"Cath Guide TaperTip 5FR GR1","C":"278","D":"C1887","F":"727.362","G":"**"},{"Policy Line":"72106424","B":"Perfusion: Beating Hearts Lv 1","C":"272","F":"2022.048","G":"**"},{"Policy Line":"72106666","B":"Lead MRI Ingevity 59cm","C":"275","D":"C1898","F":"636.786"},{"Policy Line":"72106807","B":"Stent Cor Cvrd W/Del Sys Grp 3","C":"278","D":"C1874","F":"3057.552"},{"Policy Line":"72107051","B":"Cath: Angiojet Coronary Xmi","C":"272","D":"C1757","F":"2213.91"},{"Policy Line":"72107052","B":"CATH THROMBECTOMY- 12X106CM","C":"278","D":"C1757","F":"3038.274","G":"**"},{"Policy Line":"72107058","B":"Cath: Balloon GRP 1","C":"278","D":"C1725","F":"171.666","G":"**"},{"Policy Line":"72107059","B":"Cath: Balloon GRP 2","C":"278","D":"C1725","F":"208.998","G":"**"},{"Policy Line":"72107060","B":"Cath: Balloon GRP 3","C":"278","D":"C1725","F":"255.204","G":"**"},{"Policy Line":"72107061","B":"Cath: Angiojet Peripheral Xmi","C":"272","D":"C1757","F":"1327.734"},{"Policy Line":"72107062","B":"Cath Jet Stream","C":"272","D":"C1714","F":"3645.684"},{"Policy Line":"72107063","B":"Cath Diagnostic Grp 2","C":"272","F":"53.856","G":"**"},{"Policy Line":"72107064","B":"Cath Atherectomy Diamond Orbtl","C":"278","D":"C1724","F":"3849.786","G":"**"},{"Policy Line":"72107065","B":"Guidewire Viper (For Diamond)","C":"272","D":"C1769","F":"302.328","G":"**"},{"Policy Line":"72107066","B":"Cath: Balloon Angio Level 4","C":"278","D":"C1725","F":"1407.6"},{"Policy Line":"72107067","B":"CATH:Tranluminal Atherectomy","C":"278","D":"C1724","F":"4833.27"},{"Policy Line":"72107068","B":"Cath Diagnostic Grp 3","C":"272","F":"62.424","G":"**"},{"Policy Line":"72107075","B":"Cath: Balloon Valvuloplasty","C":"272","F":"885.564"},{"Policy Line":"72107077","B":"CATH VISION IVUS 0.18PV","C":"272","D":"C1753","F":"1087.83"},{"Policy Line":"72107081","B":"Cath: Balloon GRP 4","C":"278","D":"C1725","F":"312.12","G":"**"},{"Policy Line":"72107082","B":"Cath: Balloon GRP 5","C":"278","D":"C1725","F":"382.5","G":"**"},{"Policy Line":"72107083","B":"Cath: Balloon GRP 6","C":"278","D":"C1725","F":"468.18"},{"Policy Line":"72107084","B":"Cath: Balloon GRP 7","C":"278","D":"C1725","F":"630.36"},{"Policy Line":"72107100","B":"Cath: Diagnostic Grp 1","C":"272","F":"19.89","G":"**"},{"Policy Line":"72107106","B":"Cath Guide Vascular","C":"272","D":"C1887","F":"627.912","G":"**"},{"Policy Line":"72107107","B":"Cath: Frontrunner (Cto)","C":"272","D":"C2628","F":"1389.852"},{"Policy Line":"72107108","B":"Cath Guide Front Runner","C":"272","D":"C1887","F":"426.87"},{"Policy Line":"72107110","B":"Cath: Guide","C":"272","D":"C1887","F":"75.276","G":"**"},{"Policy Line":"72107115","B":"Cath: Iabp -Cl","C":"272","F":"1063.35","G":"**"},{"Policy Line":"72107135","B":"Cath: Infusion","C":"272","D":"C1887","F":"592.416"},{"Policy Line":"72107161","B":"GUIDE CATH CENTER CROSS ULTRA","C":"278","D":"C1887","F":"1273.572"},{"Policy Line":"72107162","B":"GUIDE CATH MICRO","C":"272","D":"C1887","F":"628.83"},{"Policy Line":"72107163","B":"GUIDE CATH CENTER/MULTI CROSS","C":"272","D":"C1887","F":"1145.358"},{"Policy Line":"72107180","B":"Cath: Laser","C":"272","D":"C1885","F":"3117.222"},{"Policy Line":"72107187","B":"Cath: Right Heart","C":"272","F":"114.75"},{"Policy Line":"72107188","B":"Cath: Pioneer","C":"272","D":"C1753","F":"3163.428"},{"Policy Line":"72107190","B":"Cath: Roto Burr","C":"278","D":"C1724","F":"1630.062","G":"**"},{"Policy Line":"72107191","B":"Cath Guide Coronary Finecross","C":"272","D":"C1894","F":"671.364"},{"Policy Line":"72107203","B":"Jomed: Trak Back","C":"272","F":"155.448"},{"Policy Line":"72107204","B":"Cath: Temp Pacing","C":"272","F":"216.648","G":"**"},{"Policy Line":"72107205","B":"Cath: Swan Ganz Indwelling","C":"272","F":"192.78","G":"**"},{"Policy Line":"72107213","B":"Wire Spidrx","C":"272","F":"1301.418"},{"Policy Line":"72107221","B":"Inflator Band Xxrf06","C":"272","F":"340.272"},{"Policy Line":"72107222","B":"Glidesheath Rmafd10Hau","C":"272","D":"C1894","F":"73.134"},{"Policy Line":"72107224","B":"R-Band Vascular Closure Dev","C":"272","F":"34.272","G":"**"},{"Policy Line":"72107227","B":"Pad, Neptune","C":"272","F":"55.998"},{"Policy Line":"72107228","B":"Lead Tendril","C":"275","D":"C1898","F":"1746.036"},{"Policy Line":"72107229","B":"Lead Fineline Ii","C":"275","D":"C1898","F":"667.692"},{"Policy Line":"72107250","B":"Cath: Ultrasound","C":"272","D":"C1753","F":"838.44"},{"Policy Line":"72107251","B":"CATH IVUS - PLATINUM","C":"272","D":"C1753","F":"1087.83","G":"**"},{"Policy Line":"72107275","B":"Circuit: Blood Cps","C":"272","F":"1805.706"},{"Policy Line":"72107294","B":"Femostop: Compression","C":"272","F":"177.48","G":"**"},{"Policy Line":"72107300","B":"Guidewire Grp 1","C":"272","D":"C1769","F":"28.764","G":"**"},{"Policy Line":"72107312","B":"Filterwire Ex","C":"272","D":"C1884","F":"1604.97","G":"**"},{"Policy Line":"72107313","B":"Filter Wire Bareware","C":"272","F":"1913.418"},{"Policy Line":"72107350","B":"Guidewire Grp 3","C":"272","D":"C1769","F":"182.376","G":"**"},{"Policy Line":"72107351","B":"Guidewire Grp 4","C":"272","D":"C1769","F":"223.074","G":"**"},{"Policy Line":"72107370","B":"Guidewire: Wave Wire","C":"272","D":"C1769","F":"886.482","G":"**"},{"Policy Line":"72107420","B":"Inflation Device Kit","C":"272","F":"71.298","G":"**"},{"Policy Line":"72107432","B":"Introducer: Balkin","C":"272","D":"C1894","F":"80.478"},{"Policy Line":"72107441","B":"Kit Introducer VAD: Impella","C":"272","F":"895.662"},{"Policy Line":"72107442","B":"Sheath Introducer Grp 2A","C":"272","D":"C1894","F":"132.192"},{"Policy Line":"72107443","B":"Sheath Introducer Grp 2B","C":"272","D":"C1894","F":"162.18","G":"**"},{"Policy Line":"72107500","B":"Kit: Cannula Cps","C":"272","F":"417.078"},{"Policy Line":"72107526","B":"Kit: Essentials Cl","C":"272","F":"106.182"},{"Policy Line":"72107528","B":"Microsnare","C":"272","D":"C1773","F":"774.486"},{"Policy Line":"72107540","B":"Needle: Smart","C":"272","F":"193.392"},{"Policy Line":"72107550","B":"Kit: Cath Lab Custom","C":"272","F":"137.088","G":"**"},{"Policy Line":"72107596","B":"Guidewire Grp 3A","C":"272","D":"C1769","F":"291.924","G":"**"},{"Policy Line":"72107599","B":"Guidewire Grp 2A","C":"272","D":"C1769","F":"138.924","G":"**"},{"Policy Line":"72107609","B":"Percusurge","C":"272","D":"C2628","F":"2157.912"},{"Policy Line":"72107620","B":"Set: Angiojet Pump","C":"272","F":"410.346"},{"Policy Line":"72107630","B":"Sheath Introducer Group 1","C":"272","D":"C1894","F":"19.89","G":"**"},{"Policy Line":"72107635","B":"Sheath Introducer Grp 2","C":"272","D":"C1894","F":"109.242","G":"**"},{"Policy Line":"72107701","B":"Stent Cor Noncov W/Dlvry GRP B","C":"278","D":"C1876","F":"798.66","G":"**"},{"Policy Line":"72107706","B":"Stent Non Cov W/Deliv Sys Grp1","C":"278","D":"C1876","F":"933.606","G":"**"},{"Policy Line":"72107715","B":"Stent Non-Cov W/Deliv Sys Grp3","C":"278","D":"C1876","F":"1523.574","G":"**"},{"Policy Line":"72107716","B":"Stent Veritas Noncov W/Deliv","C":"278","D":"C1876","F":"2041.326"},{"Policy Line":"72107717","B":"Stent-Non-Coat-w/DelSys-Innova","C":"278","D":"C1876","F":"2470.95"},{"Policy Line":"72107718","B":"Stent Non-Cov W/Deliv Sys Grp4","C":"278","D":"C1876","F":"1861.704"},{"Policy Line":"72107725","B":"Stent: Drug Eluding Cypher","C":"278","D":"C1874","F":"2143.53"},{"Policy Line":"72107726","B":"Stent:Drug Eluting Promus GR2","C":"278","D":"C1874","F":"1651.176"},{"Policy Line":"72107727","B":"Stent: Drug Eluting Endeavor","C":"278","D":"C1874","F":"2384.658"},{"Policy Line":"72107728","B":"Stent-Drug Elutin Resolute GR1","C":"278","D":"C1874","F":"1853.748","G":"**"},{"Policy Line":"72107729","B":"Stent Drug Eluting Xience Prm","C":"278","D":"C1874","F":"2041.326"},{"Policy Line":"72107730","B":"Stent-Drug Elutin Resolute GR2","C":"278","D":"C1874","F":"1695.852"},{"Policy Line":"72107770","B":"Torque Device Td-2","C":"272","F":"39.168"},{"Policy Line":"72107790","B":"Tray: Percardiocentesis","C":"272","D":"C1769","F":"291.006"},{"Policy Line":"72107850","B":"Cath: Swan Ganz","C":"272","D":"C1751","F":"88.434","G":"**"},{"Policy Line":"72107959","B":"Vasc Guide Wire-Stingray","C":"272","D":"C1769","F":"537.336"},{"Policy Line":"72107979","B":"GuideWire Cath Extn-Guidezilla","C":"272","D":"C1769","F":"557.226","G":"**"},{"Policy Line":"72108004","B":"Stent Non-Cov w/Del Sys Grp 2","C":"278","D":"C1876","F":"1240.218","G":"**"},{"Policy Line":"72108005","B":"Stent:Drug Eluting Taxus","C":"278","D":"C1874","F":"1727.676"},{"Policy Line":"72108010","B":"Catheter: Export Aspiration","C":"272","D":"C1757","F":"469.71","G":"**"},{"Policy Line":"72108125","B":"Cannula Artery 17FR","C":"272","F":"516.97782"},{"Policy Line":"72108126","B":"Cannula Fem Ven 23/25","C":"272","F":"487.58958"},{"Policy Line":"72108462","B":"Cath 3Lu 7F 16C Ask-42703-Pcsj","C":"272","F":"225.216"},{"Policy Line":"72108476","B":"Wire Spider SM Spd2Us-050","C":"272","D":"C1884","F":"2047.446","G":"**"},{"Policy Line":"72108606","B":"Perclose Proglide 12673","C":"278","D":"C1760","F":"412.182","G":"**"},{"Policy Line":"72108629","B":"TAVR VALVE","C":"278","F":"32321.25","G":"**"},{"Policy Line":"72108633","B":"Heart-Lung Dispo Kit - ECMO","C":"272","F":"13313.754"},{"Policy Line":"72108888","B":"Non-Charge Surg Supply","C":"270","F":"0"},{"Policy Line":"72108889","B":"Stent - Evaluation","C":"278","F":"0"},{"Policy Line":"72109126","B":"CATH VISION IVUS 88901","C":"272","D":"C1753","F":"1471.554"},{"Policy Line":"72109364","B":"Cath Angiographic","C":"272","F":"229.194"},{"Policy Line":"72109410","B":"Guide Cath Vascular Bern","C":"272","D":"C1887","F":"34.884","G":"**"},{"Policy Line":"72151441","B":"Patch: Topical","C":"272","F":"131.274"},{"Policy Line":"72157294","B":"Femstop: Compression","C":"272","F":"122.706"},{"Policy Line":"7219","B":"Foam Drssing <=16sqin w/oBordr","C":"623","D":"A6209","F":"14.688"},{"Policy Line":"72200019","B":"Pacemaker, Micra","C":"275","D":"C1786","F":"9628.29","G":"**"},{"Policy Line":"72200020","B":"Sheath, Micra","C":"278","D":"C1894","F":"716.04","G":"**"},{"Policy Line":"72200021","B":"Catheter, 3 Fr Diagn","C":"278","D":"C1887","F":"725.22"},{"Policy Line":"72200060","B":"Impl Watchman LAA closure","C":"278","F":"12071.394","G":"**"},{"Policy Line":"72200061","B":"Watchman LAA Access Syst Curve","C":"272","F":"1279.692","G":"**"},{"Policy Line":"72200144","B":"Cath Irrigation","C":"272","F":"145.044","G":"**"},{"Policy Line":"72200145","B":"Device Pouch - ECM - Cangaroo","C":"278","F":"1273.572","G":"**"},{"Policy Line":"72200224","B":"LINQ SYS-REVEAL CARD MON","C":"278","D":"C1764","F":"5371.218","G":"**"},{"Policy Line":"72200264","B":"Mynx Vasc Closure Device","C":"278","D":"C1760","F":"337.518","G":"**"},{"Policy Line":"72200270","B":"Cath Balloon PTA MR Quantum","C":"272","D":"C1725","F":"199.206"},{"Policy Line":"72201037","B":"OCCLUDER PFO AMPLATZER 25MM","C":"278","F":"421.974","G":"**"},{"Policy Line":"72201128","B":"EP Intro/Sheath-SafeSheath 7Fr","C":"272","D":"C1892","F":"71.604","G":"**"},{"Policy Line":"72201234","B":"Glidewire GT 01.018","C":"272","D":"C1769","F":"268.4232"},{"Policy Line":"72201312","B":"Micro Cath Progreate 2.8fr","C":"272","D":"C1887","F":"677.484"},{"Policy Line":"72201353","B":"Cath Guiding Low Cost Grp 1","C":"278","D":"C1887","F":"21.726"},{"Policy Line":"72201499","B":"Glidewire, Angled","C":"272","D":"C1769","F":"84.762"},{"Policy Line":"72201600","B":"Gen Pm Dual Explant Partial Cr","C":"275","D":"C1785","F":"0"},{"Policy Line":"72201601","B":"Gen Pm Dual Explant Full Credt","C":"275","D":"C1785","F":"0.306"},{"Policy Line":"72201602","B":"Cath Ep Deflect 6FR Quad 2-5-2","C":"278","D":"C1730","F":"454.104","G":"**"},{"Policy Line":"72201700","B":"Oxygen Therapy-D","C":"270","F":"0"},{"Policy Line":"72202227","B":"Pad, Neptune","C":"272","F":"55.998"},{"Policy Line":"72202228","B":"Lead Cs Replacement/No Cost","C":"275","D":"C1900","F":"0.306"},{"Policy Line":"72202229","B":"Pacemaker Other - Allure RF","C":"275","D":"C2621","F":"6593.688","G":"**"},{"Policy Line":"72202230","B":"Lead, LV Quick Flex Micro","C":"275","D":"C1900","F":"2372.112"},{"Policy Line":"72202975","B":"Tilt Table-D","C":"270","F":"0"},{"Policy Line":"72203102","B":"GEN: AICD DUAL GRP A","C":"275","D":"C1721","F":"12640.86"},{"Policy Line":"72203168","B":"Cath: Diagnostic Grp 1","C":"272","F":"19.89","G":"**"},{"Policy Line":"72203711","B":"SHEATH DILATION - TIGHTRAIL","C":"272","D":"C1773","F":"2169.234"},{"Policy Line":"72203712","B":"CATHGUIDE STRT QUIKCROS 150CM","C":"278","F":"265.914"},{"Policy Line":"72204054","B":"PM OTHR, RF ALLURE QUADRA","C":"275","D":"C2621","F":"8224.362"},{"Policy Line":"72204100","B":"Pack: Basic Pacer Set Up","C":"272","F":"71.298"},{"Policy Line":"72204365","B":"Vasc Closure Device Angioseal","C":"278","D":"C1760","F":"334.152","G":"**"},{"Policy Line":"72204396","B":"Cath EP <19Elect; 7FR Bipolar","C":"278","D":"C1730","F":"1085.382"},{"Policy Line":"72204401","B":"Crtd Concerto Ii D274Trk Biv","C":"275","D":"C1882","F":"24786.612"},{"Policy Line":"72204402","B":"ICD Virtuoso Ii D274Drg","C":"275","D":"C1721","F":"17340.408"},{"Policy Line":"72204403","B":"ICD Gen Secura Dr D224Drg","C":"275","D":"C1721","F":"18512.694"},{"Policy Line":"72204404","B":"Pacemaker Gen Accent Pm1110","C":"275","D":"C1786","F":"4059.09","G":"**"},{"Policy Line":"72204405","B":"Gen Icd Sgl Secura Vr D224Vrc","C":"275","D":"C1722","F":"16737.588"},{"Policy Line":"72204406","B":"ICD Gen Teligen He Dr E110","C":"275","D":"C1721","F":"16866.414"},{"Policy Line":"72204407","B":"Gen Pacemaker Accent Pm2110","C":"275","D":"C1785","F":"5413.446"},{"Policy Line":"72204408","B":"Gen Icd Incepta Dr He Df4 E162","C":"275","D":"C1721","F":"18519.732"},{"Policy Line":"72204409","B":"Gen Incepta Dr He E163","C":"275","D":"C1721","F":"17262.99"},{"Policy Line":"72204411","B":"Energen Dr He Df4 E142","C":"275","D":"C1721","F":"13712.778"},{"Policy Line":"72204412","B":"Energen Dr He E143","C":"275","D":"C1721","F":"13443.498"},{"Policy Line":"72204413","B":"Gen Incepta Vr He Df4 E160","C":"275","D":"C1722","F":"13961.556"},{"Policy Line":"72204414","B":"Gen Incepta Vr He E161","C":"275","D":"C1722","F":"16831.53"},{"Policy Line":"72204415","B":"Energen Vr He Df4 E140","C":"275","D":"C1722","F":"13230.828"},{"Policy Line":"72204416","B":"Energen Vr He E141","C":"275","D":"C1722","F":"12971.952"},{"Policy Line":"72204417","B":"Teligen Rf He Vr E102","C":"275","D":"C1722","F":"15587.946"},{"Policy Line":"72204418","B":"Lead Reliance Gore ICD GRP 2","C":"275","D":"C1777","F":"4564.908"},{"Policy Line":"72204419","B":"Gen Crtd Incepta Rdhe Df4 N160","C":"275","D":"C1882","F":"20954.574"},{"Policy Line":"72204420","B":"Gen Incepta Rf He N161/N164","C":"275","D":"C1882","F":"20519.136"},{"Policy Line":"72204421","B":"Gen Energen Rf He Df4 N140","C":"275","D":"C1882","F":"20519.136"},{"Policy Line":"72204422","B":"Gen Energen Rf He N141","C":"275","D":"C1882","F":"20047.59"},{"Policy Line":"72204423","B":"Gen Cognis Rf He N118 / N119","C":"275","D":"C1882","F":"22732.128"},{"Policy Line":"72204424","B":"Gen Unify Quadra Crt Cd3249","C":"275","D":"C1882","F":"22316.58"},{"Policy Line":"72204425","B":"Cath Ep Thermocool Sf Nav","C":"278","D":"C1732","F":"3186.378","G":"**"},{"Policy Line":"72204426","B":"Gen Icd Fortify Dr Cd2231-40Q","C":"275","D":"C1721","F":"17219.232"},{"Policy Line":"72204427","B":"Gen Pacer Accent Pm2210","C":"275","D":"C1785","F":"5508"},{"Policy Line":"72204428","B":"Gen Crt-D Protecta Xt D314Trg","C":"275","D":"C1882","F":"26456.454"},{"Policy Line":"72204429","B":"Gen Crt-D Protecta D314Drg","C":"275","D":"C1721","F":"17520.642"},{"Policy Line":"72204430","B":"Invive Crt-P Is1 Gen V173","C":"275","D":"C2621","F":"8622.468"},{"Policy Line":"72204431","B":"Cath Eps Ez Steer Thermo","C":"278","D":"C1733","F":"1750.626","G":"**"},{"Policy Line":"72204432","B":"ICD Protecta Vr D334Vrm","C":"275","D":"C1722","F":"15063.768"},{"Policy Line":"72204433","B":"Ingenio Dr K173 Pacemaker","C":"275","D":"C1785","F":"4528.188"},{"Policy Line":"72204434","B":"Ingenio Sr K172 Pacemaker","C":"275","D":"C1786","F":"3962.394"},{"Policy Line":"72204435","B":"Advantio Sr Pacemaker K062","C":"275","D":"C1786","F":"3773.592"},{"Policy Line":"72204436","B":"Advantio Dr Pacemaker K063","C":"275","D":"C1785","F":"4245.138"},{"Policy Line":"72204437","B":"Lead Quartet Cs","C":"275","D":"C1900","F":"3737.79"},{"Policy Line":"72204438","B":"Cath Dual Access Twin Pass","C":"272","D":"C1887","F":"476.136"},{"Policy Line":"72204439","B":"Cath Balloon","C":"272","D":"C1725","F":"315.486","G":"**"},{"Policy Line":"72204440","B":"Glidecath","C":"272","D":"C1887","F":"102.816"},{"Policy Line":"72204441","B":"Arctic Front Ablation Cath","C":"278","D":"C1733","F":"4389.876","G":"**"},{"Policy Line":"72204442","B":"Elipse Vr Cd1311-36Q Defib","C":"275","D":"C1722","F":"15684.336"},{"Policy Line":"72204443","B":"ICD Defib Evera Dr Dc Ddbb1D1","C":"275","D":"C1721","F":"15288.984"},{"Policy Line":"72204444","B":"Achieve EP Catheter 1-19Elec","C":"278","D":"C1730","F":"1023.876","G":"**"},{"Policy Line":"72204445","B":"Arctic Front Retraction Kit","C":"272","F":"238.68"},{"Policy Line":"72204446","B":"CATH OCCLUSION","C":"278","D":"C2628","F":"96.696","G":"**"},{"Policy Line":"72204447","B":"ESOPHASTAR MAPPING CATH","C":"278","D":"C1732","F":"792.846"},{"Policy Line":"72204448","B":"VIVA CRT-D GEN DTBA1D1/DTBA1D4","C":"275","D":"C1882","F":"19691.1"},{"Policy Line":"72204449","B":"TEMPORARY PACING ELECTRODE","C":"272","F":"262.854","G":"**"},{"Policy Line":"72204451","B":"ICD GEN SQ-RX 1010","C":"275","D":"C1722","F":"19780.758"},{"Policy Line":"72204452","B":"LEAD Q-TRAK 3010","C":"275","D":"C1896","F":"4057.56"},{"Policy Line":"72204453","B":"CRT-D ELLIPSE DR CD2311-36/Q","C":"275","D":"C1721","F":"16940.466"},{"Policy Line":"72204454","B":"CRT-D FORTIFY VR CD1231-40/Q","C":"275","D":"C1722","F":"15743.394"},{"Policy Line":"72204455","B":"CRT-D FORTIFY ASSURA CD1257-40","C":"275","D":"C1722","F":"14900.976"},{"Policy Line":"72204456","B":"CRT-D ELLIPSE DR CD2411-40/Q","C":"275","D":"C1721","F":"13440.438","G":"**"},{"Policy Line":"72204457","B":"ICD GEN EVERA XT VR DVBB1D1","C":"275","D":"C1722","F":"15913.836"},{"Policy Line":"72204458","B":"LEAD EXTENDER BULLDOG","C":"278","F":"368.424"},{"Policy Line":"72204459","B":"CATH FREEZOR CRYOABLATION","C":"278","F":"1420.146"},{"Policy Line":"72204460","B":"SHEATH CPS DIRECT SL","C":"272","D":"C1893","F":"979.2","G":"**"},{"Policy Line":"72204461","B":"ELLIPSE VR36 ICD GENER Single","C":"275","D":"C1722","F":"12045.996","G":"**"},{"Policy Line":"72204462","B":"Lead Reliance Gore ICD GR 1","C":"275","D":"C1777","F":"3804.192"},{"Policy Line":"72204463","B":"CRT-D AMPLIA MRI Sure Scan","C":"275","D":"C1882","F":"22112.784","G":"**"},{"Policy Line":"72204464","B":"Cath EP Non 3-D Map 7FR","C":"278","D":"C1730","F":"1274.796"},{"Policy Line":"72204465","B":"Lead ICD Singl Coil-PLEXA DF-1","C":"275","D":"C1777","F":"3306.636","G":"**"},{"Policy Line":"72204476","B":"Lead AICDEndoDualCoil-Optisure","C":"275","D":"C1895","F":"3550.518","G":"**"},{"Policy Line":"72204477","B":"AICD DR MRI XT - EVERA","C":"275","D":"C1721","F":"17346.222","G":"**"},{"Policy Line":"72204478","B":"Lead Reliance Gore DF4 ICD","C":"275","D":"C1777","F":"3804.192","G":"**"},{"Policy Line":"72204481","B":"Sheath Introducr NonLsr 12x30","C":"272","D":"C1894","F":"135.864"},{"Policy Line":"72204800","B":"Pack: Pacermaker","C":"272","F":"91.494","G":"**"},{"Policy Line":"72204881","B":"Generator:ICD Dual Cham Grp A","C":"275","D":"C1721","F":"13327.524","G":"**"},{"Policy Line":"72204882","B":"Gen: ICD Single Grp 1","C":"275","D":"C1722","F":"11860.56","G":"**"},{"Policy Line":"72204883","B":"Gen: ICD Single Grp 2","C":"275","D":"C1722","F":"13592.826"},{"Policy Line":"72204884","B":"Guidewire Vascular Imaging","C":"272","D":"C1769","F":"262.854","G":"**"},{"Policy Line":"72205214","B":"Gen Icd Energen","C":"275","D":"C1722","F":"14908.932"},{"Policy Line":"72205215","B":"Cath Ep Dx 1-19 Elec Ascent","C":"272","D":"C1730","F":"108.324"},{"Policy Line":"72205216","B":"Gen Biv Pacer Syncra C2Tr01","C":"275","D":"C2621","F":"8622.468"},{"Policy Line":"72205217","B":"EP Cath Lasso Nav 3D Mapping","C":"272","D":"C1732","F":"1895.058","G":"**"},{"Policy Line":"72205218","B":"Lead Pacing Revo Mri","C":"275","D":"C1898","F":"951.966"},{"Policy Line":"72205219","B":"Pacemaker Gen Revo Dvdr01","C":"275","D":"C1785","F":"5477.706","G":"**"},{"Policy Line":"72205220","B":"Pacemaker Zephyr Xl Sr 5626","C":"275","D":"C1786","F":"4681.8"},{"Policy Line":"72205222","B":"Sleeve, Lead Anchoring","C":"272","F":"67.626"},{"Policy Line":"72205223","B":"Stylet","C":"272","F":"96.696","G":"**"},{"Policy Line":"72205224","B":"EP Guidewire Grp 1","C":"272","F":"77.112"},{"Policy Line":"72205225","B":"EP Guidewire Grp 2","C":"272","D":"C1769","F":"222.768","G":"**"},{"Policy Line":"72205226","B":"Tunneling Tool Disp","C":"272","F":"1279.692"},{"Policy Line":"72205228","B":"Pacemaker Gen Dual Rr Grp 3","C":"275","D":"C1785","F":"7197.732"},{"Policy Line":"72205229","B":"Crt-D Consulta Biv D224Trk","C":"275","D":"C1882","F":"21225.996"},{"Policy Line":"72205230","B":"Crt Consulta Biv D224Trk Sys-D","C":"275","F":"0"},{"Policy Line":"72205232","B":"Lead Sprint Quattro Secure","C":"275","D":"C1895","F":"5590.314"},{"Policy Line":"72205234","B":"Gen Crtd Ventak Prizm He1857","C":"275","D":"C1722","F":"13260.816"},{"Policy Line":"72205235","B":"Retrieval Set","C":"278","D":"C1773","F":"1485.63"},{"Policy Line":"72205236","B":"Wire Tip Handle G20010","C":"272","F":"468.792"},{"Policy Line":"72205237","B":"Cath Ep Pentaray Nav 3D Map","C":"278","D":"C1732","F":"2119.356","G":"**"},{"Policy Line":"72205238","B":"Cath Ep 3D Mapping Decanav","C":"278","D":"C1732","F":"1222.164","G":"**"},{"Policy Line":"72205239","B":"Lead Attain Ability Strait Cs","C":"275","D":"C1900","F":"3071.322"},{"Policy Line":"72205241","B":"RETRIEVER ENDO HRD WIR","C":"272","F":"670.14"},{"Policy Line":"72205242","B":"EP Cath, Card US 10Fr SDSTR","C":"278","D":"C1759","F":"1472.778","G":"**"},{"Policy Line":"72205243","B":"Cath Intra Cardiac US 8FR","C":"278","D":"C1759","F":"3080.196"},{"Policy Line":"72205250","B":"Pacemaker Microny Ii Sr 2525T","C":"275","D":"C1786","F":"3550.518"},{"Policy Line":"72205251","B":"ICD Gen Dual Cd2211-36","C":"275","D":"C1721","F":"18360.612"},{"Policy Line":"72205376","B":"Cath Ep Dx/Abl 3D Map Grp 2","C":"278","D":"C1732","F":"2809.08"},{"Policy Line":"72205377","B":"Cath Ep Dx/Abl 3D Map Grp 3","C":"278","D":"C1732","F":"3121.2"},{"Policy Line":"72205405","B":"Gen Current Plus Vr Cd1211-36","C":"275","D":"C1722","F":"17085.816"},{"Policy Line":"72205406","B":"Lead Crtd/Icd Durata 7120Q","C":"275","D":"C1895","F":"4013.802","G":"**"},{"Policy Line":"72205407","B":"Gen Promote Plus Cd3211-36","C":"275","D":"C1882","F":"21505.068"},{"Policy Line":"72205481","B":"Gen Crt-D Dual Fortify Cd2231","C":"275","D":"C1721","F":"18946.908"},{"Policy Line":"72205482","B":"Gen Crt-D Unify Cd3231-40","C":"275","D":"C1882","F":"18727.2","G":"**"},{"Policy Line":"72205483","B":"Intro/Sheath Fixed Pl-Awy Grp1","C":"272","D":"C1892","F":"144.738","G":"**"},{"Policy Line":"72205484","B":"Intro/Sheath Fixed Pl-Awy Grp2","C":"272","D":"C1892","F":"434.826"},{"Policy Line":"72205485","B":"Intro/Shth FixdNon-Peelawy GR1","C":"272","D":"C1893","F":"237.762","G":"**"},{"Policy Line":"72205486","B":"Intro/Sheath Laser","C":"272","D":"C2629","F":"3225.852","G":"**"},{"Policy Line":"72205487","B":"Intro/Sheath Non-Laser","C":"272","D":"C1894","F":"44.676","G":"**"},{"Policy Line":"72205488","B":"Intro/Sheath Ep Guiding","C":"278","D":"C1766","F":"1278.468","G":"**"},{"Policy Line":"72205489","B":"Lead Clipper, Disp","C":"272","F":"146.88","G":"**"},{"Policy Line":"72205490","B":"Lead Plug, Disp","C":"272","F":"183.906","G":"**"},{"Policy Line":"72205492","B":"Guidewire","C":"272","D":"C1769","F":"193.086","G":"**"},{"Policy Line":"72205493","B":"Guidewire, Low Cost","C":"272","D":"C1769","F":"14.994","G":"**"},{"Policy Line":"72205494","B":"Sheath/Introducer Low Cost","C":"272","D":"C1894","F":"24.174","G":"**"},{"Policy Line":"72205495","B":"SET,INTRODUCER NONLSR PLVN","C":"272","D":"C1894","F":"205.938"},{"Policy Line":"72205496","B":"SHEATH,INTRDCR NONLSR 16FR30CM","C":"272","D":"C1894","F":"187.272","G":"**"},{"Policy Line":"72205497","B":"Intro/Shth Fixd NonPeelawy GR3","C":"272","D":"C1893","F":"337.518","G":"**"},{"Policy Line":"72205498","B":"Kit Intro/Sheath Crvd Femoral","C":"272","D":"C1893","F":"654.228","G":"**"},{"Policy Line":"72205501","B":"Intro/Shth FixdNon-Peelawy GR2","C":"272","D":"C1893","F":"290.394","G":"**"},{"Policy Line":"72205548","B":"Lead Cs Grp 1","C":"275","D":"C1900","F":"2879.46","G":"**"},{"Policy Line":"72205549","B":"Lead Cs Grp 2","C":"275","D":"C1900","F":"2978.91","G":"**"},{"Policy Line":"72205550","B":"ICD Gen, Single Chamber Grp 1","C":"275","D":"C1722","F":"18839.502"},{"Policy Line":"72205551","B":"ICD Gen, Single Chamber Grp 2","C":"275","D":"C1722","F":"20684.376"},{"Policy Line":"72205552","B":"Gen, Icd Dual Chamber Grp 1","C":"275","D":"C1721","F":"17855.406"},{"Policy Line":"72205553","B":"Gen, Icd Dual Chamber Grp 2","C":"275","D":"C1721","F":"23463.162"},{"Policy Line":"72205554","B":"Generator, Icd Bi-V Grp 1","C":"275","D":"C1882","F":"19788.408","G":"**"},{"Policy Line":"72205555","B":"Generator, Icd Bi-V Grp 2","C":"275","D":"C1882","F":"25798.86"},{"Policy Line":"72205556","B":"Generator, Icd Bi-V Grp 3","C":"275","D":"C1882","F":"28733.706"},{"Policy Line":"72205557","B":"Lead Ppm Grp 1","C":"275","D":"C1898","F":"794.07","G":"**"},{"Policy Line":"72205558","B":"Lead Ppm Grp 2","C":"275","D":"C1898","F":"759.186","G":"**"},{"Policy Line":"72205559","B":"Cable Ep Grp 1","C":"272","F":"238.986"},{"Policy Line":"72205560","B":"Cath Ep Dx 1-19 Elec Grp 1","C":"278","D":"C1730","F":"363.222","G":"**"},{"Policy Line":"72205561","B":"Cath Ep Dx 20++Elec Grp 1","C":"278","D":"C1731","F":"1223.694"},{"Policy Line":"72205562","B":"Cath Ep Dx/Abl 3D Map Grp 1","C":"278","D":"C1732","F":"2705.958","G":"**"},{"Policy Line":"72205563","B":"Cath Ep Dx/Abl Other Grp1","C":"278","D":"C1733","F":"374.85"},{"Policy Line":"72205564","B":"CATH EP DX/ABL OTHER GRP 2","C":"278","D":"C1733","F":"895.662","G":"**"},{"Policy Line":"72205565","B":"Cath Guiding Grp 1","C":"278","D":"C1887","F":"310.59"},{"Policy Line":"72205566","B":"Cath Guiding Grp 2","C":"272","D":"C1887","F":"696.15","G":"**"},{"Policy Line":"72205567","B":"Cath Guiding Grp 3","C":"272","D":"C1887","F":"895.662","G":"**"},{"Policy Line":"72205568","B":"Cath Intracardiac Echo Grp 1","C":"278","D":"C1759","F":"1904.544"},{"Policy Line":"72205569","B":"Lead End Cap","C":"272","F":"65.79","G":"**"},{"Policy Line":"72205570","B":"Patch External Reference","C":"272","F":"555.696","G":"**"},{"Policy Line":"72205571","B":"Transseptal Needle","C":"272","F":"234.09","G":"**"},{"Policy Line":"72205572","B":"Introducer/Sheath Ep Grp 1","C":"278","D":"C1766","F":"1535.508","G":"**"},{"Policy Line":"72205575","B":"PM/NS Lead Adapter/Xtn Implant","C":"278","D":"C1883","F":"313.65"},{"Policy Line":"72205576","B":"Connector","C":"278","F":"406.674"},{"Policy Line":"72205577","B":"Lead Lock Device (Disp)","C":"272","D":"C1773","F":"795.6","G":"**"},{"Policy Line":"72205578","B":"Wrench Pacemaker/Icd (Disp)","C":"272","F":"96.696","G":"**"},{"Policy Line":"72205579","B":"Lead Repair Kit","C":"272","F":"193.392"},{"Policy Line":"72205587","B":"Lead PPM Group A","C":"275","D":"C1898","F":"608.634"},{"Policy Line":"72205589","B":"Sleeve Upsizing","C":"272","F":"96.696"},{"Policy Line":"72205590","B":"Pacemaker Adapta Addr01 Sys -D","C":"275","F":"0"},{"Policy Line":"72205591","B":"Gen Pacer Addr01","C":"275","D":"C1785","F":"4341.834"},{"Policy Line":"72205592","B":"Lead 1 Medtronic","C":"275","D":"C1898","F":"636.48"},{"Policy Line":"72205593","B":"Lead 2 Medtronic","C":"275","D":"C1898","F":"778.158"},{"Policy Line":"72205594","B":"Pacemaker Sensia Sedr01 Sys-D","C":"275","F":"0"},{"Policy Line":"72205595","B":"Gen Ppm Sensia Sedr01","C":"275","D":"C1785","F":"2587.842"},{"Policy Line":"72205596","B":"Navistar Ep Cath","C":"278","D":"C1732","F":"2336.922"},{"Policy Line":"72205599","B":"EP Cable Grp 2","C":"272","F":"346.698"},{"Policy Line":"72205601","B":"Needle, Transseptal NRG RF","C":"272","F":"788.256","G":"**"},{"Policy Line":"72205602","B":"Cath Guiding Grp 1A","C":"278","D":"C1887","F":"343.332","G":"**"},{"Policy Line":"72205603","B":"Kit Snare Lead Extrctn Femoral","C":"272","D":"C1773","F":"1347.624"},{"Policy Line":"72205611","B":"Lead Ppm Grp 2A","C":"275","D":"C1898","F":"777.24"},{"Policy Line":"72205613","B":"SHEATH DIL ROTATNG-TIGHTRL13FR","C":"272","D":"C1773","F":"2936.988"},{"Policy Line":"72205614","B":"Cath Ep Dx Deca CSL 6FR","C":"278","D":"C1730","F":"700.434","G":"**"},{"Policy Line":"72205618","B":"Lead Icd Dual Coil Grp 1","C":"275","D":"C1895","F":"4557.87"},{"Policy Line":"72205619","B":"Lead Icd Other Grp 1","C":"275","D":"C1896","F":"2811.528"},{"Policy Line":"72205621","B":"Lead ICD Other Grp 2","C":"275","D":"C1896","F":"3901.5"},{"Policy Line":"72205628","B":"Cath Ep Dx 1-19 Elec Grp 1A","C":"278","D":"C1730","F":"543.762","G":"**"},{"Policy Line":"72205631","B":"GenratrPM Dual RR MRI-Accolade","C":"275","D":"C1785","F":"4767.786","G":"**"},{"Policy Line":"72205632","B":"GenratrPM Sngl RR MRI-Accolade","C":"275","D":"C1786","F":"4057.56","G":"**"},{"Policy Line":"72205633","B":"Lead Pacng/Sensng MRI-Ingevity","C":"275","D":"C1898","F":"636.786","G":"**"},{"Policy Line":"72205634","B":"GenratrPM Dual RR MRI-ASSURITY","C":"275","D":"C1785","F":"4057.56","G":"**"},{"Policy Line":"72205635","B":"Lead PPM MRI CONTENDRIL","C":"275","D":"C1898","F":"636.786","G":"**"},{"Policy Line":"72205691","B":"Lead Ppm Grp 3 C1898","C":"275","D":"C1898","F":"1251.846"},{"Policy Line":"72205692","B":"Cath Ep Dx 20++Elec Grp 2","C":"278","D":"C1731","F":"936.36"},{"Policy Line":"72205693","B":"Cath Ep Dx 20++Elec Grp 3","C":"278","D":"C1731","F":"1248.48"},{"Policy Line":"72205694","B":"Cath Ep Dx 20++Elec Grp 4","C":"278","D":"C1731","F":"1716.66"},{"Policy Line":"72205695","B":"EP INTRACRD FIX GUID INRO/SHTH","C":"278","D":"C1893","F":"589.05"},{"Policy Line":"72205701","B":"Pacing Lead Adapter 5866-40","C":"275","D":"C1883","F":"145.044"},{"Policy Line":"72205735","B":"Gen: CRT-D Dynagen","C":"275","D":"C1882","F":"20990.682","G":"**"},{"Policy Line":"72205739","B":"Cath Ep Dx 1-19 Elec Grp 2","C":"278","D":"C1730","F":"694.008"},{"Policy Line":"72205761","B":"GENERATOR S-ICD EMBLEM","C":"275","D":"C1722","F":"20287.8","G":"**"},{"Policy Line":"72205762","B":"LEAD S-ICD EMBLEM","C":"275","D":"C1896","F":"4057.56","G":"**"},{"Policy Line":"72205997","B":"Pacemaker Gen Sgl Rr Grp 1","C":"275","D":"C1786","F":"4026.348","G":"**"},{"Policy Line":"72205998","B":"Pacemaker Gen Sgl Rr Grp 2","C":"275","D":"C1786","F":"5646.618"},{"Policy Line":"72205999","B":"Pacemaker Gen Bi-V","C":"275","D":"C2621","F":"8961.822","G":"**"},{"Policy Line":"72206000","B":"Pacemaker Gen Dual Rr Grp 1","C":"275","D":"C1785","F":"4342.446","G":"**"},{"Policy Line":"72206001","B":"Pacemaker Gen Dual Rr Grp 2","C":"275","D":"C1785","F":"4761.972"},{"Policy Line":"72206010","B":"AICD Gen- Dynagen DF4 D150","C":"275","D":"C1722","F":"14375.88","G":"**"},{"Policy Line":"72206011","B":"Pacemaker Gen - Dual Rr Grp 3","C":"275","D":"C1785","F":"4499.118"},{"Policy Line":"72206424","B":"Perfusion: Beating Hearts Lv 1","C":"272","F":"2022.048","G":"**"},{"Policy Line":"72206511","B":"Loop Recorder: Reveal","C":"278","D":"C1764","F":"4153.95","G":"**"},{"Policy Line":"72206512","B":"Implantable Cardiac Monitor","C":"278","D":"C1764","F":"4641.408","G":"**"},{"Policy Line":"72206714","B":"Handpiece, Bipolar Aquamantys","C":"272","F":"627.3"},{"Policy Line":"72206733","B":"Tray: Custom Ep","C":"272","F":"65.79","G":"**"},{"Policy Line":"72206808","B":"Stent: Covered w/o Delivery Sy","C":"278","D":"C1875","F":"3463.92"},{"Policy Line":"72206840","B":"Stapler: Proximate Prw-35","C":"272","F":"56.61"},{"Policy Line":"72207000","B":"Cath: Balloon Bi-V Medt","C":"272","F":"193.392"},{"Policy Line":"72207004","B":"Cath Occlusion For Venogram","C":"272","D":"C2628","F":"100.368"},{"Policy Line":"72207005","B":"Cath Occlusion - BRIDGE","C":"278","D":"C2628","F":"1087.83","G":"**"},{"Policy Line":"72207058","B":"Cath: Balloon GRP 1","C":"272","D":"C1725","F":"171.666"},{"Policy Line":"72207101","B":"Dermabond Db12","C":"272","F":"60.282","G":"**"},{"Policy Line":"72207105","B":"Cable: Pacing 5833-S","C":"272","F":"60.588"},{"Policy Line":"72207112","B":"Cath: Guide","C":"278","D":"C1887","F":"93.024"},{"Policy Line":"72207130","B":"Cath: Diagnostic Grp 1","C":"272","F":"17.442"},{"Policy Line":"72207294","B":"Femostop: Compression","C":"272","F":"167.382"},{"Policy Line":"72207313","B":"Cath EP 1-19 Elec Curved 5F/6F","C":"278","D":"C1730","F":"157.284","G":"**"},{"Policy Line":"72207319","B":"Sheath: Hls And 808150","C":"272","D":"C1894","F":"119.952","G":"**"},{"Policy Line":"72207421","B":"Inflation Device Kit","C":"272","F":"58.752"},{"Policy Line":"72207451","B":"Generator CRT-P - VIVA","C":"275","D":"C2621","F":"7547.184"},{"Policy Line":"72207452","B":"Generator CRT-P ValitudeU125","C":"275","D":"C2621","F":"6593.688","G":"**"},{"Policy Line":"72207481","B":"Wire: Finishing","C":"272","F":"222.768"},{"Policy Line":"72207526","B":"Kit: Essentials","C":"272","F":"60.894"},{"Policy Line":"72207528","B":"Kit, Retrieval Cath/Snare","C":"272","D":"C1773","F":"514.998","G":"**"},{"Policy Line":"72207599","B":"Guidewire Grp 2A","C":"272","D":"C1769","F":"138.924"},{"Policy Line":"72207761","B":"Pinch On Tool 6056","C":"272","F":"50.49","G":"**"},{"Policy Line":"72207768","B":"Pacemaker Gen Sgl Rr Grp A","C":"275","D":"C1786","F":"3246.048"},{"Policy Line":"72207790","B":"Tray: Pericardiocentesis (Ep)","C":"272","D":"C1769","F":"302.634","G":"**"},{"Policy Line":"72208462","B":"Cath 3Lu 7F 16C Ask-42703-Pcsj","C":"272","F":"225.216"},{"Policy Line":"72208502","B":"Kit Lld Accessory 518-027","C":"272","F":"182.988"},{"Policy Line":"72208629","B":"TAVR VALVE","C":"278","F":"32321.25"},{"Policy Line":"72208888","B":"Non-Charge Surg Supply","C":"270","F":"0"},{"Policy Line":"72208916","B":"LEAD SJ4 DC 58CM","C":"275","D":"C1895","F":"3306.636"},{"Policy Line":"72208952","B":"AICD,MRI, SNGL CHMBR, EVERA","C":"275","D":"C1722","F":"16331.832"},{"Policy Line":"7221","B":"Collagen Drssing <=16sqin","C":"272","D":"A6021","F":"24.786"},{"Policy Line":"7222","B":"Collagen Drssing >16,<=48Sq In","C":"272","D":"A6022","F":"18.36"},{"Policy Line":"7243","B":"ALLGRFT PLAC AMNIOFILL 250MG","C":"278","F":"721.548"},{"Policy Line":"73100008","B":"Incentive Spirometer","C":"270","F":"20.196","G":"**"},{"Policy Line":"73100015","B":"Circuit: Ippb","C":"270","F":"10.71"},{"Policy Line":"73100052","B":"Air-Way Disp Trache Tube","C":"272","D":"A7521","F":"65.79","G":"**"},{"Policy Line":"73100053","B":"Heliox Gas Per Tank","C":"270","F":"0"},{"Policy Line":"73100074","B":"Oxygen Daily Charge","C":"270","F":"0"},{"Policy Line":"73100088","B":"Peak Flow Meter; Hand Held","C":"270","D":"A4614","F":"56.304","G":"**"},{"Policy Line":"73100203","B":"Bronch Stent W/Guidewire","C":"278","F":"1846.098"},{"Policy Line":"73101000","B":"Retrieval Basket","C":"272","F":"320.076"},{"Policy Line":"73101002","B":"Jagwire","C":"272","D":"C1769","F":"443.7"},{"Policy Line":"73101004","B":"Irridium Catheter","C":"272","D":"C1728","F":"194.616"},{"Policy Line":"73101006","B":"Inflation Baloon","C":"272","F":"223.686"},{"Policy Line":"73103110","B":"Flutter Valve","C":"270","F":"100.062","G":"**"},{"Policy Line":"73109853","B":"Tube Trach Grp 1","C":"272","F":"119.646"},{"Policy Line":"73200023","B":"Pulmonary Mini Forceps","C":"272","F":"605.7117","G":"**"},{"Policy Line":"73200202","B":"Wang Biopsy Needle","C":"272","F":"72.216"},{"Policy Line":"73200203","B":"Kit Bx Disp Superdimension","C":"272","F":"1362.924"},{"Policy Line":"73200204","B":"Visicoil Fiducial Marker","C":"278","D":"A4648","F":"266.22"},{"Policy Line":"73200205","B":"Marker Gold Seeds Per Vial","C":"278","D":"A4648","F":"20.502"},{"Policy Line":"73200208","B":"Superlock Gold Fiducial Marker","C":"278","D":"A4648","F":"263.772","G":"**"},{"Policy Line":"73200209","B":"Delivery Kit Fid Mrk Sdmdk1000","C":"272","F":"161.874","G":"**"},{"Policy Line":"73200210","B":"Stent Aero Tracheobronchial","C":"278","D":"C1874","F":"3030.93","G":"**"},{"Policy Line":"73200211","B":"Coil Embolization","C":"278","F":"205.326","G":"**"},{"Policy Line":"73200212","B":"Cath Brachytherapy","C":"272","D":"C1728","F":"182.988","G":"**"},{"Policy Line":"73200213","B":"Guide Cath Kit Supertrax","C":"272","F":"1273.572"},{"Policy Line":"73200214","B":"Probe Fiapc Argon Plasma Coag","C":"272","F":"353.43","G":"**"},{"Policy Line":"73200215","B":"Fiducial Marker Ea Strand Best","C":"278","D":"A4648","F":"193.392"},{"Policy Line":"73200216","B":"Supertrax Superd Asp Needle","C":"272","F":"186.66"},{"Policy Line":"73200217","B":"Encore Inflation Device","C":"272","F":"139.536"},{"Policy Line":"73200218","B":"Ebus Fna/Biopsy Needle","C":"272","F":"138.006","G":"**"},{"Policy Line":"73200219","B":"Cytology Brush Sheathed","C":"272","F":"193.392","G":"**"},{"Policy Line":"73200220","B":"Cath Guide Renegade Stc","C":"278","D":"C1887","F":"736.542"},{"Policy Line":"73200221","B":"Embolization Coil Vortex","C":"278","F":"722.772"},{"Policy Line":"73200222","B":"Guidewire","C":"272","D":"C1769","F":"193.392","G":"**"},{"Policy Line":"73200223","B":"Cath Balloon Pulm Dilator","C":"272","D":"C1726","F":"516.528","G":"**"},{"Policy Line":"73200224","B":"Catheter Balloon B5-2C","C":"272","F":"193.392","G":"**"},{"Policy Line":"73200225","B":"Stent Sizing Device","C":"272","F":"398.106","G":"**"},{"Policy Line":"73200226","B":"Pluerx Catheter","C":"272","D":"C1729","F":"703.8","G":"**"},{"Policy Line":"73200227","B":"Pleurx Drain Cath","C":"272","D":"C1729","F":"117.198"},{"Policy Line":"73200228","B":"IBV Valve System","C":"278","F":"3196.17","G":"**"},{"Policy Line":"73200229","B":"Cath Edge 180 Super Dimension","C":"272","F":"1470.942","G":"**"},{"Policy Line":"73200231","B":"BRONCH BX GUIDE KIT-SPIN EWC","C":"272","F":"1087.83"},{"Policy Line":"73200232","B":"Needle Asp-EBUS-TBNA 19GA","C":"272","F":"410.652","G":"**"},{"Policy Line":"73200312","B":"Cyto Brushes","C":"270","F":"21.726"},{"Policy Line":"73200313","B":"IBV Deploymnt Cath/Loader","C":"272","F":"913.104","G":"**"},{"Policy Line":"73200314","B":"IBV Balloon Airway Sizer","C":"272","F":"367.2"},{"Policy Line":"73200366","B":"Pleurx Kit Pt Starter 50-0071","C":"272","F":"192.78","G":"**"},{"Policy Line":"73200800","B":"Tracker Nav VPad","C":"272","F":"501.534"},{"Policy Line":"73200801","B":"Cath VP Steerable Nav","C":"272","F":"794.376"},{"Policy Line":"73200802","B":"Guidewire Biop Spin Nav","C":"272","F":"398.106"},{"Policy Line":"73200803","B":"Needle Nav Spin Flex","C":"272","F":"895.662"},{"Policy Line":"73200804","B":"Brush Nav Tracker","C":"272","F":"794.376"},{"Policy Line":"73200805","B":"Forcep Nav Serrated","C":"272","F":"741.438"},{"Policy Line":"73200806","B":"Needle Nav Anso Hist","C":"272","F":"794.376"},{"Policy Line":"73200807","B":"Needle Nav Anso Cyto","C":"272","F":"3193.11"},{"Policy Line":"73200808","B":"Cable Nav Single VP","C":"272","F":"437.886"},{"Policy Line":"73200809","B":"Forcep/Graspr - Tricep","C":"272","F":"284.58"},{"Policy Line":"73201000","B":"Retrieval Basket","C":"272","F":"320.076","G":"**"},{"Policy Line":"73201002","B":"Jagwire","C":"272","D":"C1769","F":"215.118","G":"**"},{"Policy Line":"73201004","B":"Irridium Catheter","C":"272","D":"C1728","F":"194.616"},{"Policy Line":"73201006","B":"Inflation Balloon","C":"272","F":"437.886"},{"Policy Line":"73201008","B":"Bronc Periph Guide Sheath Kit","C":"272","F":"192.78","G":"**"},{"Policy Line":"73203036","B":"Circuit Nebulizer Hand Held","C":"270","F":"10.098"},{"Policy Line":"73203058","B":"Micro Spec Brush","C":"270","F":"36.414"},{"Policy Line":"73203059","B":"Radial Biopsy Forcep","C":"270","F":"83.538"},{"Policy Line":"73203080","B":"Stent","C":"278","F":"155.142"},{"Policy Line":"73203170","B":"Cath Bronch Thermoplsty Alair","C":"278","D":"C1886","F":"2536.128"},{"Policy Line":"73204440","B":"CATH GUIDE, GLIDE","C":"272","D":"C1887","F":"103.428"},{"Policy Line":"73208888","B":"Bronch Suite Supply","C":"270","F":"0"},{"Policy Line":"74100123","B":"Chloraseptic Spray 180Ml","C":"272","F":"0"},{"Policy Line":"74100664","B":"Aveeno For Bath Plain 42Gm Pkt","C":"270","F":"18.054","G":"**"},{"Policy Line":"74100817","B":"Povidone-Iodine Sol 120Ml","C":"271","F":"1.836","G":"**"},{"Policy Line":"74100841","B":"Povidone-Iodine 1% Oint 30Gm","C":"271","F":"1.836","G":"**"},{"Policy Line":"74102704","B":"Fleets Enema Oil 133Ml","C":"270","F":"2.1406426459144","G":"**"},{"Policy Line":"74102707","B":"Fleet Enema Ped 67.5Ml","C":"270","F":"1.836","G":"**"},{"Policy Line":"74102854","B":"Gelfoam Size 12 3Mm","C":"270","F":"10.404","G":"**"},{"Policy Line":"74103052","B":"Chlorhexidine 4% Top Sol 120Ml","C":"271","F":"4.56969117318435","G":"**"},{"Policy Line":"74103742","B":"Thera Bath Lot Boz Bottl","C":"270","F":"3.978"},{"Policy Line":"74103811","B":"Lanolin 30Gm Cr","C":"270","F":"2.448","G":"**"},{"Policy Line":"74104870","B":"Neomycin-Bac-Polymyx Oint 30Gm","C":"270","F":"7.833313125","G":"**"},{"Policy Line":"74104936","B":"Nitrazine Paper W/Dispens","C":"271","F":"0"},{"Policy Line":"74106217","B":"Silver Sulfadiazine 1% Cr 20Gm","C":"270","F":"10.2845853658537","G":"**"},{"Policy Line":"74106220","B":"Silver Sulfadiazine 1% Cr 400G","C":"270","F":"65.9736","G":"**"},{"Policy Line":"74106223","B":"Silver Sulfadiazine Cr 1% 50Gm","C":"270","F":"14.9757603370786","G":"**"},{"Policy Line":"74106226","B":"Silver Nitrate Applicator","C":"272","F":"1.81535033307514","G":"**"},{"Policy Line":"74107114","B":"Witch Hazel Pads 12 S","C":"270","F":"18.4580541369863","G":"**"},{"Policy Line":"74107597","B":"Zinc Oxide 20% Oint 30Gm","C":"270","F":"3.366","G":"**"},{"Policy Line":"74108453","B":"Compounded Epidural Cass","C":"272","F":"73.134"},{"Policy Line":"74108598","B":"Dakins Soln 0.25% Strength 1L","C":"270","F":"45.594"},{"Policy Line":"74108835","B":"Empty Viaflex Container","C":"270","F":"0"},{"Policy Line":"74109061","B":"Emla Cream 5Gm","C":"270","F":"7.55113710583155","G":"**"},{"Policy Line":"74110036","B":"Evacuated Bottle 1000 Ml","C":"270","F":"43.452"},{"Policy Line":"74118090","B":"TPN Bag Charge","C":"270","F":"0"},{"Policy Line":"74118252","B":"Blistick Tube","C":"270","F":"1.836"},{"Policy Line":"74118308","B":"Polysporin Top Oint 15Gram","C":"270","F":"7.8642","G":"**"},{"Policy Line":"74118320","B":"Povidone-Iodine Oint 0.8Gm","C":"270","F":"1.836"},{"Policy Line":"74118329","B":"Povidone-Iodine Skin Cl 120Ml","C":"271","F":"0"},{"Policy Line":"74118432","B":"No-Rinse Shampoo 240Ml","C":"270","F":"1.836"},{"Policy Line":"74118437","B":"Chapstick Tube","C":"270","F":"1.836"},{"Policy Line":"74118461","B":"Petrolatum White Oinment 30Gm","C":"270","F":"3.366","G":"**"},{"Policy Line":"74118527","B":"Nacl Resp 0.9% 3 Ml Inh Sol","C":"272","F":"4.346443125","G":"**"},{"Policy Line":"74118620","B":"LTA II Kit (Anesthesia)","C":"270","F":"23.6338027134146","G":"**"},{"Policy Line":"74118735","B":"Icy Hot Balm 3.5Oz","C":"270","F":"1.836","G":"**"},{"Policy Line":"74120053","B":"Evacuated Bottle 250 Ml","C":"270","F":"38.25"},{"Policy Line":"74120054","B":"Evacuated Bottle 500 Ml","C":"271","F":"39.168"},{"Policy Line":"74120155","B":"Crash Intubation Bag","C":"271","F":"88.6761391304346","G":"**"},{"Policy Line":"74120345","B":"Povidone Iodine Soltn 273Ml","C":"270","F":"3.04822109589042","G":"**"},{"Policy Line":"74120352","B":"Dove Soap","C":"270","F":"18.972"},{"Policy Line":"74120410","B":"Fibrin Sealant Kit 2Ml","C":"278","D":"C2615","F":"416.16","G":"**"},{"Policy Line":"74120485","B":"Clocortolone 0.1% Cream 45Gm","C":"270","F":"338.742"},{"Policy Line":"74120516","B":"Perfluoron Or Kit","C":"272","F":"464.5845","G":"**"},{"Policy Line":"74120828","B":"Dakins 0.25% Irr 480 Ml Bot","C":"270","F":"14.8809656992084","G":"**"},{"Policy Line":"74120998","B":"Lidocaine-Prilocain Oint 30 Gm","C":"270","F":"43.3092","G":"**"},{"Policy Line":"74121314","B":"Collagenase 30 Gm Tub","C":"270","F":"268.152","G":"**"},{"Policy Line":"74121447","B":"Clocortolone 0.1% Cream 10 Gm","C":"270","F":"89.9864895145632","G":"**"},{"Policy Line":"74121449","B":"Silver Sulfadiazine 10 Gm Chg","C":"270","F":"5.48471739130437","G":"**"},{"Policy Line":"74121450","B":"Silver Sulfadiazine 50 Gm Noch","C":"270","F":"0"},{"Policy Line":"74121451","B":"Collagenase 5Gm Charge Topical","C":"270","F":"26.8201209335219","G":"**"},{"Policy Line":"74121452","B":"Clocortolone 0.1% Cm 45Gm Noch","C":"270","F":"1.45656","G":"**"},{"Policy Line":"74122073","B":"Sodium Chloride 3% 15Ml Neb","C":"272","F":"1.836"},{"Policy Line":"74122101","B":"Vasoline 71 Gm Tub","C":"270","F":"0"},{"Policy Line":"74122102","B":"Dakins-Na Hypochl 0.25% No Chg","C":"270","F":"4.8501","G":"**"},{"Policy Line":"74122103","B":"Dakins-Na Hypochlor 0.25% Each","C":"270","F":"1.836","G":"**"},{"Policy Line":"74122137","B":"Compounded Cassette On-Q Pump","C":"272","F":"289.531636363636","G":"**"},{"Policy Line":"74122218","B":"Sodium Chloride 7% 4 Ml Neb","C":"272","F":"1.836","G":"**"},{"Policy Line":"74122314","B":"Sodium Chloride 3% Neb Sol 4Ml","C":"272","F":"1.836","G":"**"},{"Policy Line":"74122335","B":"Empty Sterile Bag 100 Ml","C":"270","F":"0"},{"Policy Line":"74122390","B":"Solesta 50-15 MG/ML Syringe","C":"278","D":"L8605","F":"1697.382"},{"Policy Line":"74122527","B":"NEONATE EMERGENCY DRUG BAG","C":"271","F":"16.83","G":"**"},{"Policy Line":"74122751","B":"Dakins 0.125%% Irr 480 Ml Bot","C":"270","F":"14.535","G":"**"},{"Policy Line":"74122807","B":"Sterile Water 20Ml Vial","C":"272","F":"0"},{"Policy Line":"74128888","B":"Pharmacy No Charge","C":"272","F":"0"},{"Policy Line":"75100014","B":"Lavage Disposable","C":"272","F":"56.61"},{"Policy Line":"75300328","B":"Passy-Muir Speaking Valve","C":"274","D":"L8501","F":"129.438","G":"**"},{"Policy Line":"75301500","B":"Laryngeal Mirrors","C":"270","F":"29.682"},{"Policy Line":"75301800","B":"Vitalstim Electrodes","C":"271","F":"42.84"},{"Policy Line":"75345621","B":"OASIS ULTRA 5X7CM 306813000013","C":"278","D":"Q4124","F":"394.434"},{"Policy Line":"75375621","B":"OASIS ULTRA 5X7CM 306813000013","C":"278","D":"Q4124","F":"394.434"},{"Policy Line":"75390009","B":"PICC Introducer","C":"272","D":"C1894","F":"56.304"},{"Policy Line":"75390017","B":"Power PICC Triple","C":"272","D":"C1751","F":"278.766","G":"**"},{"Policy Line":"75390019","B":"PICC Triple Lumen 6 FR","C":"272","D":"C1751","F":"327.726"},{"Policy Line":"75390020","B":"PICC Dual Lumen- Arrow","C":"272","D":"C1751","F":"265.302"},{"Policy Line":"75390041","B":"CATH, PICC 1LUM 5Fr BIOFLO","C":"272","D":"C1751","F":"238.68"},{"Policy Line":"75390042","B":"CATH INFSN MIDLINE 1LUM 4.5Fr","C":"272","D":"C1751","F":"262.854"},{"Policy Line":"75392000","B":"Power PICC","C":"272","D":"C1751","F":"210.222","G":"**"},{"Policy Line":"75392001","B":"PI JACC KIT-TRIPLE LUMEN","C":"272","D":"C1751","F":"405.756","G":"**"},{"Policy Line":"75392003","B":"KIT CATH 3LUMEN 7FR","C":"272","F":"225.216","G":"**"},{"Policy Line":"76950005","B":"Biopsy: Tray","C":"272","F":"42.84"},{"Policy Line":"76950040","B":"Cont Ctr Perry Anal Sensor","C":"272","F":"89.352"},{"Policy Line":"76950041","B":"Cont Ctr Perry Vaginal Sensor","C":"272","F":"89.352"},{"Policy Line":"76950063","B":"Homer Mamalock Needle","C":"272","F":"54.162"},{"Policy Line":"76950089","B":"Stereo Biopsy Needle","C":"272","F":"456.858"},{"Policy Line":"76950091","B":"Clip Localization / Marker","C":"272","F":"157.284"},{"Policy Line":"76950095","B":"US Biopsy Needle","C":"272","F":"56.304"},{"Policy Line":"76950097","B":"US Biopsy Needle Vacuum-Assis","C":"272","F":"433.296"},{"Policy Line":"76970120","B":"Onc Central Line Dressing","C":"272","F":"21.114"},{"Policy Line":"76972507","B":"Sponsor supplied Study Drug","C":"624","F":"0"},{"Policy Line":"76979000","B":"Carfilzomib 60mg -study drug","C":"624","F":"0"},{"Policy Line":"76979001","B":"IMMU-114-Study drug","C":"624","F":"0"},{"Policy Line":"76979002","B":"Ipilimumab 200mg/40ml Study dr","C":"624","F":"0"},{"Policy Line":"76979003","B":"Ipilimumab 50mg/10ml Study drg","C":"624","F":"0"},{"Policy Line":"76979004","B":"Nivolumab 100mg/10ml Study drg","C":"624","F":"0.00306","G":"**"},{"Policy Line":"76979005","B":"Nivolumab 40mg/4ml Study drug","C":"624","F":"0"},{"Policy Line":"76979006","B":"Nivlumb/Plcbo100mg/10mlStdyDrg","C":"624","F":"0"},{"Policy Line":"76979007","B":"Panitumumab 100mg/5ml Stdy Drg","C":"624","F":"0"},{"Policy Line":"76979008","B":"Panitumumab 400mg/20ml Stdy Dr","C":"624","F":"0"},{"Policy Line":"76979009","B":"Pembrolizumab100mg/4ml StdyDrg","C":"624","F":"0"},{"Policy Line":"76979010","B":"Pembrolizumab 50mg/2ml StdyDrg","C":"624","F":"0"},{"Policy Line":"0005","B":"Body Analysis","C":"990","F":"13.2"},{"Policy Line":"0017","B":"Galactogram -D","C":"320","F":"0"},{"Policy Line":"0168","B":"KUB NO CHARGE","C":"990","F":"0"},{"Policy Line":"0264","B":"Galactogram-D","C":"320","F":"0"},{"Policy Line":"0266","B":"Galactogram Multiple Ducts-D","C":"320","F":"0"},{"Policy Line":"0440","B":"Hystosalpingogram-D","C":"320","F":"0"},{"Policy Line":"0500","B":"Loopogram-D","C":"320","F":"0"},{"Policy Line":"0761","B":"Sialogram Parotid - Right-D","C":"320","F":"0"},{"Policy Line":"0763","B":"Sialogram Parotid - Left-D","C":"320","F":"0"},{"Policy Line":"0765","B":"Arthrogram Ankle - Left-D","C":"320","F":"0"},{"Policy Line":"0768","B":"Arthrogram Ankle - Right-D","C":"320","F":"0"},{"Policy Line":"0771","B":"Arthrogram Hip Left-D","C":"320","F":"0"},{"Policy Line":"0774","B":"Arthrogram Hip Right-D","C":"320","F":"0"},{"Policy Line":"0777","B":"Arthrogram Knee Left-D","C":"320","F":"0"},{"Policy Line":"0780","B":"Arthrogram Knee Right-D","C":"320","F":"0"},{"Policy Line":"0783","B":"Arthrogram Shoulder - Left-D","C":"320","F":"0"},{"Policy Line":"0786","B":"Arthrogram Shoulder - Right-D","C":"320","F":"0"},{"Policy Line":"0789","B":"Arthrogram Wrist Left-D","C":"320","F":"0"},{"Policy Line":"0792","B":"Arthrogram Wrist Right-D","C":"320","F":"0"},{"Policy Line":"0945","B":"Voiding Cystourethrogram-D","C":"320","F":"0"},{"Policy Line":"0946","B":"Small Bowel Series-D","C":"320","F":"0"},{"Policy Line":"12345678","B":"room dummy cdm","C":"990","F":"0"},{"Policy Line":"2001","B":"Scrn Dig Mam Bi W/TomoW/CAD -D","C":"403","F":"0"},{"Policy Line":"2002","B":"Scrn Mam Uni Rt 3D/Tomo-D","C":"403","F":"0"},{"Policy Line":"2003","B":"Scrn Mam Uni Lt 3D/Tomo-D","C":"403","F":"0"},{"Policy Line":"2016","B":"Dx Mam BI Dgtl W/Tomo W/Cad-D","C":"401","F":"0"},{"Policy Line":"2017","B":"Dx Mam RT Dgtl W/Tomo W/Cad-D","C":"401","F":"0"},{"Policy Line":"2018","B":"Dx Mam LT Dgtl W/Tomo W/Cad-D","C":"401","F":"0"},{"Policy Line":"2050","B":"US Amniocentesis-D","C":"402","F":"0"},{"Policy Line":"2110","B":"US Guidance For Aspiration-D","C":"402","F":"0"},{"Policy Line":"2139","B":"US Biopsy: Lung-D","C":"402","F":"0"},{"Policy Line":"2146","B":"BIOPSY: LIVER-D","C":"402","F":"0"},{"Policy Line":"2152","B":"US Biopsy: Unspecified-D","C":"402","F":"0"},{"Policy Line":"2153","B":"US Biopsy: Renal-D","C":"402","F":"0"},{"Policy Line":"2199","B":"Cystogram-D","C":"320","F":"0"},{"Policy Line":"2212","B":"Fluoro Guided Hip Injection-D","C":"320","F":"0"},{"Policy Line":"2213","B":"Fluoro Guided Si Jnt Inject-D","C":"320","F":"0"},{"Policy Line":"2331","B":"US Guided Pseudoaneurysm Inj-D","C":"402","F":"0"},{"Policy Line":"2354","B":"Fistulagram Sinus Tract -D","C":"320","F":"0"},{"Policy Line":"2650","B":"Paracentesis-D","C":"402","F":"0"},{"Policy Line":"2651","B":"US PseudOAneurysm Compressn-D","C":"402","F":"0"},{"Policy Line":"2695","B":"Pelvic Histosonogram-D","C":"402","F":"0"},{"Policy Line":"2885","B":"Thoracentesis U/S Guided -D","C":"402","F":"0"},{"Policy Line":"3002","B":"PET/CT Limited Initial -D","C":"404","F":"0"},{"Policy Line":"3004","B":"PET/CT Limited Subsequent -D","C":"404","F":"0"},{"Policy Line":"3006","B":"PET/CT Bone Initial F-18 Wb -D","C":"404","F":"0"},{"Policy Line":"3007","B":"PET/CT Bone Subsqt F-18 Wb -D","C":"404","F":"0"},{"Policy Line":"3008","B":"PET/CT Skull -Thigh Initial -D","C":"404","F":"0"},{"Policy Line":"3010","B":"PET/CT Skull-Thigh Sub -D","C":"404","F":"0"},{"Policy Line":"3012","B":"PET/CT Whole Body Initial-D","C":"404","F":"0"},{"Policy Line":"3015","B":"PET/CT Whole Body Subsequent-D","C":"404","F":"0"},{"Policy Line":"3016","B":"PET/CT Dementia/Alzheimer'S-D","C":"404","F":"0"},{"Policy Line":"3451","B":"US Guidance -Abcess Drainge -D","C":"402","F":"0"},{"Policy Line":"4828","B":"Pelvic Us W/Tv Non-Ob","C":"402","F":"0"},{"Policy Line":"4829","B":"US Pel Vasc W/Ob Lmt-Tv","C":"402","F":"0"},{"Policy Line":"6101","B":"Canc. Intervential Breast Proc","C":"402","F":"0"},{"Policy Line":"61059000","B":"O/P Visit # Of Hours","C":"990","F":"0"},{"Policy Line":"61150255","B":"IV Inj Adl Seq Push Same Drug","C":"260","F":"42.6"},{"Policy Line":"61300700","B":"Extended O/P Counter","C":"990","F":"0"},{"Policy Line":"61409000","B":"O/P Visit Count 7N","C":"990","F":"0"},{"Policy Line":"61450254","B":"Hydration Each Addl Hour","C":"260","F":"102.6"},{"Policy Line":"61459000","B":"O/P Visit Count 7S","C":"990","F":"0"},{"Policy Line":"61568888","B":"CH Postpartum Outpatient Room","C":"990","F":"0"},{"Policy Line":"61702996","B":"IM / Sq Injection","C":"260","F":"123.9"},{"Policy Line":"63100101","B":"Hemodialysis (Ip)","C":"801","F":"617.1"},{"Policy Line":"63100102","B":"Visit Counter Hemodialysis","C":"990","F":"0"},{"Policy Line":"63100107","B":"Cvvh:Cavh:Cavad","C":"801","F":"414.3"},{"Policy Line":"63100137","B":"Peritoneal Dialysis","C":"802","F":"617.1"},{"Policy Line":"63101001","B":"Hemodialysis (Ip)-D","C":"801","F":"0"},{"Policy Line":"63101007","B":"Cvv:Cavh:Cavad","C":"809","F":"0"},{"Policy Line":"63101037","B":"Peritoneal Dialysis","C":"801","F":"0"},{"Policy Line":"63200032","B":"Ser Somatosensory B/Inte","C":"986","F":"0"},{"Policy Line":"63209000","B":"O/P Visit Count Otoneuro","C":"990","F":"0"},{"Policy Line":"63308999","B":"O/P Visit Count","C":"990","F":"0"},{"Policy Line":"63309001","B":"I/P Visit Counter","C":"990","F":"0"},{"Policy Line":"64100640","B":"O Arm Counter","C":"990","F":"0"},{"Policy Line":"64100794","B":"Intra-Op Mon Services","C":"990","F":"0"},{"Policy Line":"64159001","B":"Post Surgery Patient Counter","C":"990","F":"0"},{"Policy Line":"64507030","B":"GI Patient Counter","C":"990","F":"0"},{"Policy Line":"64509099","B":"OP Visit Count Bronchoscopy","C":"990","F":"0"},{"Policy Line":"65109617","B":"Drug Screen: Collection","C":"300","F":"31.8"},{"Policy Line":"6602","B":"Fluoro Ndl Plcmnt Aspiration-D","C":"320","F":"0"},{"Policy Line":"68252265","B":"Chemo Admin:Intralesnl>=7Lesns","C":"331","F":"144"},{"Policy Line":"6900","B":"Thyroid Biopsy-D","C":"402","F":"0"},{"Policy Line":"6905","B":"US Thyroid Aspiration-D","C":"402","F":"0"},{"Policy Line":"6915","B":"Thoracentesis W/Pleural Bpsy-D","C":"402","F":"0"},{"Policy Line":"70100005","B":"CMP W/ Lft - D","C":"300","F":"0"},{"Policy Line":"70100006","B":"Type And Screen-D","C":"300","F":"0"},{"Policy Line":"70100019","B":"CMP W/ Rft - D","C":"300","F":"0"},{"Policy Line":"70100020","B":"Immunoglob Profile-D","C":"300","F":"0"},{"Policy Line":"70100028","B":"CALPROTECTIN FECAL 16796 QST","C":"300","F":"238.2"},{"Policy Line":"70100210","B":"A/G Ratio-D","C":"300","F":"0"},{"Policy Line":"70100253","B":"Lymphocyte Mitogen Scr Cc -D","C":"300","F":"0"},{"Policy Line":"70100277","B":"HIV - State Lab","C":"300","F":"0"},{"Policy Line":"70100300","B":"Stat Surgical Profile-D","C":"300","F":"0"},{"Policy Line":"70100310","B":"Stat Profile-D","C":"300","F":"0"},{"Policy Line":"70100315","B":"Stat Profile W/Wbc-D","C":"300","F":"0"},{"Policy Line":"70100324","B":"TPN Profile-D","C":"300","F":"0"},{"Policy Line":"70100334","B":"VMA, Rand Ur -D Quest","C":"300","F":"0"},{"Policy Line":"70100339","B":"Meningoencephalitis Csf Comp-D","C":"300","F":"0"},{"Policy Line":"70100367","B":"Alk Phos Isoenzymes -D Quest","C":"300","F":"0"},{"Policy Line":"70100422","B":"Influenza A H1N1 Rt-Pcr Qst -D","C":"300","F":"0"},{"Policy Line":"70100509","B":"Influenza A&B Dfa -D Qst","C":"300","F":"0"},{"Policy Line":"70100533","B":"Mayo Direct Immunoflourescnc-D","C":"300","F":"0"},{"Policy Line":"70100607","B":"ENA - D","C":"300","F":"0"},{"Policy Line":"70100640","B":"Isohemagglutinin Titers -D Qst","C":"300","F":"0"},{"Policy Line":"70100647","B":"HLA Typing Narcolepsy-D Qst","C":"300","F":"0"},{"Policy Line":"70100681","B":"West Nile Virus Ab Csf -D Qst","C":"300","F":"0"},{"Policy Line":"70100690","B":"Chromosome Analysis Amnio Fl-D","C":"300","F":"0"},{"Policy Line":"70100699","B":"N.Meningitidis Igg Maid","C":"300","F":"0"},{"Policy Line":"70100745","B":"Giardia Ab Pnl -D","C":"300","F":"0"},{"Policy Line":"70100754","B":"Estronex 2/16 Oh Ratio-D Quest","C":"300","F":"0"},{"Policy Line":"70100773","B":"Poliovirus Antibody -D Quest","C":"300","F":"0"},{"Policy Line":"70100816","B":"GH Suppression Panel-D Stoever","C":"300","F":"0"},{"Policy Line":"70100838","B":"IGA Subclasses - D Qst 31488","C":"300","F":"0"},{"Policy Line":"70100848","B":"Tissue Ttg Ab -D Qst 11073","C":"300","F":"0"},{"Policy Line":"70100860","B":"PTT Mixing Studies-D","C":"300","F":"0"},{"Policy Line":"70100865","B":"Echovirus Antibody Panel -D","C":"300","F":"0"},{"Policy Line":"70100872","B":"L.Pneumophila Total Antibody-D","C":"300","F":"0"},{"Policy Line":"70100923","B":"Leishmania Antibody Ifa -D Qst","C":"300","F":"0"},{"Policy Line":"70100932","B":"Free Kappa Lambda W/Ratio Ur-D","C":"300","F":"0"},{"Policy Line":"70100940","B":"Ctng Mpl -D","C":"300","F":"0"},{"Policy Line":"70100943","B":"Cyto Bm Mpl -D","C":"300","F":"0"},{"Policy Line":"70100949","B":"Cyto Poc Mpl-D","C":"300","F":"0"},{"Policy Line":"70100953","B":"Cyto St Mpl -D","C":"300","F":"0"},{"Policy Line":"70100957","B":"Cyto Upb Mpl - D","C":"300","F":"0"},{"Policy Line":"70100964","B":"F Alk -D Mpl","C":"310","F":"0"},{"Policy Line":"70100967","B":"F Bcl 1 -D Mpl","C":"310","F":"0"},{"Policy Line":"70100970","B":"F Blc 2 -D Mpl","C":"310","F":"0"},{"Policy Line":"70100973","B":"F Egr1 -D Mpl","C":"310","F":"0"},{"Policy Line":"70100976","B":"F Her2 -D Mpl","C":"310","F":"0"},{"Policy Line":"70100979","B":"F Pml-Rara -D Mpl","C":"310","F":"0"},{"Policy Line":"70100982","B":"F Malt -D Mpl","C":"310","F":"0"},{"Policy Line":"70100985","B":"F Mm -D Mpl","C":"310","F":"0"},{"Policy Line":"70100988","B":"F Bcr Abl -D Mpl","C":"310","F":"0"},{"Policy Line":"70100992","B":"F Myc -D Mpl","C":"310","F":"0"},{"Policy Line":"70101020","B":"HSV 1/2 Igm -D Quest","C":"300","F":"0"},{"Policy Line":"70101039","B":"F Gli -D Mpl","C":"310","F":"0"},{"Policy Line":"70101071","B":"F Cll -D Mpl","C":"310","F":"0"},{"Policy Line":"70101096","B":"Warfarin Sensitiv Geno-D Mayo","C":"300","F":"0"},{"Policy Line":"70101113","B":"F Mds -D Mpl","C":"310","F":"0"},{"Policy Line":"70101122","B":"Phn -D Mpl","C":"310","F":"0"},{"Policy Line":"70101247","B":"Sensorimotor Neuropathy Profil","C":"300","F":"0"},{"Policy Line":"70101256","B":"Admark Apoe Csf -D Athena 177","C":"300","F":"0"},{"Policy Line":"70101260","B":"Iron: Tibc-D","C":"300","F":"0"},{"Policy Line":"70101296","B":"SMA Reflex Test-D Athena","C":"300","F":"0"},{"Policy Line":"70101302","B":"Glucose Tol 2Hr-D","C":"300","F":"0"},{"Policy Line":"70101303","B":"Glucose Tol 3 Hour-D","C":"300","F":"0"},{"Policy Line":"70101304","B":"Glucose Tol 4 Hour-D","C":"300","F":"0"},{"Policy Line":"70101305","B":"Glucose Tol 5 Hour-D","C":"300","F":"0"},{"Policy Line":"70101313","B":"Platelet Ab Scr Indirect-Quest","C":"300","F":"0"},{"Policy Line":"70101366","B":"Fish Subtelomere Scr Mayo -D","C":"300","F":"0"},{"Policy Line":"70101370","B":"Myodarditis Panel-D Qst","C":"300","F":"0"},{"Policy Line":"70101391","B":"Circulating Tumor Cells -D","C":"300","F":"0"},{"Policy Line":"70101395","B":"Mitochondrial Disorder Eval-D","C":"300","F":"0"},{"Policy Line":"70101401","B":"Cyclospora And Isospora Exam-D","C":"300","F":"0"},{"Policy Line":"70101404","B":"Lupus Anticoag Panel -D Quest","C":"300","F":"0"},{"Policy Line":"70101410","B":"Thyroid Profile-D","C":"300","F":"0"},{"Policy Line":"70101411","B":"Thyroid Profile: Hypo-D","C":"300","F":"0"},{"Policy Line":"70101414","B":"Magnesium 24 Hr Urine -D","C":"300","F":"0"},{"Policy Line":"70101415","B":"Citric Acid 24Hr W/Creat Qst-D","C":"300","F":"0"},{"Policy Line":"70101418","B":"Kappa Lt Ch Total Random Ur-D","C":"300","F":"0"},{"Policy Line":"70101424","B":"HSV 1&2 DNA Quant -D Qst","C":"300","F":"0"},{"Policy Line":"70101427","B":"Candida DNA Qual Pcr Serum-D","C":"300","F":"0"},{"Policy Line":"70101434","B":"Bv Panel -D Qst","C":"300","F":"0"},{"Policy Line":"70101440","B":"Paraneoplastic Auto Ab Eval-D","C":"300","F":"0"},{"Policy Line":"70101457","B":"Combisnp Poc Fresh Tissue-D","C":"300","F":"0"},{"Policy Line":"70101460","B":"Combibac Ffpe (Slides/Block)-D","C":"300","F":"0"},{"Policy Line":"70101466","B":"Transferrin Carb-Def -D Qst","C":"300","F":"0"},{"Policy Line":"70101481","B":"OB-GYN SPEC2 - D","C":"300","F":"0"},{"Policy Line":"70101490","B":"CARDIOLIPID IGG/IGM -D","C":"300","F":"0"},{"Policy Line":"70101491","B":"BETA 2 GLYCOPROTEIN AB -D","C":"300","F":"0"},{"Policy Line":"70101605","B":"CMV Culture-D Quest #2627","C":"300","F":"0"},{"Policy Line":"70101607","B":"Chrmosome Analysis: High Res-D","C":"300","F":"0"},{"Policy Line":"70101610","B":"ABO/Rh -D","C":"300","F":"0"},{"Policy Line":"70101640","B":"S.Pneumoniae Igg Ab Maid-Quest","C":"300","F":"0"},{"Policy Line":"70101656","B":"MOL Cyto Interphas In Sit Hy-","C":"300","F":"0"},{"Policy Line":"70101820","B":"CardioIQ-AdvLipid/InflamPQst-D","C":"300","F":"0"},{"Policy Line":"70101969","B":"Therapath Nerve Bx - D","C":"300","F":"0"},{"Policy Line":"70101977","B":"Therapath Ihc","C":"310","F":"271.8"},{"Policy Line":"70101980","B":"Therapath Muscle Bx -D","C":"300","F":"0"},{"Policy Line":"70102011","B":"Ehrlichia Chaffeensis Abs-D","C":"300","F":"0"},{"Policy Line":"70102014","B":"Parvoantibodies-D","C":"300","F":"0"},{"Policy Line":"70102017","B":"Cd4:Cd8 Count-D","C":"300","F":"0"},{"Policy Line":"70102023","B":"Typhus Fever Abs:Igg/Igm-D","C":"300","F":"0"},{"Policy Line":"70102026","B":"Q Fever Antibodies-D","C":"300","F":"0"},{"Policy Line":"70102044","B":"MIC/Oid-D","C":"300","F":"0"},{"Policy Line":"70102504","B":"Meningoenceph Serum Pnl A-QS-D","C":"300","F":"0"},{"Policy Line":"70102505","B":"Southeast RAST Profile 23 - D","C":"300","F":"0"},{"Policy Line":"70102551","B":"CSF Electrophoresis - D","C":"300","F":"0"},{"Policy Line":"70103815","B":"Boretella Pertussis Antibds-D","C":"300","F":"0"},{"Policy Line":"70103820","B":"Concentrated Afb Smear-D","C":"300","F":"0"},{"Policy Line":"70103822","B":"Bordetella MAID (IGG,IGA) - D","C":"300","F":"0"},{"Policy Line":"70103900","B":"RAST Food Allergen x12 - D","C":"300","F":"0"},{"Policy Line":"70104040","B":"Premarital Female-D","C":"300","F":"0"},{"Policy Line":"70104055","B":"Childhood Alergy-Food/Env-D","C":"300","F":"0"},{"Policy Line":"70104083","B":"CDIFF Toxn/GDH Ag - D","C":"300","F":"0"},{"Policy Line":"70104094","B":"Southeast RAST Profile 10 - D","C":"300","F":"0"},{"Policy Line":"70104121","B":"Total & Free Psa-D Quest","C":"300","F":"0"},{"Policy Line":"70104125","B":"Anti Gliadin Antibodies-D","C":"300","F":"0"},{"Policy Line":"70104159","B":"Hepatitis B Immun Pr-D","C":"300","F":"0"},{"Policy Line":"70104160","B":"Anti Cardiolipin Ab-D","C":"300","F":"0"},{"Policy Line":"70104162","B":"Hepatitis B Monit Pr-D","C":"300","F":"0"},{"Policy Line":"70104198","B":"Herpes I & Ii Serolo-D","C":"300","F":"0"},{"Policy Line":"70104216","B":"Rickettsial Antibodies-D","C":"300","F":"0"},{"Policy Line":"70104282","B":"RMSF Serology-D","C":"300","F":"0"},{"Policy Line":"70104293","B":"Sjogren's Antibody-D","C":"300","F":"0"},{"Policy Line":"70104467","B":"Chlamydia Serology-D","C":"300","F":"0"},{"Policy Line":"70104666","B":"Triple Test-D","C":"300","F":"0"},{"Policy Line":"70104802","B":"Cholinesterase W/Dibucn Qst-D","C":"300","F":"0"},{"Policy Line":"70105017","B":"Cd 15 R-S Cell","C":"310","F":"85.2"},{"Policy Line":"70105356","B":"Meningoenceph Serum Pnl B-QS-D","C":"300","F":"0"},{"Policy Line":"70105357","B":"Meningoenceph COMP Pnl CSF B-D","C":"300","F":"0"},{"Policy Line":"70106009","B":"Extended Phenotype -D","C":"300","F":"0"},{"Policy Line":"70106333","B":"Coxsackie A Ab Panel -D","C":"300","F":"0"},{"Policy Line":"70106341","B":"Supplemental Newborn Screen-D","C":"300","F":"0"},{"Policy Line":"70107600","B":"GC/CH Lam Probe - Candler-D","C":"300","F":"0"},{"Policy Line":"70107777","B":"Lab Procedure Chg Edit","C":"300","F":"0"},{"Policy Line":"70107779","B":"Thyroglobulin Panel-D","C":"300","F":"0"},{"Policy Line":"70108301","B":"Drug Screens-Hair (Forensic)-D","C":"300","F":"0"},{"Policy Line":"70108504","B":"Meningoenceph Comp Pnl CSF A-D","C":"300","F":"0"},{"Policy Line":"70108999","B":"O/P Visit Count","C":"990","F":"0"},{"Policy Line":"70109000","B":"O/P Visit Count Lab","C":"990","F":"0"},{"Policy Line":"70109002","B":"O/P Visit Count Optifast","C":"990","F":"0"},{"Policy Line":"70109034","B":"5HIAA Rand Ur Quest -D","C":"300","F":"0"},{"Policy Line":"70109214","B":"Fibrospect Liver Fib Panel-D","C":"300","F":"0"},{"Policy Line":"70109215","B":"IBD SGI Dx Prometheus -D","C":"300","F":"0"},{"Policy Line":"70109217","B":"Thiopurine Metabolite-D","C":"300","F":"0"},{"Policy Line":"70109218","B":"TPMT Enzyme Activity Phenoty-","C":"300","F":"0"},{"Policy Line":"70109245","B":"Celiac Serology Prometheus-D","C":"300","F":"0"},{"Policy Line":"70109290","B":"Alergy Panel16, Vegetable Grp","C":"300","F":"0"},{"Policy Line":"70109500","B":"Lab Test Send Out","C":"300","F":"0"},{"Policy Line":"70109501","B":"Lab Test","C":"300","F":"0"},{"Policy Line":"70109617","B":"Drug Screen: Collection","C":"300","F":"31.8"},{"Policy Line":"70109654","B":"O & P Screen-D","C":"300","F":"0"},{"Policy Line":"70109702","B":"Immuno Histo Chemical Stain","C":"310","F":"81.6"},{"Policy Line":"70109918","B":"Serum/Plasma Drg Scrn&Alcohol","C":"300","F":"0"},{"Policy Line":"70109921","B":"Cat Scratch Fever Antibodies-D","C":"300","F":"0"},{"Policy Line":"70109928","B":"Chromosone Analysis: Blood-D","C":"300","F":"0"},{"Policy Line":"70109930","B":"Chromosome Analysis: Tissue-D","C":"300","F":"0"},{"Policy Line":"70109933","B":"EVEROLIMUS BLOOD 18883 QST","C":"300","F":"140.4"},{"Policy Line":"70109935","B":"Second Screen-D","C":"300","F":"0"},{"Policy Line":"70109944","B":"Estrogen: Fractionated-D","C":"300","F":"0"},{"Policy Line":"70109948","B":"Meningoencephalitis Panel-D","C":"300","F":"0"},{"Policy Line":"70109954","B":"Testosterone: Total & Free-D","C":"300","F":"0"},{"Policy Line":"70109957","B":"Glucose Insulin Tolerance-D","C":"300","F":"0"},{"Policy Line":"70109978","B":"Coxsackie B1-6 Serol-D","C":"300","F":"0"},{"Policy Line":"70109989","B":"Lymphocte Enumeration Panel-D","C":"300","F":"0"},{"Policy Line":"70109990","B":"Aspergillus Serology-D","C":"300","F":"0"},{"Policy Line":"70109993","B":"Hypersen Pneumonitis Scr-D","C":"300","F":"0"},{"Policy Line":"70110002","B":"ARC Service Call","C":"390","F":"6"},{"Policy Line":"70110158","B":"Open Number","C":"300","F":"0"},{"Policy Line":"70110237","B":"HIV 1-2 Ab Differentiation (Q)","C":"300","F":"0"},{"Policy Line":"70110294","B":"Flow Cytometry Mrkrs 1&2 - D","C":"300","F":"0"},{"Policy Line":"70111010","B":"Lyme Disease: Western Blot-D","C":"300","F":"0"},{"Policy Line":"70111015","B":"Maternal Serum Screen 4-D","C":"300","F":"0"},{"Policy Line":"70111019","B":"Leuk/Lymph Phenotyping-D","C":"300","F":"0"},{"Policy Line":"70111020","B":"West Nile Virus: Ab Panel-D","C":"300","F":"0"},{"Policy Line":"70111040","B":"Chromosome Analysis:Bone Mar-D","C":"300","F":"0"},{"Policy Line":"70111192","B":"Platelet Function-D","C":"300","F":"0"},{"Policy Line":"70111713","B":"HGB/HCT-D","C":"300","F":"0"},{"Policy Line":"70111980","B":"ACIS - KI67 -D","C":"300","F":"0"},{"Policy Line":"70111985","B":"ACIS - PR - D","C":"300","F":"0"},{"Policy Line":"70111990","B":"ACIS - HER 2 -D","C":"300","F":"0"},{"Policy Line":"70111995","B":"ACIS - ER -D","C":"300","F":"0"},{"Policy Line":"70112005","B":"Molecular Cytogenetics/Fish-D","C":"300","F":"0"},{"Policy Line":"70112015","B":"HPV Typing: Thin Prep-D","C":"300","F":"0"},{"Policy Line":"70112020","B":"Alpha 1Antitrypsin Quant/Phn-D","C":"300","F":"0"},{"Policy Line":"70112025","B":"Myositis Assessr Plus-D","C":"300","F":"0"},{"Policy Line":"70112030","B":"Kidney Stone Formation Panel-D","C":"300","F":"0"},{"Policy Line":"70112040","B":"Phenosense Hiv Comp Panel-D","C":"300","F":"0"},{"Policy Line":"70112045","B":"Anti Ena-D","C":"300","F":"0"},{"Policy Line":"70112050","B":"Neutrophilic Cytoplasmic Ab-D","C":"300","F":"0"},{"Policy Line":"70112055","B":"Anti Phospholipid Antibodies-D","C":"300","F":"0"},{"Policy Line":"70112060","B":"Bilirubin: Total & Fractiona-D","C":"300","F":"0"},{"Policy Line":"70112065","B":"Celiac Disease Ab Panel-D","C":"300","F":"0"},{"Policy Line":"70112070","B":"Cholesterol/HDL-D","C":"300","F":"0"},{"Policy Line":"70112075","B":"Circulating Immune Complex-D","C":"300","F":"0"},{"Policy Line":"70112080","B":"Coagulation Profile-D","C":"300","F":"0"},{"Policy Line":"70112090","B":"CKMB-D","C":"300","F":"0"},{"Policy Line":"70112095","B":"IGG Subclasses-D","C":"300","F":"0"},{"Policy Line":"70112105","B":"Lupus Anticoagulant Panel-D","C":"300","F":"0"},{"Policy Line":"70112110","B":"Methylmalonic/Homocysteine-D","C":"300","F":"0"},{"Policy Line":"70112115","B":"MI Profile-D","C":"300","F":"0"},{"Policy Line":"70112120","B":"Renin/Aldosterone Profile-D","C":"300","F":"0"},{"Policy Line":"70112125","B":"Respiratory Virus Evaluation-D","C":"300","F":"0"},{"Policy Line":"70112130","B":"Serum Drug Screen-D","C":"300","F":"0"},{"Policy Line":"70112135","B":"Thyroid Autoantibodies-D","C":"300","F":"0"},{"Policy Line":"70112140","B":"Herpes Type II - D","C":"300","F":"0"},{"Policy Line":"70112145","B":"Toxoplasma Antibodies-D","C":"300","F":"0"},{"Policy Line":"70112150","B":"Dizzy Profile-D","C":"300","F":"0"},{"Policy Line":"70112155","B":"Plastic Profile-D","C":"300","F":"0"},{"Policy Line":"70112400","B":"Hepatic Functn Panel-Kuttner-D","C":"300","F":"0"},{"Policy Line":"70112517","B":"Alk By Fish-D Clarient","C":"310","F":"0"},{"Policy Line":"70115017","B":"Bortetella (Dfa)-D","C":"300","F":"0"},{"Policy Line":"70115018","B":"Vap Cholesterol-D","C":"300","F":"0"},{"Policy Line":"70115480","B":"Plt Mapping TEG - D","C":"300","F":"0"},{"Policy Line":"70115600","B":"Meconium Drug Screen-D","C":"300","F":"0"},{"Policy Line":"70115625","B":"Mening/Enceph Panel-Biofire -D","C":"300","F":"0"},{"Policy Line":"70115630","B":"ToxAssure CompProf Ur-LabCorpD","C":"300","F":"0"},{"Policy Line":"70115633","B":"Pain Mgmt Prof1 w/ conf-QST-D","C":"300","F":"0"},{"Policy Line":"70115634","B":"Bact Cult ID(BCID)DNAx12-BF-D","C":"306","F":"0"},{"Policy Line":"70115651","B":"NuSwab Vaginitis Plus-Quest-D","C":"300","F":"0"},{"Policy Line":"70115652","B":"NuSwab Vaginitis - Quest - D","C":"300","F":"0"},{"Policy Line":"70115653","B":"Therapath Muscle Bx -D","C":"300","F":"0"},{"Policy Line":"70115659","B":"Arkana Labs Renal Bx -D","C":"300","F":"0"},{"Policy Line":"70115707","B":"Breast Panel (4 Stain) - D","C":"300","F":"0"},{"Policy Line":"70115708","B":"Mismatch Repair(MMR) IHC Pnl-D","C":"300","F":"0"},{"Policy Line":"70115709","B":"ER PgR - D","C":"300","F":"0"},{"Policy Line":"70115710","B":"Breast Panel (3 Stain) - D","C":"300","F":"0"},{"Policy Line":"70115711","B":"NKX3.1 PSA PSAP/HPAP PSMA - D","C":"300","F":"0"},{"Policy Line":"70115712","B":"CD99 MyoD1 S100 - D","C":"300","F":"0"},{"Policy Line":"70115713","B":"CD117 cKIT PDGFR Alpha/Beta-D","C":"300","F":"0"},{"Policy Line":"70115719","B":"SE Reg Mixed Panel III - D","C":"300","F":"0"},{"Policy Line":"70115724","B":"M AML","C":"300","F":"0"},{"Policy Line":"70115725","B":"FLT3 ITD and TKD Mutation","C":"300","F":"0"},{"Policy Line":"70115729","B":"Peanut Component Panel - Quest","C":"300","F":"0"},{"Policy Line":"70115735","B":"Western Equine Encephalitis-D","C":"300","F":"0"},{"Policy Line":"70115739","B":"Myasthenia Gravis Pnl 3 -D Qst","C":"300","F":"0"},{"Policy Line":"70115753","B":"Global Hemostasis TEG - D","C":"300","F":"0"},{"Policy Line":"70115763","B":"Myasthenia Gravis Pnl 3 Qst-D","C":"300","F":"0"},{"Policy Line":"70115800","B":"AFB Sensitivity Xtb-D","C":"300","F":"0"},{"Policy Line":"70115821","B":"Echovirus Antibody Panel - D","C":"300","F":"0"},{"Policy Line":"70115829","B":"Arbovirus Panel - Quest","C":"300","F":"0"},{"Policy Line":"70115837","B":"Arbovirus CSF Panel - ARUP - D","C":"300","F":"0"},{"Policy Line":"70115857","B":"Pneumococcal Abs, IgG ARUP - D","C":"300","F":"0"},{"Policy Line":"70115870","B":"Supersaturation Profile, Urine","C":"300","F":"0"},{"Policy Line":"70115876","B":"Parvovirus Abs, IgG/IgM - D","C":"300","F":"0"},{"Policy Line":"70115891","B":"Chrom FISH, Interphase - D","C":"300","F":"0"},{"Policy Line":"70115926","B":"Chrmosome Analysis:Per Bld-D","C":"300","F":"0"},{"Policy Line":"70115958","B":"HIV-2 Antibody","C":"300","F":"60"},{"Policy Line":"70115983","B":"PJI Detection (Synovasure) - D","C":"300","F":"0"},{"Policy Line":"70116052","B":"Leuk/Lymph Pheno, 5 markers-D","C":"300","F":"0"},{"Policy Line":"70116053","B":"Leuk/Lymph Pheno, 6 markers-D","C":"300","F":"0"},{"Policy Line":"70116054","B":"Leuk/Lymph Pheno, 7 markers-D","C":"300","F":"0"},{"Policy Line":"70116055","B":"Leuk/Lymph Pheno, 8 markers-D","C":"300","F":"0"},{"Policy Line":"70116056","B":"Leuk/Lymph Pheno, 9 markers-D","C":"300","F":"0"},{"Policy Line":"70116057","B":"Leuk/Lymph Pheno, 10 markers-D","C":"300","F":"0"},{"Policy Line":"70116058","B":"Leuk/Lymph Pheno, 11 markers-D","C":"300","F":"0"},{"Policy Line":"70116059","B":"Leuk/Lymph Pheno, 12 markers-D","C":"300","F":"0"},{"Policy Line":"70116060","B":"Leuk/Lymph Pheno, 13 markers-D","C":"300","F":"0"},{"Policy Line":"70116061","B":"Leuk/Lymph Pheno, 14 markers-D","C":"300","F":"0"},{"Policy Line":"70116062","B":"Leuk/Lymph Pheno, 15 markers-D","C":"300","F":"0"},{"Policy Line":"70116063","B":"Leuk/Lymph Pheno, 16 markers-D","C":"300","F":"0"},{"Policy Line":"70116064","B":"Leuk/Lymph Pheno, 17 markers-D","C":"300","F":"0"},{"Policy Line":"70116065","B":"Leuk/Lymph Pheno, 18 markers-D","C":"300","F":"0"},{"Policy Line":"70116066","B":"Leuk/Lymph Pheno, 19 markers-D","C":"300","F":"0"},{"Policy Line":"70116067","B":"Leuk/Lymph Pheno, 20 markers-D","C":"300","F":"0"},{"Policy Line":"70116068","B":"Leuk/Lymph Pheno, 21 markers-D","C":"300","F":"0"},{"Policy Line":"70116069","B":"Leuk/Lymph Pheno, 22 markers-D","C":"300","F":"0"},{"Policy Line":"70116070","B":"Leuk/Lymph Pheno, 23 markers-D","C":"300","F":"0"},{"Policy Line":"70116071","B":"Leuk/Lymph Pheno, 24 markers-D","C":"300","F":"0"},{"Policy Line":"70116072","B":"Leuk/Lymph Pheno, 25 markers-D","C":"300","F":"0"},{"Policy Line":"70116073","B":"Leuk/Lymph Pheno, 26 markers-D","C":"300","F":"0"},{"Policy Line":"70116074","B":"Leuk/Lymph Pheno, 27 markers-D","C":"300","F":"0"},{"Policy Line":"70116075","B":"Leuk/Lymph Pheno, 28 markers-D","C":"300","F":"0"},{"Policy Line":"70116076","B":"Leuk/Lymph Pheno, 29 markers-D","C":"300","F":"0"},{"Policy Line":"70116077","B":"Leuk/Lymph Pheno, 30 markers-D","C":"300","F":"0"},{"Policy Line":"70116092","B":"Antiphospholipid Ab Panel - D","C":"300","F":"0"},{"Policy Line":"70116104","B":"Arbovirus Serum Panel-ARUP-D","C":"300","F":"0"},{"Policy Line":"70116266","B":"Lymph Subset 7 Panel - D","C":"300","F":"0"},{"Policy Line":"70116306","B":"Lymph Ag and Mitogen Panel - D","C":"300","F":"0"},{"Policy Line":"70116307","B":"Chlamydia Ab Differentiation-D","C":"300","F":"0"},{"Policy Line":"70116355","B":"Pneumococcal Abs, IgG 23 - D","C":"300","F":"0"},{"Policy Line":"70116371","B":"Fibrosure CVH - D","C":"300","F":"0"},{"Policy Line":"70116372","B":"Fibrosure NAFLD - D","C":"300","F":"0"},{"Policy Line":"70116396","B":"HIV-1 Qt w/Rfx to Phenosense-D","C":"300","F":"0"},{"Policy Line":"70116402","B":"Reg 3 Respiratory Panel IgE-D","C":"300","F":"0"},{"Policy Line":"70116420","B":"Bone Specific ALKP","C":"300","F":"96.3"},{"Policy Line":"70116465","B":"Forensic Block (to incl 1 H&E)","C":"300","F":"3.6"},{"Policy Line":"70116466","B":"Forensic Additional slides(ea)","C":"300","F":"0.6"},{"Policy Line":"70116467","B":"Forensic Recut","C":"300","F":"1.5"},{"Policy Line":"70116533","B":"Allergen,Inhalant/Food,Pro 2-D","C":"300","F":"0"},{"Policy Line":"70116534","B":"Chromosome FISH CLL Panel-D","C":"300","F":"0"},{"Policy Line":"70116573","B":"PNH Panel High Sensitivity -D","C":"300","F":"0"},{"Policy Line":"70116584","B":"HIV Phenotype Comprehensive-D","C":"300","F":"0"},{"Policy Line":"70116602","B":"Chromosome FISH Metaphase - D","C":"300","F":"0"},{"Policy Line":"70116603","B":"Extended Myositis Panel EMP-D","C":"300","F":"0"},{"Policy Line":"70116649","B":"Lymphoma Panel by FISH - D","C":"300","F":"0"},{"Policy Line":"70116659","B":"Epitherlial B96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","De-Identified Minimum Negotiated Charge":105759.0},{"MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","De-Identified Minimum Negotiated Charge":69812.0},{"MS-DRG":"020","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","De-Identified Minimum Negotiated Charge":65095.0},{"MS-DRG":"021","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","De-Identified Minimum Negotiated Charge":77350.0},{"MS-DRG":"023","Description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera","De-Identified Minimum Negotiated Charge":80667.0},{"MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","De-Identified Minimum Negotiated Charge":17688.0},{"MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","De-Identified Minimum Negotiated Charge":16127.0},{"MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":12830.0},{"MS-DRG":"028","Description":"Spinal Procedures With Mcc","De-Identified Minimum Negotiated Charge":28831.0},{"MS-DRG":"029","Description":"Spinal Procedures With Cc Or Spinal Neurostimulators","De-Identified Minimum Negotiated Charge":37012.0},{"MS-DRG":"030","Description":"Spinal Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":11969.0},{"MS-DRG":"031","Description":"Ventricular Shunt Procedures With Mcc","De-Identified Minimum Negotiated Charge":22330.0},{"MS-DRG":"033","Description":"Ventricular Shunt Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8919.0},{"MS-DRG":"036","Description":"Carotid Artery Stent Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7913.0},{"MS-DRG":"038","Description":"Extracranial Procedures With Cc","De-Identified Minimum Negotiated Charge":9067.0},{"MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6092.0},{"MS-DRG":"040","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","De-Identified Minimum Negotiated Charge":17818.0},{"MS-DRG":"041","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","De-Identified Minimum Negotiated Charge":12650.0},{"MS-DRG":"042","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":9969.0},{"MS-DRG":"053","Description":"Spinal Disorders And Injuries Without Cc/Mcc","De-Identified Minimum Negotiated Charge":11150.0},{"MS-DRG":"054","Description":"Nervous System Neoplasms With Mcc","De-Identified Minimum Negotiated Charge":7296.0},{"MS-DRG":"055","Description":"Nervous System Neoplasms Without Mcc","De-Identified Minimum Negotiated Charge":5518.0},{"MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","De-Identified Minimum Negotiated Charge":11616.0},{"MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","De-Identified Minimum Negotiated Charge":6635.0},{"MS-DRG":"060","Description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","De-Identified Minimum Negotiated Charge":13017.0},{"MS-DRG":"061","Description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","De-Identified Minimum Negotiated Charge":15474.0},{"MS-DRG":"063","Description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8929.0},{"MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","De-Identified Minimum Negotiated Charge":10200.0},{"MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","De-Identified Minimum Negotiated Charge":5559.0},{"MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3935.0},{"MS-DRG":"068","Description":"Nonspecific Cva And Precerebral Occlusion Without Infarction Without Mcc","De-Identified Minimum Negotiated Charge":4791.0},{"MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","De-Identified Minimum Negotiated Charge":4050.0},{"MS-DRG":"070","Description":"Nonspecific Cerebrovascular Disorders With Mcc","De-Identified Minimum Negotiated Charge":3561.0},{"MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","De-Identified Minimum Negotiated Charge":5493.0},{"MS-DRG":"072","Description":"Nonspecific Cerebrovascular Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4211.0},{"MS-DRG":"073","Description":"Cranial And Peripheral Nerve Disorders With Mcc","De-Identified Minimum Negotiated Charge":405183.0},{"MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","De-Identified Minimum Negotiated Charge":5795.0},{"MS-DRG":"076","Description":"Viral Meningitis Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8911.0},{"MS-DRG":"077","Description":"Hypertensive Encephalopathy With Mcc","De-Identified Minimum Negotiated Charge":8378.0},{"MS-DRG":"078","Description":"Hypertensive Encephalopathy With Cc","De-Identified Minimum Negotiated Charge":5428.0},{"MS-DRG":"079","Description":"Hypertensive Encephalopathy Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3950.0},{"MS-DRG":"082","Description":"Traumatic Stupor And Coma >1 Hour With Mcc","De-Identified Minimum Negotiated Charge":12275.0},{"MS-DRG":"083","Description":"Traumatic Stupor And Coma >1 Hour With Cc","De-Identified Minimum Negotiated Charge":4449.0},{"MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","De-Identified Minimum Negotiated Charge":1543.0},{"MS-DRG":"086","Description":"Traumatic Stupor And Coma <1 Hour With Cc","De-Identified Minimum Negotiated Charge":6739.0},{"MS-DRG":"087","Description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4279.0},{"MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","De-Identified Minimum Negotiated Charge":8567.0},{"MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","De-Identified Minimum Negotiated Charge":5270.0},{"MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4118.0},{"MS-DRG":"094","Description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","De-Identified Minimum Negotiated Charge":41372.0},{"MS-DRG":"096","Description":"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","De-Identified Minimum Negotiated Charge":10128.0},{"MS-DRG":"097","Description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","De-Identified Minimum Negotiated Charge":19487.0},{"MS-DRG":"100","Description":"Seizures With Mcc","De-Identified Minimum Negotiated Charge":9994.0},{"MS-DRG":"101","Description":"Seizures Without Mcc","De-Identified Minimum Negotiated Charge":1543.0},{"MS-DRG":"102","Description":"Headaches With Mcc","De-Identified Minimum Negotiated Charge":6540.0},{"MS-DRG":"103","Description":"Headaches Without Mcc","De-Identified Minimum Negotiated Charge":4221.0},{"MS-DRG":"125","Description":"Other Disorders Of The Eye Without Mcc","De-Identified Minimum Negotiated Charge":11655.0},{"MS-DRG":"133","Description":"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","De-Identified Minimum Negotiated Charge":13056.0},{"MS-DRG":"149","Description":"Dysequilibrium","De-Identified Minimum Negotiated Charge":3916.0},{"MS-DRG":"151","Description":"Epistaxis Without Mcc","De-Identified Minimum Negotiated Charge":4920.0},{"MS-DRG":"153","Description":"Otitis Media And Uri Without Mcc","De-Identified Minimum Negotiated Charge":3968.0},{"MS-DRG":"154","Description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","De-Identified Minimum Negotiated Charge":8008.0},{"MS-DRG":"155","Description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","De-Identified Minimum Negotiated Charge":4778.0},{"MS-DRG":"156","Description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3086.0},{"MS-DRG":"157","Description":"Dental And Oral Diseases With Mcc","De-Identified Minimum Negotiated Charge":14512.0},{"MS-DRG":"158","Description":"Dental And Oral Diseases With Cc","De-Identified Minimum Negotiated Charge":5083.0},{"MS-DRG":"163","Description":"Major Chest Procedures With Mcc","De-Identified Minimum Negotiated Charge":25090.0},{"MS-DRG":"164","Description":"Major Chest Procedures With Cc","De-Identified Minimum Negotiated Charge":13416.0},{"MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7092.0},{"MS-DRG":"166","Description":"Other Respiratory System O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":20844.0},{"MS-DRG":"167","Description":"Other Respiratory System O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":10410.0},{"MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7260.0},{"MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","De-Identified Minimum Negotiated Charge":7842.0},{"MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","De-Identified Minimum Negotiated Charge":4540.0},{"MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","De-Identified Minimum Negotiated Charge":3690.0},{"MS-DRG":"178","Description":"Respiratory Infections And Inflammations With Cc","De-Identified Minimum Negotiated Charge":6933.0},{"MS-DRG":"179","Description":"Respiratory Infections And Inflammations Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6095.0},{"MS-DRG":"180","Description":"Respiratory Neoplasms With Mcc","De-Identified Minimum Negotiated Charge":9356.0},{"MS-DRG":"181","Description":"Respiratory Neoplasms With Cc","De-Identified Minimum Negotiated Charge":6177.0},{"MS-DRG":"184","Description":"Major Chest Trauma With Cc","De-Identified Minimum Negotiated Charge":5959.0},{"MS-DRG":"185","Description":"Major Chest Trauma Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4305.0},{"MS-DRG":"186","Description":"Pleural Effusion With Mcc","De-Identified Minimum Negotiated Charge":8630.0},{"MS-DRG":"187","Description":"Pleural Effusion With Cc","De-Identified Minimum Negotiated Charge":10149.0},{"MS-DRG":"188","Description":"Pleural Effusion Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4191.0},{"MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","De-Identified Minimum Negotiated Charge":6644.0},{"MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","De-Identified Minimum Negotiated Charge":6407.0},{"MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","De-Identified Minimum Negotiated Charge":4910.0},{"MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3989.0},{"MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","De-Identified Minimum Negotiated Charge":7117.0},{"MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","De-Identified Minimum Negotiated Charge":1543.0},{"MS-DRG":"195","Description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3086.0},{"MS-DRG":"196","Description":"Interstitial Lung Disease With Mcc","De-Identified Minimum Negotiated Charge":8748.0},{"MS-DRG":"197","Description":"Interstitial Lung Disease With Cc","De-Identified Minimum Negotiated Charge":5615.0},{"MS-DRG":"198","Description":"Interstitial Lung Disease Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7455.0},{"MS-DRG":"200","Description":"Pneumothorax With Cc","De-Identified Minimum Negotiated Charge":6004.0},{"MS-DRG":"201","Description":"Pneumothorax Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7090.0},{"MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","De-Identified Minimum Negotiated Charge":5121.0},{"MS-DRG":"203","Description":"Bronchitis And Asthma Without Cc/Mcc","De-Identified Minimum Negotiated Charge":5609.0},{"MS-DRG":"204","Description":"Respiratory Signs And Symptoms","De-Identified Minimum Negotiated Charge":4586.0},{"MS-DRG":"205","Description":"Other Respiratory System Diagnoses With Mcc","De-Identified Minimum Negotiated Charge":16136.0},{"MS-DRG":"206","Description":"Other Respiratory System Diagnoses Without Mcc","De-Identified Minimum Negotiated Charge":4651.0},{"MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","De-Identified Minimum Negotiated Charge":29877.0},{"MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","De-Identified Minimum Negotiated Charge":13368.0},{"MS-DRG":"215","Description":"Other Heart Assist System Implant","De-Identified Minimum Negotiated Charge":67915.0},{"MS-DRG":"216","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","De-Identified Minimum Negotiated Charge":54169.0},{"MS-DRG":"217","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","De-Identified Minimum Negotiated Charge":114647.0},{"MS-DRG":"219","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","De-Identified Minimum Negotiated Charge":82530.0},{"MS-DRG":"220","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","De-Identified Minimum Negotiated Charge":27085.0},{"MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","De-Identified Minimum Negotiated Charge":24410.0},{"MS-DRG":"222","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","De-Identified Minimum Negotiated Charge":43285.0},{"MS-DRG":"223","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","De-Identified Minimum Negotiated Charge":32267.0},{"MS-DRG":"224","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","De-Identified Minimum Negotiated Charge":39959.0},{"MS-DRG":"225","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","De-Identified Minimum Negotiated Charge":31258.0},{"MS-DRG":"226","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","De-Identified Minimum Negotiated Charge":36389.0},{"MS-DRG":"227","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","De-Identified Minimum Negotiated Charge":28083.0},{"MS-DRG":"228","Description":"Other Cardiothoracic Procedures With Mcc","De-Identified Minimum Negotiated Charge":40667.0},{"MS-DRG":"229","Description":"Other Cardiothoracic Procedures Without Mcc","De-Identified Minimum Negotiated Charge":28116.0},{"MS-DRG":"231","Description":"Coronary Bypass With Ptca With Mcc","De-Identified Minimum Negotiated Charge":408763.0},{"MS-DRG":"233","Description":"Coronary Bypass With Cardiac Catheterization With Mcc","De-Identified Minimum Negotiated Charge":41708.0},{"MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","De-Identified Minimum Negotiated Charge":27377.0},{"MS-DRG":"235","Description":"Coronary Bypass Without Cardiac Catheterization With Mcc","De-Identified Minimum Negotiated Charge":31970.0},{"MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","De-Identified Minimum Negotiated Charge":20852.0},{"MS-DRG":"239","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","De-Identified Minimum Negotiated Charge":25612.0},{"MS-DRG":"240","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","De-Identified Minimum Negotiated Charge":11397.0},{"MS-DRG":"242","Description":"Permanent Cardiac Pacemaker Implant With Mcc","De-Identified Minimum Negotiated Charge":18375.0},{"MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","De-Identified Minimum Negotiated Charge":13523.0},{"MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","De-Identified Minimum Negotiated Charge":11135.0},{"MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","De-Identified Minimum Negotiated Charge":17095.0},{"MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","De-Identified Minimum Negotiated Charge":10836.0},{"MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","De-Identified Minimum Negotiated Charge":16688.0},{"MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","De-Identified Minimum Negotiated Charge":10345.0},{"MS-DRG":"250","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent With Mcc","De-Identified Minimum Negotiated Charge":13918.0},{"MS-DRG":"251","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without Mcc","De-Identified Minimum Negotiated Charge":8821.0},{"MS-DRG":"252","Description":"Other Vascular Procedures With Mcc","De-Identified Minimum Negotiated Charge":17672.0},{"MS-DRG":"253","Description":"Other Vascular Procedures With Cc","De-Identified Minimum Negotiated Charge":13797.0},{"MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":9564.0},{"MS-DRG":"256","Description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","De-Identified Minimum Negotiated Charge":9723.0},{"MS-DRG":"260","Description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","De-Identified Minimum Negotiated Charge":20010.0},{"MS-DRG":"261","Description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","De-Identified Minimum Negotiated Charge":10468.0},{"MS-DRG":"262","Description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","De-Identified Minimum Negotiated Charge":10012.0},{"MS-DRG":"264","Description":"Other Circulatory System O.R. Procedures","De-Identified Minimum Negotiated Charge":16303.0},{"MS-DRG":"266","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","De-Identified Minimum Negotiated Charge":37540.0},{"MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","De-Identified Minimum Negotiated Charge":30385.0},{"MS-DRG":"268","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","De-Identified Minimum Negotiated Charge":35303.0},{"MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","De-Identified Minimum Negotiated Charge":21919.0},{"MS-DRG":"270","Description":"Other Major Cardiovascular Procedures With Mcc","De-Identified Minimum Negotiated Charge":28825.0},{"MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","De-Identified Minimum Negotiated Charge":18355.0},{"MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":13859.0},{"MS-DRG":"273","Description":"Percutaneous And Other Intracardiac Procedures With Mcc","De-Identified Minimum Negotiated Charge":20155.0},{"MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","De-Identified Minimum Negotiated Charge":16349.0},{"MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","De-Identified Minimum Negotiated Charge":8760.0},{"MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","De-Identified Minimum Negotiated Charge":5284.0},{"MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4028.0},{"MS-DRG":"283","Description":"Acute Myocardial Infarction, Expired With Mcc","De-Identified Minimum Negotiated Charge":9823.0},{"MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","De-Identified Minimum Negotiated Charge":2268.0},{"MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","De-Identified Minimum Negotiated Charge":1543.0},{"MS-DRG":"289","Description":"Acute And Subacute Endocarditis With Cc","De-Identified Minimum Negotiated Charge":14399.0},{"MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","De-Identified Minimum Negotiated Charge":6895.0},{"MS-DRG":"292","Description":"Heart Failure And Shock With Cc","De-Identified Minimum Negotiated Charge":4970.0},{"MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","De-Identified Minimum Negotiated Charge":1546.0},{"MS-DRG":"296","Description":"Cardiac Arrest, Unexplained With Mcc","De-Identified Minimum Negotiated Charge":8209.0},{"MS-DRG":"297","Description":"Cardiac Arrest, Unexplained With Cc","De-Identified Minimum Negotiated Charge":4017.0},{"MS-DRG":"299","Description":"Peripheral Vascular Disorders With Mcc","De-Identified Minimum Negotiated Charge":8161.0},{"MS-DRG":"300","Description":"Peripheral Vascular Disorders With Cc","De-Identified Minimum Negotiated Charge":6268.0},{"MS-DRG":"301","Description":"Peripheral Vascular Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3767.0},{"MS-DRG":"302","Description":"Atherosclerosis With Mcc","De-Identified Minimum Negotiated Charge":8912.0},{"MS-DRG":"303","Description":"Atherosclerosis Without Mcc","De-Identified Minimum Negotiated Charge":3656.0},{"MS-DRG":"304","Description":"Hypertension With Mcc","De-Identified Minimum Negotiated Charge":5879.0},{"MS-DRG":"305","Description":"Hypertension Without Mcc","De-Identified Minimum Negotiated Charge":3855.0},{"MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","De-Identified Minimum Negotiated Charge":6437.0},{"MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","De-Identified Minimum Negotiated Charge":4131.0},{"MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":2988.0},{"MS-DRG":"311","Description":"Angina Pectoris","De-Identified Minimum Negotiated Charge":4018.0},{"MS-DRG":"312","Description":"Syncope And Collapse","De-Identified Minimum Negotiated Charge":4348.0},{"MS-DRG":"313","Description":"Chest Pain","De-Identified Minimum Negotiated Charge":3877.0},{"MS-DRG":"314","Description":"Other Circulatory System Diagnoses With Mcc","De-Identified Minimum Negotiated Charge":11125.0},{"MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","De-Identified Minimum Negotiated Charge":2806.0},{"MS-DRG":"316","Description":"Other Circulatory System Diagnoses Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4353.0},{"MS-DRG":"326","Description":"Stomach, Esophageal And Duodenal Procedures With Mcc","De-Identified Minimum Negotiated Charge":27948.0},{"MS-DRG":"327","Description":"Stomach, Esophageal And Duodenal Procedures With Cc","De-Identified Minimum Negotiated Charge":39614.0},{"MS-DRG":"328","Description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8683.0},{"MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","De-Identified Minimum Negotiated Charge":26525.0},{"MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","De-Identified Minimum Negotiated Charge":11467.0},{"MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":9162.0},{"MS-DRG":"335","Description":"Peritoneal Adhesiolysis With Mcc","De-Identified Minimum Negotiated Charge":22071.0},{"MS-DRG":"336","Description":"Peritoneal Adhesiolysis With Cc","De-Identified Minimum Negotiated Charge":12510.0},{"MS-DRG":"337","Description":"Peritoneal Adhesiolysis Without Cc/Mcc","De-Identified Minimum Negotiated Charge":9617.0},{"MS-DRG":"339","Description":"Appendectomy With Complicated Principal Diagnosis With Cc","De-Identified Minimum Negotiated Charge":19806.0},{"MS-DRG":"340","Description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3086.0},{"MS-DRG":"342","Description":"Appendectomy Without Complicated Principal Diagnosis With Cc","De-Identified Minimum Negotiated Charge":9444.0},{"MS-DRG":"343","Description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6754.0},{"MS-DRG":"348","Description":"Anal And Stomal Procedures With Cc","De-Identified Minimum Negotiated Charge":20807.0},{"MS-DRG":"351","Description":"Inguinal And Femoral Hernia Procedures With Cc","De-Identified Minimum Negotiated Charge":7928.0},{"MS-DRG":"352","Description":"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6315.0},{"MS-DRG":"353","Description":"Hernia Procedures Except Inguinal And Femoral With Mcc","De-Identified Minimum Negotiated Charge":16344.0},{"MS-DRG":"354","Description":"Hernia Procedures Except Inguinal And Femoral With Cc","De-Identified Minimum Negotiated Charge":9382.0},{"MS-DRG":"355","Description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8049.0},{"MS-DRG":"356","Description":"Other Digestive System O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":20442.0},{"MS-DRG":"357","Description":"Other Digestive System O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":11503.0},{"MS-DRG":"358","Description":"Other Digestive System O.R. Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7232.0},{"MS-DRG":"369","Description":"Major Esophageal Disorders With Cc","De-Identified Minimum Negotiated Charge":5888.0},{"MS-DRG":"370","Description":"Major Esophageal Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7379.0},{"MS-DRG":"371","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","De-Identified Minimum Negotiated Charge":10056.0},{"MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","De-Identified Minimum Negotiated Charge":5594.0},{"MS-DRG":"373","Description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6795.0},{"MS-DRG":"374","Description":"Digestive Malignancy With Mcc","De-Identified Minimum Negotiated Charge":11422.0},{"MS-DRG":"375","Description":"Digestive Malignancy With Cc","De-Identified Minimum Negotiated Charge":6530.0},{"MS-DRG":"377","Description":"Gastrointestinal Hemorrhage With Mcc","De-Identified Minimum Negotiated Charge":9673.0},{"MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","De-Identified Minimum Negotiated Charge":5190.0},{"MS-DRG":"379","Description":"Gastrointestinal Hemorrhage Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3584.0},{"MS-DRG":"381","Description":"Complicated Peptic Ulcer With Cc","De-Identified Minimum Negotiated Charge":7577.0},{"MS-DRG":"382","Description":"Complicated Peptic Ulcer Without Cc/Mcc","De-Identified Minimum Negotiated Charge":9026.0},{"MS-DRG":"384","Description":"Uncomplicated Peptic Ulcer Without Mcc","De-Identified Minimum Negotiated Charge":5095.0},{"MS-DRG":"385","Description":"Inflammatory Bowel Disease With Mcc","De-Identified Minimum Negotiated Charge":18585.0},{"MS-DRG":"386","Description":"Inflammatory Bowel Disease With Cc","De-Identified Minimum Negotiated Charge":9082.0},{"MS-DRG":"387","Description":"Inflammatory Bowel Disease Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3721.0},{"MS-DRG":"388","Description":"Gastrointestinal Obstruction With Mcc","De-Identified Minimum Negotiated Charge":8547.0},{"MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","De-Identified Minimum Negotiated Charge":4612.0},{"MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3138.0},{"MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","De-Identified Minimum Negotiated Charge":6795.0},{"MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","De-Identified Minimum Negotiated Charge":4203.0},{"MS-DRG":"393","Description":"Other Digestive System Diagnoses With Mcc","De-Identified Minimum Negotiated Charge":8816.0},{"MS-DRG":"394","Description":"Other Digestive System Diagnoses With Cc","De-Identified Minimum Negotiated Charge":5261.0},{"MS-DRG":"395","Description":"Other Digestive System Diagnoses Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3648.0},{"MS-DRG":"405","Description":"Pancreas, Liver And Shunt Procedures With Mcc","De-Identified Minimum Negotiated Charge":17811.0},{"MS-DRG":"406","Description":"Pancreas, Liver And Shunt Procedures With Cc","De-Identified Minimum Negotiated Charge":34183.0},{"MS-DRG":"410","Description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","De-Identified Minimum Negotiated Charge":16391.0},{"MS-DRG":"411","Description":"Cholecystectomy With C.D.E. With Mcc","De-Identified Minimum Negotiated Charge":21691.0},{"MS-DRG":"412","Description":"Cholecystectomy With C.D.E. With Cc","De-Identified Minimum Negotiated Charge":12641.0},{"MS-DRG":"414","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","De-Identified Minimum Negotiated Charge":19204.0},{"MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","De-Identified Minimum Negotiated Charge":10720.0},{"MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7240.0},{"MS-DRG":"417","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","De-Identified Minimum Negotiated Charge":6012.0},{"MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","De-Identified Minimum Negotiated Charge":8906.0},{"MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3690.0},{"MS-DRG":"423","Description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":83720.0},{"MS-DRG":"432","Description":"Cirrhosis And Alcoholic Hepatitis With Mcc","De-Identified Minimum Negotiated Charge":9600.0},{"MS-DRG":"433","Description":"Cirrhosis And Alcoholic Hepatitis With Cc","De-Identified Minimum Negotiated Charge":10190.0},{"MS-DRG":"435","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","De-Identified Minimum Negotiated Charge":7715.0},{"MS-DRG":"436","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","De-Identified Minimum Negotiated Charge":6151.0},{"MS-DRG":"437","Description":"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","De-Identified Minimum Negotiated Charge":5149.0},{"MS-DRG":"438","Description":"Disorders Of Pancreas Except Malignancy With Mcc","De-Identified Minimum Negotiated Charge":9066.0},{"MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","De-Identified Minimum Negotiated Charge":3690.0},{"MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3423.0},{"MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","De-Identified Minimum Negotiated Charge":10119.0},{"MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","De-Identified Minimum Negotiated Charge":5114.0},{"MS-DRG":"443","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4787.0},{"MS-DRG":"444","Description":"Disorders Of The Biliary Tract With Mcc","De-Identified Minimum Negotiated Charge":8649.0},{"MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","De-Identified Minimum Negotiated Charge":5832.0},{"MS-DRG":"446","Description":"Disorders Of The Biliary Tract Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4446.0},{"MS-DRG":"453","Description":"Combined Anterior And Posterior Spinal Fusion With Mcc","De-Identified Minimum Negotiated Charge":52819.0},{"MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","De-Identified Minimum Negotiated Charge":33041.0},{"MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","De-Identified Minimum Negotiated Charge":25859.0},{"MS-DRG":"457","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","De-Identified Minimum Negotiated Charge":35230.0},{"MS-DRG":"458","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","De-Identified Minimum Negotiated Charge":82919.0},{"MS-DRG":"459","Description":"Spinal Fusion Except Cervical With Mcc","De-Identified Minimum Negotiated Charge":53042.0},{"MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","De-Identified Minimum Negotiated Charge":20897.0},{"MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","De-Identified Minimum Negotiated Charge":17072.0},{"MS-DRG":"463","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","De-Identified Minimum Negotiated Charge":36608.0},{"MS-DRG":"464","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","De-Identified Minimum Negotiated Charge":15846.0},{"MS-DRG":"465","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","De-Identified Minimum Negotiated Charge":10378.0},{"MS-DRG":"466","Description":"Revision Of Hip Or Knee Replacement With Mcc","De-Identified Minimum Negotiated Charge":12932.0},{"MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","De-Identified Minimum Negotiated Charge":18606.0},{"MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","De-Identified Minimum Negotiated Charge":14931.0},{"MS-DRG":"469","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","De-Identified Minimum Negotiated Charge":17045.0},{"MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","De-Identified Minimum Negotiated Charge":10300.0},{"MS-DRG":"471","Description":"Cervical Spinal Fusion With Mcc","De-Identified Minimum Negotiated Charge":26487.0},{"MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","De-Identified Minimum Negotiated Charge":15564.0},{"MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","De-Identified Minimum Negotiated Charge":12506.0},{"MS-DRG":"474","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","De-Identified Minimum Negotiated Charge":20564.0},{"MS-DRG":"475","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","De-Identified Minimum Negotiated Charge":11232.0},{"MS-DRG":"476","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6710.0},{"MS-DRG":"477","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","De-Identified Minimum Negotiated Charge":16860.0},{"MS-DRG":"478","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","De-Identified Minimum Negotiated Charge":11764.0},{"MS-DRG":"479","Description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","De-Identified Minimum Negotiated Charge":9498.0},{"MS-DRG":"480","Description":"Hip And Femur Procedures Except Major Joint With Mcc","De-Identified Minimum Negotiated Charge":16349.0},{"MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","De-Identified Minimum Negotiated Charge":11100.0},{"MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8924.0},{"MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","De-Identified Minimum Negotiated Charge":12518.0},{"MS-DRG":"486","Description":"Knee Procedures With Principal Diagnosis Of Infection With Cc","De-Identified Minimum Negotiated Charge":12374.0},{"MS-DRG":"487","Description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8768.0},{"MS-DRG":"488","Description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","De-Identified Minimum Negotiated Charge":20191.0},{"MS-DRG":"489","Description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","De-Identified Minimum Negotiated Charge":14530.0},{"MS-DRG":"492","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","De-Identified Minimum Negotiated Charge":19209.0},{"MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","De-Identified Minimum Negotiated Charge":12457.0},{"MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","De-Identified Minimum Negotiated Charge":9446.0},{"MS-DRG":"496","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","De-Identified Minimum Negotiated Charge":11084.0},{"MS-DRG":"497","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7983.0},{"MS-DRG":"500","Description":"Soft Tissue Procedures With Mcc","De-Identified Minimum Negotiated Charge":16822.0},{"MS-DRG":"501","Description":"Soft Tissue Procedures With Cc","De-Identified Minimum Negotiated Charge":6573.0},{"MS-DRG":"502","Description":"Soft Tissue Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7258.0},{"MS-DRG":"504","Description":"Foot Procedures With Cc","De-Identified Minimum Negotiated Charge":9683.0},{"MS-DRG":"505","Description":"Foot Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":14561.0},{"MS-DRG":"507","Description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","De-Identified Minimum Negotiated Charge":11358.0},{"MS-DRG":"511","Description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","De-Identified Minimum Negotiated Charge":21746.0},{"MS-DRG":"513","Description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","De-Identified Minimum Negotiated Charge":6970.0},{"MS-DRG":"515","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":16740.0},{"MS-DRG":"516","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":9473.0},{"MS-DRG":"517","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7610.0},{"MS-DRG":"518","Description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","De-Identified Minimum Negotiated Charge":18402.0},{"MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","De-Identified Minimum Negotiated Charge":8342.0},{"MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6956.0},{"MS-DRG":"535","Description":"Fractures Of Hip And Pelvis With Mcc","De-Identified Minimum Negotiated Charge":6909.0},{"MS-DRG":"536","Description":"Fractures Of Hip And Pelvis Without Mcc","De-Identified Minimum Negotiated Charge":4072.0},{"MS-DRG":"539","Description":"Osteomyelitis With Mcc","De-Identified Minimum Negotiated Charge":11018.0},{"MS-DRG":"540","Description":"Osteomyelitis With Cc","De-Identified Minimum Negotiated Charge":5318.0},{"MS-DRG":"542","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","De-Identified Minimum Negotiated Charge":10160.0},{"MS-DRG":"543","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","De-Identified Minimum Negotiated Charge":5984.0},{"MS-DRG":"545","Description":"Connective Tissue Disorders With Mcc","De-Identified Minimum Negotiated Charge":13367.0},{"MS-DRG":"546","Description":"Connective Tissue Disorders With Cc","De-Identified Minimum Negotiated Charge":6519.0},{"MS-DRG":"547","Description":"Connective Tissue Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6304.0},{"MS-DRG":"551","Description":"Medical Back Problems With Mcc","De-Identified Minimum Negotiated Charge":8504.0},{"MS-DRG":"552","Description":"Medical Back Problems Without Mcc","De-Identified Minimum Negotiated Charge":5076.0},{"MS-DRG":"554","Description":"Bone Diseases And Arthropathies Without Mcc","De-Identified Minimum Negotiated Charge":4467.0},{"MS-DRG":"555","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","De-Identified Minimum Negotiated Charge":7266.0},{"MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","De-Identified Minimum Negotiated Charge":4566.0},{"MS-DRG":"558","Description":"Tendonitis, Myositis And Bursitis Without Mcc","De-Identified Minimum Negotiated Charge":9941.0},{"MS-DRG":"559","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","De-Identified Minimum Negotiated Charge":10006.0},{"MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","De-Identified Minimum Negotiated Charge":5874.0},{"MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4396.0},{"MS-DRG":"563","Description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","De-Identified Minimum Negotiated Charge":9101.0},{"MS-DRG":"565","Description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","De-Identified Minimum Negotiated Charge":5441.0},{"MS-DRG":"566","Description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4561.0},{"MS-DRG":"570","Description":"Skin Debridement With Mcc","De-Identified Minimum Negotiated Charge":16580.0},{"MS-DRG":"571","Description":"Skin Debridement With Cc","De-Identified Minimum Negotiated Charge":9218.0},{"MS-DRG":"572","Description":"Skin Debridement Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3858.0},{"MS-DRG":"575","Description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","De-Identified Minimum Negotiated Charge":21122.0},{"MS-DRG":"579","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","De-Identified Minimum Negotiated Charge":14101.0},{"MS-DRG":"580","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","De-Identified Minimum Negotiated Charge":2651.0},{"MS-DRG":"581","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6602.0},{"MS-DRG":"582","Description":"Mastectomy For Malignancy With Cc/Mcc","De-Identified Minimum Negotiated Charge":13784.0},{"MS-DRG":"593","Description":"Skin Ulcers With Cc","De-Identified Minimum Negotiated Charge":15627.0},{"MS-DRG":"596","Description":"Major Skin Disorders Without Mcc","De-Identified Minimum Negotiated Charge":14030.0},{"MS-DRG":"598","Description":"Malignant Breast Disorders With Cc","De-Identified Minimum Negotiated Charge":12415.0},{"MS-DRG":"599","Description":"Malignant Breast Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7972.0},{"MS-DRG":"601","Description":"Non-Malignant Breast Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7961.0},{"MS-DRG":"602","Description":"Cellulitis With Mcc","De-Identified Minimum Negotiated Charge":7992.0},{"MS-DRG":"603","Description":"Cellulitis Without Mcc","De-Identified Minimum Negotiated Charge":4724.0},{"MS-DRG":"605","Description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","De-Identified Minimum Negotiated Charge":10106.0},{"MS-DRG":"606","Description":"Minor Skin Disorders With Mcc","De-Identified Minimum Negotiated Charge":7857.0},{"MS-DRG":"607","Description":"Minor Skin Disorders Without Mcc","De-Identified Minimum Negotiated Charge":8157.0},{"MS-DRG":"614","Description":"Adrenal And Pituitary Procedures With Cc/Mcc","De-Identified Minimum Negotiated Charge":13331.0},{"MS-DRG":"616","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","De-Identified Minimum Negotiated Charge":19994.0},{"MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","De-Identified Minimum Negotiated Charge":11151.0},{"MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","De-Identified Minimum Negotiated Charge":10714.0},{"MS-DRG":"625","Description":"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","De-Identified Minimum Negotiated Charge":33759.0},{"MS-DRG":"626","Description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","De-Identified Minimum Negotiated Charge":8957.0},{"MS-DRG":"627","Description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6696.0},{"MS-DRG":"628","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":49310.0},{"MS-DRG":"629","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":9355.0},{"MS-DRG":"637","Description":"Diabetes With Mcc","De-Identified Minimum Negotiated Charge":7530.0},{"MS-DRG":"638","Description":"Diabetes With Cc","De-Identified Minimum Negotiated Charge":3691.0},{"MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3388.0},{"MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","De-Identified Minimum Negotiated Charge":6700.0},{"MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","De-Identified Minimum Negotiated Charge":4175.0},{"MS-DRG":"643","Description":"Endocrine Disorders With Mcc","De-Identified Minimum Negotiated Charge":9085.0},{"MS-DRG":"644","Description":"Endocrine Disorders With Cc","De-Identified Minimum Negotiated Charge":5479.0},{"MS-DRG":"645","Description":"Endocrine Disorders Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4488.0},{"MS-DRG":"659","Description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","De-Identified Minimum Negotiated Charge":22887.0},{"MS-DRG":"661","Description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6260.0},{"MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","De-Identified Minimum Negotiated Charge":19329.0},{"MS-DRG":"674","Description":"Other Kidney And Urinary Tract Procedures With Cc","De-Identified Minimum Negotiated Charge":13242.0},{"MS-DRG":"682","Description":"Renal Failure With Mcc","De-Identified Minimum Negotiated Charge":8281.0},{"MS-DRG":"683","Description":"Renal Failure With Cc","De-Identified Minimum Negotiated Charge":5003.0},{"MS-DRG":"684","Description":"Renal Failure Without Cc/Mcc","De-Identified Minimum Negotiated Charge":3587.0},{"MS-DRG":"689","Description":"Kidney And Urinary Tract Infections With Mcc","De-Identified Minimum Negotiated Charge":6112.0},{"MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","De-Identified Minimum Negotiated Charge":4353.0},{"MS-DRG":"693","Description":"Urinary Stones With Mcc","De-Identified Minimum Negotiated Charge":9067.0},{"MS-DRG":"694","Description":"Urinary Stones Without Mcc","De-Identified Minimum Negotiated Charge":4342.0},{"MS-DRG":"695","Description":"Kidney And Urinary Tract Signs And Symptoms With Mcc","De-Identified Minimum Negotiated Charge":6275.0},{"MS-DRG":"696","Description":"Kidney And Urinary Tract Signs And Symptoms Without Mcc","De-Identified Minimum Negotiated Charge":3823.0},{"MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","De-Identified Minimum Negotiated Charge":7935.0},{"MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","De-Identified Minimum Negotiated Charge":5642.0},{"MS-DRG":"700","Description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4283.0},{"MS-DRG":"718","Description":"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","De-Identified Minimum Negotiated Charge":14073.0},{"MS-DRG":"722","Description":"Malignancy, Male Reproductive System With Mcc","De-Identified Minimum Negotiated Charge":20830.0},{"MS-DRG":"728","Description":"Inflammation Of The Male Reproductive System Without Mcc","De-Identified Minimum Negotiated Charge":5178.0},{"MS-DRG":"776","Description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","De-Identified Minimum Negotiated Charge":6948.0},{"MS-DRG":"803","Description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","De-Identified Minimum Negotiated Charge":10359.0},{"MS-DRG":"808","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","De-Identified Minimum Negotiated Charge":20155.0},{"MS-DRG":"809","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","De-Identified Minimum Negotiated Charge":6435.0},{"MS-DRG":"810","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","De-Identified Minimum Negotiated Charge":8464.0},{"MS-DRG":"811","Description":"Red Blood Cell Disorders With Mcc","De-Identified Minimum Negotiated Charge":7341.0},{"MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","De-Identified Minimum Negotiated Charge":2453.0},{"MS-DRG":"813","Description":"Coagulation Disorders","De-Identified Minimum Negotiated Charge":8606.0},{"MS-DRG":"815","Description":"Reticuloendothelial And Immunity Disorders With Cc","De-Identified Minimum Negotiated Charge":11689.0},{"MS-DRG":"822","Description":"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":12485.0},{"MS-DRG":"823","Description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","De-Identified Minimum Negotiated Charge":25203.0},{"MS-DRG":"824","Description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","De-Identified Minimum Negotiated Charge":12845.0},{"MS-DRG":"826","Description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":27342.0},{"MS-DRG":"830","Description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7771.0},{"MS-DRG":"832","Description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":10564.0},{"MS-DRG":"834","Description":"Acute Leukemia Without Major O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":43265.0},{"MS-DRG":"835","Description":"Acute Leukemia Without Major O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":11455.0},{"MS-DRG":"840","Description":"Lymphoma And Non-Acute Leukemia With Mcc","De-Identified Minimum Negotiated Charge":17805.0},{"MS-DRG":"841","Description":"Lymphoma And Non-Acute Leukemia With Cc","De-Identified Minimum Negotiated Charge":8571.0},{"MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":16856.0},{"MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":10234.0},{"MS-DRG":"855","Description":"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":23671.0},{"MS-DRG":"856","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","De-Identified Minimum Negotiated Charge":24137.0},{"MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","De-Identified Minimum Negotiated Charge":9623.0},{"MS-DRG":"858","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7666.0},{"MS-DRG":"862","Description":"Postoperative And Post-Traumatic Infections With Mcc","De-Identified Minimum Negotiated Charge":15023.0},{"MS-DRG":"863","Description":"Postoperative And Post-Traumatic Infections Without Mcc","De-Identified Minimum Negotiated Charge":5517.0},{"MS-DRG":"864","Description":"Fever And Inflammatory Conditions","De-Identified Minimum Negotiated Charge":3058.0},{"MS-DRG":"865","Description":"Viral Illness With Mcc","De-Identified Minimum Negotiated Charge":7402.0},{"MS-DRG":"866","Description":"Viral Illness Without Mcc","De-Identified Minimum Negotiated Charge":4557.0},{"MS-DRG":"870","Description":"Septicemia Or Severe Sepsis With Mv >96 Hours","De-Identified Minimum Negotiated Charge":33994.0},{"MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","De-Identified Minimum Negotiated Charge":10153.0},{"MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","De-Identified Minimum Negotiated Charge":5535.0},{"MS-DRG":"880","Description":"Acute Adjustment Reaction And Psychosocial Dysfunction","De-Identified Minimum Negotiated Charge":3852.0},{"MS-DRG":"882","Description":"Neuroses Except Depressive","De-Identified Minimum Negotiated Charge":4442.0},{"MS-DRG":"884","Description":"Organic Disturbances And Intellectual Disability","De-Identified Minimum Negotiated Charge":8300.0},{"MS-DRG":"885","Description":"Psychoses","De-Identified Minimum Negotiated Charge":6512.0},{"MS-DRG":"896","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","De-Identified Minimum Negotiated Charge":9405.0},{"MS-DRG":"897","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","De-Identified Minimum Negotiated Charge":4582.0},{"MS-DRG":"901","Description":"Wound Debridements For Injuries With Mcc","De-Identified Minimum Negotiated Charge":23881.0},{"MS-DRG":"902","Description":"Wound Debridements For Injuries With Cc","De-Identified Minimum Negotiated Charge":10182.0},{"MS-DRG":"903","Description":"Wound Debridements For Injuries Without Cc/Mcc","De-Identified Minimum Negotiated Charge":6191.0},{"MS-DRG":"904","Description":"Skin Grafts For Injuries With Cc/Mcc","De-Identified Minimum Negotiated Charge":19758.0},{"MS-DRG":"907","Description":"Other O.R. Procedures For Injuries With Mcc","De-Identified Minimum Negotiated Charge":22443.0},{"MS-DRG":"908","Description":"Other O.R. Procedures For Injuries With Cc","De-Identified Minimum Negotiated Charge":10561.0},{"MS-DRG":"909","Description":"Other O.R. Procedures For Injuries Without Cc/Mcc","De-Identified Minimum Negotiated Charge":7225.0},{"MS-DRG":"914","Description":"Traumatic Injury Without Mcc","De-Identified Minimum Negotiated Charge":4671.0},{"MS-DRG":"915","Description":"Allergic Reactions With Mcc","De-Identified Minimum Negotiated Charge":9676.0},{"MS-DRG":"916","Description":"Allergic Reactions Without Mcc","De-Identified Minimum Negotiated Charge":3686.0},{"MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","De-Identified Minimum Negotiated Charge":5248.0},{"MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","De-Identified Minimum Negotiated Charge":4294.0},{"MS-DRG":"919","Description":"Complications Of Treatment With Mcc","De-Identified Minimum Negotiated Charge":9926.0},{"MS-DRG":"920","Description":"Complications Of Treatment With Cc","De-Identified Minimum Negotiated Charge":5541.0},{"MS-DRG":"921","Description":"Complications Of Treatment Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4005.0},{"MS-DRG":"923","Description":"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","De-Identified Minimum Negotiated Charge":4759.0},{"MS-DRG":"935","Description":"Non-Extensive Burns","De-Identified Minimum Negotiated Charge":9839.0},{"MS-DRG":"939","Description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","De-Identified Minimum Negotiated Charge":18717.0},{"MS-DRG":"940","Description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","De-Identified Minimum Negotiated Charge":26219.0},{"MS-DRG":"945","Description":"Rehabilitation With Cc/Mcc","De-Identified Minimum Negotiated Charge":21973.0},{"MS-DRG":"946","Description":"Rehabilitation Without Cc/Mcc","De-Identified Minimum Negotiated Charge":16241.0},{"MS-DRG":"947","Description":"Signs And Symptoms With Mcc","De-Identified Minimum Negotiated Charge":6561.0},{"MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","De-Identified Minimum Negotiated Charge":4457.0},{"MS-DRG":"949","Description":"Aftercare With Cc/Mcc","De-Identified Minimum Negotiated Charge":5597.0},{"MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","De-Identified Minimum Negotiated Charge":4353.0},{"MS-DRG":"956","Description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","De-Identified Minimum Negotiated Charge":21476.0},{"MS-DRG":"964","Description":"Other Multiple Significant Trauma With Cc","De-Identified Minimum Negotiated Charge":8538.0},{"MS-DRG":"974","Description":"Hiv With Major Related Condition With Mcc","De-Identified Minimum Negotiated Charge":21899.0},{"MS-DRG":"977","Description":"Hiv With Or Without Other Related Condition","De-Identified Minimum Negotiated Charge":15009.0},{"MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","De-Identified Minimum Negotiated Charge":23778.0},{"MS-DRG":"982","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","De-Identified Minimum Negotiated Charge":13561.0},{"MS-DRG":"983","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","De-Identified Minimum Negotiated Charge":8431.0},{"MS-DRG":"987","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","De-Identified Minimum Negotiated Charge":17792.0},{"MS-DRG":"988","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","De-Identified Minimum Negotiated Charge":9463.0}],"Inpatient De-identified Maximum Negotiated Charge":[{"MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","De-Identified Maximum Negotiated Charge":375543.0},{"MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","De-Identified Maximum Negotiated Charge":573703.0},{"MS-DRG":"020","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","De-Identified Maximum Negotiated Charge":172978.0},{"MS-DRG":"021","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","De-Identified Maximum Negotiated Charge":143054.0},{"MS-DRG":"023","Description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera","De-Identified Maximum Negotiated Charge":149176.0},{"MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","De-Identified Maximum Negotiated Charge":79181.0},{"MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","De-Identified Maximum Negotiated Charge":47989.0},{"MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":35385.0},{"MS-DRG":"028","Description":"Spinal Procedures With Mcc","De-Identified Maximum Negotiated Charge":69090.0},{"MS-DRG":"029","Description":"Spinal Procedures With Cc Or Spinal Neurostimulators","De-Identified Maximum Negotiated Charge":89642.0},{"MS-DRG":"030","Description":"Spinal Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":13326.0},{"MS-DRG":"031","Description":"Ventricular Shunt Procedures With Mcc","De-Identified Maximum Negotiated Charge":23989.0},{"MS-DRG":"033","Description":"Ventricular Shunt Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":9403.0},{"MS-DRG":"036","Description":"Carotid Artery Stent Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":25852.0},{"MS-DRG":"038","Description":"Extracranial Procedures With Cc","De-Identified Maximum Negotiated Charge":19334.0},{"MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":13056.0},{"MS-DRG":"040","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","De-Identified Maximum Negotiated Charge":42910.0},{"MS-DRG":"041","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","De-Identified Maximum Negotiated Charge":28484.0},{"MS-DRG":"042","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":21331.0},{"MS-DRG":"053","Description":"Spinal Disorders And Injuries Without Cc/Mcc","De-Identified Maximum Negotiated Charge":11150.0},{"MS-DRG":"054","Description":"Nervous System Neoplasms With Mcc","De-Identified Maximum Negotiated Charge":15466.0},{"MS-DRG":"055","Description":"Nervous System Neoplasms Without Mcc","De-Identified Maximum Negotiated Charge":6764.0},{"MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","De-Identified Maximum Negotiated Charge":25553.0},{"MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","De-Identified Maximum Negotiated Charge":44594.0},{"MS-DRG":"060","Description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","De-Identified Maximum Negotiated Charge":13017.0},{"MS-DRG":"061","Description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","De-Identified Maximum Negotiated Charge":15474.0},{"MS-DRG":"063","Description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","De-Identified Maximum Negotiated Charge":25710.0},{"MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","De-Identified Maximum Negotiated Charge":127373.0},{"MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","De-Identified Maximum Negotiated Charge":11861.0},{"MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","De-Identified Maximum Negotiated Charge":10586.0},{"MS-DRG":"068","Description":"Nonspecific Cva And Precerebral Occlusion Without Infarction Without Mcc","De-Identified Maximum Negotiated Charge":4791.0},{"MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","De-Identified Maximum Negotiated Charge":11520.0},{"MS-DRG":"070","Description":"Nonspecific Cerebrovascular Disorders With Mcc","De-Identified Maximum Negotiated Charge":9006.0},{"MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","De-Identified Maximum Negotiated Charge":11480.0},{"MS-DRG":"072","Description":"Nonspecific Cerebrovascular Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":8523.0},{"MS-DRG":"073","Description":"Cranial And Peripheral Nerve Disorders With Mcc","De-Identified Maximum Negotiated Charge":405183.0},{"MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","De-Identified Maximum Negotiated Charge":11404.0},{"MS-DRG":"076","Description":"Viral Meningitis Without Cc/Mcc","De-Identified Maximum Negotiated Charge":8911.0},{"MS-DRG":"077","Description":"Hypertensive Encephalopathy With Mcc","De-Identified Maximum Negotiated Charge":8378.0},{"MS-DRG":"078","Description":"Hypertensive Encephalopathy With Cc","De-Identified Maximum Negotiated Charge":11102.0},{"MS-DRG":"079","Description":"Hypertensive Encephalopathy Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7318.0},{"MS-DRG":"082","Description":"Traumatic Stupor And Coma >1 Hour With Mcc","De-Identified Maximum Negotiated Charge":12275.0},{"MS-DRG":"083","Description":"Traumatic Stupor And Coma >1 Hour With Cc","De-Identified Maximum Negotiated Charge":7009.0},{"MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","De-Identified Maximum Negotiated Charge":13248.0},{"MS-DRG":"086","Description":"Traumatic Stupor And Coma <1 Hour With Cc","De-Identified Maximum Negotiated Charge":6915.0},{"MS-DRG":"087","Description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","De-Identified Maximum Negotiated Charge":5905.0},{"MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","De-Identified Maximum Negotiated Charge":15454.0},{"MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","De-Identified Maximum Negotiated Charge":11150.0},{"MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","De-Identified Maximum Negotiated Charge":11238.0},{"MS-DRG":"094","Description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","De-Identified Maximum Negotiated Charge":41372.0},{"MS-DRG":"096","Description":"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","De-Identified Maximum Negotiated Charge":10128.0},{"MS-DRG":"097","Description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","De-Identified Maximum Negotiated Charge":52795.0},{"MS-DRG":"100","Description":"Seizures With Mcc","De-Identified Maximum Negotiated Charge":27941.0},{"MS-DRG":"101","Description":"Seizures Without Mcc","De-Identified Maximum Negotiated Charge":13947.0},{"MS-DRG":"102","Description":"Headaches With Mcc","De-Identified Maximum Negotiated Charge":6540.0},{"MS-DRG":"103","Description":"Headaches Without Mcc","De-Identified Maximum Negotiated Charge":12470.0},{"MS-DRG":"125","Description":"Other Disorders Of The Eye Without Mcc","De-Identified Maximum Negotiated Charge":11655.0},{"MS-DRG":"133","Description":"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","De-Identified Maximum Negotiated Charge":13056.0},{"MS-DRG":"149","Description":"Dysequilibrium","De-Identified Maximum Negotiated Charge":8431.0},{"MS-DRG":"151","Description":"Epistaxis Without Mcc","De-Identified Maximum Negotiated Charge":4920.0},{"MS-DRG":"153","Description":"Otitis Media And Uri Without Mcc","De-Identified Maximum Negotiated Charge":8153.0},{"MS-DRG":"154","Description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","De-Identified Maximum Negotiated Charge":8008.0},{"MS-DRG":"155","Description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","De-Identified Maximum Negotiated Charge":4778.0},{"MS-DRG":"156","Description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","De-Identified Maximum Negotiated Charge":3086.0},{"MS-DRG":"157","Description":"Dental And Oral Diseases With Mcc","De-Identified Maximum Negotiated Charge":14512.0},{"MS-DRG":"158","Description":"Dental And Oral Diseases With Cc","De-Identified Maximum Negotiated Charge":5083.0},{"MS-DRG":"163","Description":"Major Chest Procedures With Mcc","De-Identified Maximum Negotiated Charge":56248.0},{"MS-DRG":"164","Description":"Major Chest Procedures With Cc","De-Identified Maximum Negotiated Charge":29217.0},{"MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":27302.0},{"MS-DRG":"166","Description":"Other Respiratory System O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":50977.0},{"MS-DRG":"167","Description":"Other Respiratory System O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":15302.0},{"MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":19587.0},{"MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","De-Identified Maximum Negotiated Charge":25857.0},{"MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","De-Identified Maximum Negotiated Charge":9791.0},{"MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","De-Identified Maximum Negotiated Charge":18674.0},{"MS-DRG":"178","Description":"Respiratory Infections And Inflammations With Cc","De-Identified Maximum Negotiated Charge":7155.0},{"MS-DRG":"179","Description":"Respiratory Infections And Inflammations Without Cc/Mcc","De-Identified Maximum Negotiated Charge":12787.0},{"MS-DRG":"180","Description":"Respiratory Neoplasms With Mcc","De-Identified Maximum Negotiated Charge":25466.0},{"MS-DRG":"181","Description":"Respiratory Neoplasms With Cc","De-Identified Maximum Negotiated Charge":17008.0},{"MS-DRG":"184","Description":"Major Chest Trauma With Cc","De-Identified Maximum Negotiated Charge":11751.0},{"MS-DRG":"185","Description":"Major Chest Trauma Without Cc/Mcc","De-Identified Maximum Negotiated Charge":4305.0},{"MS-DRG":"186","Description":"Pleural Effusion With Mcc","De-Identified Maximum Negotiated Charge":9049.0},{"MS-DRG":"187","Description":"Pleural Effusion With Cc","De-Identified Maximum Negotiated Charge":12594.0},{"MS-DRG":"188","Description":"Pleural Effusion Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7217.0},{"MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","De-Identified Maximum Negotiated Charge":21945.0},{"MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","De-Identified Maximum Negotiated Charge":16890.0},{"MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","De-Identified Maximum Negotiated Charge":9968.0},{"MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","De-Identified Maximum Negotiated Charge":8185.0},{"MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","De-Identified Maximum Negotiated Charge":15390.0},{"MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","De-Identified Maximum Negotiated Charge":27416.0},{"MS-DRG":"195","Description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","De-Identified Maximum Negotiated Charge":3952.0},{"MS-DRG":"196","Description":"Interstitial Lung Disease With Mcc","De-Identified Maximum Negotiated Charge":39841.0},{"MS-DRG":"197","Description":"Interstitial Lung Disease With Cc","De-Identified Maximum Negotiated Charge":11789.0},{"MS-DRG":"198","Description":"Interstitial Lung Disease Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7455.0},{"MS-DRG":"200","Description":"Pneumothorax With Cc","De-Identified Maximum Negotiated Charge":15976.0},{"MS-DRG":"201","Description":"Pneumothorax Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7090.0},{"MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","De-Identified Maximum Negotiated Charge":96347.0},{"MS-DRG":"203","Description":"Bronchitis And Asthma Without Cc/Mcc","De-Identified Maximum Negotiated Charge":5609.0},{"MS-DRG":"204","Description":"Respiratory Signs And Symptoms","De-Identified Maximum Negotiated Charge":9377.0},{"MS-DRG":"205","Description":"Other Respiratory System Diagnoses With Mcc","De-Identified Maximum Negotiated Charge":16136.0},{"MS-DRG":"206","Description":"Other Respiratory System Diagnoses Without Mcc","De-Identified Maximum Negotiated Charge":4681.0},{"MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","De-Identified Maximum Negotiated Charge":163701.0},{"MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","De-Identified Maximum Negotiated Charge":42549.0},{"MS-DRG":"215","Description":"Other Heart Assist System Implant","De-Identified Maximum Negotiated Charge":436726.0},{"MS-DRG":"216","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","De-Identified Maximum Negotiated Charge":205566.0},{"MS-DRG":"217","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","De-Identified Maximum Negotiated Charge":114647.0},{"MS-DRG":"219","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","De-Identified Maximum Negotiated Charge":157665.0},{"MS-DRG":"220","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","De-Identified Maximum Negotiated Charge":113897.0},{"MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","De-Identified Maximum Negotiated Charge":100139.0},{"MS-DRG":"222","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","De-Identified Maximum Negotiated Charge":43285.0},{"MS-DRG":"223","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","De-Identified Maximum Negotiated Charge":32267.0},{"MS-DRG":"224","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","De-Identified Maximum Negotiated Charge":39959.0},{"MS-DRG":"225","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","De-Identified Maximum Negotiated Charge":55776.0},{"MS-DRG":"226","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","De-Identified Maximum Negotiated Charge":36389.0},{"MS-DRG":"227","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","De-Identified Maximum Negotiated Charge":144437.0},{"MS-DRG":"228","Description":"Other Cardiothoracic Procedures With Mcc","De-Identified Maximum Negotiated Charge":44787.0},{"MS-DRG":"229","Description":"Other Cardiothoracic Procedures Without Mcc","De-Identified Maximum Negotiated Charge":154008.0},{"MS-DRG":"231","Description":"Coronary Bypass With Ptca With Mcc","De-Identified Maximum Negotiated Charge":408763.0},{"MS-DRG":"233","Description":"Coronary Bypass With Cardiac Catheterization With Mcc","De-Identified Maximum Negotiated Charge":117685.0},{"MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","De-Identified Maximum Negotiated Charge":133818.0},{"MS-DRG":"235","Description":"Coronary Bypass Without Cardiac Catheterization With Mcc","De-Identified Maximum Negotiated Charge":71997.0},{"MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","De-Identified Maximum Negotiated Charge":91986.0},{"MS-DRG":"239","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","De-Identified Maximum Negotiated Charge":25648.0},{"MS-DRG":"240","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","De-Identified Maximum Negotiated Charge":31853.0},{"MS-DRG":"242","Description":"Permanent Cardiac Pacemaker Implant With Mcc","De-Identified Maximum Negotiated Charge":20292.0},{"MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","De-Identified Maximum Negotiated Charge":37344.0},{"MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","De-Identified Maximum Negotiated Charge":27638.0},{"MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","De-Identified Maximum Negotiated Charge":137727.0},{"MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","De-Identified Maximum Negotiated Charge":35855.0},{"MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","De-Identified Maximum Negotiated Charge":98608.0},{"MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","De-Identified Maximum Negotiated Charge":27305.0},{"MS-DRG":"250","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent With Mcc","De-Identified Maximum Negotiated Charge":13918.0},{"MS-DRG":"251","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without Mcc","De-Identified Maximum Negotiated Charge":19424.0},{"MS-DRG":"252","Description":"Other Vascular Procedures With Mcc","De-Identified Maximum Negotiated Charge":127506.0},{"MS-DRG":"253","Description":"Other Vascular Procedures With Cc","De-Identified Maximum Negotiated Charge":35325.0},{"MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":26872.0},{"MS-DRG":"256","Description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","De-Identified Maximum Negotiated Charge":9726.0},{"MS-DRG":"260","Description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","De-Identified Maximum Negotiated Charge":54621.0},{"MS-DRG":"261","Description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","De-Identified Maximum Negotiated Charge":22488.0},{"MS-DRG":"262","Description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","De-Identified Maximum Negotiated Charge":10012.0},{"MS-DRG":"264","Description":"Other Circulatory System O.R. Procedures","De-Identified Maximum Negotiated Charge":107037.0},{"MS-DRG":"266","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","De-Identified Maximum Negotiated Charge":115072.0},{"MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","De-Identified Maximum Negotiated Charge":107390.0},{"MS-DRG":"268","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","De-Identified Maximum Negotiated Charge":114277.0},{"MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","De-Identified Maximum Negotiated Charge":83861.0},{"MS-DRG":"270","Description":"Other Major Cardiovascular Procedures With Mcc","De-Identified Maximum Negotiated Charge":67480.0},{"MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","De-Identified Maximum Negotiated Charge":99327.0},{"MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":26189.0},{"MS-DRG":"273","Description":"Percutaneous And Other Intracardiac Procedures With Mcc","De-Identified Maximum Negotiated Charge":69884.0},{"MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","De-Identified Maximum Negotiated Charge":46651.0},{"MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","De-Identified Maximum Negotiated Charge":118776.0},{"MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","De-Identified Maximum Negotiated Charge":8337.0},{"MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","De-Identified Maximum Negotiated Charge":10894.0},{"MS-DRG":"283","Description":"Acute Myocardial Infarction, Expired With Mcc","De-Identified Maximum Negotiated Charge":10927.0},{"MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","De-Identified Maximum Negotiated Charge":25360.0},{"MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","De-Identified Maximum Negotiated Charge":17011.0},{"MS-DRG":"289","Description":"Acute And Subacute Endocarditis With Cc","De-Identified Maximum Negotiated Charge":14399.0},{"MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","De-Identified Maximum Negotiated Charge":28431.0},{"MS-DRG":"292","Description":"Heart Failure And Shock With Cc","De-Identified Maximum Negotiated Charge":13369.0},{"MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7563.0},{"MS-DRG":"296","Description":"Cardiac Arrest, Unexplained With Mcc","De-Identified Maximum Negotiated Charge":46238.0},{"MS-DRG":"297","Description":"Cardiac Arrest, Unexplained With Cc","De-Identified Maximum Negotiated Charge":45437.0},{"MS-DRG":"299","Description":"Peripheral Vascular Disorders With Mcc","De-Identified Maximum Negotiated Charge":8161.0},{"MS-DRG":"300","Description":"Peripheral Vascular Disorders With Cc","De-Identified Maximum Negotiated Charge":8308.0},{"MS-DRG":"301","Description":"Peripheral Vascular Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":113788.0},{"MS-DRG":"302","Description":"Atherosclerosis With Mcc","De-Identified Maximum Negotiated Charge":8912.0},{"MS-DRG":"303","Description":"Atherosclerosis Without Mcc","De-Identified Maximum Negotiated Charge":24223.0},{"MS-DRG":"304","Description":"Hypertension With Mcc","De-Identified Maximum Negotiated Charge":10777.0},{"MS-DRG":"305","Description":"Hypertension Without Mcc","De-Identified Maximum Negotiated Charge":8442.0},{"MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","De-Identified Maximum Negotiated Charge":14674.0},{"MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","De-Identified Maximum Negotiated Charge":11166.0},{"MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":8258.0},{"MS-DRG":"311","Description":"Angina Pectoris","De-Identified Maximum Negotiated Charge":6107.0},{"MS-DRG":"312","Description":"Syncope And Collapse","De-Identified Maximum Negotiated Charge":10688.0},{"MS-DRG":"313","Description":"Chest Pain","De-Identified Maximum Negotiated Charge":10561.0},{"MS-DRG":"314","Description":"Other Circulatory System Diagnoses With Mcc","De-Identified Maximum Negotiated Charge":13078.0},{"MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","De-Identified Maximum Negotiated Charge":15823.0},{"MS-DRG":"316","Description":"Other Circulatory System Diagnoses Without Cc/Mcc","De-Identified Maximum Negotiated Charge":6001.0},{"MS-DRG":"326","Description":"Stomach, Esophageal And Duodenal Procedures With Mcc","De-Identified Maximum Negotiated Charge":104160.0},{"MS-DRG":"327","Description":"Stomach, Esophageal And Duodenal Procedures With Cc","De-Identified Maximum Negotiated Charge":109854.0},{"MS-DRG":"328","Description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":8683.0},{"MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","De-Identified Maximum Negotiated Charge":84891.0},{"MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","De-Identified Maximum Negotiated Charge":37306.0},{"MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":24939.0},{"MS-DRG":"335","Description":"Peritoneal Adhesiolysis With Mcc","De-Identified Maximum Negotiated Charge":22071.0},{"MS-DRG":"336","Description":"Peritoneal Adhesiolysis With Cc","De-Identified Maximum Negotiated Charge":36479.0},{"MS-DRG":"337","Description":"Peritoneal Adhesiolysis Without Cc/Mcc","De-Identified Maximum Negotiated Charge":16190.0},{"MS-DRG":"339","Description":"Appendectomy With Complicated Principal Diagnosis With Cc","De-Identified Maximum Negotiated Charge":19806.0},{"MS-DRG":"340","Description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","De-Identified Maximum Negotiated Charge":18270.0},{"MS-DRG":"342","Description":"Appendectomy Without Complicated Principal Diagnosis With Cc","De-Identified Maximum Negotiated Charge":9444.0},{"MS-DRG":"343","Description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","De-Identified Maximum Negotiated Charge":16350.0},{"MS-DRG":"348","Description":"Anal And Stomal Procedures With Cc","De-Identified Maximum Negotiated Charge":20807.0},{"MS-DRG":"351","Description":"Inguinal And Femoral Hernia Procedures With Cc","De-Identified Maximum Negotiated Charge":7928.0},{"MS-DRG":"352","Description":"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":6315.0},{"MS-DRG":"353","Description":"Hernia Procedures Except Inguinal And Femoral With Mcc","De-Identified Maximum Negotiated Charge":16344.0},{"MS-DRG":"354","Description":"Hernia Procedures Except Inguinal And Femoral With Cc","De-Identified Maximum Negotiated Charge":25425.0},{"MS-DRG":"355","Description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","De-Identified Maximum Negotiated Charge":16205.0},{"MS-DRG":"356","Description":"Other Digestive System O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":22148.0},{"MS-DRG":"357","Description":"Other Digestive System O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":24004.0},{"MS-DRG":"358","Description":"Other Digestive System O.R. Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7232.0},{"MS-DRG":"369","Description":"Major Esophageal Disorders With Cc","De-Identified Maximum Negotiated Charge":17245.0},{"MS-DRG":"370","Description":"Major Esophageal Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7379.0},{"MS-DRG":"371","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","De-Identified Maximum Negotiated Charge":19914.0},{"MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","De-Identified Maximum Negotiated Charge":11801.0},{"MS-DRG":"373","Description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","De-Identified Maximum Negotiated Charge":8561.0},{"MS-DRG":"374","Description":"Digestive Malignancy With Mcc","De-Identified Maximum Negotiated Charge":23053.0},{"MS-DRG":"375","Description":"Digestive Malignancy With Cc","De-Identified Maximum Negotiated Charge":15778.0},{"MS-DRG":"377","Description":"Gastrointestinal Hemorrhage With Mcc","De-Identified Maximum Negotiated Charge":65404.0},{"MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","De-Identified Maximum Negotiated Charge":26969.0},{"MS-DRG":"379","Description":"Gastrointestinal Hemorrhage Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7430.0},{"MS-DRG":"381","Description":"Complicated Peptic Ulcer With Cc","De-Identified Maximum Negotiated Charge":7577.0},{"MS-DRG":"382","Description":"Complicated Peptic Ulcer Without Cc/Mcc","De-Identified Maximum Negotiated Charge":9026.0},{"MS-DRG":"384","Description":"Uncomplicated Peptic Ulcer Without Mcc","De-Identified Maximum Negotiated Charge":5461.0},{"MS-DRG":"385","Description":"Inflammatory Bowel Disease With Mcc","De-Identified Maximum Negotiated Charge":18585.0},{"MS-DRG":"386","Description":"Inflammatory Bowel Disease With Cc","De-Identified Maximum Negotiated Charge":10896.0},{"MS-DRG":"387","Description":"Inflammatory Bowel Disease Without Cc/Mcc","De-Identified Maximum Negotiated Charge":11236.0},{"MS-DRG":"388","Description":"Gastrointestinal Obstruction With Mcc","De-Identified Maximum Negotiated Charge":22517.0},{"MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","De-Identified Maximum Negotiated Charge":16929.0},{"MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7512.0},{"MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","De-Identified Maximum Negotiated Charge":15435.0},{"MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","De-Identified Maximum Negotiated Charge":12420.0},{"MS-DRG":"393","Description":"Other Digestive System Diagnoses With Mcc","De-Identified Maximum Negotiated Charge":9117.0},{"MS-DRG":"394","Description":"Other Digestive System Diagnoses With Cc","De-Identified Maximum Negotiated Charge":8055.0},{"MS-DRG":"395","Description":"Other Digestive System Diagnoses Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7552.0},{"MS-DRG":"405","Description":"Pancreas, Liver And Shunt Procedures With Mcc","De-Identified Maximum Negotiated Charge":29303.0},{"MS-DRG":"406","Description":"Pancreas, Liver And Shunt Procedures With Cc","De-Identified Maximum Negotiated Charge":34183.0},{"MS-DRG":"410","Description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","De-Identified Maximum Negotiated Charge":19158.0},{"MS-DRG":"411","Description":"Cholecystectomy With C.D.E. With Mcc","De-Identified Maximum Negotiated Charge":21691.0},{"MS-DRG":"412","Description":"Cholecystectomy With C.D.E. With Cc","De-Identified Maximum Negotiated Charge":12641.0},{"MS-DRG":"414","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","De-Identified Maximum Negotiated Charge":39429.0},{"MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","De-Identified Maximum Negotiated Charge":28326.0},{"MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","De-Identified Maximum Negotiated Charge":15584.0},{"MS-DRG":"417","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","De-Identified Maximum Negotiated Charge":27822.0},{"MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","De-Identified Maximum Negotiated Charge":19261.0},{"MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","De-Identified Maximum Negotiated Charge":19294.0},{"MS-DRG":"423","Description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":83720.0},{"MS-DRG":"432","Description":"Cirrhosis And Alcoholic Hepatitis With Mcc","De-Identified Maximum Negotiated Charge":18004.0},{"MS-DRG":"433","Description":"Cirrhosis And Alcoholic Hepatitis With Cc","De-Identified Maximum Negotiated Charge":15236.0},{"MS-DRG":"435","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","De-Identified Maximum Negotiated Charge":44159.0},{"MS-DRG":"436","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","De-Identified Maximum Negotiated Charge":16620.0},{"MS-DRG":"437","Description":"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","De-Identified Maximum Negotiated Charge":5149.0},{"MS-DRG":"438","Description":"Disorders Of Pancreas Except Malignancy With Mcc","De-Identified Maximum Negotiated Charge":42161.0},{"MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","De-Identified Maximum Negotiated Charge":15105.0},{"MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","De-Identified Maximum Negotiated Charge":14184.0},{"MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","De-Identified Maximum Negotiated Charge":29102.0},{"MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","De-Identified Maximum Negotiated Charge":20219.0},{"MS-DRG":"443","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7851.0},{"MS-DRG":"444","Description":"Disorders Of The Biliary Tract With Mcc","De-Identified Maximum Negotiated Charge":18767.0},{"MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","De-Identified Maximum Negotiated Charge":15864.0},{"MS-DRG":"446","Description":"Disorders Of The Biliary Tract Without Cc/Mcc","De-Identified Maximum Negotiated Charge":11999.0},{"MS-DRG":"453","Description":"Combined Anterior And Posterior Spinal Fusion With Mcc","De-Identified Maximum Negotiated Charge":93090.0},{"MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","De-Identified Maximum Negotiated Charge":180019.0},{"MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","De-Identified Maximum Negotiated Charge":78237.0},{"MS-DRG":"457","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","De-Identified Maximum Negotiated Charge":138080.0},{"MS-DRG":"458","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","De-Identified Maximum Negotiated Charge":82919.0},{"MS-DRG":"459","Description":"Spinal Fusion Except Cervical With Mcc","De-Identified Maximum Negotiated Charge":101163.0},{"MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","De-Identified Maximum Negotiated Charge":114680.0},{"MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","De-Identified Maximum Negotiated Charge":50973.0},{"MS-DRG":"463","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","De-Identified Maximum Negotiated Charge":39785.0},{"MS-DRG":"464","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","De-Identified Maximum Negotiated Charge":22747.0},{"MS-DRG":"465","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","De-Identified Maximum Negotiated Charge":10378.0},{"MS-DRG":"466","Description":"Revision Of Hip Or Knee Replacement With Mcc","De-Identified Maximum Negotiated Charge":36401.0},{"MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","De-Identified Maximum Negotiated Charge":70416.0},{"MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","De-Identified Maximum Negotiated Charge":60804.0},{"MS-DRG":"469","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","De-Identified Maximum Negotiated Charge":36380.0},{"MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","De-Identified Maximum Negotiated Charge":42830.0},{"MS-DRG":"471","Description":"Cervical Spinal Fusion With Mcc","De-Identified Maximum Negotiated Charge":89837.0},{"MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","De-Identified Maximum Negotiated Charge":98499.0},{"MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","De-Identified Maximum Negotiated Charge":40967.0},{"MS-DRG":"474","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","De-Identified Maximum Negotiated Charge":21393.0},{"MS-DRG":"475","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","De-Identified Maximum Negotiated Charge":20745.0},{"MS-DRG":"476","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":6710.0},{"MS-DRG":"477","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","De-Identified Maximum Negotiated Charge":16860.0},{"MS-DRG":"478","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","De-Identified Maximum Negotiated Charge":27461.0},{"MS-DRG":"479","Description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","De-Identified Maximum Negotiated Charge":9498.0},{"MS-DRG":"480","Description":"Hip And Femur Procedures Except Major Joint With Mcc","De-Identified Maximum Negotiated Charge":29805.0},{"MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","De-Identified Maximum Negotiated Charge":24769.0},{"MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","De-Identified Maximum Negotiated Charge":18988.0},{"MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","De-Identified Maximum Negotiated Charge":37665.0},{"MS-DRG":"486","Description":"Knee Procedures With Principal Diagnosis Of Infection With Cc","De-Identified Maximum Negotiated Charge":12374.0},{"MS-DRG":"487","Description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","De-Identified Maximum Negotiated Charge":15888.0},{"MS-DRG":"488","Description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","De-Identified Maximum Negotiated Charge":73391.0},{"MS-DRG":"489","Description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","De-Identified Maximum Negotiated Charge":14530.0},{"MS-DRG":"492","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","De-Identified Maximum Negotiated Charge":41413.0},{"MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","De-Identified Maximum Negotiated Charge":33987.0},{"MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","De-Identified Maximum Negotiated Charge":26744.0},{"MS-DRG":"496","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","De-Identified Maximum Negotiated Charge":30126.0},{"MS-DRG":"497","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","De-Identified Maximum Negotiated Charge":22955.0},{"MS-DRG":"500","Description":"Soft Tissue Procedures With Mcc","De-Identified Maximum Negotiated Charge":16822.0},{"MS-DRG":"501","Description":"Soft Tissue Procedures With Cc","De-Identified Maximum Negotiated Charge":19366.0},{"MS-DRG":"502","Description":"Soft Tissue Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":19499.0},{"MS-DRG":"504","Description":"Foot Procedures With Cc","De-Identified Maximum Negotiated Charge":9683.0},{"MS-DRG":"505","Description":"Foot Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":14561.0},{"MS-DRG":"507","Description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","De-Identified Maximum Negotiated Charge":11358.0},{"MS-DRG":"511","Description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","De-Identified Maximum Negotiated Charge":21746.0},{"MS-DRG":"513","Description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","De-Identified Maximum Negotiated Charge":6970.0},{"MS-DRG":"515","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":16949.0},{"MS-DRG":"516","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":23893.0},{"MS-DRG":"517","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":12129.0},{"MS-DRG":"518","Description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","De-Identified Maximum Negotiated Charge":19991.0},{"MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","De-Identified Maximum Negotiated Charge":67846.0},{"MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","De-Identified Maximum Negotiated Charge":15442.0},{"MS-DRG":"535","Description":"Fractures Of Hip And Pelvis With Mcc","De-Identified Maximum Negotiated Charge":15249.0},{"MS-DRG":"536","Description":"Fractures Of Hip And Pelvis Without Mcc","De-Identified Maximum Negotiated Charge":7489.0},{"MS-DRG":"539","Description":"Osteomyelitis With Mcc","De-Identified Maximum Negotiated Charge":21276.0},{"MS-DRG":"540","Description":"Osteomyelitis With Cc","De-Identified Maximum Negotiated Charge":5318.0},{"MS-DRG":"542","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","De-Identified Maximum Negotiated Charge":10160.0},{"MS-DRG":"543","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","De-Identified Maximum Negotiated Charge":10896.0},{"MS-DRG":"545","Description":"Connective Tissue Disorders With Mcc","De-Identified Maximum Negotiated Charge":13367.0},{"MS-DRG":"546","Description":"Connective Tissue Disorders With Cc","De-Identified Maximum Negotiated Charge":6519.0},{"MS-DRG":"547","Description":"Connective Tissue Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":6304.0},{"MS-DRG":"551","Description":"Medical Back Problems With Mcc","De-Identified Maximum Negotiated Charge":18343.0},{"MS-DRG":"552","Description":"Medical Back Problems Without Mcc","De-Identified Maximum Negotiated Charge":13463.0},{"MS-DRG":"554","Description":"Bone Diseases And Arthropathies Without Mcc","De-Identified Maximum Negotiated Charge":9085.0},{"MS-DRG":"555","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","De-Identified Maximum Negotiated Charge":7906.0},{"MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","De-Identified Maximum Negotiated Charge":11635.0},{"MS-DRG":"558","Description":"Tendonitis, Myositis And Bursitis Without Mcc","De-Identified Maximum Negotiated Charge":9941.0},{"MS-DRG":"559","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","De-Identified Maximum Negotiated Charge":15193.0},{"MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","De-Identified Maximum Negotiated Charge":15406.0},{"MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","De-Identified Maximum Negotiated Charge":12306.0},{"MS-DRG":"563","Description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","De-Identified Maximum Negotiated Charge":9101.0},{"MS-DRG":"565","Description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","De-Identified Maximum Negotiated Charge":5441.0},{"MS-DRG":"566","Description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","De-Identified Maximum Negotiated Charge":4561.0},{"MS-DRG":"570","Description":"Skin Debridement With Mcc","De-Identified Maximum Negotiated Charge":16580.0},{"MS-DRG":"571","Description":"Skin Debridement With Cc","De-Identified Maximum Negotiated Charge":13871.0},{"MS-DRG":"572","Description":"Skin Debridement Without Cc/Mcc","De-Identified Maximum Negotiated Charge":16561.0},{"MS-DRG":"575","Description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","De-Identified Maximum Negotiated Charge":21122.0},{"MS-DRG":"579","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","De-Identified Maximum Negotiated Charge":14101.0},{"MS-DRG":"580","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","De-Identified Maximum Negotiated Charge":23751.0},{"MS-DRG":"581","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":6680.0},{"MS-DRG":"582","Description":"Mastectomy For Malignancy With Cc/Mcc","De-Identified Maximum Negotiated Charge":13784.0},{"MS-DRG":"593","Description":"Skin Ulcers With Cc","De-Identified Maximum Negotiated Charge":15627.0},{"MS-DRG":"596","Description":"Major Skin Disorders Without Mcc","De-Identified Maximum Negotiated Charge":14030.0},{"MS-DRG":"598","Description":"Malignant Breast Disorders With Cc","De-Identified Maximum Negotiated Charge":12415.0},{"MS-DRG":"599","Description":"Malignant Breast Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7972.0},{"MS-DRG":"601","Description":"Non-Malignant Breast Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7961.0},{"MS-DRG":"602","Description":"Cellulitis With Mcc","De-Identified Maximum Negotiated Charge":8776.0},{"MS-DRG":"603","Description":"Cellulitis Without Mcc","De-Identified Maximum Negotiated Charge":17964.0},{"MS-DRG":"605","Description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","De-Identified Maximum Negotiated Charge":10106.0},{"MS-DRG":"606","Description":"Minor Skin Disorders With Mcc","De-Identified Maximum Negotiated Charge":8479.0},{"MS-DRG":"607","Description":"Minor Skin Disorders Without Mcc","De-Identified Maximum Negotiated Charge":12197.0},{"MS-DRG":"614","Description":"Adrenal And Pituitary Procedures With Cc/Mcc","De-Identified Maximum Negotiated Charge":13331.0},{"MS-DRG":"616","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","De-Identified Maximum Negotiated Charge":22368.0},{"MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","De-Identified Maximum Negotiated Charge":30285.0},{"MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","De-Identified Maximum Negotiated Charge":26101.0},{"MS-DRG":"625","Description":"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","De-Identified Maximum Negotiated Charge":33759.0},{"MS-DRG":"626","Description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","De-Identified Maximum Negotiated Charge":8957.0},{"MS-DRG":"627","Description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":6696.0},{"MS-DRG":"628","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":52699.0},{"MS-DRG":"629","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":12789.0},{"MS-DRG":"637","Description":"Diabetes With Mcc","De-Identified Maximum Negotiated Charge":20458.0},{"MS-DRG":"638","Description":"Diabetes With Cc","De-Identified Maximum Negotiated Charge":12779.0},{"MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","De-Identified Maximum Negotiated Charge":14150.0},{"MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","De-Identified Maximum Negotiated Charge":55956.0},{"MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","De-Identified Maximum Negotiated Charge":9278.0},{"MS-DRG":"643","Description":"Endocrine Disorders With Mcc","De-Identified Maximum Negotiated Charge":22415.0},{"MS-DRG":"644","Description":"Endocrine Disorders With Cc","De-Identified Maximum Negotiated Charge":11865.0},{"MS-DRG":"645","Description":"Endocrine Disorders Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7556.0},{"MS-DRG":"659","Description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","De-Identified Maximum Negotiated Charge":22887.0},{"MS-DRG":"661","Description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","De-Identified Maximum Negotiated Charge":12581.0},{"MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","De-Identified Maximum Negotiated Charge":111182.0},{"MS-DRG":"674","Description":"Other Kidney And Urinary Tract Procedures With Cc","De-Identified Maximum Negotiated Charge":28209.0},{"MS-DRG":"682","Description":"Renal Failure With Mcc","De-Identified Maximum Negotiated Charge":42389.0},{"MS-DRG":"683","Description":"Renal Failure With Cc","De-Identified Maximum Negotiated Charge":12708.0},{"MS-DRG":"684","Description":"Renal Failure Without Cc/Mcc","De-Identified Maximum Negotiated Charge":4975.0},{"MS-DRG":"689","Description":"Kidney And Urinary Tract Infections With Mcc","De-Identified Maximum Negotiated Charge":12910.0},{"MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","De-Identified Maximum Negotiated Charge":9733.0},{"MS-DRG":"693","Description":"Urinary Stones With Mcc","De-Identified Maximum Negotiated Charge":9067.0},{"MS-DRG":"694","Description":"Urinary Stones Without Mcc","De-Identified Maximum Negotiated Charge":8545.0},{"MS-DRG":"695","Description":"Kidney And Urinary Tract Signs And Symptoms With Mcc","De-Identified Maximum Negotiated Charge":6275.0},{"MS-DRG":"696","Description":"Kidney And Urinary Tract Signs And Symptoms Without Mcc","De-Identified Maximum Negotiated Charge":3823.0},{"MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","De-Identified Maximum Negotiated Charge":120385.0},{"MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","De-Identified Maximum Negotiated Charge":13470.0},{"MS-DRG":"700","Description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","De-Identified Maximum Negotiated Charge":5996.0},{"MS-DRG":"718","Description":"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","De-Identified Maximum Negotiated Charge":14073.0},{"MS-DRG":"722","Description":"Malignancy, Male Reproductive System With Mcc","De-Identified Maximum Negotiated Charge":20830.0},{"MS-DRG":"728","Description":"Inflammation Of The Male Reproductive System Without Mcc","De-Identified Maximum Negotiated Charge":5178.0},{"MS-DRG":"776","Description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","De-Identified Maximum Negotiated Charge":6948.0},{"MS-DRG":"803","Description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","De-Identified Maximum Negotiated Charge":10359.0},{"MS-DRG":"808","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","De-Identified Maximum Negotiated Charge":20155.0},{"MS-DRG":"809","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","De-Identified Maximum Negotiated Charge":12006.0},{"MS-DRG":"810","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","De-Identified Maximum Negotiated Charge":8464.0},{"MS-DRG":"811","Description":"Red Blood Cell Disorders With Mcc","De-Identified Maximum Negotiated Charge":29239.0},{"MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","De-Identified Maximum Negotiated Charge":10049.0},{"MS-DRG":"813","Description":"Coagulation Disorders","De-Identified Maximum Negotiated Charge":9297.0},{"MS-DRG":"815","Description":"Reticuloendothelial And Immunity Disorders With Cc","De-Identified Maximum Negotiated Charge":11689.0},{"MS-DRG":"822","Description":"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":12485.0},{"MS-DRG":"823","Description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","De-Identified Maximum Negotiated Charge":25203.0},{"MS-DRG":"824","Description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","De-Identified Maximum Negotiated Charge":33031.0},{"MS-DRG":"826","Description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":27342.0},{"MS-DRG":"830","Description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7771.0},{"MS-DRG":"832","Description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":10564.0},{"MS-DRG":"834","Description":"Acute Leukemia Without Major O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":43265.0},{"MS-DRG":"835","Description":"Acute Leukemia Without Major O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":41501.0},{"MS-DRG":"840","Description":"Lymphoma And Non-Acute Leukemia With Mcc","De-Identified Maximum Negotiated Charge":24389.0},{"MS-DRG":"841","Description":"Lymphoma And Non-Acute Leukemia With Cc","De-Identified Maximum Negotiated Charge":23795.0},{"MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":96838.0},{"MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":59097.0},{"MS-DRG":"855","Description":"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":23671.0},{"MS-DRG":"856","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","De-Identified Maximum Negotiated Charge":77400.0},{"MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","De-Identified Maximum Negotiated Charge":23466.0},{"MS-DRG":"858","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","De-Identified Maximum Negotiated Charge":7666.0},{"MS-DRG":"862","Description":"Postoperative And Post-Traumatic Infections With Mcc","De-Identified Maximum Negotiated Charge":15023.0},{"MS-DRG":"863","Description":"Postoperative And Post-Traumatic Infections Without Mcc","De-Identified Maximum Negotiated Charge":11403.0},{"MS-DRG":"864","Description":"Fever And Inflammatory Conditions","De-Identified Maximum Negotiated Charge":9780.0},{"MS-DRG":"865","Description":"Viral Illness With Mcc","De-Identified Maximum Negotiated Charge":7402.0},{"MS-DRG":"866","Description":"Viral Illness Without Mcc","De-Identified Maximum Negotiated Charge":9449.0},{"MS-DRG":"870","Description":"Septicemia Or Severe Sepsis With Mv >96 Hours","De-Identified Maximum Negotiated Charge":34465.0},{"MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","De-Identified Maximum Negotiated Charge":27554.0},{"MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","De-Identified Maximum Negotiated Charge":26779.0},{"MS-DRG":"880","Description":"Acute Adjustment Reaction And Psychosocial Dysfunction","De-Identified Maximum Negotiated Charge":12818.0},{"MS-DRG":"882","Description":"Neuroses Except Depressive","De-Identified Maximum Negotiated Charge":4442.0},{"MS-DRG":"884","Description":"Organic Disturbances And Intellectual Disability","De-Identified Maximum Negotiated Charge":10119.0},{"MS-DRG":"885","Description":"Psychoses","De-Identified Maximum Negotiated Charge":6512.0},{"MS-DRG":"896","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","De-Identified Maximum Negotiated Charge":110652.0},{"MS-DRG":"897","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","De-Identified Maximum Negotiated Charge":12133.0},{"MS-DRG":"901","Description":"Wound Debridements For Injuries With Mcc","De-Identified Maximum Negotiated Charge":23881.0},{"MS-DRG":"902","Description":"Wound Debridements For Injuries With Cc","De-Identified Maximum Negotiated Charge":10182.0},{"MS-DRG":"903","Description":"Wound Debridements For Injuries Without Cc/Mcc","De-Identified Maximum Negotiated Charge":6291.0},{"MS-DRG":"904","Description":"Skin Grafts For Injuries With Cc/Mcc","De-Identified Maximum Negotiated Charge":19758.0},{"MS-DRG":"907","Description":"Other O.R. Procedures For Injuries With Mcc","De-Identified Maximum Negotiated Charge":22593.0},{"MS-DRG":"908","Description":"Other O.R. Procedures For Injuries With Cc","De-Identified Maximum Negotiated Charge":47671.0},{"MS-DRG":"909","Description":"Other O.R. Procedures For Injuries Without Cc/Mcc","De-Identified Maximum Negotiated Charge":19469.0},{"MS-DRG":"914","Description":"Traumatic Injury Without Mcc","De-Identified Maximum Negotiated Charge":4671.0},{"MS-DRG":"915","Description":"Allergic Reactions With Mcc","De-Identified Maximum Negotiated Charge":19609.0},{"MS-DRG":"916","Description":"Allergic Reactions Without Mcc","De-Identified Maximum Negotiated Charge":3686.0},{"MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","De-Identified Maximum Negotiated Charge":16887.0},{"MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","De-Identified Maximum Negotiated Charge":11575.0},{"MS-DRG":"919","Description":"Complications Of Treatment With Mcc","De-Identified Maximum Negotiated Charge":9926.0},{"MS-DRG":"920","Description":"Complications Of Treatment With Cc","De-Identified Maximum Negotiated Charge":14875.0},{"MS-DRG":"921","Description":"Complications Of Treatment Without Cc/Mcc","De-Identified Maximum Negotiated Charge":5583.0},{"MS-DRG":"923","Description":"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","De-Identified Maximum Negotiated Charge":4759.0},{"MS-DRG":"935","Description":"Non-Extensive Burns","De-Identified Maximum Negotiated Charge":9839.0},{"MS-DRG":"939","Description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","De-Identified Maximum Negotiated Charge":18717.0},{"MS-DRG":"940","Description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","De-Identified Maximum Negotiated Charge":26219.0},{"MS-DRG":"945","Description":"Rehabilitation With Cc/Mcc","De-Identified Maximum Negotiated Charge":24839.0},{"MS-DRG":"946","Description":"Rehabilitation Without Cc/Mcc","De-Identified Maximum Negotiated Charge":22928.0},{"MS-DRG":"947","Description":"Signs And Symptoms With Mcc","De-Identified Maximum Negotiated Charge":17677.0},{"MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","De-Identified Maximum Negotiated Charge":19058.0},{"MS-DRG":"949","Description":"Aftercare With Cc/Mcc","De-Identified Maximum Negotiated Charge":21101.0},{"MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","De-Identified Maximum Negotiated Charge":10027.0},{"MS-DRG":"956","Description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","De-Identified Maximum Negotiated Charge":21476.0},{"MS-DRG":"964","Description":"Other Multiple Significant Trauma With Cc","De-Identified Maximum Negotiated Charge":8538.0},{"MS-DRG":"974","Description":"Hiv With Major Related Condition With Mcc","De-Identified Maximum Negotiated Charge":21899.0},{"MS-DRG":"977","Description":"Hiv With Or Without Other Related Condition","De-Identified Maximum Negotiated Charge":15009.0},{"MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","De-Identified Maximum Negotiated Charge":198106.0},{"MS-DRG":"982","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","De-Identified Maximum Negotiated Charge":56875.0},{"MS-DRG":"983","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","De-Identified Maximum Negotiated Charge":18894.0},{"MS-DRG":"987","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","De-Identified Maximum Negotiated Charge":97154.0},{"MS-DRG":"988","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","De-Identified Maximum Negotiated Charge":26608.0}],"Inpatient Payer Specific Charge 1":[{"Payer":"Ambetter Exchange","MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","Payer Specific Negotiated Charge":375543.0},{"Payer":"Ambetter Exchange","MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","Payer Specific Negotiated Charge":242448.0},{"Payer":"Ambetter Exchange","MS-DRG":"021","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","Payer Specific Negotiated Charge":82587.0},{"Payer":"Ambetter Exchange","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":79181.0},{"Payer":"Ambetter Exchange","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":31539.0},{"Payer":"Ambetter Exchange","MS-DRG":"038","Description":"Extracranial Procedures With Cc","Payer Specific Negotiated Charge":14533.0},{"Payer":"Ambetter Exchange","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9980.0},{"Payer":"Ambetter Exchange","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":44594.0},{"Payer":"Ambetter Exchange","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":8309.0},{"Payer":"Ambetter Exchange","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":8569.0},{"Payer":"Ambetter Exchange","MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","Payer Specific Negotiated Charge":9435.0},{"Payer":"Ambetter Exchange","MS-DRG":"073","Description":"Cranial And Peripheral Nerve Disorders With Mcc","Payer Specific Negotiated Charge":405183.0},{"Payer":"Ambetter Exchange","MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","Payer Specific Negotiated Charge":8435.0},{"Payer":"Ambetter Exchange","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":7811.0},{"Payer":"Ambetter Exchange","MS-DRG":"096","Description":"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":10128.0},{"Payer":"Ambetter Exchange","MS-DRG":"100","Description":"Seizures With Mcc","Payer Specific Negotiated Charge":24248.0},{"Payer":"Ambetter Exchange","MS-DRG":"163","Description":"Major Chest Procedures With Mcc","Payer Specific Negotiated Charge":53600.0},{"Payer":"Ambetter Exchange","MS-DRG":"164","Description":"Major Chest Procedures With Cc","Payer Specific Negotiated Charge":24570.0},{"Payer":"Ambetter Exchange","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":17372.0},{"Payer":"Ambetter Exchange","MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":12830.0},{"Payer":"Ambetter Exchange","MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","Payer Specific Negotiated Charge":11678.0},{"Payer":"Ambetter Exchange","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":6859.0},{"Payer":"Ambetter Exchange","MS-DRG":"184","Description":"Major Chest Trauma With Cc","Payer Specific Negotiated Charge":8232.0},{"Payer":"Ambetter Exchange","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":21945.0},{"Payer":"Ambetter Exchange","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":10415.0},{"Payer":"Ambetter Exchange","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":7891.0},{"Payer":"Ambetter Exchange","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":11652.0},{"Payer":"Ambetter Exchange","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":7817.0},{"Payer":"Ambetter Exchange","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":8480.0},{"Payer":"Ambetter Exchange","MS-DRG":"203","Description":"Bronchitis And Asthma Without Cc/Mcc","Payer Specific Negotiated Charge":5609.0},{"Payer":"Ambetter Exchange","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":23138.0},{"Payer":"Ambetter Exchange","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":173303.0},{"Payer":"Ambetter Exchange","MS-DRG":"217","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Cc","Payer Specific Negotiated Charge":114647.0},{"Payer":"Ambetter Exchange","MS-DRG":"219","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":95558.0},{"Payer":"Ambetter Exchange","MS-DRG":"220","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","Payer Specific Negotiated Charge":84096.0},{"Payer":"Ambetter Exchange","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":71255.0},{"Payer":"Ambetter Exchange","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":99782.0},{"Payer":"Ambetter Exchange","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":57930.0},{"Payer":"Ambetter Exchange","MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","Payer Specific Negotiated Charge":27638.0},{"Payer":"Ambetter Exchange","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":33316.0},{"Payer":"Ambetter Exchange","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":22361.0},{"Payer":"Ambetter Exchange","MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":32384.0},{"Payer":"Ambetter Exchange","MS-DRG":"253","Description":"Other Vascular Procedures With Cc","Payer Specific Negotiated Charge":33469.0},{"Payer":"Ambetter Exchange","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":15628.0},{"Payer":"Ambetter Exchange","MS-DRG":"264","Description":"Other Circulatory System O.R. Procedures","Payer Specific Negotiated Charge":107037.0},{"Payer":"Ambetter Exchange","MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","Payer Specific Negotiated Charge":107390.0},{"Payer":"Ambetter Exchange","MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","Payer Specific Negotiated Charge":83861.0},{"Payer":"Ambetter Exchange","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":30890.0},{"Payer":"Ambetter Exchange","MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":26189.0},{"Payer":"Ambetter Exchange","MS-DRG":"273","Description":"Percutaneous And Other Intracardiac Procedures With Mcc","Payer Specific Negotiated Charge":41644.0},{"Payer":"Ambetter Exchange","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":39600.0},{"Payer":"Ambetter Exchange","MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","Payer Specific Negotiated Charge":8337.0},{"Payer":"Ambetter Exchange","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":5966.0},{"Payer":"Ambetter Exchange","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":18455.0},{"Payer":"Ambetter Exchange","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":9889.0},{"Payer":"Ambetter Exchange","MS-DRG":"289","Description":"Acute And Subacute Endocarditis With Cc","Payer Specific Negotiated Charge":14399.0},{"Payer":"Ambetter Exchange","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":13408.0},{"Payer":"Ambetter Exchange","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":7965.0},{"Payer":"Ambetter Exchange","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":5710.0},{"Payer":"Ambetter Exchange","MS-DRG":"296","Description":"Cardiac Arrest, Unexplained With Mcc","Payer Specific Negotiated Charge":17824.0},{"Payer":"Ambetter Exchange","MS-DRG":"297","Description":"Cardiac Arrest, Unexplained With Cc","Payer Specific Negotiated Charge":45437.0},{"Payer":"Ambetter Exchange","MS-DRG":"300","Description":"Peripheral Vascular Disorders With Cc","Payer Specific Negotiated Charge":8308.0},{"Payer":"Ambetter Exchange","MS-DRG":"302","Description":"Atherosclerosis With Mcc","Payer Specific Negotiated Charge":8912.0},{"Payer":"Ambetter Exchange","MS-DRG":"303","Description":"Atherosclerosis Without Mcc","Payer Specific Negotiated Charge":24223.0},{"Payer":"Ambetter Exchange","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":10235.0},{"Payer":"Ambetter Exchange","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":6115.0},{"Payer":"Ambetter Exchange","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":4522.0},{"Payer":"Ambetter Exchange","MS-DRG":"311","Description":"Angina Pectoris","Payer Specific Negotiated Charge":6107.0},{"Payer":"Ambetter Exchange","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":6602.0},{"Payer":"Ambetter Exchange","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":6366.0},{"Payer":"Ambetter Exchange","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":8693.0},{"Payer":"Ambetter Exchange","MS-DRG":"316","Description":"Other Circulatory System Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":6001.0},{"Payer":"Ambetter Exchange","MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","Payer Specific Negotiated Charge":43145.0},{"Payer":"Ambetter Exchange","MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":15339.0},{"Payer":"Ambetter Exchange","MS-DRG":"336","Description":"Peritoneal Adhesiolysis With Cc","Payer Specific Negotiated Charge":20143.0},{"Payer":"Ambetter Exchange","MS-DRG":"354","Description":"Hernia Procedures Except Inguinal And Femoral With Cc","Payer Specific Negotiated Charge":16170.0},{"Payer":"Ambetter Exchange","MS-DRG":"355","Description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","Payer Specific Negotiated Charge":16205.0},{"Payer":"Ambetter Exchange","MS-DRG":"357","Description":"Other Digestive System O.R. Procedures With Cc","Payer Specific Negotiated Charge":24004.0},{"Payer":"Ambetter Exchange","MS-DRG":"371","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","Payer Specific Negotiated Charge":19557.0},{"Payer":"Ambetter Exchange","MS-DRG":"373","Description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","Payer Specific Negotiated Charge":6795.0},{"Payer":"Ambetter Exchange","MS-DRG":"375","Description":"Digestive Malignancy With Cc","Payer Specific Negotiated Charge":15778.0},{"Payer":"Ambetter Exchange","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":8605.0},{"Payer":"Ambetter Exchange","MS-DRG":"379","Description":"Gastrointestinal Hemorrhage Without Cc/Mcc","Payer Specific Negotiated Charge":5220.0},{"Payer":"Ambetter Exchange","MS-DRG":"386","Description":"Inflammatory Bowel Disease With Cc","Payer Specific Negotiated Charge":9082.0},{"Payer":"Ambetter Exchange","MS-DRG":"388","Description":"Gastrointestinal Obstruction With Mcc","Payer Specific Negotiated Charge":14142.0},{"Payer":"Ambetter Exchange","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":5487.0},{"Payer":"Ambetter Exchange","MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","Payer Specific Negotiated Charge":13382.0},{"Payer":"Ambetter Exchange","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":6779.0},{"Payer":"Ambetter Exchange","MS-DRG":"394","Description":"Other Digestive System Diagnoses With Cc","Payer Specific Negotiated Charge":7584.0},{"Payer":"Ambetter Exchange","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":11632.0},{"Payer":"Ambetter Exchange","MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":19520.0},{"Payer":"Ambetter Exchange","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":14009.0},{"Payer":"Ambetter Exchange","MS-DRG":"443","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","Payer Specific Negotiated Charge":5500.0},{"Payer":"Ambetter Exchange","MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","Payer Specific Negotiated Charge":8687.0},{"Payer":"Ambetter Exchange","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":71589.0},{"Payer":"Ambetter Exchange","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":58232.0},{"Payer":"Ambetter Exchange","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":46105.0},{"Payer":"Ambetter Exchange","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":40029.0},{"Payer":"Ambetter Exchange","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":29435.0},{"Payer":"Ambetter Exchange","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":31274.0},{"Payer":"Ambetter Exchange","MS-DRG":"478","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":27461.0},{"Payer":"Ambetter Exchange","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":24769.0},{"Payer":"Ambetter Exchange","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":31927.0},{"Payer":"Ambetter Exchange","MS-DRG":"497","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":22955.0},{"Payer":"Ambetter Exchange","MS-DRG":"516","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","Payer Specific Negotiated Charge":23893.0},{"Payer":"Ambetter Exchange","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":16856.0},{"Payer":"Ambetter Exchange","MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":13736.0},{"Payer":"Ambetter Exchange","MS-DRG":"543","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","Payer Specific Negotiated Charge":10896.0},{"Payer":"Ambetter Exchange","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":13407.0},{"Payer":"Ambetter Exchange","MS-DRG":"554","Description":"Bone Diseases And Arthropathies Without Mcc","Payer Specific Negotiated Charge":7138.0},{"Payer":"Ambetter Exchange","MS-DRG":"559","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":15193.0},{"Payer":"Ambetter Exchange","MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":12306.0},{"Payer":"Ambetter Exchange","MS-DRG":"580","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","Payer Specific Negotiated Charge":14604.0},{"Payer":"Ambetter Exchange","MS-DRG":"582","Description":"Mastectomy For Malignancy With Cc/Mcc","Payer Specific Negotiated Charge":13784.0},{"Payer":"Ambetter Exchange","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":8200.0},{"Payer":"Ambetter Exchange","MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":17105.0},{"Payer":"Ambetter Exchange","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":11203.0},{"Payer":"Ambetter Exchange","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":8577.0},{"Payer":"Ambetter Exchange","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":6127.0},{"Payer":"Ambetter Exchange","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":6714.0},{"Payer":"Ambetter Exchange","MS-DRG":"645","Description":"Endocrine Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":7303.0},{"Payer":"Ambetter Exchange","MS-DRG":"659","Description":"Kidney And Ureter Procedures For Non-Neoplasm With Mcc","Payer Specific Negotiated Charge":22887.0},{"Payer":"Ambetter Exchange","MS-DRG":"661","Description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","Payer Specific Negotiated Charge":9645.0},{"Payer":"Ambetter Exchange","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":32649.0},{"Payer":"Ambetter Exchange","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":11949.0},{"Payer":"Ambetter Exchange","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":7254.0},{"Payer":"Ambetter Exchange","MS-DRG":"684","Description":"Renal Failure Without Cc/Mcc","Payer Specific Negotiated Charge":4975.0},{"Payer":"Ambetter Exchange","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":6393.0},{"Payer":"Ambetter Exchange","MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","Payer Specific Negotiated Charge":9852.0},{"Payer":"Ambetter Exchange","MS-DRG":"700","Description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":5996.0},{"Payer":"Ambetter Exchange","MS-DRG":"808","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","Payer Specific Negotiated Charge":20155.0},{"Payer":"Ambetter Exchange","MS-DRG":"809","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","Payer Specific Negotiated Charge":11529.0},{"Payer":"Ambetter Exchange","MS-DRG":"810","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","Payer Specific Negotiated Charge":8464.0},{"Payer":"Ambetter Exchange","MS-DRG":"811","Description":"Red Blood Cell Disorders With Mcc","Payer Specific Negotiated Charge":12797.0},{"Payer":"Ambetter Exchange","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":73779.0},{"Payer":"Ambetter Exchange","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":39284.0},{"Payer":"Ambetter Exchange","MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","Payer Specific Negotiated Charge":17660.0},{"Payer":"Ambetter Exchange","MS-DRG":"864","Description":"Fever And Inflammatory Conditions","Payer Specific Negotiated Charge":6851.0},{"Payer":"Ambetter Exchange","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":15858.0},{"Payer":"Ambetter Exchange","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":9455.0},{"Payer":"Ambetter Exchange","MS-DRG":"897","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","Payer Specific Negotiated Charge":7091.0},{"Payer":"Ambetter Exchange","MS-DRG":"908","Description":"Other O.R. Procedures For Injuries With Cc","Payer Specific Negotiated Charge":26594.0},{"Payer":"Ambetter Exchange","MS-DRG":"909","Description":"Other O.R. Procedures For Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":12725.0},{"Payer":"Ambetter Exchange","MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","Payer Specific Negotiated Charge":7500.0},{"Payer":"Ambetter Exchange","MS-DRG":"921","Description":"Complications Of Treatment Without Cc/Mcc","Payer Specific Negotiated Charge":5583.0},{"Payer":"Ambetter Exchange","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":6303.0},{"Payer":"Ambetter Exchange","MS-DRG":"949","Description":"Aftercare With Cc/Mcc","Payer Specific Negotiated Charge":21101.0},{"Payer":"Ambetter Exchange","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":10027.0},{"Payer":"Ambetter Exchange","MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":61080.0},{"Payer":"Ambetter Exchange","MS-DRG":"988","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","Payer Specific Negotiated Charge":26608.0}],"Inpatient Payer Specific Charge 2":[{"Payer":"BCBS HMO","MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","Payer Specific Negotiated Charge":302227.0},{"Payer":"BCBS HMO","MS-DRG":"020","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","Payer Specific Negotiated Charge":172978.0},{"Payer":"BCBS HMO","MS-DRG":"023","Description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera","Payer Specific Negotiated Charge":80667.0},{"Payer":"BCBS HMO","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":43391.0},{"Payer":"BCBS HMO","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":30074.0},{"Payer":"BCBS HMO","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":23665.0},{"Payer":"BCBS HMO","MS-DRG":"038","Description":"Extracranial Procedures With Cc","Payer Specific Negotiated Charge":16541.0},{"Payer":"BCBS HMO","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":11170.0},{"Payer":"BCBS HMO","MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","Payer Specific Negotiated Charge":18512.0},{"Payer":"BCBS HMO","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":10148.0},{"Payer":"BCBS HMO","MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","Payer Specific Negotiated Charge":7705.0},{"Payer":"BCBS HMO","MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","Payer Specific Negotiated Charge":9757.0},{"Payer":"BCBS HMO","MS-DRG":"076","Description":"Viral Meningitis Without Cc/Mcc","Payer Specific Negotiated Charge":8911.0},{"Payer":"BCBS HMO","MS-DRG":"079","Description":"Hypertensive Encephalopathy Without Cc/Mcc","Payer Specific Negotiated Charge":7318.0},{"Payer":"BCBS HMO","MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":8860.0},{"Payer":"BCBS HMO","MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","Payer Specific Negotiated Charge":15454.0},{"Payer":"BCBS HMO","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":9539.0},{"Payer":"BCBS HMO","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":8718.0},{"Payer":"BCBS HMO","MS-DRG":"153","Description":"Otitis Media And Uri Without Mcc","Payer Specific Negotiated Charge":6975.0},{"Payer":"BCBS HMO","MS-DRG":"157","Description":"Dental And Oral Diseases With Mcc","Payer Specific Negotiated Charge":14512.0},{"Payer":"BCBS HMO","MS-DRG":"164","Description":"Major Chest Procedures With Cc","Payer Specific Negotiated Charge":24997.0},{"Payer":"BCBS HMO","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":18259.0},{"Payer":"BCBS HMO","MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","Payer Specific Negotiated Charge":14262.0},{"Payer":"BCBS HMO","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":8377.0},{"Payer":"BCBS HMO","MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","Payer Specific Negotiated Charge":18674.0},{"Payer":"BCBS HMO","MS-DRG":"180","Description":"Respiratory Neoplasms With Mcc","Payer Specific Negotiated Charge":17032.0},{"Payer":"BCBS HMO","MS-DRG":"181","Description":"Respiratory Neoplasms With Cc","Payer Specific Negotiated Charge":11375.0},{"Payer":"BCBS HMO","MS-DRG":"187","Description":"Pleural Effusion With Cc","Payer Specific Negotiated Charge":10149.0},{"Payer":"BCBS HMO","MS-DRG":"188","Description":"Pleural Effusion Without Cc/Mcc","Payer Specific Negotiated Charge":7217.0},{"Payer":"BCBS HMO","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":12004.0},{"Payer":"BCBS HMO","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":11296.0},{"Payer":"BCBS HMO","MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","Payer Specific Negotiated Charge":7003.0},{"Payer":"BCBS HMO","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":13167.0},{"Payer":"BCBS HMO","MS-DRG":"198","Description":"Interstitial Lung Disease Without Cc/Mcc","Payer Specific Negotiated Charge":7455.0},{"Payer":"BCBS HMO","MS-DRG":"201","Description":"Pneumothorax Without Cc/Mcc","Payer Specific Negotiated Charge":7090.0},{"Payer":"BCBS HMO","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":9361.0},{"Payer":"BCBS HMO","MS-DRG":"205","Description":"Other Respiratory System Diagnoses With Mcc","Payer Specific Negotiated Charge":16136.0},{"Payer":"BCBS HMO","MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","Payer Specific Negotiated Charge":75789.0},{"Payer":"BCBS HMO","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":31604.0},{"Payer":"BCBS HMO","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":229594.0},{"Payer":"BCBS HMO","MS-DRG":"219","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":157665.0},{"Payer":"BCBS HMO","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":100139.0},{"Payer":"BCBS HMO","MS-DRG":"225","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","Payer Specific Negotiated Charge":55776.0},{"Payer":"BCBS HMO","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":73109.0},{"Payer":"BCBS HMO","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":56247.0},{"Payer":"BCBS HMO","MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","Payer Specific Negotiated Charge":24975.0},{"Payer":"BCBS HMO","MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","Payer Specific Negotiated Charge":20493.0},{"Payer":"BCBS HMO","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":137727.0},{"Payer":"BCBS HMO","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":20091.0},{"Payer":"BCBS HMO","MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":30575.0},{"Payer":"BCBS HMO","MS-DRG":"252","Description":"Other Vascular Procedures With Mcc","Payer Specific Negotiated Charge":127506.0},{"Payer":"BCBS HMO","MS-DRG":"253","Description":"Other Vascular Procedures With Cc","Payer Specific Negotiated Charge":35325.0},{"Payer":"BCBS HMO","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":17972.0},{"Payer":"BCBS HMO","MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","Payer Specific Negotiated Charge":96930.0},{"Payer":"BCBS HMO","MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","Payer Specific Negotiated Charge":42126.0},{"Payer":"BCBS HMO","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":39374.0},{"Payer":"BCBS HMO","MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":25685.0},{"Payer":"BCBS HMO","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":31200.0},{"Payer":"BCBS HMO","MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","Payer Specific Negotiated Charge":118776.0},{"Payer":"BCBS HMO","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":7286.0},{"Payer":"BCBS HMO","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":21697.0},{"Payer":"BCBS HMO","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":11377.0},{"Payer":"BCBS HMO","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":13288.0},{"Payer":"BCBS HMO","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":8941.0},{"Payer":"BCBS HMO","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":6470.0},{"Payer":"BCBS HMO","MS-DRG":"296","Description":"Cardiac Arrest, Unexplained With Mcc","Payer Specific Negotiated Charge":46238.0},{"Payer":"BCBS HMO","MS-DRG":"304","Description":"Hypertension With Mcc","Payer Specific Negotiated Charge":10777.0},{"Payer":"BCBS HMO","MS-DRG":"305","Description":"Hypertension Without Mcc","Payer Specific Negotiated Charge":7223.0},{"Payer":"BCBS HMO","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":7468.0},{"Payer":"BCBS HMO","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":5523.0},{"Payer":"BCBS HMO","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":8063.0},{"Payer":"BCBS HMO","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":7063.0},{"Payer":"BCBS HMO","MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","Payer Specific Negotiated Charge":41708.0},{"Payer":"BCBS HMO","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":24950.0},{"Payer":"BCBS HMO","MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":16679.0},{"Payer":"BCBS HMO","MS-DRG":"336","Description":"Peritoneal Adhesiolysis With Cc","Payer Specific Negotiated Charge":22376.0},{"Payer":"BCBS HMO","MS-DRG":"337","Description":"Peritoneal Adhesiolysis Without Cc/Mcc","Payer Specific Negotiated Charge":16190.0},{"Payer":"BCBS HMO","MS-DRG":"340","Description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":12219.0},{"Payer":"BCBS HMO","MS-DRG":"343","Description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":11371.0},{"Payer":"BCBS HMO","MS-DRG":"355","Description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","Payer Specific Negotiated Charge":13551.0},{"Payer":"BCBS HMO","MS-DRG":"370","Description":"Major Esophageal Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":7379.0},{"Payer":"BCBS HMO","MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","Payer Specific Negotiated Charge":10096.0},{"Payer":"BCBS HMO","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":9757.0},{"Payer":"BCBS HMO","MS-DRG":"387","Description":"Inflammatory Bowel Disease Without Cc/Mcc","Payer Specific Negotiated Charge":6919.0},{"Payer":"BCBS HMO","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":5723.0},{"Payer":"BCBS HMO","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":7519.0},{"Payer":"BCBS HMO","MS-DRG":"395","Description":"Other Digestive System Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":6462.0},{"Payer":"BCBS HMO","MS-DRG":"410","Description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":16391.0},{"Payer":"BCBS HMO","MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","Payer Specific Negotiated Charge":20259.0},{"Payer":"BCBS HMO","MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":13333.0},{"Payer":"BCBS HMO","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":16479.0},{"Payer":"BCBS HMO","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":12903.0},{"Payer":"BCBS HMO","MS-DRG":"432","Description":"Cirrhosis And Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":18004.0},{"Payer":"BCBS HMO","MS-DRG":"433","Description":"Cirrhosis And Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":10190.0},{"Payer":"BCBS HMO","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":8365.0},{"Payer":"BCBS HMO","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":6078.0},{"Payer":"BCBS HMO","MS-DRG":"444","Description":"Disorders Of The Biliary Tract With Mcc","Payer Specific Negotiated Charge":16056.0},{"Payer":"BCBS HMO","MS-DRG":"446","Description":"Disorders Of The Biliary Tract Without Cc/Mcc","Payer Specific Negotiated Charge":8025.0},{"Payer":"BCBS HMO","MS-DRG":"453","Description":"Combined Anterior And Posterior Spinal Fusion With Mcc","Payer Specific Negotiated Charge":93090.0},{"Payer":"BCBS HMO","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":157151.0},{"Payer":"BCBS HMO","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":48938.0},{"Payer":"BCBS HMO","MS-DRG":"457","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","Payer Specific Negotiated Charge":75336.0},{"Payer":"BCBS HMO","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":39105.0},{"Payer":"BCBS HMO","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":70416.0},{"Payer":"BCBS HMO","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":19436.0},{"Payer":"BCBS HMO","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":30032.0},{"Payer":"BCBS HMO","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":24807.0},{"Payer":"BCBS HMO","MS-DRG":"475","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","Payer Specific Negotiated Charge":20745.0},{"Payer":"BCBS HMO","MS-DRG":"480","Description":"Hip And Femur Procedures Except Major Joint With Mcc","Payer Specific Negotiated Charge":29805.0},{"Payer":"BCBS HMO","MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","Payer Specific Negotiated Charge":16246.0},{"Payer":"BCBS HMO","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":23620.0},{"Payer":"BCBS HMO","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":17886.0},{"Payer":"BCBS HMO","MS-DRG":"496","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","Payer Specific Negotiated Charge":20148.0},{"Payer":"BCBS HMO","MS-DRG":"501","Description":"Soft Tissue Procedures With Cc","Payer Specific Negotiated Charge":16569.0},{"Payer":"BCBS HMO","MS-DRG":"536","Description":"Fractures Of Hip And Pelvis Without Mcc","Payer Specific Negotiated Charge":7489.0},{"Payer":"BCBS HMO","MS-DRG":"551","Description":"Medical Back Problems With Mcc","Payer Specific Negotiated Charge":15694.0},{"Payer":"BCBS HMO","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":9004.0},{"Payer":"BCBS HMO","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":7818.0},{"Payer":"BCBS HMO","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":8329.0},{"Payer":"BCBS HMO","MS-DRG":"607","Description":"Minor Skin Disorders Without Mcc","Payer Specific Negotiated Charge":8157.0},{"Payer":"BCBS HMO","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":21679.0},{"Payer":"BCBS HMO","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":13682.0},{"Payer":"BCBS HMO","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":8730.0},{"Payer":"BCBS HMO","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":6055.0},{"Payer":"BCBS HMO","MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","Payer Specific Negotiated Charge":11989.0},{"Payer":"BCBS HMO","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":7471.0},{"Payer":"BCBS HMO","MS-DRG":"644","Description":"Endocrine Disorders With Cc","Payer Specific Negotiated Charge":10151.0},{"Payer":"BCBS HMO","MS-DRG":"645","Description":"Endocrine Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":7556.0},{"Payer":"BCBS HMO","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":27826.0},{"Payer":"BCBS HMO","MS-DRG":"674","Description":"Other Kidney And Urinary Tract Procedures With Cc","Payer Specific Negotiated Charge":24134.0},{"Payer":"BCBS HMO","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":8860.0},{"Payer":"BCBS HMO","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":7808.0},{"Payer":"BCBS HMO","MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","Payer Specific Negotiated Charge":10197.0},{"Payer":"BCBS HMO","MS-DRG":"809","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","Payer Specific Negotiated Charge":12006.0},{"Payer":"BCBS HMO","MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","Payer Specific Negotiated Charge":8597.0},{"Payer":"BCBS HMO","MS-DRG":"822","Description":"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":12485.0},{"Payer":"BCBS HMO","MS-DRG":"835","Description":"Acute Leukemia Without Major O.R. Procedures With Cc","Payer Specific Negotiated Charge":41501.0},{"Payer":"BCBS HMO","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":96838.0},{"Payer":"BCBS HMO","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":21340.0},{"Payer":"BCBS HMO","MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","Payer Specific Negotiated Charge":20077.0},{"Payer":"BCBS HMO","MS-DRG":"863","Description":"Postoperative And Post-Traumatic Infections Without Mcc","Payer Specific Negotiated Charge":9756.0},{"Payer":"BCBS HMO","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":18428.0},{"Payer":"BCBS HMO","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":10262.0},{"Payer":"BCBS HMO","MS-DRG":"909","Description":"Other O.R. Procedures For Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":13021.0},{"Payer":"BCBS HMO","MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","Payer Specific Negotiated Charge":7775.0},{"Payer":"BCBS HMO","MS-DRG":"920","Description":"Complications Of Treatment With Cc","Payer Specific Negotiated Charge":9948.0},{"Payer":"BCBS HMO","MS-DRG":"945","Description":"Rehabilitation With Cc/Mcc","Payer Specific Negotiated Charge":21973.0},{"Payer":"BCBS HMO","MS-DRG":"946","Description":"Rehabilitation Without Cc/Mcc","Payer Specific Negotiated Charge":22928.0},{"Payer":"BCBS HMO","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":7698.0},{"Payer":"BCBS HMO","MS-DRG":"987","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":32917.0}],"Inpatient Payer Specific Charge 3":[{"Payer":"BCBS PPO","MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","Payer Specific Negotiated Charge":370110.0},{"Payer":"BCBS PPO","MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","Payer Specific Negotiated Charge":573703.0},{"Payer":"BCBS PPO","MS-DRG":"021","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","Payer Specific Negotiated Charge":143054.0},{"Payer":"BCBS PPO","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":72179.0},{"Payer":"BCBS PPO","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":35152.0},{"Payer":"BCBS PPO","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":27660.0},{"Payer":"BCBS PPO","MS-DRG":"029","Description":"Spinal Procedures With Cc Or Spinal Neurostimulators","Payer Specific Negotiated Charge":37012.0},{"Payer":"BCBS PPO","MS-DRG":"038","Description":"Extracranial Procedures With Cc","Payer Specific Negotiated Charge":19334.0},{"Payer":"BCBS PPO","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":13056.0},{"Payer":"BCBS PPO","MS-DRG":"042","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":21331.0},{"Payer":"BCBS PPO","MS-DRG":"053","Description":"Spinal Disorders And Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":11150.0},{"Payer":"BCBS PPO","MS-DRG":"054","Description":"Nervous System Neoplasms With Mcc","Payer Specific Negotiated Charge":15466.0},{"Payer":"BCBS PPO","MS-DRG":"055","Description":"Nervous System Neoplasms Without Mcc","Payer Specific Negotiated Charge":6764.0},{"Payer":"BCBS PPO","MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","Payer Specific Negotiated Charge":12632.0},{"Payer":"BCBS PPO","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":29294.0},{"Payer":"BCBS PPO","MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","Payer Specific Negotiated Charge":17342.0},{"Payer":"BCBS PPO","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":11861.0},{"Payer":"BCBS PPO","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":8275.0},{"Payer":"BCBS PPO","MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","Payer Specific Negotiated Charge":9005.0},{"Payer":"BCBS PPO","MS-DRG":"070","Description":"Nonspecific Cerebrovascular Disorders With Mcc","Payer Specific Negotiated Charge":4968.0},{"Payer":"BCBS PPO","MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","Payer Specific Negotiated Charge":11480.0},{"Payer":"BCBS PPO","MS-DRG":"072","Description":"Nonspecific Cerebrovascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":8523.0},{"Payer":"BCBS PPO","MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","Payer Specific Negotiated Charge":11404.0},{"Payer":"BCBS PPO","MS-DRG":"078","Description":"Hypertensive Encephalopathy With Cc","Payer Specific Negotiated Charge":11102.0},{"Payer":"BCBS PPO","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":11150.0},{"Payer":"BCBS PPO","MS-DRG":"094","Description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","Payer Specific Negotiated Charge":41372.0},{"Payer":"BCBS PPO","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":10190.0},{"Payer":"BCBS PPO","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":9227.0},{"Payer":"BCBS PPO","MS-DRG":"149","Description":"Dysequilibrium","Payer Specific Negotiated Charge":8431.0},{"Payer":"BCBS PPO","MS-DRG":"153","Description":"Otitis Media And Uri Without Mcc","Payer Specific Negotiated Charge":8153.0},{"Payer":"BCBS PPO","MS-DRG":"163","Description":"Major Chest Procedures With Mcc","Payer Specific Negotiated Charge":56248.0},{"Payer":"BCBS PPO","MS-DRG":"164","Description":"Major Chest Procedures With Cc","Payer Specific Negotiated Charge":29217.0},{"Payer":"BCBS PPO","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":21342.0},{"Payer":"BCBS PPO","MS-DRG":"166","Description":"Other Respiratory System O.R. Procedures With Mcc","Payer Specific Negotiated Charge":50977.0},{"Payer":"BCBS PPO","MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":15312.0},{"Payer":"BCBS PPO","MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","Payer Specific Negotiated Charge":16670.0},{"Payer":"BCBS PPO","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":9791.0},{"Payer":"BCBS PPO","MS-DRG":"184","Description":"Major Chest Trauma With Cc","Payer Specific Negotiated Charge":11751.0},{"Payer":"BCBS PPO","MS-DRG":"187","Description":"Pleural Effusion With Cc","Payer Specific Negotiated Charge":11863.0},{"Payer":"BCBS PPO","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":14030.0},{"Payer":"BCBS PPO","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":13203.0},{"Payer":"BCBS PPO","MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","Payer Specific Negotiated Charge":8185.0},{"Payer":"BCBS PPO","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":15390.0},{"Payer":"BCBS PPO","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":10255.0},{"Payer":"BCBS PPO","MS-DRG":"197","Description":"Interstitial Lung Disease With Cc","Payer Specific Negotiated Charge":11789.0},{"Payer":"BCBS PPO","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":10941.0},{"Payer":"BCBS PPO","MS-DRG":"204","Description":"Respiratory Signs And Symptoms","Payer Specific Negotiated Charge":9377.0},{"Payer":"BCBS PPO","MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","Payer Specific Negotiated Charge":163701.0},{"Payer":"BCBS PPO","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":28669.0},{"Payer":"BCBS PPO","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":301229.0},{"Payer":"BCBS PPO","MS-DRG":"220","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","Payer Specific Negotiated Charge":113897.0},{"Payer":"BCBS PPO","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":91383.0},{"Payer":"BCBS PPO","MS-DRG":"231","Description":"Coronary Bypass With Ptca With Mcc","Payer Specific Negotiated Charge":408763.0},{"Payer":"BCBS PPO","MS-DRG":"233","Description":"Coronary Bypass With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":117685.0},{"Payer":"BCBS PPO","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":92957.0},{"Payer":"BCBS PPO","MS-DRG":"235","Description":"Coronary Bypass Without Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":71997.0},{"Payer":"BCBS PPO","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":54699.0},{"Payer":"BCBS PPO","MS-DRG":"240","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","Payer Specific Negotiated Charge":31853.0},{"Payer":"BCBS PPO","MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","Payer Specific Negotiated Charge":23952.0},{"Payer":"BCBS PPO","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":51103.0},{"Payer":"BCBS PPO","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":23483.0},{"Payer":"BCBS PPO","MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":22120.0},{"Payer":"BCBS PPO","MS-DRG":"251","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without Mcc","Payer Specific Negotiated Charge":19424.0},{"Payer":"BCBS PPO","MS-DRG":"252","Description":"Other Vascular Procedures With Mcc","Payer Specific Negotiated Charge":32463.0},{"Payer":"BCBS PPO","MS-DRG":"253","Description":"Other Vascular Procedures With Cc","Payer Specific Negotiated Charge":30083.0},{"Payer":"BCBS PPO","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":21006.0},{"Payer":"BCBS PPO","MS-DRG":"261","Description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","Payer Specific Negotiated Charge":22488.0},{"Payer":"BCBS PPO","MS-DRG":"266","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","Payer Specific Negotiated Charge":115072.0},{"Payer":"BCBS PPO","MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","Payer Specific Negotiated Charge":97067.0},{"Payer":"BCBS PPO","MS-DRG":"268","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","Payer Specific Negotiated Charge":114277.0},{"Payer":"BCBS PPO","MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","Payer Specific Negotiated Charge":49239.0},{"Payer":"BCBS PPO","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":40948.0},{"Payer":"BCBS PPO","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":36467.0},{"Payer":"BCBS PPO","MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","Payer Specific Negotiated Charge":18822.0},{"Payer":"BCBS PPO","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":25360.0},{"Payer":"BCBS PPO","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":13298.0},{"Payer":"BCBS PPO","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":15532.0},{"Payer":"BCBS PPO","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":10271.0},{"Payer":"BCBS PPO","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":7563.0},{"Payer":"BCBS PPO","MS-DRG":"301","Description":"Peripheral Vascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":7515.0},{"Payer":"BCBS PPO","MS-DRG":"303","Description":"Atherosclerosis Without Mcc","Payer Specific Negotiated Charge":5634.0},{"Payer":"BCBS PPO","MS-DRG":"305","Description":"Hypertension Without Mcc","Payer Specific Negotiated Charge":8442.0},{"Payer":"BCBS PPO","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":13707.0},{"Payer":"BCBS PPO","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":8728.0},{"Payer":"BCBS PPO","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":6455.0},{"Payer":"BCBS PPO","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":9424.0},{"Payer":"BCBS PPO","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":8255.0},{"Payer":"BCBS PPO","MS-DRG":"314","Description":"Other Circulatory System Diagnoses With Mcc","Payer Specific Negotiated Charge":13078.0},{"Payer":"BCBS PPO","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":11199.0},{"Payer":"BCBS PPO","MS-DRG":"326","Description":"Stomach, Esophageal And Duodenal Procedures With Mcc","Payer Specific Negotiated Charge":104160.0},{"Payer":"BCBS PPO","MS-DRG":"327","Description":"Stomach, Esophageal And Duodenal Procedures With Cc","Payer Specific Negotiated Charge":39614.0},{"Payer":"BCBS PPO","MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","Payer Specific Negotiated Charge":84891.0},{"Payer":"BCBS PPO","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":29162.0},{"Payer":"BCBS PPO","MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":19495.0},{"Payer":"BCBS PPO","MS-DRG":"339","Description":"Appendectomy With Complicated Principal Diagnosis With Cc","Payer Specific Negotiated Charge":19806.0},{"Payer":"BCBS PPO","MS-DRG":"340","Description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":14282.0},{"Payer":"BCBS PPO","MS-DRG":"343","Description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":13291.0},{"Payer":"BCBS PPO","MS-DRG":"369","Description":"Major Esophageal Disorders With Cc","Payer Specific Negotiated Charge":12269.0},{"Payer":"BCBS PPO","MS-DRG":"371","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","Payer Specific Negotiated Charge":19914.0},{"Payer":"BCBS PPO","MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","Payer Specific Negotiated Charge":11801.0},{"Payer":"BCBS PPO","MS-DRG":"373","Description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","Payer Specific Negotiated Charge":8561.0},{"Payer":"BCBS PPO","MS-DRG":"374","Description":"Digestive Malignancy With Mcc","Payer Specific Negotiated Charge":23053.0},{"Payer":"BCBS PPO","MS-DRG":"377","Description":"Gastrointestinal Hemorrhage With Mcc","Payer Specific Negotiated Charge":20426.0},{"Payer":"BCBS PPO","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":11404.0},{"Payer":"BCBS PPO","MS-DRG":"385","Description":"Inflammatory Bowel Disease With Mcc","Payer Specific Negotiated Charge":18585.0},{"Payer":"BCBS PPO","MS-DRG":"386","Description":"Inflammatory Bowel Disease With Cc","Payer Specific Negotiated Charge":10896.0},{"Payer":"BCBS PPO","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":6689.0},{"Payer":"BCBS PPO","MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","Payer Specific Negotiated Charge":14253.0},{"Payer":"BCBS PPO","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":8789.0},{"Payer":"BCBS PPO","MS-DRG":"395","Description":"Other Digestive System Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":7552.0},{"Payer":"BCBS PPO","MS-DRG":"410","Description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":19158.0},{"Payer":"BCBS PPO","MS-DRG":"414","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","Payer Specific Negotiated Charge":39429.0},{"Payer":"BCBS PPO","MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","Payer Specific Negotiated Charge":28326.0},{"Payer":"BCBS PPO","MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":15584.0},{"Payer":"BCBS PPO","MS-DRG":"417","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","Payer Specific Negotiated Charge":27822.0},{"Payer":"BCBS PPO","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":19261.0},{"Payer":"BCBS PPO","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":15082.0},{"Payer":"BCBS PPO","MS-DRG":"433","Description":"Cirrhosis And Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":11910.0},{"Payer":"BCBS PPO","MS-DRG":"435","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","Payer Specific Negotiated Charge":44159.0},{"Payer":"BCBS PPO","MS-DRG":"438","Description":"Disorders Of Pancreas Except Malignancy With Mcc","Payer Specific Negotiated Charge":42161.0},{"Payer":"BCBS PPO","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":9778.0},{"Payer":"BCBS PPO","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":7105.0},{"Payer":"BCBS PPO","MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":21357.0},{"Payer":"BCBS PPO","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":10772.0},{"Payer":"BCBS PPO","MS-DRG":"443","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","Payer Specific Negotiated Charge":7851.0},{"Payer":"BCBS PPO","MS-DRG":"444","Description":"Disorders Of The Biliary Tract With Mcc","Payer Specific Negotiated Charge":18767.0},{"Payer":"BCBS PPO","MS-DRG":"446","Description":"Disorders Of The Biliary Tract Without Cc/Mcc","Payer Specific Negotiated Charge":9379.0},{"Payer":"BCBS PPO","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":89705.0},{"Payer":"BCBS PPO","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":64258.0},{"Payer":"BCBS PPO","MS-DRG":"457","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","Payer Specific Negotiated Charge":138080.0},{"Payer":"BCBS PPO","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":45707.0},{"Payer":"BCBS PPO","MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":36197.0},{"Payer":"BCBS PPO","MS-DRG":"464","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","Payer Specific Negotiated Charge":22747.0},{"Payer":"BCBS PPO","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":40533.0},{"Payer":"BCBS PPO","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":36144.0},{"Payer":"BCBS PPO","MS-DRG":"469","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","Payer Specific Negotiated Charge":36238.0},{"Payer":"BCBS PPO","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":22717.0},{"Payer":"BCBS PPO","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":35102.0},{"Payer":"BCBS PPO","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":28996.0},{"Payer":"BCBS PPO","MS-DRG":"478","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":26742.0},{"Payer":"BCBS PPO","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":24095.0},{"Payer":"BCBS PPO","MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","Payer Specific Negotiated Charge":18988.0},{"Payer":"BCBS PPO","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":27607.0},{"Payer":"BCBS PPO","MS-DRG":"489","Description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","Payer Specific Negotiated Charge":14530.0},{"Payer":"BCBS PPO","MS-DRG":"492","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","Payer Specific Negotiated Charge":41413.0},{"Payer":"BCBS PPO","MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","Payer Specific Negotiated Charge":26568.0},{"Payer":"BCBS PPO","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":20905.0},{"Payer":"BCBS PPO","MS-DRG":"501","Description":"Soft Tissue Procedures With Cc","Payer Specific Negotiated Charge":19366.0},{"Payer":"BCBS PPO","MS-DRG":"502","Description":"Soft Tissue Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":15242.0},{"Payer":"BCBS PPO","MS-DRG":"511","Description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","Payer Specific Negotiated Charge":21746.0},{"Payer":"BCBS PPO","MS-DRG":"516","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","Payer Specific Negotiated Charge":22379.0},{"Payer":"BCBS PPO","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":22028.0},{"Payer":"BCBS PPO","MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":15442.0},{"Payer":"BCBS PPO","MS-DRG":"539","Description":"Osteomyelitis With Mcc","Payer Specific Negotiated Charge":21276.0},{"Payer":"BCBS PPO","MS-DRG":"551","Description":"Medical Back Problems With Mcc","Payer Specific Negotiated Charge":18343.0},{"Payer":"BCBS PPO","MS-DRG":"554","Description":"Bone Diseases And Arthropathies Without Mcc","Payer Specific Negotiated Charge":9085.0},{"Payer":"BCBS PPO","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":9138.0},{"Payer":"BCBS PPO","MS-DRG":"558","Description":"Tendonitis, Myositis And Bursitis Without Mcc","Payer Specific Negotiated Charge":9941.0},{"Payer":"BCBS PPO","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":12043.0},{"Payer":"BCBS PPO","MS-DRG":"599","Description":"Malignant Breast Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":7972.0},{"Payer":"BCBS PPO","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":9735.0},{"Payer":"BCBS PPO","MS-DRG":"605","Description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","Payer Specific Negotiated Charge":10106.0},{"Payer":"BCBS PPO","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":23674.0},{"Payer":"BCBS PPO","MS-DRG":"625","Description":"Thyroid, Parathyroid And Thyroglossal Procedures With Mcc","Payer Specific Negotiated Charge":33759.0},{"Payer":"BCBS PPO","MS-DRG":"628","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","Payer Specific Negotiated Charge":52699.0},{"Payer":"BCBS PPO","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":10203.0},{"Payer":"BCBS PPO","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":7077.0},{"Payer":"BCBS PPO","MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","Payer Specific Negotiated Charge":55956.0},{"Payer":"BCBS PPO","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":8732.0},{"Payer":"BCBS PPO","MS-DRG":"643","Description":"Endocrine Disorders With Mcc","Payer Specific Negotiated Charge":18760.0},{"Payer":"BCBS PPO","MS-DRG":"644","Description":"Endocrine Disorders With Cc","Payer Specific Negotiated Charge":11865.0},{"Payer":"BCBS PPO","MS-DRG":"661","Description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","Payer Specific Negotiated Charge":12581.0},{"Payer":"BCBS PPO","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":73986.0},{"Payer":"BCBS PPO","MS-DRG":"674","Description":"Other Kidney And Urinary Tract Procedures With Cc","Payer Specific Negotiated Charge":28209.0},{"Payer":"BCBS PPO","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":10139.0},{"Payer":"BCBS PPO","MS-DRG":"689","Description":"Kidney And Urinary Tract Infections With Mcc","Payer Specific Negotiated Charge":12910.0},{"Payer":"BCBS PPO","MS-DRG":"694","Description":"Urinary Stones Without Mcc","Payer Specific Negotiated Charge":8545.0},{"Payer":"BCBS PPO","MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","Payer Specific Negotiated Charge":18680.0},{"Payer":"BCBS PPO","MS-DRG":"718","Description":"Other Male Reproductive System O.R. Procedures Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":14073.0},{"Payer":"BCBS PPO","MS-DRG":"722","Description":"Malignancy, Male Reproductive System With Mcc","Payer Specific Negotiated Charge":20830.0},{"Payer":"BCBS PPO","MS-DRG":"811","Description":"Red Blood Cell Disorders With Mcc","Payer Specific Negotiated Charge":29239.0},{"Payer":"BCBS PPO","MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","Payer Specific Negotiated Charge":10049.0},{"Payer":"BCBS PPO","MS-DRG":"815","Description":"Reticuloendothelial And Immunity Disorders With Cc","Payer Specific Negotiated Charge":11689.0},{"Payer":"BCBS PPO","MS-DRG":"834","Description":"Acute Leukemia Without Major O.R. Procedures With Mcc","Payer Specific Negotiated Charge":43265.0},{"Payer":"BCBS PPO","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":65578.0},{"Payer":"BCBS PPO","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":24943.0},{"Payer":"BCBS PPO","MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","Payer Specific Negotiated Charge":23466.0},{"Payer":"BCBS PPO","MS-DRG":"863","Description":"Postoperative And Post-Traumatic Infections Without Mcc","Payer Specific Negotiated Charge":11403.0},{"Payer":"BCBS PPO","MS-DRG":"864","Description":"Fever And Inflammatory Conditions","Payer Specific Negotiated Charge":9780.0},{"Payer":"BCBS PPO","MS-DRG":"866","Description":"Viral Illness Without Mcc","Payer Specific Negotiated Charge":9449.0},{"Payer":"BCBS PPO","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":21539.0},{"Payer":"BCBS PPO","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":11995.0},{"Payer":"BCBS PPO","MS-DRG":"896","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","Payer Specific Negotiated Charge":110652.0},{"Payer":"BCBS PPO","MS-DRG":"897","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","Payer Specific Negotiated Charge":9484.0},{"Payer":"BCBS PPO","MS-DRG":"915","Description":"Allergic Reactions With Mcc","Payer Specific Negotiated Charge":19609.0},{"Payer":"BCBS PPO","MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","Payer Specific Negotiated Charge":16887.0},{"Payer":"BCBS PPO","MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","Payer Specific Negotiated Charge":9048.0},{"Payer":"BCBS PPO","MS-DRG":"940","Description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","Payer Specific Negotiated Charge":26219.0},{"Payer":"BCBS PPO","MS-DRG":"945","Description":"Rehabilitation With Cc/Mcc","Payer Specific Negotiated Charge":24839.0},{"Payer":"BCBS PPO","MS-DRG":"946","Description":"Rehabilitation Without Cc/Mcc","Payer Specific Negotiated Charge":16241.0},{"Payer":"BCBS PPO","MS-DRG":"947","Description":"Signs And Symptoms With Mcc","Payer Specific Negotiated Charge":13818.0},{"Payer":"BCBS PPO","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":8997.0},{"Payer":"BCBS PPO","MS-DRG":"949","Description":"Aftercare With Cc/Mcc","Payer Specific Negotiated Charge":12567.0},{"Payer":"BCBS PPO","MS-DRG":"977","Description":"Hiv With Or Without Other Related Condition","Payer Specific Negotiated Charge":15009.0},{"Payer":"BCBS PPO","MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":51958.0},{"Payer":"BCBS PPO","MS-DRG":"982","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","Payer Specific Negotiated Charge":56875.0},{"Payer":"BCBS PPO","MS-DRG":"983","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":18894.0},{"Payer":"BCBS PPO","MS-DRG":"987","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":97154.0},{"Payer":"BCBS PPO","MS-DRG":"988","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","Payer Specific Negotiated Charge":19831.0}],"Inpatient Payer Specific Charge 4":[{"Payer":"CIGNA HMO/PPO","MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","Payer Specific Negotiated Charge":281060.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","Payer Specific Negotiated Charge":198101.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":40310.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"041","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","Payer Specific Negotiated Charge":28484.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"054","Description":"Nervous System Neoplasms With Mcc","Payer Specific Negotiated Charge":12015.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":8520.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"063","Description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","Payer Specific Negotiated Charge":25710.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":7232.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":5046.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","Payer Specific Negotiated Charge":7000.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","Payer Specific Negotiated Charge":8125.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"087","Description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":5905.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","Payer Specific Negotiated Charge":11900.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":6798.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":5357.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":6213.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"149","Description":"Dysequilibrium","Payer Specific Negotiated Charge":5141.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"151","Description":"Epistaxis Without Mcc","Payer Specific Negotiated Charge":4920.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"153","Description":"Otitis Media And Uri Without Mcc","Payer Specific Negotiated Charge":6181.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"164","Description":"Major Chest Procedures With Cc","Payer Specific Negotiated Charge":20445.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"166","Description":"Other Respiratory System O.R. Procedures With Mcc","Payer Specific Negotiated Charge":28248.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"167","Description":"Other Respiratory System O.R. Procedures With Cc","Payer Specific Negotiated Charge":15302.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":5970.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"179","Description":"Respiratory Infections And Inflammations Without Cc/Mcc","Payer Specific Negotiated Charge":6095.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":9322.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":8050.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":6283.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":10497.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","Payer Specific Negotiated Charge":86085.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":20253.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":204284.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"216","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":205566.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":59968.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":41275.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","Payer Specific Negotiated Charge":29793.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","Payer Specific Negotiated Charge":25996.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":37383.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":22662.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":13603.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","Payer Specific Negotiated Charge":103673.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":19676.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","Payer Specific Negotiated Charge":6817.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":6465.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":17933.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":8607.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":28431.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":6372.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"300","Description":"Peripheral Vascular Disorders With Cc","Payer Specific Negotiated Charge":7231.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"303","Description":"Atherosclerosis Without Mcc","Payer Specific Negotiated Charge":6162.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"305","Description":"Hypertension Without Mcc","Payer Specific Negotiated Charge":5148.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":8827.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":5965.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":3936.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":5746.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":5742.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":6829.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","Payer Specific Negotiated Charge":75630.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":19504.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"343","Description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":9043.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"357","Description":"Other Digestive System O.R. Procedures With Cc","Payer Specific Negotiated Charge":23933.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":7587.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"381","Description":"Complicated Peptic Ulcer With Cc","Payer Specific Negotiated Charge":7577.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","Payer Specific Negotiated Charge":7256.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":4079.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":6179.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"394","Description":"Other Digestive System Diagnoses With Cc","Payer Specific Negotiated Charge":8055.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":14754.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":10134.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"432","Description":"Cirrhosis And Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":14640.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"433","Description":"Cirrhosis And Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":13767.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"438","Description":"Disorders Of Pancreas Except Malignancy With Mcc","Payer Specific Negotiated Charge":13594.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":8285.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":4746.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":13022.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":6568.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"443","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","Payer Specific Negotiated Charge":4787.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","Payer Specific Negotiated Charge":9578.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"446","Description":"Disorders Of The Biliary Tract Without Cc/Mcc","Payer Specific Negotiated Charge":7564.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":180019.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":68214.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":49130.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":50973.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":36336.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":60804.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"469","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","Payer Specific Negotiated Charge":36380.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":28456.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":44124.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":32838.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":18535.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":32873.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"487","Description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","Payer Specific Negotiated Charge":15888.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"505","Description":"Foot Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":14561.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"517","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":12129.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":17149.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"547","Description":"Connective Tissue Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":6304.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":5572.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":7343.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"563","Description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","Payer Specific Negotiated Charge":9101.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"571","Description":"Skin Debridement With Cc","Payer Specific Negotiated Charge":13871.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":6712.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"628","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Mcc","Payer Specific Negotiated Charge":49310.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":9751.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":7542.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":4315.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":5919.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"645","Description":"Endocrine Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":5385.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"684","Description":"Renal Failure Without Cc/Mcc","Payer Specific Negotiated Charge":4932.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"694","Description":"Urinary Stones Without Mcc","Payer Specific Negotiated Charge":5210.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":37447.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","Payer Specific Negotiated Charge":18877.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"862","Description":"Postoperative And Post-Traumatic Infections With Mcc","Payer Specific Negotiated Charge":15023.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"866","Description":"Viral Illness Without Mcc","Payer Specific Negotiated Charge":6999.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":16679.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":8301.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"880","Description":"Acute Adjustment Reaction And Psychosocial Dysfunction","Payer Specific Negotiated Charge":6030.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"884","Description":"Organic Disturbances And Intellectual Disability","Payer Specific Negotiated Charge":10119.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"908","Description":"Other O.R. Procedures For Injuries With Cc","Payer Specific Negotiated Charge":15575.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","Payer Specific Negotiated Charge":5517.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"920","Description":"Complications Of Treatment With Cc","Payer Specific Negotiated Charge":9083.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":5486.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":5214.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"974","Description":"Hiv With Major Related Condition With Mcc","Payer Specific Negotiated Charge":21899.0},{"Payer":"CIGNA HMO/PPO","MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":60442.0}],"Inpatient Payer Specific Charge 5":[{"Payer":"Coventry/Aetna HMO","MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","Payer Specific Negotiated Charge":201973.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"021","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","Payer Specific Negotiated Charge":77350.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"036","Description":"Carotid Artery Stent Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7913.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":16055.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":9225.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":3690.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":6094.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7092.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","Payer Specific Negotiated Charge":3690.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":11820.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":9225.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":14184.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":77427.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":49784.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":12840.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"266","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","Payer Specific Negotiated Charge":41037.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7380.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"337","Description":"Peritoneal Adhesiolysis Without Cc/Mcc","Payer Specific Negotiated Charge":11070.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","Payer Specific Negotiated Charge":16605.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":3690.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":3690.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":14184.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":29031.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":20128.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":13692.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","Payer Specific Negotiated Charge":12457.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":12217.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"501","Description":"Soft Tissue Procedures With Cc","Payer Specific Negotiated Charge":6573.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":18464.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":9141.0},{"Payer":"Coventry/Aetna HMO","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5535.0}],"Inpatient Payer Specific Charge 6":[{"Payer":"Humana Medicare","MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","Payer Specific Negotiated Charge":105759.0},{"Payer":"Humana Medicare","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":44505.0},{"Payer":"Humana Medicare","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":18457.0},{"Payer":"Humana Medicare","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":12830.0},{"Payer":"Humana Medicare","MS-DRG":"031","Description":"Ventricular Shunt Procedures With Mcc","Payer Specific Negotiated Charge":23989.0},{"Payer":"Humana Medicare","MS-DRG":"033","Description":"Ventricular Shunt Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9403.0},{"Payer":"Humana Medicare","MS-DRG":"038","Description":"Extracranial Procedures With Cc","Payer Specific Negotiated Charge":9067.0},{"Payer":"Humana Medicare","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6122.0},{"Payer":"Humana Medicare","MS-DRG":"040","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","Payer Specific Negotiated Charge":17818.0},{"Payer":"Humana Medicare","MS-DRG":"041","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","Payer Specific Negotiated Charge":12904.0},{"Payer":"Humana Medicare","MS-DRG":"055","Description":"Nervous System Neoplasms Without Mcc","Payer Specific Negotiated Charge":5518.0},{"Payer":"Humana Medicare","MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","Payer Specific Negotiated Charge":11616.0},{"Payer":"Humana Medicare","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":6844.0},{"Payer":"Humana Medicare","MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","Payer Specific Negotiated Charge":10360.0},{"Payer":"Humana Medicare","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":5610.0},{"Payer":"Humana Medicare","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":4007.0},{"Payer":"Humana Medicare","MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","Payer Specific Negotiated Charge":4115.0},{"Payer":"Humana Medicare","MS-DRG":"070","Description":"Nonspecific Cerebrovascular Disorders With Mcc","Payer Specific Negotiated Charge":8785.0},{"Payer":"Humana Medicare","MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","Payer Specific Negotiated Charge":5516.0},{"Payer":"Humana Medicare","MS-DRG":"083","Description":"Traumatic Stupor And Coma >1 Hour With Cc","Payer Specific Negotiated Charge":7009.0},{"Payer":"Humana Medicare","MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":4900.0},{"Payer":"Humana Medicare","MS-DRG":"087","Description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":4279.0},{"Payer":"Humana Medicare","MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","Payer Specific Negotiated Charge":8762.0},{"Payer":"Humana Medicare","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":5694.0},{"Payer":"Humana Medicare","MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":4118.0},{"Payer":"Humana Medicare","MS-DRG":"100","Description":"Seizures With Mcc","Payer Specific Negotiated Charge":10000.0},{"Payer":"Humana Medicare","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":5053.0},{"Payer":"Humana Medicare","MS-DRG":"102","Description":"Headaches With Mcc","Payer Specific Negotiated Charge":6540.0},{"Payer":"Humana Medicare","MS-DRG":"149","Description":"Dysequilibrium","Payer Specific Negotiated Charge":4057.0},{"Payer":"Humana Medicare","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":10090.0},{"Payer":"Humana Medicare","MS-DRG":"166","Description":"Other Respiratory System O.R. Procedures With Mcc","Payer Specific Negotiated Charge":22312.0},{"Payer":"Humana Medicare","MS-DRG":"167","Description":"Other Respiratory System O.R. Procedures With Cc","Payer Specific Negotiated Charge":10506.0},{"Payer":"Humana Medicare","MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7542.0},{"Payer":"Humana Medicare","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":4883.0},{"Payer":"Humana Medicare","MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","Payer Specific Negotiated Charge":10432.0},{"Payer":"Humana Medicare","MS-DRG":"181","Description":"Respiratory Neoplasms With Cc","Payer Specific Negotiated Charge":6177.0},{"Payer":"Humana Medicare","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":6850.0},{"Payer":"Humana Medicare","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":6549.0},{"Payer":"Humana Medicare","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":5304.0},{"Payer":"Humana Medicare","MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","Payer Specific Negotiated Charge":4073.0},{"Payer":"Humana Medicare","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7385.0},{"Payer":"Humana Medicare","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":5151.0},{"Payer":"Humana Medicare","MS-DRG":"195","Description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","Payer Specific Negotiated Charge":3841.0},{"Payer":"Humana Medicare","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":5121.0},{"Payer":"Humana Medicare","MS-DRG":"206","Description":"Other Respiratory System Diagnoses Without Mcc","Payer Specific Negotiated Charge":4681.0},{"Payer":"Humana Medicare","MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","Payer Specific Negotiated Charge":29877.0},{"Payer":"Humana Medicare","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":13547.0},{"Payer":"Humana Medicare","MS-DRG":"220","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","Payer Specific Negotiated Charge":28640.0},{"Payer":"Humana Medicare","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":24410.0},{"Payer":"Humana Medicare","MS-DRG":"224","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","Payer Specific Negotiated Charge":39959.0},{"Payer":"Humana Medicare","MS-DRG":"227","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":28669.0},{"Payer":"Humana Medicare","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":28392.0},{"Payer":"Humana Medicare","MS-DRG":"235","Description":"Coronary Bypass Without Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":31970.0},{"Payer":"Humana Medicare","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":21348.0},{"Payer":"Humana Medicare","MS-DRG":"240","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","Payer Specific Negotiated Charge":19267.0},{"Payer":"Humana Medicare","MS-DRG":"242","Description":"Permanent Cardiac Pacemaker Implant With Mcc","Payer Specific Negotiated Charge":20292.0},{"Payer":"Humana Medicare","MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","Payer Specific Negotiated Charge":13523.0},{"Payer":"Humana Medicare","MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","Payer Specific Negotiated Charge":11144.0},{"Payer":"Humana Medicare","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":17151.0},{"Payer":"Humana Medicare","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":11013.0},{"Payer":"Humana Medicare","MS-DRG":"251","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without Mcc","Payer Specific Negotiated Charge":9175.0},{"Payer":"Humana Medicare","MS-DRG":"252","Description":"Other Vascular Procedures With Mcc","Payer Specific Negotiated Charge":17672.0},{"Payer":"Humana Medicare","MS-DRG":"253","Description":"Other Vascular Procedures With Cc","Payer Specific Negotiated Charge":14336.0},{"Payer":"Humana Medicare","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9782.0},{"Payer":"Humana Medicare","MS-DRG":"260","Description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","Payer Specific Negotiated Charge":20010.0},{"Payer":"Humana Medicare","MS-DRG":"264","Description":"Other Circulatory System O.R. Procedures","Payer Specific Negotiated Charge":16900.0},{"Payer":"Humana Medicare","MS-DRG":"266","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","Payer Specific Negotiated Charge":37869.0},{"Payer":"Humana Medicare","MS-DRG":"268","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","Payer Specific Negotiated Charge":36618.0},{"Payer":"Humana Medicare","MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","Payer Specific Negotiated Charge":22967.0},{"Payer":"Humana Medicare","MS-DRG":"270","Description":"Other Major Cardiovascular Procedures With Mcc","Payer Specific Negotiated Charge":34230.0},{"Payer":"Humana Medicare","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":21586.0},{"Payer":"Humana Medicare","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":17021.0},{"Payer":"Humana Medicare","MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","Payer Specific Negotiated Charge":9049.0},{"Payer":"Humana Medicare","MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","Payer Specific Negotiated Charge":5708.0},{"Payer":"Humana Medicare","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":4028.0},{"Payer":"Humana Medicare","MS-DRG":"283","Description":"Acute Myocardial Infarction, Expired With Mcc","Payer Specific Negotiated Charge":9823.0},{"Payer":"Humana Medicare","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6101.0},{"Payer":"Humana Medicare","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7440.0},{"Payer":"Humana Medicare","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":5138.0},{"Payer":"Humana Medicare","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":3589.0},{"Payer":"Humana Medicare","MS-DRG":"297","Description":"Cardiac Arrest, Unexplained With Cc","Payer Specific Negotiated Charge":4017.0},{"Payer":"Humana Medicare","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":6599.0},{"Payer":"Humana Medicare","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":4240.0},{"Payer":"Humana Medicare","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":3092.0},{"Payer":"Humana Medicare","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":4564.0},{"Payer":"Humana Medicare","MS-DRG":"314","Description":"Other Circulatory System Diagnoses With Mcc","Payer Specific Negotiated Charge":11125.0},{"Payer":"Humana Medicare","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":11467.0},{"Payer":"Humana Medicare","MS-DRG":"335","Description":"Peritoneal Adhesiolysis With Mcc","Payer Specific Negotiated Charge":22071.0},{"Payer":"Humana Medicare","MS-DRG":"356","Description":"Other Digestive System O.R. Procedures With Mcc","Payer Specific Negotiated Charge":21850.0},{"Payer":"Humana Medicare","MS-DRG":"369","Description":"Major Esophageal Disorders With Cc","Payer Specific Negotiated Charge":5888.0},{"Payer":"Humana Medicare","MS-DRG":"371","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","Payer Specific Negotiated Charge":10312.0},{"Payer":"Humana Medicare","MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","Payer Specific Negotiated Charge":5771.0},{"Payer":"Humana Medicare","MS-DRG":"377","Description":"Gastrointestinal Hemorrhage With Mcc","Payer Specific Negotiated Charge":9673.0},{"Payer":"Humana Medicare","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":5502.0},{"Payer":"Humana Medicare","MS-DRG":"384","Description":"Uncomplicated Peptic Ulcer Without Mcc","Payer Specific Negotiated Charge":5095.0},{"Payer":"Humana Medicare","MS-DRG":"388","Description":"Gastrointestinal Obstruction With Mcc","Payer Specific Negotiated Charge":8547.0},{"Payer":"Humana Medicare","MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","Payer Specific Negotiated Charge":4744.0},{"Payer":"Humana Medicare","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":3202.0},{"Payer":"Humana Medicare","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":4268.0},{"Payer":"Humana Medicare","MS-DRG":"393","Description":"Other Digestive System Diagnoses With Mcc","Payer Specific Negotiated Charge":8993.0},{"Payer":"Humana Medicare","MS-DRG":"394","Description":"Other Digestive System Diagnoses With Cc","Payer Specific Negotiated Charge":5261.0},{"Payer":"Humana Medicare","MS-DRG":"395","Description":"Other Digestive System Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":3648.0},{"Payer":"Humana Medicare","MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":7512.0},{"Payer":"Humana Medicare","MS-DRG":"417","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","Payer Specific Negotiated Charge":13004.0},{"Payer":"Humana Medicare","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":8906.0},{"Payer":"Humana Medicare","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":7198.0},{"Payer":"Humana Medicare","MS-DRG":"432","Description":"Cirrhosis And Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":10002.0},{"Payer":"Humana Medicare","MS-DRG":"435","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","Payer Specific Negotiated Charge":9106.0},{"Payer":"Humana Medicare","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":5114.0},{"Payer":"Humana Medicare","MS-DRG":"444","Description":"Disorders Of The Biliary Tract With Mcc","Payer Specific Negotiated Charge":8649.0},{"Payer":"Humana Medicare","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":33041.0},{"Payer":"Humana Medicare","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":26382.0},{"Payer":"Humana Medicare","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":21323.0},{"Payer":"Humana Medicare","MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":17072.0},{"Payer":"Humana Medicare","MS-DRG":"465","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","Payer Specific Negotiated Charge":10378.0},{"Payer":"Humana Medicare","MS-DRG":"466","Description":"Revision Of Hip Or Knee Replacement With Mcc","Payer Specific Negotiated Charge":12932.0},{"Payer":"Humana Medicare","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":18606.0},{"Payer":"Humana Medicare","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":15032.0},{"Payer":"Humana Medicare","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":10552.0},{"Payer":"Humana Medicare","MS-DRG":"471","Description":"Cervical Spinal Fusion With Mcc","Payer Specific Negotiated Charge":27238.0},{"Payer":"Humana Medicare","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":15564.0},{"Payer":"Humana Medicare","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":13034.0},{"Payer":"Humana Medicare","MS-DRG":"474","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","Payer Specific Negotiated Charge":21393.0},{"Payer":"Humana Medicare","MS-DRG":"477","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":16860.0},{"Payer":"Humana Medicare","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":11394.0},{"Payer":"Humana Medicare","MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","Payer Specific Negotiated Charge":9018.0},{"Payer":"Humana Medicare","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":12739.0},{"Payer":"Humana Medicare","MS-DRG":"486","Description":"Knee Procedures With Principal Diagnosis Of Infection With Cc","Payer Specific Negotiated Charge":12374.0},{"Payer":"Humana Medicare","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":9446.0},{"Payer":"Humana Medicare","MS-DRG":"504","Description":"Foot Procedures With Cc","Payer Specific Negotiated Charge":9683.0},{"Payer":"Humana Medicare","MS-DRG":"517","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7737.0},{"Payer":"Humana Medicare","MS-DRG":"518","Description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","Payer Specific Negotiated Charge":18402.0},{"Payer":"Humana Medicare","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":10147.0},{"Payer":"Humana Medicare","MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":6956.0},{"Payer":"Humana Medicare","MS-DRG":"535","Description":"Fractures Of Hip And Pelvis With Mcc","Payer Specific Negotiated Charge":6909.0},{"Payer":"Humana Medicare","MS-DRG":"539","Description":"Osteomyelitis With Mcc","Payer Specific Negotiated Charge":11018.0},{"Payer":"Humana Medicare","MS-DRG":"543","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","Payer Specific Negotiated Charge":5984.0},{"Payer":"Humana Medicare","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":5225.0},{"Payer":"Humana Medicare","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":4568.0},{"Payer":"Humana Medicare","MS-DRG":"559","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":10917.0},{"Payer":"Humana Medicare","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":6152.0},{"Payer":"Humana Medicare","MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":4413.0},{"Payer":"Humana Medicare","MS-DRG":"570","Description":"Skin Debridement With Mcc","Payer Specific Negotiated Charge":16580.0},{"Payer":"Humana Medicare","MS-DRG":"571","Description":"Skin Debridement With Cc","Payer Specific Negotiated Charge":12514.0},{"Payer":"Humana Medicare","MS-DRG":"580","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","Payer Specific Negotiated Charge":9482.0},{"Payer":"Humana Medicare","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":4848.0},{"Payer":"Humana Medicare","MS-DRG":"606","Description":"Minor Skin Disorders With Mcc","Payer Specific Negotiated Charge":7857.0},{"Payer":"Humana Medicare","MS-DRG":"616","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","Payer Specific Negotiated Charge":22368.0},{"Payer":"Humana Medicare","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":11242.0},{"Payer":"Humana Medicare","MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":10800.0},{"Payer":"Humana Medicare","MS-DRG":"626","Description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","Payer Specific Negotiated Charge":8957.0},{"Payer":"Humana Medicare","MS-DRG":"629","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","Payer Specific Negotiated Charge":12789.0},{"Payer":"Humana Medicare","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":7530.0},{"Payer":"Humana Medicare","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":3544.0},{"Payer":"Humana Medicare","MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","Payer Specific Negotiated Charge":6700.0},{"Payer":"Humana Medicare","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":4286.0},{"Payer":"Humana Medicare","MS-DRG":"644","Description":"Endocrine Disorders With Cc","Payer Specific Negotiated Charge":5744.0},{"Payer":"Humana Medicare","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":19934.0},{"Payer":"Humana Medicare","MS-DRG":"674","Description":"Other Kidney And Urinary Tract Procedures With Cc","Payer Specific Negotiated Charge":13485.0},{"Payer":"Humana Medicare","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":8367.0},{"Payer":"Humana Medicare","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":5003.0},{"Payer":"Humana Medicare","MS-DRG":"689","Description":"Kidney And Urinary Tract Infections With Mcc","Payer Specific Negotiated Charge":6222.0},{"Payer":"Humana Medicare","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":4381.0},{"Payer":"Humana Medicare","MS-DRG":"693","Description":"Urinary Stones With Mcc","Payer Specific Negotiated Charge":9067.0},{"Payer":"Humana Medicare","MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","Payer Specific Negotiated Charge":7935.0},{"Payer":"Humana Medicare","MS-DRG":"811","Description":"Red Blood Cell Disorders With Mcc","Payer Specific Negotiated Charge":7378.0},{"Payer":"Humana Medicare","MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","Payer Specific Negotiated Charge":4910.0},{"Payer":"Humana Medicare","MS-DRG":"823","Description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","Payer Specific Negotiated Charge":25203.0},{"Payer":"Humana Medicare","MS-DRG":"826","Description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. Procedures With Mcc","Payer Specific Negotiated Charge":27342.0},{"Payer":"Humana Medicare","MS-DRG":"840","Description":"Lymphoma And Non-Acute Leukemia With Mcc","Payer Specific Negotiated Charge":17805.0},{"Payer":"Humana Medicare","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":27482.0},{"Payer":"Humana Medicare","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":10234.0},{"Payer":"Humana Medicare","MS-DRG":"856","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":24137.0},{"Payer":"Humana Medicare","MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","Payer Specific Negotiated Charge":9623.0},{"Payer":"Humana Medicare","MS-DRG":"865","Description":"Viral Illness With Mcc","Payer Specific Negotiated Charge":7402.0},{"Payer":"Humana Medicare","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":10248.0},{"Payer":"Humana Medicare","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5805.0},{"Payer":"Humana Medicare","MS-DRG":"885","Description":"Psychoses","Payer Specific Negotiated Charge":6512.0},{"Payer":"Humana Medicare","MS-DRG":"901","Description":"Wound Debridements For Injuries With Mcc","Payer Specific Negotiated Charge":23881.0},{"Payer":"Humana Medicare","MS-DRG":"907","Description":"Other O.R. Procedures For Injuries With Mcc","Payer Specific Negotiated Charge":22593.0},{"Payer":"Humana Medicare","MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","Payer Specific Negotiated Charge":8093.0},{"Payer":"Humana Medicare","MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","Payer Specific Negotiated Charge":4477.0},{"Payer":"Humana Medicare","MS-DRG":"919","Description":"Complications Of Treatment With Mcc","Payer Specific Negotiated Charge":9926.0},{"Payer":"Humana Medicare","MS-DRG":"920","Description":"Complications Of Treatment With Cc","Payer Specific Negotiated Charge":5541.0},{"Payer":"Humana Medicare","MS-DRG":"947","Description":"Signs And Symptoms With Mcc","Payer Specific Negotiated Charge":6698.0},{"Payer":"Humana Medicare","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":4457.0},{"Payer":"Humana Medicare","MS-DRG":"949","Description":"Aftercare With Cc/Mcc","Payer Specific Negotiated Charge":6424.0},{"Payer":"Humana Medicare","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":4510.0},{"Payer":"Humana Medicare","MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":23778.0},{"Payer":"Humana Medicare","MS-DRG":"982","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","Payer Specific Negotiated Charge":13596.0}],"Inpatient Payer Specific Charge 7":[{"Payer":"United Healthcare Medicare","MS-DRG":"003","Description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","Payer Specific Negotiated Charge":190833.0},{"Payer":"United Healthcare Medicare","MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","Payer Specific Negotiated Charge":69812.0},{"Payer":"United Healthcare Medicare","MS-DRG":"020","Description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","Payer Specific Negotiated Charge":65095.0},{"Payer":"United Healthcare Medicare","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":23866.0},{"Payer":"United Healthcare Medicare","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":16397.0},{"Payer":"United Healthcare Medicare","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":12854.0},{"Payer":"United Healthcare Medicare","MS-DRG":"028","Description":"Spinal Procedures With Mcc","Payer Specific Negotiated Charge":28831.0},{"Payer":"United Healthcare Medicare","MS-DRG":"030","Description":"Spinal Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":12278.0},{"Payer":"United Healthcare Medicare","MS-DRG":"031","Description":"Ventricular Shunt Procedures With Mcc","Payer Specific Negotiated Charge":22330.0},{"Payer":"United Healthcare Medicare","MS-DRG":"033","Description":"Ventricular Shunt Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9312.0},{"Payer":"United Healthcare Medicare","MS-DRG":"036","Description":"Carotid Artery Stent Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9121.0},{"Payer":"United Healthcare Medicare","MS-DRG":"038","Description":"Extracranial Procedures With Cc","Payer Specific Negotiated Charge":9483.0},{"Payer":"United Healthcare Medicare","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6092.0},{"Payer":"United Healthcare Medicare","MS-DRG":"040","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","Payer Specific Negotiated Charge":20154.0},{"Payer":"United Healthcare Medicare","MS-DRG":"041","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","Payer Specific Negotiated Charge":12650.0},{"Payer":"United Healthcare Medicare","MS-DRG":"042","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9969.0},{"Payer":"United Healthcare Medicare","MS-DRG":"054","Description":"Nervous System Neoplasms With Mcc","Payer Specific Negotiated Charge":7296.0},{"Payer":"United Healthcare Medicare","MS-DRG":"055","Description":"Nervous System Neoplasms Without Mcc","Payer Specific Negotiated Charge":5876.0},{"Payer":"United Healthcare Medicare","MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","Payer Specific Negotiated Charge":25553.0},{"Payer":"United Healthcare Medicare","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":7015.0},{"Payer":"United Healthcare Medicare","MS-DRG":"061","Description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","Payer Specific Negotiated Charge":15474.0},{"Payer":"United Healthcare Medicare","MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","Payer Specific Negotiated Charge":10200.0},{"Payer":"United Healthcare Medicare","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":5714.0},{"Payer":"United Healthcare Medicare","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":3935.0},{"Payer":"United Healthcare Medicare","MS-DRG":"068","Description":"Nonspecific Cva And Precerebral Occlusion Without Infarction Without Mcc","Payer Specific Negotiated Charge":4791.0},{"Payer":"United Healthcare Medicare","MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","Payer Specific Negotiated Charge":4050.0},{"Payer":"United Healthcare Medicare","MS-DRG":"070","Description":"Nonspecific Cerebrovascular Disorders With Mcc","Payer Specific Negotiated Charge":9006.0},{"Payer":"United Healthcare Medicare","MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","Payer Specific Negotiated Charge":5493.0},{"Payer":"United Healthcare Medicare","MS-DRG":"072","Description":"Nonspecific Cerebrovascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":4211.0},{"Payer":"United Healthcare Medicare","MS-DRG":"077","Description":"Hypertensive Encephalopathy With Mcc","Payer Specific Negotiated Charge":8378.0},{"Payer":"United Healthcare Medicare","MS-DRG":"078","Description":"Hypertensive Encephalopathy With Cc","Payer Specific Negotiated Charge":5428.0},{"Payer":"United Healthcare Medicare","MS-DRG":"079","Description":"Hypertensive Encephalopathy Without Cc/Mcc","Payer Specific Negotiated Charge":3950.0},{"Payer":"United Healthcare Medicare","MS-DRG":"086","Description":"Traumatic Stupor And Coma <1 Hour With Cc","Payer Specific Negotiated Charge":6793.0},{"Payer":"United Healthcare Medicare","MS-DRG":"087","Description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":4574.0},{"Payer":"United Healthcare Medicare","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":5332.0},{"Payer":"United Healthcare Medicare","MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":4404.0},{"Payer":"United Healthcare Medicare","MS-DRG":"097","Description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","Payer Specific Negotiated Charge":19487.0},{"Payer":"United Healthcare Medicare","MS-DRG":"100","Description":"Seizures With Mcc","Payer Specific Negotiated Charge":9994.0},{"Payer":"United Healthcare Medicare","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":4813.0},{"Payer":"United Healthcare Medicare","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":4221.0},{"Payer":"United Healthcare Medicare","MS-DRG":"154","Description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","Payer Specific Negotiated Charge":8008.0},{"Payer":"United Healthcare Medicare","MS-DRG":"164","Description":"Major Chest Procedures With Cc","Payer Specific Negotiated Charge":13709.0},{"Payer":"United Healthcare Medicare","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":10105.0},{"Payer":"United Healthcare Medicare","MS-DRG":"166","Description":"Other Respiratory System O.R. Procedures With Mcc","Payer Specific Negotiated Charge":20844.0},{"Payer":"United Healthcare Medicare","MS-DRG":"167","Description":"Other Respiratory System O.R. Procedures With Cc","Payer Specific Negotiated Charge":10410.0},{"Payer":"United Healthcare Medicare","MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","Payer Specific Negotiated Charge":7842.0},{"Payer":"United Healthcare Medicare","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":4881.0},{"Payer":"United Healthcare Medicare","MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","Payer Specific Negotiated Charge":10857.0},{"Payer":"United Healthcare Medicare","MS-DRG":"178","Description":"Respiratory Infections And Inflammations With Cc","Payer Specific Negotiated Charge":6933.0},{"Payer":"United Healthcare Medicare","MS-DRG":"180","Description":"Respiratory Neoplasms With Mcc","Payer Specific Negotiated Charge":9356.0},{"Payer":"United Healthcare Medicare","MS-DRG":"181","Description":"Respiratory Neoplasms With Cc","Payer Specific Negotiated Charge":6190.0},{"Payer":"United Healthcare Medicare","MS-DRG":"184","Description":"Major Chest Trauma With Cc","Payer Specific Negotiated Charge":5959.0},{"Payer":"United Healthcare Medicare","MS-DRG":"188","Description":"Pleural Effusion Without Cc/Mcc","Payer Specific Negotiated Charge":4191.0},{"Payer":"United Healthcare Medicare","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":6697.0},{"Payer":"United Healthcare Medicare","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":6407.0},{"Payer":"United Healthcare Medicare","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":4910.0},{"Payer":"United Healthcare Medicare","MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","Payer Specific Negotiated Charge":3989.0},{"Payer":"United Healthcare Medicare","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7418.0},{"Payer":"United Healthcare Medicare","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":4931.0},{"Payer":"United Healthcare Medicare","MS-DRG":"195","Description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","Payer Specific Negotiated Charge":3682.0},{"Payer":"United Healthcare Medicare","MS-DRG":"196","Description":"Interstitial Lung Disease With Mcc","Payer Specific Negotiated Charge":8791.0},{"Payer":"United Healthcare Medicare","MS-DRG":"197","Description":"Interstitial Lung Disease With Cc","Payer Specific Negotiated Charge":5615.0},{"Payer":"United Healthcare Medicare","MS-DRG":"200","Description":"Pneumothorax With Cc","Payer Specific Negotiated Charge":6004.0},{"Payer":"United Healthcare Medicare","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":5336.0},{"Payer":"United Healthcare Medicare","MS-DRG":"206","Description":"Other Respiratory System Diagnoses Without Mcc","Payer Specific Negotiated Charge":4651.0},{"Payer":"United Healthcare Medicare","MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","Payer Specific Negotiated Charge":31233.0},{"Payer":"United Healthcare Medicare","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":13368.0},{"Payer":"United Healthcare Medicare","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":67915.0},{"Payer":"United Healthcare Medicare","MS-DRG":"216","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":54169.0},{"Payer":"United Healthcare Medicare","MS-DRG":"219","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":104067.0},{"Payer":"United Healthcare Medicare","MS-DRG":"220","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","Payer Specific Negotiated Charge":27549.0},{"Payer":"United Healthcare Medicare","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":24615.0},{"Payer":"United Healthcare Medicare","MS-DRG":"223","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","Payer Specific Negotiated Charge":32267.0},{"Payer":"United Healthcare Medicare","MS-DRG":"226","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":36389.0},{"Payer":"United Healthcare Medicare","MS-DRG":"227","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":28083.0},{"Payer":"United Healthcare Medicare","MS-DRG":"233","Description":"Coronary Bypass With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":41708.0},{"Payer":"United Healthcare Medicare","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":27377.0},{"Payer":"United Healthcare Medicare","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":20852.0},{"Payer":"United Healthcare Medicare","MS-DRG":"239","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","Payer Specific Negotiated Charge":25612.0},{"Payer":"United Healthcare Medicare","MS-DRG":"240","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","Payer Specific Negotiated Charge":11397.0},{"Payer":"United Healthcare Medicare","MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","Payer Specific Negotiated Charge":13555.0},{"Payer":"United Healthcare Medicare","MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","Payer Specific Negotiated Charge":11135.0},{"Payer":"United Healthcare Medicare","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":17137.0},{"Payer":"United Healthcare Medicare","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":10980.0},{"Payer":"United Healthcare Medicare","MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":16688.0},{"Payer":"United Healthcare Medicare","MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":10550.0},{"Payer":"United Healthcare Medicare","MS-DRG":"250","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent With Mcc","Payer Specific Negotiated Charge":13918.0},{"Payer":"United Healthcare Medicare","MS-DRG":"251","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without Mcc","Payer Specific Negotiated Charge":9041.0},{"Payer":"United Healthcare Medicare","MS-DRG":"252","Description":"Other Vascular Procedures With Mcc","Payer Specific Negotiated Charge":18020.0},{"Payer":"United Healthcare Medicare","MS-DRG":"253","Description":"Other Vascular Procedures With Cc","Payer Specific Negotiated Charge":13797.0},{"Payer":"United Healthcare Medicare","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9733.0},{"Payer":"United Healthcare Medicare","MS-DRG":"256","Description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","Payer Specific Negotiated Charge":9723.0},{"Payer":"United Healthcare Medicare","MS-DRG":"261","Description":"Cardiac Pacemaker Revision Except Device Replacement With Cc","Payer Specific Negotiated Charge":10468.0},{"Payer":"United Healthcare Medicare","MS-DRG":"266","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","Payer Specific Negotiated Charge":37680.0},{"Payer":"United Healthcare Medicare","MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","Payer Specific Negotiated Charge":30385.0},{"Payer":"United Healthcare Medicare","MS-DRG":"268","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","Payer Specific Negotiated Charge":35303.0},{"Payer":"United Healthcare Medicare","MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","Payer Specific Negotiated Charge":22852.0},{"Payer":"United Healthcare Medicare","MS-DRG":"270","Description":"Other Major Cardiovascular Procedures With Mcc","Payer Specific Negotiated Charge":59686.0},{"Payer":"United Healthcare Medicare","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":19099.0},{"Payer":"United Healthcare Medicare","MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":13950.0},{"Payer":"United Healthcare Medicare","MS-DRG":"273","Description":"Percutaneous And Other Intracardiac Procedures With Mcc","Payer Specific Negotiated Charge":20230.0},{"Payer":"United Healthcare Medicare","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":16349.0},{"Payer":"United Healthcare Medicare","MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","Payer Specific Negotiated Charge":5284.0},{"Payer":"United Healthcare Medicare","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":4042.0},{"Payer":"United Healthcare Medicare","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":11967.0},{"Payer":"United Healthcare Medicare","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6180.0},{"Payer":"United Healthcare Medicare","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7337.0},{"Payer":"United Healthcare Medicare","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":5003.0},{"Payer":"United Healthcare Medicare","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":3767.0},{"Payer":"United Healthcare Medicare","MS-DRG":"296","Description":"Cardiac Arrest, Unexplained With Mcc","Payer Specific Negotiated Charge":8747.0},{"Payer":"United Healthcare Medicare","MS-DRG":"299","Description":"Peripheral Vascular Disorders With Mcc","Payer Specific Negotiated Charge":8161.0},{"Payer":"United Healthcare Medicare","MS-DRG":"300","Description":"Peripheral Vascular Disorders With Cc","Payer Specific Negotiated Charge":6268.0},{"Payer":"United Healthcare Medicare","MS-DRG":"301","Description":"Peripheral Vascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":4020.0},{"Payer":"United Healthcare Medicare","MS-DRG":"303","Description":"Atherosclerosis Without Mcc","Payer Specific Negotiated Charge":3656.0},{"Payer":"United Healthcare Medicare","MS-DRG":"304","Description":"Hypertension With Mcc","Payer Specific Negotiated Charge":5879.0},{"Payer":"United Healthcare Medicare","MS-DRG":"305","Description":"Hypertension Without Mcc","Payer Specific Negotiated Charge":3855.0},{"Payer":"United Healthcare Medicare","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":6437.0},{"Payer":"United Healthcare Medicare","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":4131.0},{"Payer":"United Healthcare Medicare","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":3034.0},{"Payer":"United Healthcare Medicare","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":4497.0},{"Payer":"United Healthcare Medicare","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":3877.0},{"Payer":"United Healthcare Medicare","MS-DRG":"314","Description":"Other Circulatory System Diagnoses With Mcc","Payer Specific Negotiated Charge":11246.0},{"Payer":"United Healthcare Medicare","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":5442.0},{"Payer":"United Healthcare Medicare","MS-DRG":"328","Description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":8683.0},{"Payer":"United Healthcare Medicare","MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","Payer Specific Negotiated Charge":27208.0},{"Payer":"United Healthcare Medicare","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":13947.0},{"Payer":"United Healthcare Medicare","MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9162.0},{"Payer":"United Healthcare Medicare","MS-DRG":"336","Description":"Peritoneal Adhesiolysis With Cc","Payer Specific Negotiated Charge":12510.0},{"Payer":"United Healthcare Medicare","MS-DRG":"351","Description":"Inguinal And Femoral Hernia Procedures With Cc","Payer Specific Negotiated Charge":7928.0},{"Payer":"United Healthcare Medicare","MS-DRG":"353","Description":"Hernia Procedures Except Inguinal And Femoral With Mcc","Payer Specific Negotiated Charge":16344.0},{"Payer":"United Healthcare Medicare","MS-DRG":"354","Description":"Hernia Procedures Except Inguinal And Femoral With Cc","Payer Specific Negotiated Charge":9382.0},{"Payer":"United Healthcare Medicare","MS-DRG":"356","Description":"Other Digestive System O.R. Procedures With Mcc","Payer Specific Negotiated Charge":22148.0},{"Payer":"United Healthcare Medicare","MS-DRG":"357","Description":"Other Digestive System O.R. Procedures With Cc","Payer Specific Negotiated Charge":12250.0},{"Payer":"United Healthcare Medicare","MS-DRG":"358","Description":"Other Digestive System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7232.0},{"Payer":"United Healthcare Medicare","MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","Payer Specific Negotiated Charge":5642.0},{"Payer":"United Healthcare Medicare","MS-DRG":"374","Description":"Digestive Malignancy With Mcc","Payer Specific Negotiated Charge":11422.0},{"Payer":"United Healthcare Medicare","MS-DRG":"377","Description":"Gastrointestinal Hemorrhage With Mcc","Payer Specific Negotiated Charge":9681.0},{"Payer":"United Healthcare Medicare","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":5401.0},{"Payer":"United Healthcare Medicare","MS-DRG":"379","Description":"Gastrointestinal Hemorrhage Without Cc/Mcc","Payer Specific Negotiated Charge":3584.0},{"Payer":"United Healthcare Medicare","MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","Payer Specific Negotiated Charge":4621.0},{"Payer":"United Healthcare Medicare","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":3249.0},{"Payer":"United Healthcare Medicare","MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","Payer Specific Negotiated Charge":6954.0},{"Payer":"United Healthcare Medicare","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":4203.0},{"Payer":"United Healthcare Medicare","MS-DRG":"393","Description":"Other Digestive System Diagnoses With Mcc","Payer Specific Negotiated Charge":8816.0},{"Payer":"United Healthcare Medicare","MS-DRG":"394","Description":"Other Digestive System Diagnoses With Cc","Payer Specific Negotiated Charge":5342.0},{"Payer":"United Healthcare Medicare","MS-DRG":"395","Description":"Other Digestive System Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":3803.0},{"Payer":"United Healthcare Medicare","MS-DRG":"405","Description":"Pancreas, Liver And Shunt Procedures With Mcc","Payer Specific Negotiated Charge":17811.0},{"Payer":"United Healthcare Medicare","MS-DRG":"412","Description":"Cholecystectomy With C.D.E. With Cc","Payer Specific Negotiated Charge":12641.0},{"Payer":"United Healthcare Medicare","MS-DRG":"414","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Mcc","Payer Specific Negotiated Charge":19204.0},{"Payer":"United Healthcare Medicare","MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","Payer Specific Negotiated Charge":21933.0},{"Payer":"United Healthcare Medicare","MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":7509.0},{"Payer":"United Healthcare Medicare","MS-DRG":"432","Description":"Cirrhosis And Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":9600.0},{"Payer":"United Healthcare Medicare","MS-DRG":"435","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","Payer Specific Negotiated Charge":9380.0},{"Payer":"United Healthcare Medicare","MS-DRG":"438","Description":"Disorders Of Pancreas Except Malignancy With Mcc","Payer Specific Negotiated Charge":9066.0},{"Payer":"United Healthcare Medicare","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":3423.0},{"Payer":"United Healthcare Medicare","MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":10464.0},{"Payer":"United Healthcare Medicare","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":5303.0},{"Payer":"United Healthcare Medicare","MS-DRG":"444","Description":"Disorders Of The Biliary Tract With Mcc","Payer Specific Negotiated Charge":15199.0},{"Payer":"United Healthcare Medicare","MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","Payer Specific Negotiated Charge":5832.0},{"Payer":"United Healthcare Medicare","MS-DRG":"453","Description":"Combined Anterior And Posterior Spinal Fusion With Mcc","Payer Specific Negotiated Charge":58263.0},{"Payer":"United Healthcare Medicare","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":33339.0},{"Payer":"United Healthcare Medicare","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":25863.0},{"Payer":"United Healthcare Medicare","MS-DRG":"457","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","Payer Specific Negotiated Charge":35230.0},{"Payer":"United Healthcare Medicare","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":21216.0},{"Payer":"United Healthcare Medicare","MS-DRG":"463","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","Payer Specific Negotiated Charge":36608.0},{"Payer":"United Healthcare Medicare","MS-DRG":"464","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","Payer Specific Negotiated Charge":15846.0},{"Payer":"United Healthcare Medicare","MS-DRG":"466","Description":"Revision Of Hip Or Knee Replacement With Mcc","Payer Specific Negotiated Charge":27471.0},{"Payer":"United Healthcare Medicare","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":18820.0},{"Payer":"United Healthcare Medicare","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":14931.0},{"Payer":"United Healthcare Medicare","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":10543.0},{"Payer":"United Healthcare Medicare","MS-DRG":"471","Description":"Cervical Spinal Fusion With Mcc","Payer Specific Negotiated Charge":26487.0},{"Payer":"United Healthcare Medicare","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":16304.0},{"Payer":"United Healthcare Medicare","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":12506.0},{"Payer":"United Healthcare Medicare","MS-DRG":"474","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","Payer Specific Negotiated Charge":20564.0},{"Payer":"United Healthcare Medicare","MS-DRG":"476","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":6710.0},{"Payer":"United Healthcare Medicare","MS-DRG":"478","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":11764.0},{"Payer":"United Healthcare Medicare","MS-DRG":"479","Description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":9498.0},{"Payer":"United Healthcare Medicare","MS-DRG":"480","Description":"Hip And Femur Procedures Except Major Joint With Mcc","Payer Specific Negotiated Charge":16349.0},{"Payer":"United Healthcare Medicare","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":11100.0},{"Payer":"United Healthcare Medicare","MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","Payer Specific Negotiated Charge":8929.0},{"Payer":"United Healthcare Medicare","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":12518.0},{"Payer":"United Healthcare Medicare","MS-DRG":"487","Description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","Payer Specific Negotiated Charge":8768.0},{"Payer":"United Healthcare Medicare","MS-DRG":"492","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","Payer Specific Negotiated Charge":19209.0},{"Payer":"United Healthcare Medicare","MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","Payer Specific Negotiated Charge":12667.0},{"Payer":"United Healthcare Medicare","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":10123.0},{"Payer":"United Healthcare Medicare","MS-DRG":"496","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","Payer Specific Negotiated Charge":11084.0},{"Payer":"United Healthcare Medicare","MS-DRG":"500","Description":"Soft Tissue Procedures With Mcc","Payer Specific Negotiated Charge":16822.0},{"Payer":"United Healthcare Medicare","MS-DRG":"501","Description":"Soft Tissue Procedures With Cc","Payer Specific Negotiated Charge":9300.0},{"Payer":"United Healthcare Medicare","MS-DRG":"502","Description":"Soft Tissue Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7258.0},{"Payer":"United Healthcare Medicare","MS-DRG":"507","Description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","Payer Specific Negotiated Charge":11358.0},{"Payer":"United Healthcare Medicare","MS-DRG":"515","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","Payer Specific Negotiated Charge":16949.0},{"Payer":"United Healthcare Medicare","MS-DRG":"516","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","Payer Specific Negotiated Charge":9473.0},{"Payer":"United Healthcare Medicare","MS-DRG":"517","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7610.0},{"Payer":"United Healthcare Medicare","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":10248.0},{"Payer":"United Healthcare Medicare","MS-DRG":"535","Description":"Fractures Of Hip And Pelvis With Mcc","Payer Specific Negotiated Charge":7526.0},{"Payer":"United Healthcare Medicare","MS-DRG":"536","Description":"Fractures Of Hip And Pelvis Without Mcc","Payer Specific Negotiated Charge":4072.0},{"Payer":"United Healthcare Medicare","MS-DRG":"540","Description":"Osteomyelitis With Cc","Payer Specific Negotiated Charge":5318.0},{"Payer":"United Healthcare Medicare","MS-DRG":"545","Description":"Connective Tissue Disorders With Mcc","Payer Specific Negotiated Charge":13367.0},{"Payer":"United Healthcare Medicare","MS-DRG":"551","Description":"Medical Back Problems With Mcc","Payer Specific Negotiated Charge":8879.0},{"Payer":"United Healthcare Medicare","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":5155.0},{"Payer":"United Healthcare Medicare","MS-DRG":"555","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":7266.0},{"Payer":"United Healthcare Medicare","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":4586.0},{"Payer":"United Healthcare Medicare","MS-DRG":"559","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":10006.0},{"Payer":"United Healthcare Medicare","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":5874.0},{"Payer":"United Healthcare Medicare","MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":4396.0},{"Payer":"United Healthcare Medicare","MS-DRG":"571","Description":"Skin Debridement With Cc","Payer Specific Negotiated Charge":9263.0},{"Payer":"United Healthcare Medicare","MS-DRG":"579","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","Payer Specific Negotiated Charge":14101.0},{"Payer":"United Healthcare Medicare","MS-DRG":"581","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6602.0},{"Payer":"United Healthcare Medicare","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":4744.0},{"Payer":"United Healthcare Medicare","MS-DRG":"616","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Mcc","Payer Specific Negotiated Charge":19994.0},{"Payer":"United Healthcare Medicare","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":11151.0},{"Payer":"United Healthcare Medicare","MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":26101.0},{"Payer":"United Healthcare Medicare","MS-DRG":"629","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","Payer Specific Negotiated Charge":9355.0},{"Payer":"United Healthcare Medicare","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":7670.0},{"Payer":"United Healthcare Medicare","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":4784.0},{"Payer":"United Healthcare Medicare","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":3388.0},{"Payer":"United Healthcare Medicare","MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","Payer Specific Negotiated Charge":6952.0},{"Payer":"United Healthcare Medicare","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":4242.0},{"Payer":"United Healthcare Medicare","MS-DRG":"643","Description":"Endocrine Disorders With Mcc","Payer Specific Negotiated Charge":9085.0},{"Payer":"United Healthcare Medicare","MS-DRG":"644","Description":"Endocrine Disorders With Cc","Payer Specific Negotiated Charge":5694.0},{"Payer":"United Healthcare Medicare","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":19329.0},{"Payer":"United Healthcare Medicare","MS-DRG":"674","Description":"Other Kidney And Urinary Tract Procedures With Cc","Payer Specific Negotiated Charge":13242.0},{"Payer":"United Healthcare Medicare","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":8281.0},{"Payer":"United Healthcare Medicare","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":5161.0},{"Payer":"United Healthcare Medicare","MS-DRG":"689","Description":"Kidney And Urinary Tract Infections With Mcc","Payer Specific Negotiated Charge":6112.0},{"Payer":"United Healthcare Medicare","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":4477.0},{"Payer":"United Healthcare Medicare","MS-DRG":"695","Description":"Kidney And Urinary Tract Signs And Symptoms With Mcc","Payer Specific Negotiated Charge":6275.0},{"Payer":"United Healthcare Medicare","MS-DRG":"696","Description":"Kidney And Urinary Tract Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":3823.0},{"Payer":"United Healthcare Medicare","MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","Payer Specific Negotiated Charge":8894.0},{"Payer":"United Healthcare Medicare","MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","Payer Specific Negotiated Charge":5642.0},{"Payer":"United Healthcare Medicare","MS-DRG":"700","Description":"Other Kidney And Urinary Tract Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":4283.0},{"Payer":"United Healthcare Medicare","MS-DRG":"809","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","Payer Specific Negotiated Charge":6435.0},{"Payer":"United Healthcare Medicare","MS-DRG":"811","Description":"Red Blood Cell Disorders With Mcc","Payer Specific Negotiated Charge":7341.0},{"Payer":"United Healthcare Medicare","MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","Payer Specific Negotiated Charge":4962.0},{"Payer":"United Healthcare Medicare","MS-DRG":"813","Description":"Coagulation Disorders","Payer Specific Negotiated Charge":8606.0},{"Payer":"United Healthcare Medicare","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":26947.0},{"Payer":"United Healthcare Medicare","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":11616.0},{"Payer":"United Healthcare Medicare","MS-DRG":"856","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":77400.0},{"Payer":"United Healthcare Medicare","MS-DRG":"858","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7666.0},{"Payer":"United Healthcare Medicare","MS-DRG":"863","Description":"Postoperative And Post-Traumatic Infections Without Mcc","Payer Specific Negotiated Charge":5633.0},{"Payer":"United Healthcare Medicare","MS-DRG":"864","Description":"Fever And Inflammatory Conditions","Payer Specific Negotiated Charge":4706.0},{"Payer":"United Healthcare Medicare","MS-DRG":"866","Description":"Viral Illness Without Mcc","Payer Specific Negotiated Charge":4557.0},{"Payer":"United Healthcare Medicare","MS-DRG":"870","Description":"Septicemia Or Severe Sepsis With Mv >96 Hours","Payer Specific Negotiated Charge":33994.0},{"Payer":"United Healthcare Medicare","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":10153.0},{"Payer":"United Healthcare Medicare","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5863.0},{"Payer":"United Healthcare Medicare","MS-DRG":"882","Description":"Neuroses Except Depressive","Payer Specific Negotiated Charge":4442.0},{"Payer":"United Healthcare Medicare","MS-DRG":"896","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","Payer Specific Negotiated Charge":9405.0},{"Payer":"United Healthcare Medicare","MS-DRG":"897","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","Payer Specific Negotiated Charge":4651.0},{"Payer":"United Healthcare Medicare","MS-DRG":"902","Description":"Wound Debridements For Injuries With Cc","Payer Specific Negotiated Charge":10182.0},{"Payer":"United Healthcare Medicare","MS-DRG":"903","Description":"Wound Debridements For Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":6291.0},{"Payer":"United Healthcare Medicare","MS-DRG":"907","Description":"Other O.R. Procedures For Injuries With Mcc","Payer Specific Negotiated Charge":22443.0},{"Payer":"United Healthcare Medicare","MS-DRG":"908","Description":"Other O.R. Procedures For Injuries With Cc","Payer Specific Negotiated Charge":10561.0},{"Payer":"United Healthcare Medicare","MS-DRG":"909","Description":"Other O.R. Procedures For Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":7225.0},{"Payer":"United Healthcare Medicare","MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","Payer Specific Negotiated Charge":7954.0},{"Payer":"United Healthcare Medicare","MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","Payer Specific Negotiated Charge":4294.0},{"Payer":"United Healthcare Medicare","MS-DRG":"921","Description":"Complications Of Treatment Without Cc/Mcc","Payer Specific Negotiated Charge":4005.0},{"Payer":"United Healthcare Medicare","MS-DRG":"923","Description":"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","Payer Specific Negotiated Charge":4759.0},{"Payer":"United Healthcare Medicare","MS-DRG":"935","Description":"Non-Extensive Burns","Payer Specific Negotiated Charge":9839.0},{"Payer":"United Healthcare Medicare","MS-DRG":"947","Description":"Signs And Symptoms With Mcc","Payer Specific Negotiated Charge":6970.0},{"Payer":"United Healthcare Medicare","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":4544.0},{"Payer":"United Healthcare Medicare","MS-DRG":"949","Description":"Aftercare With Cc/Mcc","Payer Specific Negotiated Charge":6306.0},{"Payer":"United Healthcare Medicare","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":4544.0},{"Payer":"United Healthcare Medicare","MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":24336.0},{"Payer":"United Healthcare Medicare","MS-DRG":"982","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","Payer Specific Negotiated Charge":13561.0},{"Payer":"United Healthcare Medicare","MS-DRG":"983","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":8431.0},{"Payer":"United Healthcare Medicare","MS-DRG":"987","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":17792.0},{"Payer":"United Healthcare Medicare","MS-DRG":"988","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","Payer Specific Negotiated Charge":9463.0}],"Inpatient Payer Specific Charge 8":[{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","Payer Specific Negotiated Charge":72248.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":6635.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":5559.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","Payer Specific Negotiated Charge":4076.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"164","Description":"Major Chest Procedures With Cc","Payer Specific Negotiated Charge":13416.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":6380.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":6644.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7194.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":4769.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","Payer Specific Negotiated Charge":30892.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"220","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Cc","Payer Specific Negotiated Charge":27085.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"233","Description":"Coronary Bypass With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":41814.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":17095.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":10836.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":10345.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"251","Description":"Percutaneous Cardiovascular Procedures Without Coronary Artery Stent Without Mcc","Payer Specific Negotiated Charge":8821.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"266","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","Payer Specific Negotiated Charge":37540.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":18355.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","Payer Specific Negotiated Charge":8760.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6110.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":6895.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":6513.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":2988.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"375","Description":"Digestive Malignancy With Cc","Payer Specific Negotiated Charge":6530.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":5190.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"387","Description":"Inflammatory Bowel Disease Without Cc/Mcc","Payer Specific Negotiated Charge":3721.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":3138.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":7240.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":9004.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":25859.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":20897.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":10300.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":13358.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","Payer Specific Negotiated Charge":8924.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":12638.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":4845.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"614","Description":"Adrenal And Pituitary Procedures With Cc/Mcc","Payer Specific Negotiated Charge":13331.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":10714.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"629","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","Payer Specific Negotiated Charge":12401.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"644","Description":"Endocrine Disorders With Cc","Payer Specific Negotiated Charge":5543.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"689","Description":"Kidney And Urinary Tract Infections With Mcc","Payer Specific Negotiated Charge":6452.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":4423.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":11942.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"857","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Cc","Payer Specific Negotiated Charge":10774.0},{"Payer":"Blue Cross Medicare Advantage","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5797.0}],"Inpatient Payer Specific Charge 9":[{"Payer":"SBG","MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","Payer Specific Negotiated Charge":179272.0},{"Payer":"SBG","MS-DRG":"023","Description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Chemothera","Payer Specific Negotiated Charge":149176.0},{"Payer":"SBG","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":32981.0},{"Payer":"SBG","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":19294.0},{"Payer":"SBG","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":17214.0},{"Payer":"SBG","MS-DRG":"030","Description":"Spinal Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":13326.0},{"Payer":"SBG","MS-DRG":"041","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","Payer Specific Negotiated Charge":13909.0},{"Payer":"SBG","MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","Payer Specific Negotiated Charge":12858.0},{"Payer":"SBG","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":13475.0},{"Payer":"SBG","MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","Payer Specific Negotiated Charge":10996.0},{"Payer":"SBG","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":6027.0},{"Payer":"SBG","MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","Payer Specific Negotiated Charge":4576.0},{"Payer":"SBG","MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","Payer Specific Negotiated Charge":5795.0},{"Payer":"SBG","MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","Payer Specific Negotiated Charge":10715.0},{"Payer":"SBG","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":4689.0},{"Payer":"SBG","MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7781.0},{"Payer":"SBG","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":4976.0},{"Payer":"SBG","MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","Payer Specific Negotiated Charge":11092.0},{"Payer":"SBG","MS-DRG":"185","Description":"Major Chest Trauma Without Cc/Mcc","Payer Specific Negotiated Charge":4305.0},{"Payer":"SBG","MS-DRG":"186","Description":"Pleural Effusion With Mcc","Payer Specific Negotiated Charge":9049.0},{"Payer":"SBG","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":7130.0},{"Payer":"SBG","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":6710.0},{"Payer":"SBG","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":9968.0},{"Payer":"SBG","MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","Payer Specific Negotiated Charge":4159.0},{"Payer":"SBG","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7821.0},{"Payer":"SBG","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":5560.0},{"Payer":"SBG","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":189129.0},{"Payer":"SBG","MS-DRG":"219","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":82530.0},{"Payer":"SBG","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":59337.0},{"Payer":"SBG","MS-DRG":"227","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":62606.0},{"Payer":"SBG","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":46938.0},{"Payer":"SBG","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":23166.0},{"Payer":"SBG","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":16033.0},{"Payer":"SBG","MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":22874.0},{"Payer":"SBG","MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":14102.0},{"Payer":"SBG","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":15657.0},{"Payer":"SBG","MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":15257.0},{"Payer":"SBG","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":31651.0},{"Payer":"SBG","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":7676.0},{"Payer":"SBG","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":12888.0},{"Payer":"SBG","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6758.0},{"Payer":"SBG","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7893.0},{"Payer":"SBG","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":5311.0},{"Payer":"SBG","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":3843.0},{"Payer":"SBG","MS-DRG":"301","Description":"Peripheral Vascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":4257.0},{"Payer":"SBG","MS-DRG":"305","Description":"Hypertension Without Mcc","Payer Specific Negotiated Charge":4290.0},{"Payer":"SBG","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":7515.0},{"Payer":"SBG","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":4436.0},{"Payer":"SBG","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":3280.0},{"Payer":"SBG","MS-DRG":"311","Description":"Angina Pectoris","Payer Specific Negotiated Charge":4018.0},{"Payer":"SBG","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":4789.0},{"Payer":"SBG","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":4195.0},{"Payer":"SBG","MS-DRG":"316","Description":"Other Circulatory System Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":4353.0},{"Payer":"SBG","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":14820.0},{"Payer":"SBG","MS-DRG":"342","Description":"Appendectomy Without Complicated Principal Diagnosis With Cc","Payer Specific Negotiated Charge":9444.0},{"Payer":"SBG","MS-DRG":"343","Description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":6754.0},{"Payer":"SBG","MS-DRG":"355","Description":"Hernia Procedures Except Inguinal And Femoral Without Cc/Mcc","Payer Specific Negotiated Charge":8049.0},{"Payer":"SBG","MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","Payer Specific Negotiated Charge":5997.0},{"Payer":"SBG","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":5795.0},{"Payer":"SBG","MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","Payer Specific Negotiated Charge":4925.0},{"Payer":"SBG","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":3399.0},{"Payer":"SBG","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":4466.0},{"Payer":"SBG","MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","Payer Specific Negotiated Charge":14201.0},{"Payer":"SBG","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":9788.0},{"Payer":"SBG","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":7664.0},{"Payer":"SBG","MS-DRG":"437","Description":"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","Payer Specific Negotiated Charge":5149.0},{"Payer":"SBG","MS-DRG":"438","Description":"Disorders Of Pancreas Except Malignancy With Mcc","Payer Specific Negotiated Charge":9609.0},{"Payer":"SBG","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":4969.0},{"Payer":"SBG","MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","Payer Specific Negotiated Charge":6302.0},{"Payer":"SBG","MS-DRG":"458","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","Payer Specific Negotiated Charge":82919.0},{"Payer":"SBG","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":39145.0},{"Payer":"SBG","MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":38980.0},{"Payer":"SBG","MS-DRG":"466","Description":"Revision Of Hip Or Knee Replacement With Mcc","Payer Specific Negotiated Charge":36401.0},{"Payer":"SBG","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":33602.0},{"Payer":"SBG","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":44250.0},{"Payer":"SBG","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":23383.0},{"Payer":"SBG","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":32693.0},{"Payer":"SBG","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":27134.0},{"Payer":"SBG","MS-DRG":"480","Description":"Hip And Femur Procedures Except Major Joint With Mcc","Payer Specific Negotiated Charge":21546.0},{"Payer":"SBG","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":37665.0},{"Payer":"SBG","MS-DRG":"492","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","Payer Specific Negotiated Charge":25381.0},{"Payer":"SBG","MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","Payer Specific Negotiated Charge":25663.0},{"Payer":"SBG","MS-DRG":"516","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","Payer Specific Negotiated Charge":16669.0},{"Payer":"SBG","MS-DRG":"518","Description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","Payer Specific Negotiated Charge":19991.0},{"Payer":"SBG","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":11195.0},{"Payer":"SBG","MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":7847.0},{"Payer":"SBG","MS-DRG":"543","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","Payer Specific Negotiated Charge":6195.0},{"Payer":"SBG","MS-DRG":"554","Description":"Bone Diseases And Arthropathies Without Mcc","Payer Specific Negotiated Charge":4617.0},{"Payer":"SBG","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":4644.0},{"Payer":"SBG","MS-DRG":"559","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":11638.0},{"Payer":"SBG","MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":12250.0},{"Payer":"SBG","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":12031.0},{"Payer":"SBG","MS-DRG":"627","Description":"Thyroid, Parathyroid And Thyroglossal Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6696.0},{"Payer":"SBG","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":5185.0},{"Payer":"SBG","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":3596.0},{"Payer":"SBG","MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","Payer Specific Negotiated Charge":7121.0},{"Payer":"SBG","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":5263.0},{"Payer":"SBG","MS-DRG":"694","Description":"Urinary Stones Without Mcc","Payer Specific Negotiated Charge":4342.0},{"Payer":"SBG","MS-DRG":"813","Description":"Coagulation Disorders","Payer Specific Negotiated Charge":9297.0},{"Payer":"SBG","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":39201.0},{"Payer":"SBG","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":12675.0},{"Payer":"SBG","MS-DRG":"864","Description":"Fever And Inflammatory Conditions","Payer Specific Negotiated Charge":4970.0},{"Payer":"SBG","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":10946.0},{"Payer":"SBG","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":6095.0},{"Payer":"SBG","MS-DRG":"909","Description":"Other O.R. Procedures For Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":7734.0},{"Payer":"SBG","MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","Payer Specific Negotiated Charge":8582.0},{"Payer":"SBG","MS-DRG":"949","Description":"Aftercare With Cc/Mcc","Payer Specific Negotiated Charge":6386.0}],"Inpatient Payer Specific Charge 10":[{"Payer":"United Healthcare","MS-DRG":"004","Description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","Payer Specific Negotiated Charge":170433.0},{"Payer":"United Healthcare","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":47989.0},{"Payer":"United Healthcare","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":35385.0},{"Payer":"United Healthcare","MS-DRG":"028","Description":"Spinal Procedures With Mcc","Payer Specific Negotiated Charge":69090.0},{"Payer":"United Healthcare","MS-DRG":"029","Description":"Spinal Procedures With Cc Or Spinal Neurostimulators","Payer Specific Negotiated Charge":89642.0},{"Payer":"United Healthcare","MS-DRG":"036","Description":"Carotid Artery Stent Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":25852.0},{"Payer":"United Healthcare","MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","Payer Specific Negotiated Charge":21411.0},{"Payer":"United Healthcare","MS-DRG":"060","Description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","Payer Specific Negotiated Charge":13017.0},{"Payer":"United Healthcare","MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","Payer Specific Negotiated Charge":127373.0},{"Payer":"United Healthcare","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":10586.0},{"Payer":"United Healthcare","MS-DRG":"069","Description":"Transient Ischemia Without Thrombolytic","Payer Specific Negotiated Charge":11520.0},{"Payer":"United Healthcare","MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":13248.0},{"Payer":"United Healthcare","MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":11238.0},{"Payer":"United Healthcare","MS-DRG":"097","Description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","Payer Specific Negotiated Charge":52795.0},{"Payer":"United Healthcare","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":13035.0},{"Payer":"United Healthcare","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":11804.0},{"Payer":"United Healthcare","MS-DRG":"125","Description":"Other Disorders Of The Eye Without Mcc","Payer Specific Negotiated Charge":11655.0},{"Payer":"United Healthcare","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":27302.0},{"Payer":"United Healthcare","MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":19587.0},{"Payer":"United Healthcare","MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","Payer Specific Negotiated Charge":25857.0},{"Payer":"United Healthcare","MS-DRG":"179","Description":"Respiratory Infections And Inflammations Without Cc/Mcc","Payer Specific Negotiated Charge":12787.0},{"Payer":"United Healthcare","MS-DRG":"180","Description":"Respiratory Neoplasms With Mcc","Payer Specific Negotiated Charge":25466.0},{"Payer":"United Healthcare","MS-DRG":"181","Description":"Respiratory Neoplasms With Cc","Payer Specific Negotiated Charge":17008.0},{"Payer":"United Healthcare","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":17949.0},{"Payer":"United Healthcare","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":16890.0},{"Payer":"United Healthcare","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":12789.0},{"Payer":"United Healthcare","MS-DRG":"196","Description":"Interstitial Lung Disease With Mcc","Payer Specific Negotiated Charge":39841.0},{"Payer":"United Healthcare","MS-DRG":"200","Description":"Pneumothorax With Cc","Payer Specific Negotiated Charge":15976.0},{"Payer":"United Healthcare","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":12718.0},{"Payer":"United Healthcare","MS-DRG":"207","Description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","Payer Specific Negotiated Charge":87701.0},{"Payer":"United Healthcare","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":190250.0},{"Payer":"United Healthcare","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":76866.0},{"Payer":"United Healthcare","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":59486.0},{"Payer":"United Healthcare","MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","Payer Specific Negotiated Charge":37344.0},{"Payer":"United Healthcare","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":46843.0},{"Payer":"United Healthcare","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":30040.0},{"Payer":"United Healthcare","MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":27305.0},{"Payer":"United Healthcare","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":26872.0},{"Payer":"United Healthcare","MS-DRG":"260","Description":"Cardiac Pacemaker Revision Except Device Replacement With Mcc","Payer Specific Negotiated Charge":54621.0},{"Payer":"United Healthcare","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":45689.0},{"Payer":"United Healthcare","MS-DRG":"273","Description":"Percutaneous And Other Intracardiac Procedures With Mcc","Payer Specific Negotiated Charge":69884.0},{"Payer":"United Healthcare","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":46651.0},{"Payer":"United Healthcare","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":10894.0},{"Payer":"United Healthcare","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":17011.0},{"Payer":"United Healthcare","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":13118.0},{"Payer":"United Healthcare","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":13369.0},{"Payer":"United Healthcare","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":11166.0},{"Payer":"United Healthcare","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":8258.0},{"Payer":"United Healthcare","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":8405.0},{"Payer":"United Healthcare","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":10561.0},{"Payer":"United Healthcare","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":37306.0},{"Payer":"United Healthcare","MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":24939.0},{"Payer":"United Healthcare","MS-DRG":"336","Description":"Peritoneal Adhesiolysis With Cc","Payer Specific Negotiated Charge":36479.0},{"Payer":"United Healthcare","MS-DRG":"340","Description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":18270.0},{"Payer":"United Healthcare","MS-DRG":"348","Description":"Anal And Stomal Procedures With Cc","Payer Specific Negotiated Charge":20807.0},{"Payer":"United Healthcare","MS-DRG":"354","Description":"Hernia Procedures Except Inguinal And Femoral With Cc","Payer Specific Negotiated Charge":25425.0},{"Payer":"United Healthcare","MS-DRG":"377","Description":"Gastrointestinal Hemorrhage With Mcc","Payer Specific Negotiated Charge":65404.0},{"Payer":"United Healthcare","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":14588.0},{"Payer":"United Healthcare","MS-DRG":"388","Description":"Gastrointestinal Obstruction With Mcc","Payer Specific Negotiated Charge":22517.0},{"Payer":"United Healthcare","MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","Payer Specific Negotiated Charge":16929.0},{"Payer":"United Healthcare","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":11243.0},{"Payer":"United Healthcare","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":19294.0},{"Payer":"United Healthcare","MS-DRG":"423","Description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","Payer Specific Negotiated Charge":83720.0},{"Payer":"United Healthcare","MS-DRG":"433","Description":"Cirrhosis And Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":15236.0},{"Payer":"United Healthcare","MS-DRG":"436","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","Payer Specific Negotiated Charge":16620.0},{"Payer":"United Healthcare","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":12508.0},{"Payer":"United Healthcare","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":9089.0},{"Payer":"United Healthcare","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":7423.0},{"Payer":"United Healthcare","MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","Payer Specific Negotiated Charge":15864.0},{"Payer":"United Healthcare","MS-DRG":"446","Description":"Disorders Of The Biliary Tract Without Cc/Mcc","Payer Specific Negotiated Charge":11999.0},{"Payer":"United Healthcare","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":71064.0},{"Payer":"United Healthcare","MS-DRG":"459","Description":"Spinal Fusion Except Cervical With Mcc","Payer Specific Negotiated Charge":101163.0},{"Payer":"United Healthcare","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":58471.0},{"Payer":"United Healthcare","MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":46306.0},{"Payer":"United Healthcare","MS-DRG":"463","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","Payer Specific Negotiated Charge":39785.0},{"Payer":"United Healthcare","MS-DRG":"467","Description":"Revision Of Hip Or Knee Replacement With Cc","Payer Specific Negotiated Charge":51853.0},{"Payer":"United Healthcare","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":41518.0},{"Payer":"United Healthcare","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":29061.0},{"Payer":"United Healthcare","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":44905.0},{"Payer":"United Healthcare","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":37093.0},{"Payer":"United Healthcare","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":35317.0},{"Payer":"United Healthcare","MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","Payer Specific Negotiated Charge":33987.0},{"Payer":"United Healthcare","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":26744.0},{"Payer":"United Healthcare","MS-DRG":"496","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","Payer Specific Negotiated Charge":30126.0},{"Payer":"United Healthcare","MS-DRG":"502","Description":"Soft Tissue Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":19499.0},{"Payer":"United Healthcare","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":13463.0},{"Payer":"United Healthcare","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":11635.0},{"Payer":"United Healthcare","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":15406.0},{"Payer":"United Healthcare","MS-DRG":"572","Description":"Skin Debridement Without Cc/Mcc","Payer Specific Negotiated Charge":16561.0},{"Payer":"United Healthcare","MS-DRG":"575","Description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","Payer Specific Negotiated Charge":21122.0},{"Payer":"United Healthcare","MS-DRG":"580","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","Payer Specific Negotiated Charge":23751.0},{"Payer":"United Healthcare","MS-DRG":"593","Description":"Skin Ulcers With Cc","Payer Specific Negotiated Charge":15627.0},{"Payer":"United Healthcare","MS-DRG":"596","Description":"Major Skin Disorders Without Mcc","Payer Specific Negotiated Charge":14030.0},{"Payer":"United Healthcare","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":12453.0},{"Payer":"United Healthcare","MS-DRG":"607","Description":"Minor Skin Disorders Without Mcc","Payer Specific Negotiated Charge":12197.0},{"Payer":"United Healthcare","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":30285.0},{"Payer":"United Healthcare","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":20458.0},{"Payer":"United Healthcare","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":11920.0},{"Payer":"United Healthcare","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":9053.0},{"Payer":"United Healthcare","MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","Payer Specific Negotiated Charge":16475.0},{"Payer":"United Healthcare","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":6546.0},{"Payer":"United Healthcare","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":55796.0},{"Payer":"United Healthcare","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":11268.0},{"Payer":"United Healthcare","MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","Payer Specific Negotiated Charge":23897.0},{"Payer":"United Healthcare","MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","Payer Specific Negotiated Charge":13470.0},{"Payer":"United Healthcare","MS-DRG":"809","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","Payer Specific Negotiated Charge":10194.0},{"Payer":"United Healthcare","MS-DRG":"824","Description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","Payer Specific Negotiated Charge":33031.0},{"Payer":"United Healthcare","MS-DRG":"832","Description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","Payer Specific Negotiated Charge":10564.0},{"Payer":"United Healthcare","MS-DRG":"841","Description":"Lymphoma And Non-Acute Leukemia With Cc","Payer Specific Negotiated Charge":23795.0},{"Payer":"United Healthcare","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":59097.0},{"Payer":"United Healthcare","MS-DRG":"855","Description":"Infectious And Parasitic Diseases With O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":23671.0},{"Payer":"United Healthcare","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":27554.0},{"Payer":"United Healthcare","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":14578.0},{"Payer":"United Healthcare","MS-DRG":"897","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","Payer Specific Negotiated Charge":12133.0},{"Payer":"United Healthcare","MS-DRG":"909","Description":"Other O.R. Procedures For Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":19469.0},{"Payer":"United Healthcare","MS-DRG":"918","Description":"Poisoning And Toxic Effects Of Drugs Without Mcc","Payer Specific Negotiated Charge":11575.0},{"Payer":"United Healthcare","MS-DRG":"920","Description":"Complications Of Treatment With Cc","Payer Specific Negotiated Charge":14875.0},{"Payer":"United Healthcare","MS-DRG":"947","Description":"Signs And Symptoms With Mcc","Payer Specific Negotiated Charge":17677.0},{"Payer":"United Healthcare","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":19058.0},{"Payer":"United Healthcare","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":9882.0},{"Payer":"United Healthcare","MS-DRG":"982","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","Payer Specific Negotiated Charge":35995.0}],"Inpatient Payer Specific Charge 11":[{"Payer":"Aetna Medicare","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":22940.0},{"Payer":"Aetna Medicare","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":16127.0},{"Payer":"Aetna Medicare","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":13407.0},{"Payer":"Aetna Medicare","MS-DRG":"033","Description":"Ventricular Shunt Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":8919.0},{"Payer":"Aetna Medicare","MS-DRG":"038","Description":"Extracranial Procedures With Cc","Payer Specific Negotiated Charge":9530.0},{"Payer":"Aetna Medicare","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6122.0},{"Payer":"Aetna Medicare","MS-DRG":"056","Description":"Degenerative Nervous System Disorders With Mcc","Payer Specific Negotiated Charge":22041.0},{"Payer":"Aetna Medicare","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":6940.0},{"Payer":"Aetna Medicare","MS-DRG":"063","Description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","Payer Specific Negotiated Charge":8929.0},{"Payer":"Aetna Medicare","MS-DRG":"064","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","Payer Specific Negotiated Charge":10249.0},{"Payer":"Aetna Medicare","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":5720.0},{"Payer":"Aetna Medicare","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":3941.0},{"Payer":"Aetna Medicare","MS-DRG":"072","Description":"Nonspecific Cerebrovascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":4277.0},{"Payer":"Aetna Medicare","MS-DRG":"082","Description":"Traumatic Stupor And Coma >1 Hour With Mcc","Payer Specific Negotiated Charge":12275.0},{"Payer":"Aetna Medicare","MS-DRG":"086","Description":"Traumatic Stupor And Coma <1 Hour With Cc","Payer Specific Negotiated Charge":6739.0},{"Payer":"Aetna Medicare","MS-DRG":"087","Description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":4711.0},{"Payer":"Aetna Medicare","MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","Payer Specific Negotiated Charge":8567.0},{"Payer":"Aetna Medicare","MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":4277.0},{"Payer":"Aetna Medicare","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":4945.0},{"Payer":"Aetna Medicare","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":4242.0},{"Payer":"Aetna Medicare","MS-DRG":"149","Description":"Dysequilibrium","Payer Specific Negotiated Charge":3916.0},{"Payer":"Aetna Medicare","MS-DRG":"153","Description":"Otitis Media And Uri Without Mcc","Payer Specific Negotiated Charge":3968.0},{"Payer":"Aetna Medicare","MS-DRG":"155","Description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","Payer Specific Negotiated Charge":4778.0},{"Payer":"Aetna Medicare","MS-DRG":"164","Description":"Major Chest Procedures With Cc","Payer Specific Negotiated Charge":13688.0},{"Payer":"Aetna Medicare","MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7260.0},{"Payer":"Aetna Medicare","MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","Payer Specific Negotiated Charge":8114.0},{"Payer":"Aetna Medicare","MS-DRG":"178","Description":"Respiratory Infections And Inflammations With Cc","Payer Specific Negotiated Charge":7155.0},{"Payer":"Aetna Medicare","MS-DRG":"180","Description":"Respiratory Neoplasms With Mcc","Payer Specific Negotiated Charge":9447.0},{"Payer":"Aetna Medicare","MS-DRG":"181","Description":"Respiratory Neoplasms With Cc","Payer Specific Negotiated Charge":6322.0},{"Payer":"Aetna Medicare","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":6669.0},{"Payer":"Aetna Medicare","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":6659.0},{"Payer":"Aetna Medicare","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":4973.0},{"Payer":"Aetna Medicare","MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","Payer Specific Negotiated Charge":4031.0},{"Payer":"Aetna Medicare","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7309.0},{"Payer":"Aetna Medicare","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":4863.0},{"Payer":"Aetna Medicare","MS-DRG":"195","Description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","Payer Specific Negotiated Charge":3793.0},{"Payer":"Aetna Medicare","MS-DRG":"196","Description":"Interstitial Lung Disease With Mcc","Payer Specific Negotiated Charge":8748.0},{"Payer":"Aetna Medicare","MS-DRG":"197","Description":"Interstitial Lung Disease With Cc","Payer Specific Negotiated Charge":5887.0},{"Payer":"Aetna Medicare","MS-DRG":"204","Description":"Respiratory Signs And Symptoms","Payer Specific Negotiated Charge":4586.0},{"Payer":"Aetna Medicare","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":42549.0},{"Payer":"Aetna Medicare","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":68263.0},{"Payer":"Aetna Medicare","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":25666.0},{"Payer":"Aetna Medicare","MS-DRG":"222","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","Payer Specific Negotiated Charge":43285.0},{"Payer":"Aetna Medicare","MS-DRG":"229","Description":"Other Cardiothoracic Procedures Without Mcc","Payer Specific Negotiated Charge":28116.0},{"Payer":"Aetna Medicare","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":27512.0},{"Payer":"Aetna Medicare","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":21912.0},{"Payer":"Aetna Medicare","MS-DRG":"242","Description":"Permanent Cardiac Pacemaker Implant With Mcc","Payer Specific Negotiated Charge":18375.0},{"Payer":"Aetna Medicare","MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","Payer Specific Negotiated Charge":13545.0},{"Payer":"Aetna Medicare","MS-DRG":"244","Description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","Payer Specific Negotiated Charge":11281.0},{"Payer":"Aetna Medicare","MS-DRG":"246","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":18967.0},{"Payer":"Aetna Medicare","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":11011.0},{"Payer":"Aetna Medicare","MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":17409.0},{"Payer":"Aetna Medicare","MS-DRG":"249","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":10603.0},{"Payer":"Aetna Medicare","MS-DRG":"253","Description":"Other Vascular Procedures With Cc","Payer Specific Negotiated Charge":14446.0},{"Payer":"Aetna Medicare","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9564.0},{"Payer":"Aetna Medicare","MS-DRG":"264","Description":"Other Circulatory System O.R. Procedures","Payer Specific Negotiated Charge":16303.0},{"Payer":"Aetna Medicare","MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","Payer Specific Negotiated Charge":30538.0},{"Payer":"Aetna Medicare","MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","Payer Specific Negotiated Charge":21919.0},{"Payer":"Aetna Medicare","MS-DRG":"270","Description":"Other Major Cardiovascular Procedures With Mcc","Payer Specific Negotiated Charge":67480.0},{"Payer":"Aetna Medicare","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":19195.0},{"Payer":"Aetna Medicare","MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":13859.0},{"Payer":"Aetna Medicare","MS-DRG":"273","Description":"Percutaneous And Other Intracardiac Procedures With Mcc","Payer Specific Negotiated Charge":20155.0},{"Payer":"Aetna Medicare","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":17021.0},{"Payer":"Aetna Medicare","MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","Payer Specific Negotiated Charge":9160.0},{"Payer":"Aetna Medicare","MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","Payer Specific Negotiated Charge":5293.0},{"Payer":"Aetna Medicare","MS-DRG":"282","Description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","Payer Specific Negotiated Charge":4053.0},{"Payer":"Aetna Medicare","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6279.0},{"Payer":"Aetna Medicare","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7296.0},{"Payer":"Aetna Medicare","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":4970.0},{"Payer":"Aetna Medicare","MS-DRG":"296","Description":"Cardiac Arrest, Unexplained With Mcc","Payer Specific Negotiated Charge":8209.0},{"Payer":"Aetna Medicare","MS-DRG":"305","Description":"Hypertension Without Mcc","Payer Specific Negotiated Charge":3919.0},{"Payer":"Aetna Medicare","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":6485.0},{"Payer":"Aetna Medicare","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":4240.0},{"Payer":"Aetna Medicare","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":3114.0},{"Payer":"Aetna Medicare","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":4348.0},{"Payer":"Aetna Medicare","MS-DRG":"314","Description":"Other Circulatory System Diagnoses With Mcc","Payer Specific Negotiated Charge":11345.0},{"Payer":"Aetna Medicare","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":5337.0},{"Payer":"Aetna Medicare","MS-DRG":"326","Description":"Stomach, Esophageal And Duodenal Procedures With Mcc","Payer Specific Negotiated Charge":27948.0},{"Payer":"Aetna Medicare","MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","Payer Specific Negotiated Charge":26525.0},{"Payer":"Aetna Medicare","MS-DRG":"330","Description":"Major Small And Large Bowel Procedures With Cc","Payer Specific Negotiated Charge":13645.0},{"Payer":"Aetna Medicare","MS-DRG":"356","Description":"Other Digestive System O.R. Procedures With Mcc","Payer Specific Negotiated Charge":20442.0},{"Payer":"Aetna Medicare","MS-DRG":"357","Description":"Other Digestive System O.R. Procedures With Cc","Payer Specific Negotiated Charge":11503.0},{"Payer":"Aetna Medicare","MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","Payer Specific Negotiated Charge":5594.0},{"Payer":"Aetna Medicare","MS-DRG":"375","Description":"Digestive Malignancy With Cc","Payer Specific Negotiated Charge":6663.0},{"Payer":"Aetna Medicare","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":5407.0},{"Payer":"Aetna Medicare","MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","Payer Specific Negotiated Charge":4612.0},{"Payer":"Aetna Medicare","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":3417.0},{"Payer":"Aetna Medicare","MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","Payer Specific Negotiated Charge":6795.0},{"Payer":"Aetna Medicare","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":4238.0},{"Payer":"Aetna Medicare","MS-DRG":"405","Description":"Pancreas, Liver And Shunt Procedures With Mcc","Payer Specific Negotiated Charge":29303.0},{"Payer":"Aetna Medicare","MS-DRG":"411","Description":"Cholecystectomy With C.D.E. With Mcc","Payer Specific Negotiated Charge":21691.0},{"Payer":"Aetna Medicare","MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","Payer Specific Negotiated Charge":11413.0},{"Payer":"Aetna Medicare","MS-DRG":"416","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":7520.0},{"Payer":"Aetna Medicare","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":11636.0},{"Payer":"Aetna Medicare","MS-DRG":"435","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","Payer Specific Negotiated Charge":9295.0},{"Payer":"Aetna Medicare","MS-DRG":"436","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","Payer Specific Negotiated Charge":6151.0},{"Payer":"Aetna Medicare","MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","Payer Specific Negotiated Charge":6038.0},{"Payer":"Aetna Medicare","MS-DRG":"446","Description":"Disorders Of The Biliary Tract Without Cc/Mcc","Payer Specific Negotiated Charge":4446.0},{"Payer":"Aetna Medicare","MS-DRG":"453","Description":"Combined Anterior And Posterior Spinal Fusion With Mcc","Payer Specific Negotiated Charge":52819.0},{"Payer":"Aetna Medicare","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":33406.0},{"Payer":"Aetna Medicare","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":26387.0},{"Payer":"Aetna Medicare","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":21323.0},{"Payer":"Aetna Medicare","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":14984.0},{"Payer":"Aetna Medicare","MS-DRG":"469","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","Payer Specific Negotiated Charge":17045.0},{"Payer":"Aetna Medicare","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":10598.0},{"Payer":"Aetna Medicare","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":17016.0},{"Payer":"Aetna Medicare","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":13430.0},{"Payer":"Aetna Medicare","MS-DRG":"480","Description":"Hip And Femur Procedures Except Major Joint With Mcc","Payer Specific Negotiated Charge":16571.0},{"Payer":"Aetna Medicare","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":11496.0},{"Payer":"Aetna Medicare","MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","Payer Specific Negotiated Charge":9063.0},{"Payer":"Aetna Medicare","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":12896.0},{"Payer":"Aetna Medicare","MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","Payer Specific Negotiated Charge":12677.0},{"Payer":"Aetna Medicare","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":9909.0},{"Payer":"Aetna Medicare","MS-DRG":"496","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","Payer Specific Negotiated Charge":11140.0},{"Payer":"Aetna Medicare","MS-DRG":"497","Description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":7983.0},{"Payer":"Aetna Medicare","MS-DRG":"515","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","Payer Specific Negotiated Charge":16740.0},{"Payer":"Aetna Medicare","MS-DRG":"517","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":8189.0},{"Payer":"Aetna Medicare","MS-DRG":"518","Description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","Payer Specific Negotiated Charge":18932.0},{"Payer":"Aetna Medicare","MS-DRG":"546","Description":"Connective Tissue Disorders With Cc","Payer Specific Negotiated Charge":6519.0},{"Payer":"Aetna Medicare","MS-DRG":"551","Description":"Medical Back Problems With Mcc","Payer Specific Negotiated Charge":8504.0},{"Payer":"Aetna Medicare","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":5076.0},{"Payer":"Aetna Medicare","MS-DRG":"554","Description":"Bone Diseases And Arthropathies Without Mcc","Payer Specific Negotiated Charge":4467.0},{"Payer":"Aetna Medicare","MS-DRG":"555","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":7906.0},{"Payer":"Aetna Medicare","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":4567.0},{"Payer":"Aetna Medicare","MS-DRG":"559","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","Payer Specific Negotiated Charge":10961.0},{"Payer":"Aetna Medicare","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":5991.0},{"Payer":"Aetna Medicare","MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":4396.0},{"Payer":"Aetna Medicare","MS-DRG":"565","Description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","Payer Specific Negotiated Charge":5441.0},{"Payer":"Aetna Medicare","MS-DRG":"566","Description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":4561.0},{"Payer":"Aetna Medicare","MS-DRG":"581","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6680.0},{"Payer":"Aetna Medicare","MS-DRG":"602","Description":"Cellulitis With Mcc","Payer Specific Negotiated Charge":7992.0},{"Payer":"Aetna Medicare","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":4724.0},{"Payer":"Aetna Medicare","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":11361.0},{"Payer":"Aetna Medicare","MS-DRG":"629","Description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","Payer Specific Negotiated Charge":12789.0},{"Payer":"Aetna Medicare","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":7666.0},{"Payer":"Aetna Medicare","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":4764.0},{"Payer":"Aetna Medicare","MS-DRG":"640","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","Payer Specific Negotiated Charge":6788.0},{"Payer":"Aetna Medicare","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":4175.0},{"Payer":"Aetna Medicare","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":19982.0},{"Payer":"Aetna Medicare","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":8691.0},{"Payer":"Aetna Medicare","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":5158.0},{"Payer":"Aetna Medicare","MS-DRG":"689","Description":"Kidney And Urinary Tract Infections With Mcc","Payer Specific Negotiated Charge":6281.0},{"Payer":"Aetna Medicare","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":4425.0},{"Payer":"Aetna Medicare","MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","Payer Specific Negotiated Charge":8671.0},{"Payer":"Aetna Medicare","MS-DRG":"728","Description":"Inflammation Of The Male Reproductive System Without Mcc","Payer Specific Negotiated Charge":5178.0},{"Payer":"Aetna Medicare","MS-DRG":"809","Description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","Payer Specific Negotiated Charge":6787.0},{"Payer":"Aetna Medicare","MS-DRG":"813","Description":"Coagulation Disorders","Payer Specific Negotiated Charge":8981.0},{"Payer":"Aetna Medicare","MS-DRG":"830","Description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":7771.0},{"Payer":"Aetna Medicare","MS-DRG":"835","Description":"Acute Leukemia Without Major O.R. Procedures With Cc","Payer Specific Negotiated Charge":11455.0},{"Payer":"Aetna Medicare","MS-DRG":"840","Description":"Lymphoma And Non-Acute Leukemia With Mcc","Payer Specific Negotiated Charge":24389.0},{"Payer":"Aetna Medicare","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":27923.0},{"Payer":"Aetna Medicare","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":11937.0},{"Payer":"Aetna Medicare","MS-DRG":"870","Description":"Septicemia Or Severe Sepsis With Mv >96 Hours","Payer Specific Negotiated Charge":34465.0},{"Payer":"Aetna Medicare","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":10204.0},{"Payer":"Aetna Medicare","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5891.0},{"Payer":"Aetna Medicare","MS-DRG":"884","Description":"Organic Disturbances And Intellectual Disability","Payer Specific Negotiated Charge":8300.0},{"Payer":"Aetna Medicare","MS-DRG":"897","Description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy Without Mcc","Payer Specific Negotiated Charge":4582.0},{"Payer":"Aetna Medicare","MS-DRG":"903","Description":"Wound Debridements For Injuries Without Cc/Mcc","Payer Specific Negotiated Charge":6191.0},{"Payer":"Aetna Medicare","MS-DRG":"908","Description":"Other O.R. Procedures For Injuries With Cc","Payer Specific Negotiated Charge":11305.0},{"Payer":"Aetna Medicare","MS-DRG":"914","Description":"Traumatic Injury Without Mcc","Payer Specific Negotiated Charge":4671.0},{"Payer":"Aetna Medicare","MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","Payer Specific Negotiated Charge":8082.0},{"Payer":"Aetna Medicare","MS-DRG":"920","Description":"Complications Of Treatment With Cc","Payer Specific Negotiated Charge":5546.0},{"Payer":"Aetna Medicare","MS-DRG":"947","Description":"Signs And Symptoms With Mcc","Payer Specific Negotiated Charge":6561.0},{"Payer":"Aetna Medicare","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":4501.0},{"Payer":"Aetna Medicare","MS-DRG":"949","Description":"Aftercare With Cc/Mcc","Payer Specific Negotiated Charge":5597.0},{"Payer":"Aetna Medicare","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":4712.0},{"Payer":"Aetna Medicare","MS-DRG":"956","Description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","Payer Specific Negotiated Charge":21476.0},{"Payer":"Aetna Medicare","MS-DRG":"987","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":18147.0}],"Inpatient Payer Specific Charge 12":[{"Payer":"Wellcare Medicare","MS-DRG":"025","Description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","Payer Specific Negotiated Charge":17688.0},{"Payer":"Wellcare Medicare","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":16700.0},{"Payer":"Wellcare Medicare","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":13262.0},{"Payer":"Wellcare Medicare","MS-DRG":"030","Description":"Spinal Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":11969.0},{"Payer":"Wellcare Medicare","MS-DRG":"036","Description":"Carotid Artery Stent Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9781.0},{"Payer":"Wellcare Medicare","MS-DRG":"038","Description":"Extracranial Procedures With Cc","Payer Specific Negotiated Charge":9407.0},{"Payer":"Wellcare Medicare","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6180.0},{"Payer":"Wellcare Medicare","MS-DRG":"041","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","Payer Specific Negotiated Charge":13473.0},{"Payer":"Wellcare Medicare","MS-DRG":"057","Description":"Degenerative Nervous System Disorders Without Mcc","Payer Specific Negotiated Charge":7254.0},{"Payer":"Wellcare Medicare","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":5816.0},{"Payer":"Wellcare Medicare","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":4369.0},{"Payer":"Wellcare Medicare","MS-DRG":"071","Description":"Nonspecific Cerebrovascular Disorders With Cc","Payer Specific Negotiated Charge":5809.0},{"Payer":"Wellcare Medicare","MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":5643.0},{"Payer":"Wellcare Medicare","MS-DRG":"087","Description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":4989.0},{"Payer":"Wellcare Medicare","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":5547.0},{"Payer":"Wellcare Medicare","MS-DRG":"163","Description":"Major Chest Procedures With Mcc","Payer Specific Negotiated Charge":25090.0},{"Payer":"Wellcare Medicare","MS-DRG":"165","Description":"Major Chest Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":10415.0},{"Payer":"Wellcare Medicare","MS-DRG":"167","Description":"Other Respiratory System O.R. Procedures With Cc","Payer Specific Negotiated Charge":11458.0},{"Payer":"Wellcare Medicare","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":4939.0},{"Payer":"Wellcare Medicare","MS-DRG":"177","Description":"Respiratory Infections And Inflammations With Mcc","Payer Specific Negotiated Charge":10648.0},{"Payer":"Wellcare Medicare","MS-DRG":"180","Description":"Respiratory Neoplasms With Mcc","Payer Specific Negotiated Charge":9779.0},{"Payer":"Wellcare Medicare","MS-DRG":"186","Description":"Pleural Effusion With Mcc","Payer Specific Negotiated Charge":8630.0},{"Payer":"Wellcare Medicare","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":6955.0},{"Payer":"Wellcare Medicare","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":6686.0},{"Payer":"Wellcare Medicare","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":5224.0},{"Payer":"Wellcare Medicare","MS-DRG":"192","Description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","Payer Specific Negotiated Charge":4105.0},{"Payer":"Wellcare Medicare","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7406.0},{"Payer":"Wellcare Medicare","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":5213.0},{"Payer":"Wellcare Medicare","MS-DRG":"195","Description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","Payer Specific Negotiated Charge":3952.0},{"Payer":"Wellcare Medicare","MS-DRG":"196","Description":"Interstitial Lung Disease With Mcc","Payer Specific Negotiated Charge":9726.0},{"Payer":"Wellcare Medicare","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":5397.0},{"Payer":"Wellcare Medicare","MS-DRG":"208","Description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","Payer Specific Negotiated Charge":14247.0},{"Payer":"Wellcare Medicare","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":73589.0},{"Payer":"Wellcare Medicare","MS-DRG":"221","Description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","Payer Specific Negotiated Charge":25183.0},{"Payer":"Wellcare Medicare","MS-DRG":"225","Description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","Payer Specific Negotiated Charge":31258.0},{"Payer":"Wellcare Medicare","MS-DRG":"228","Description":"Other Cardiothoracic Procedures With Mcc","Payer Specific Negotiated Charge":40667.0},{"Payer":"Wellcare Medicare","MS-DRG":"229","Description":"Other Cardiothoracic Procedures Without Mcc","Payer Specific Negotiated Charge":30052.0},{"Payer":"Wellcare Medicare","MS-DRG":"233","Description":"Coronary Bypass With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":42935.0},{"Payer":"Wellcare Medicare","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":29312.0},{"Payer":"Wellcare Medicare","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":21585.0},{"Payer":"Wellcare Medicare","MS-DRG":"240","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","Payer Specific Negotiated Charge":12973.0},{"Payer":"Wellcare Medicare","MS-DRG":"243","Description":"Permanent Cardiac Pacemaker Implant With Cc","Payer Specific Negotiated Charge":14589.0},{"Payer":"Wellcare Medicare","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":11389.0},{"Payer":"Wellcare Medicare","MS-DRG":"252","Description":"Other Vascular Procedures With Mcc","Payer Specific Negotiated Charge":39636.0},{"Payer":"Wellcare Medicare","MS-DRG":"253","Description":"Other Vascular Procedures With Cc","Payer Specific Negotiated Charge":14467.0},{"Payer":"Wellcare Medicare","MS-DRG":"254","Description":"Other Vascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":10163.0},{"Payer":"Wellcare Medicare","MS-DRG":"256","Description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","Payer Specific Negotiated Charge":9726.0},{"Payer":"Wellcare Medicare","MS-DRG":"267","Description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","Payer Specific Negotiated Charge":31454.0},{"Payer":"Wellcare Medicare","MS-DRG":"268","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","Payer Specific Negotiated Charge":46784.0},{"Payer":"Wellcare Medicare","MS-DRG":"269","Description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","Payer Specific Negotiated Charge":22579.0},{"Payer":"Wellcare Medicare","MS-DRG":"270","Description":"Other Major Cardiovascular Procedures With Mcc","Payer Specific Negotiated Charge":28825.0},{"Payer":"Wellcare Medicare","MS-DRG":"272","Description":"Other Major Cardiovascular Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":14987.0},{"Payer":"Wellcare Medicare","MS-DRG":"280","Description":"Acute Myocardial Infarction, Discharged Alive With Mcc","Payer Specific Negotiated Charge":9207.0},{"Payer":"Wellcare Medicare","MS-DRG":"281","Description":"Acute Myocardial Infarction, Discharged Alive With Cc","Payer Specific Negotiated Charge":5398.0},{"Payer":"Wellcare Medicare","MS-DRG":"283","Description":"Acute Myocardial Infarction, Expired With Mcc","Payer Specific Negotiated Charge":10927.0},{"Payer":"Wellcare Medicare","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":12087.0},{"Payer":"Wellcare Medicare","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6397.0},{"Payer":"Wellcare Medicare","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7607.0},{"Payer":"Wellcare Medicare","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":3788.0},{"Payer":"Wellcare Medicare","MS-DRG":"303","Description":"Atherosclerosis Without Mcc","Payer Specific Negotiated Charge":3878.0},{"Payer":"Wellcare Medicare","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":14674.0},{"Payer":"Wellcare Medicare","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":4913.0},{"Payer":"Wellcare Medicare","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":3183.0},{"Payer":"Wellcare Medicare","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":4655.0},{"Payer":"Wellcare Medicare","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":5269.0},{"Payer":"Wellcare Medicare","MS-DRG":"326","Description":"Stomach, Esophageal And Duodenal Procedures With Mcc","Payer Specific Negotiated Charge":29383.0},{"Payer":"Wellcare Medicare","MS-DRG":"329","Description":"Major Small And Large Bowel Procedures With Mcc","Payer Specific Negotiated Charge":46704.0},{"Payer":"Wellcare Medicare","MS-DRG":"371","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","Payer Specific Negotiated Charge":10056.0},{"Payer":"Wellcare Medicare","MS-DRG":"372","Description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","Payer Specific Negotiated Charge":5840.0},{"Payer":"Wellcare Medicare","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":5547.0},{"Payer":"Wellcare Medicare","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":3475.0},{"Payer":"Wellcare Medicare","MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","Payer Specific Negotiated Charge":6981.0},{"Payer":"Wellcare Medicare","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":4229.0},{"Payer":"Wellcare Medicare","MS-DRG":"393","Description":"Other Digestive System Diagnoses With Mcc","Payer Specific Negotiated Charge":9117.0},{"Payer":"Wellcare Medicare","MS-DRG":"394","Description":"Other Digestive System Diagnoses With Cc","Payer Specific Negotiated Charge":5351.0},{"Payer":"Wellcare Medicare","MS-DRG":"418","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Cc","Payer Specific Negotiated Charge":9512.0},{"Payer":"Wellcare Medicare","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":4825.0},{"Payer":"Wellcare Medicare","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":3498.0},{"Payer":"Wellcare Medicare","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":34512.0},{"Payer":"Wellcare Medicare","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":26773.0},{"Payer":"Wellcare Medicare","MS-DRG":"459","Description":"Spinal Fusion Except Cervical With Mcc","Payer Specific Negotiated Charge":53042.0},{"Payer":"Wellcare Medicare","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":22008.0},{"Payer":"Wellcare Medicare","MS-DRG":"464","Description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","Payer Specific Negotiated Charge":17113.0},{"Payer":"Wellcare Medicare","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":15213.0},{"Payer":"Wellcare Medicare","MS-DRG":"469","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","Payer Specific Negotiated Charge":17969.0},{"Payer":"Wellcare Medicare","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":10871.0},{"Payer":"Wellcare Medicare","MS-DRG":"471","Description":"Cervical Spinal Fusion With Mcc","Payer Specific Negotiated Charge":27737.0},{"Payer":"Wellcare Medicare","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":16101.0},{"Payer":"Wellcare Medicare","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":12944.0},{"Payer":"Wellcare Medicare","MS-DRG":"475","Description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","Payer Specific Negotiated Charge":11232.0},{"Payer":"Wellcare Medicare","MS-DRG":"478","Description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":12802.0},{"Payer":"Wellcare Medicare","MS-DRG":"480","Description":"Hip And Femur Procedures Except Major Joint With Mcc","Payer Specific Negotiated Charge":17145.0},{"Payer":"Wellcare Medicare","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":11827.0},{"Payer":"Wellcare Medicare","MS-DRG":"482","Description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","Payer Specific Negotiated Charge":9198.0},{"Payer":"Wellcare Medicare","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":12958.0},{"Payer":"Wellcare Medicare","MS-DRG":"492","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","Payer Specific Negotiated Charge":19232.0},{"Payer":"Wellcare Medicare","MS-DRG":"493","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","Payer Specific Negotiated Charge":12487.0},{"Payer":"Wellcare Medicare","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":9820.0},{"Payer":"Wellcare Medicare","MS-DRG":"517","Description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":8014.0},{"Payer":"Wellcare Medicare","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":8342.0},{"Payer":"Wellcare Medicare","MS-DRG":"535","Description":"Fractures Of Hip And Pelvis With Mcc","Payer Specific Negotiated Charge":7291.0},{"Payer":"Wellcare Medicare","MS-DRG":"542","Description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","Payer Specific Negotiated Charge":10160.0},{"Payer":"Wellcare Medicare","MS-DRG":"551","Description":"Medical Back Problems With Mcc","Payer Specific Negotiated Charge":9214.0},{"Payer":"Wellcare Medicare","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":5228.0},{"Payer":"Wellcare Medicare","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":4566.0},{"Payer":"Wellcare Medicare","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":6138.0},{"Payer":"Wellcare Medicare","MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":4505.0},{"Payer":"Wellcare Medicare","MS-DRG":"602","Description":"Cellulitis With Mcc","Payer Specific Negotiated Charge":8776.0},{"Payer":"Wellcare Medicare","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":4789.0},{"Payer":"Wellcare Medicare","MS-DRG":"606","Description":"Minor Skin Disorders With Mcc","Payer Specific Negotiated Charge":8479.0},{"Payer":"Wellcare Medicare","MS-DRG":"617","Description":"Amputation Of Lower Limb For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":11579.0},{"Payer":"Wellcare Medicare","MS-DRG":"623","Description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","Payer Specific Negotiated Charge":11351.0},{"Payer":"Wellcare Medicare","MS-DRG":"637","Description":"Diabetes With Mcc","Payer Specific Negotiated Charge":7917.0},{"Payer":"Wellcare Medicare","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":4984.0},{"Payer":"Wellcare Medicare","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":4312.0},{"Payer":"Wellcare Medicare","MS-DRG":"643","Description":"Endocrine Disorders With Mcc","Payer Specific Negotiated Charge":9169.0},{"Payer":"Wellcare Medicare","MS-DRG":"661","Description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","Payer Specific Negotiated Charge":6260.0},{"Payer":"Wellcare Medicare","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":19698.0},{"Payer":"Wellcare Medicare","MS-DRG":"674","Description":"Other Kidney And Urinary Tract Procedures With Cc","Payer Specific Negotiated Charge":15393.0},{"Payer":"Wellcare Medicare","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":8527.0},{"Payer":"Wellcare Medicare","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":5268.0},{"Payer":"Wellcare Medicare","MS-DRG":"684","Description":"Renal Failure Without Cc/Mcc","Payer Specific Negotiated Charge":3587.0},{"Payer":"Wellcare Medicare","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":4438.0},{"Payer":"Wellcare Medicare","MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","Payer Specific Negotiated Charge":5851.0},{"Payer":"Wellcare Medicare","MS-DRG":"803","Description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","Payer Specific Negotiated Charge":10359.0},{"Payer":"Wellcare Medicare","MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","Payer Specific Negotiated Charge":5046.0},{"Payer":"Wellcare Medicare","MS-DRG":"841","Description":"Lymphoma And Non-Acute Leukemia With Cc","Payer Specific Negotiated Charge":8571.0},{"Payer":"Wellcare Medicare","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":29398.0},{"Payer":"Wellcare Medicare","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":12161.0},{"Payer":"Wellcare Medicare","MS-DRG":"856","Description":"Postoperative Or Post-Traumatic Infections With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":25791.0},{"Payer":"Wellcare Medicare","MS-DRG":"863","Description":"Postoperative And Post-Traumatic Infections Without Mcc","Payer Specific Negotiated Charge":5517.0},{"Payer":"Wellcare Medicare","MS-DRG":"864","Description":"Fever And Inflammatory Conditions","Payer Specific Negotiated Charge":4819.0},{"Payer":"Wellcare Medicare","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":10692.0},{"Payer":"Wellcare Medicare","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5886.0},{"Payer":"Wellcare Medicare","MS-DRG":"884","Description":"Organic Disturbances And Intellectual Disability","Payer Specific Negotiated Charge":8322.0},{"Payer":"Wellcare Medicare","MS-DRG":"904","Description":"Skin Grafts For Injuries With Cc/Mcc","Payer Specific Negotiated Charge":19758.0},{"Payer":"Wellcare Medicare","MS-DRG":"915","Description":"Allergic Reactions With Mcc","Payer Specific Negotiated Charge":9676.0},{"Payer":"Wellcare Medicare","MS-DRG":"916","Description":"Allergic Reactions Without Mcc","Payer Specific Negotiated Charge":3686.0},{"Payer":"Wellcare Medicare","MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","Payer Specific Negotiated Charge":8290.0},{"Payer":"Wellcare Medicare","MS-DRG":"920","Description":"Complications Of Treatment With Cc","Payer Specific Negotiated Charge":5616.0},{"Payer":"Wellcare Medicare","MS-DRG":"939","Description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","Payer Specific Negotiated Charge":18717.0},{"Payer":"Wellcare Medicare","MS-DRG":"947","Description":"Signs And Symptoms With Mcc","Payer Specific Negotiated Charge":7078.0},{"Payer":"Wellcare Medicare","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":4837.0},{"Payer":"Wellcare Medicare","MS-DRG":"949","Description":"Aftercare With Cc/Mcc","Payer Specific Negotiated Charge":6594.0},{"Payer":"Wellcare Medicare","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":4353.0},{"Payer":"Wellcare Medicare","MS-DRG":"964","Description":"Other Multiple Significant Trauma With Cc","Payer Specific Negotiated Charge":8538.0},{"Payer":"Wellcare Medicare","MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":24632.0},{"Payer":"Wellcare Medicare","MS-DRG":"983","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":9287.0},{"Payer":"Wellcare Medicare","MS-DRG":"987","Description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":18812.0}],"Inpatient Payer Specific Charge 13":[{"Payer":"Coventry/Aetna PPO","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":37084.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","Payer Specific Negotiated Charge":15137.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"093","Description":"Other Disorders Of Nervous System Without Cc/Mcc","Payer Specific Negotiated Charge":8681.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"100","Description":"Seizures With Mcc","Payer Specific Negotiated Charge":23307.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":10069.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":12470.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":9676.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"187","Description":"Pleural Effusion With Cc","Payer Specific Negotiated Charge":12594.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":15808.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":11457.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":10812.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":256977.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"227","Description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":144437.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":133818.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":35855.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"264","Description":"Other Circulatory System O.R. Procedures","Payer Specific Negotiated Charge":38062.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":14515.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":16986.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":12333.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":9593.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":6379.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"312","Description":"Syncope And Collapse","Payer Specific Negotiated Charge":10688.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":9319.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":15823.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"343","Description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":16350.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"369","Description":"Major Esophageal Disorders With Cc","Payer Specific Negotiated Charge":17245.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"382","Description":"Complicated Peptic Ulcer Without Cc/Mcc","Payer Specific Negotiated Charge":9026.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":11681.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":17246.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"438","Description":"Disorders Of Pancreas Except Malignancy With Mcc","Payer Specific Negotiated Charge":38741.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"439","Description":"Disorders Of Pancreas Except Malignancy With Cc","Payer Specific Negotiated Charge":15105.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"440","Description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","Payer Specific Negotiated Charge":8348.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":20219.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":50984.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":42830.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"471","Description":"Cervical Spinal Fusion With Mcc","Payer Specific Negotiated Charge":89837.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":98499.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":40967.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":9030.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"598","Description":"Malignant Breast Disorders With Cc","Payer Specific Negotiated Charge":12415.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"601","Description":"Non-Malignant Breast Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":7961.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":11130.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":12779.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":9278.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"643","Description":"Endocrine Disorders With Mcc","Payer Specific Negotiated Charge":22415.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":12708.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":9733.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":23623.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":26779.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"880","Description":"Acute Adjustment Reaction And Psychosocial Dysfunction","Payer Specific Negotiated Charge":12818.0},{"Payer":"Coventry/Aetna PPO","MS-DRG":"948","Description":"Signs And Symptoms Without Mcc","Payer Specific Negotiated Charge":8891.0}],"Inpatient Payer Specific Charge 14":[{"Payer":"Wellcare Medicaid","MS-DRG":"026","Description":"Craniotomy And Endovascular Intracranial Procedures With Cc","Payer Specific Negotiated Charge":23216.0},{"Payer":"Wellcare Medicaid","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":15902.0},{"Payer":"Wellcare Medicaid","MS-DRG":"074","Description":"Cranial And Peripheral Nerve Disorders Without Mcc","Payer Specific Negotiated Charge":7700.0},{"Payer":"Wellcare Medicaid","MS-DRG":"100","Description":"Seizures With Mcc","Payer Specific Negotiated Charge":27941.0},{"Payer":"Wellcare Medicaid","MS-DRG":"133","Description":"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","Payer Specific Negotiated Charge":13056.0},{"Payer":"Wellcare Medicaid","MS-DRG":"163","Description":"Major Chest Procedures With Mcc","Payer Specific Negotiated Charge":55343.0},{"Payer":"Wellcare Medicaid","MS-DRG":"168","Description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":10752.0},{"Payer":"Wellcare Medicaid","MS-DRG":"176","Description":"Pulmonary Embolism Without Mcc","Payer Specific Negotiated Charge":4540.0},{"Payer":"Wellcare Medicaid","MS-DRG":"190","Description":"Chronic Obstructive Pulmonary Disease With Mcc","Payer Specific Negotiated Charge":16191.0},{"Payer":"Wellcare Medicaid","MS-DRG":"228","Description":"Other Cardiothoracic Procedures With Mcc","Payer Specific Negotiated Charge":44787.0},{"Payer":"Wellcare Medicaid","MS-DRG":"301","Description":"Peripheral Vascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":3767.0},{"Payer":"Wellcare Medicaid","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":26969.0},{"Payer":"Wellcare Medicaid","MS-DRG":"389","Description":"Gastrointestinal Obstruction With Cc","Payer Specific Negotiated Charge":5141.0},{"Payer":"Wellcare Medicaid","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":12420.0},{"Payer":"Wellcare Medicaid","MS-DRG":"415","Description":"Cholecystectomy Except By Laparoscope Without C.D.E. With Cc","Payer Specific Negotiated Charge":10720.0},{"Payer":"Wellcare Medicaid","MS-DRG":"419","Description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","Payer Specific Negotiated Charge":12947.0},{"Payer":"Wellcare Medicaid","MS-DRG":"454","Description":"Combined Anterior And Posterior Spinal Fusion With Cc","Payer Specific Negotiated Charge":34692.0},{"Payer":"Wellcare Medicaid","MS-DRG":"457","Description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","Payer Specific Negotiated Charge":63567.0},{"Payer":"Wellcare Medicaid","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":23434.0},{"Payer":"Wellcare Medicaid","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":15351.0},{"Payer":"Wellcare Medicaid","MS-DRG":"513","Description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","Payer Specific Negotiated Charge":6970.0},{"Payer":"Wellcare Medicaid","MS-DRG":"571","Description":"Skin Debridement With Cc","Payer Specific Negotiated Charge":9218.0},{"Payer":"Wellcare Medicaid","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":17888.0},{"Payer":"Wellcare Medicaid","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":5993.0},{"Payer":"Wellcare Medicaid","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":14150.0},{"Payer":"Wellcare Medicaid","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":9274.0},{"Payer":"Wellcare Medicaid","MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","Payer Specific Negotiated Charge":27529.0},{"Payer":"Wellcare Medicaid","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":16856.0},{"Payer":"Wellcare Medicaid","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":20308.0},{"Payer":"Wellcare Medicaid","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5719.0},{"Payer":"Wellcare Medicaid","MS-DRG":"981","Description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","Payer Specific Negotiated Charge":198106.0}],"Inpatient Payer Specific Charge 15":[{"Payer":"Caresource Medicaid","MS-DRG":"027","Description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":21274.0},{"Payer":"Caresource Medicaid","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":10003.0},{"Payer":"Caresource Medicaid","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7117.0},{"Payer":"Caresource Medicaid","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":27416.0},{"Payer":"Caresource Medicaid","MS-DRG":"262","Description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":10012.0},{"Payer":"Caresource Medicaid","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":9957.0},{"Payer":"Caresource Medicaid","MS-DRG":"293","Description":"Heart Failure And Shock Without Cc/Mcc","Payer Specific Negotiated Charge":1546.0},{"Payer":"Caresource Medicaid","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":5276.0},{"Payer":"Caresource Medicaid","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":4933.0},{"Payer":"Caresource Medicaid","MS-DRG":"379","Description":"Gastrointestinal Hemorrhage Without Cc/Mcc","Payer Specific Negotiated Charge":7430.0},{"Payer":"Caresource Medicaid","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":6498.0},{"Payer":"Caresource Medicaid","MS-DRG":"391","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","Payer Specific Negotiated Charge":15435.0},{"Payer":"Caresource Medicaid","MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":29102.0},{"Payer":"Caresource Medicaid","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":78237.0},{"Payer":"Caresource Medicaid","MS-DRG":"462","Description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":27258.0},{"Payer":"Caresource Medicaid","MS-DRG":"487","Description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","Payer Specific Negotiated Charge":11771.0},{"Payer":"Caresource Medicaid","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":4943.0},{"Payer":"Caresource Medicaid","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":5065.0},{"Payer":"Caresource Medicaid","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":20877.0},{"Payer":"Caresource Medicaid","MS-DRG":"812","Description":"Red Blood Cell Disorders Without Mcc","Payer Specific Negotiated Charge":2453.0},{"Payer":"Caresource Medicaid","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":29018.0},{"Payer":"Caresource Medicaid","MS-DRG":"908","Description":"Other O.R. Procedures For Injuries With Cc","Payer Specific Negotiated Charge":47671.0}],"Inpatient Payer Specific Charge 16":[{"Payer":"Choicecare (Humana)","MS-DRG":"039","Description":"Extracranial Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":10140.0},{"Payer":"Choicecare (Humana)","MS-DRG":"065","Description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","Payer Specific Negotiated Charge":8635.0},{"Payer":"Choicecare (Humana)","MS-DRG":"066","Description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","Payer Specific Negotiated Charge":6024.0},{"Payer":"Choicecare (Humana)","MS-DRG":"070","Description":"Nonspecific Cerebrovascular Disorders With Mcc","Payer Specific Negotiated Charge":3561.0},{"Payer":"Choicecare (Humana)","MS-DRG":"084","Description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","Payer Specific Negotiated Charge":1543.0},{"Payer":"Choicecare (Humana)","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":8117.0},{"Payer":"Choicecare (Humana)","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":1543.0},{"Payer":"Choicecare (Humana)","MS-DRG":"156","Description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","Payer Specific Negotiated Charge":3086.0},{"Payer":"Choicecare (Humana)","MS-DRG":"175","Description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","Payer Specific Negotiated Charge":12136.0},{"Payer":"Choicecare (Humana)","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":1543.0},{"Payer":"Choicecare (Humana)","MS-DRG":"195","Description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","Payer Specific Negotiated Charge":3086.0},{"Payer":"Choicecare (Humana)","MS-DRG":"229","Description":"Other Cardiothoracic Procedures Without Mcc","Payer Specific Negotiated Charge":154008.0},{"Payer":"Choicecare (Humana)","MS-DRG":"234","Description":"Coronary Bypass With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":113590.0},{"Payer":"Choicecare (Humana)","MS-DRG":"236","Description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":91986.0},{"Payer":"Choicecare (Humana)","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":25489.0},{"Payer":"Choicecare (Humana)","MS-DRG":"248","Description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","Payer Specific Negotiated Charge":98608.0},{"Payer":"Choicecare (Humana)","MS-DRG":"271","Description":"Other Major Cardiovascular Procedures With Cc","Payer Specific Negotiated Charge":99327.0},{"Payer":"Choicecare (Humana)","MS-DRG":"274","Description":"Percutaneous And Other Intracardiac Procedures Without Mcc","Payer Specific Negotiated Charge":26377.0},{"Payer":"Choicecare (Humana)","MS-DRG":"286","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","Payer Specific Negotiated Charge":2268.0},{"Payer":"Choicecare (Humana)","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":1543.0},{"Payer":"Choicecare (Humana)","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":11637.0},{"Payer":"Choicecare (Humana)","MS-DRG":"301","Description":"Peripheral Vascular Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":113788.0},{"Payer":"Choicecare (Humana)","MS-DRG":"310","Description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":5436.0},{"Payer":"Choicecare (Humana)","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":6010.0},{"Payer":"Choicecare (Humana)","MS-DRG":"327","Description":"Stomach, Esophageal And Duodenal Procedures With Cc","Payer Specific Negotiated Charge":109854.0},{"Payer":"Choicecare (Humana)","MS-DRG":"340","Description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","Payer Specific Negotiated Charge":3086.0},{"Payer":"Choicecare (Humana)","MS-DRG":"390","Description":"Gastrointestinal Obstruction Without Cc/Mcc","Payer Specific Negotiated Charge":7512.0},{"Payer":"Choicecare (Humana)","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":6398.0},{"Payer":"Choicecare (Humana)","MS-DRG":"417","Description":"Laparoscopic Cholecystectomy Without C.D.E. With Mcc","Payer Specific Negotiated Charge":6012.0},{"Payer":"Choicecare (Humana)","MS-DRG":"435","Description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","Payer Specific Negotiated Charge":7715.0},{"Payer":"Choicecare (Humana)","MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":16984.0},{"Payer":"Choicecare (Humana)","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":9878.0},{"Payer":"Choicecare (Humana)","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":34609.0},{"Payer":"Choicecare (Humana)","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":114680.0},{"Payer":"Choicecare (Humana)","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":51136.0},{"Payer":"Choicecare (Humana)","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":16744.0},{"Payer":"Choicecare (Humana)","MS-DRG":"473","Description":"Cervical Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":25762.0},{"Payer":"Choicecare (Humana)","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":20616.0},{"Payer":"Choicecare (Humana)","MS-DRG":"488","Description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","Payer Specific Negotiated Charge":20191.0},{"Payer":"Choicecare (Humana)","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":67846.0},{"Payer":"Choicecare (Humana)","MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":13028.0},{"Payer":"Choicecare (Humana)","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":10432.0},{"Payer":"Choicecare (Humana)","MS-DRG":"561","Description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","Payer Specific Negotiated Charge":6280.0},{"Payer":"Choicecare (Humana)","MS-DRG":"572","Description":"Skin Debridement Without Cc/Mcc","Payer Specific Negotiated Charge":3858.0},{"Payer":"Choicecare (Humana)","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":17964.0},{"Payer":"Choicecare (Humana)","MS-DRG":"641","Description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","Payer Specific Negotiated Charge":7903.0},{"Payer":"Choicecare (Humana)","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":17109.0},{"Payer":"Choicecare (Humana)","MS-DRG":"698","Description":"Other Kidney And Urinary Tract Diagnoses With Mcc","Payer Specific Negotiated Charge":120385.0},{"Payer":"Choicecare (Humana)","MS-DRG":"950","Description":"Aftercare Without Cc/Mcc","Payer Specific Negotiated Charge":6225.0}],"Inpatient Payer Specific Charge 17":[{"Payer":"Amerigroup Medicaid","MS-DRG":"040","Description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","Payer Specific Negotiated Charge":42910.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":6249.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"468","Description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","Payer Specific Negotiated Charge":18242.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"580","Description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","Payer Specific Negotiated Charge":2651.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":3691.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":4054.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":42389.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"853","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","Payer Specific Negotiated Charge":44756.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"880","Description":"Acute Adjustment Reaction And Psychosocial Dysfunction","Payer Specific Negotiated Charge":3852.0},{"Payer":"Amerigroup Medicaid","MS-DRG":"917","Description":"Poisoning And Toxic Effects Of Drugs With Mcc","Payer Specific Negotiated Charge":5248.0}],"Inpatient Payer Specific Charge 18":[{"Payer":"PHCS","MS-DRG":"083","Description":"Traumatic Stupor And Coma >1 Hour With Cc","Payer Specific Negotiated Charge":4449.0},{"Payer":"PHCS","MS-DRG":"202","Description":"Bronchitis And Asthma With Cc/Mcc","Payer Specific Negotiated Charge":96347.0},{"Payer":"PHCS","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":436726.0},{"Payer":"PHCS","MS-DRG":"315","Description":"Other Circulatory System Diagnoses With Cc","Payer Specific Negotiated Charge":2806.0},{"Payer":"PHCS","MS-DRG":"387","Description":"Inflammatory Bowel Disease Without Cc/Mcc","Payer Specific Negotiated Charge":11236.0},{"Payer":"PHCS","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":6472.0},{"Payer":"PHCS","MS-DRG":"638","Description":"Diabetes With Cc","Payer Specific Negotiated Charge":5061.0},{"Payer":"PHCS","MS-DRG":"673","Description":"Other Kidney And Urinary Tract Procedures With Mcc","Payer Specific Negotiated Charge":111182.0},{"Payer":"PHCS","MS-DRG":"864","Description":"Fever And Inflammatory Conditions","Payer Specific Negotiated Charge":3058.0}],"Inpatient Payer Specific Charge 19":[{"Payer":"Clover Health Medicare","MS-DRG":"086","Description":"Traumatic Stupor And Coma <1 Hour With Cc","Payer Specific Negotiated Charge":6915.0},{"Payer":"Clover Health Medicare","MS-DRG":"091","Description":"Other Disorders Of Nervous System With Mcc","Payer Specific Negotiated Charge":8786.0},{"Payer":"Clover Health Medicare","MS-DRG":"092","Description":"Other Disorders Of Nervous System With Cc","Payer Specific Negotiated Charge":5270.0},{"Payer":"Clover Health Medicare","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":5018.0},{"Payer":"Clover Health Medicare","MS-DRG":"193","Description":"Simple Pneumonia And Pleurisy With Mcc","Payer Specific Negotiated Charge":7146.0},{"Payer":"Clover Health Medicare","MS-DRG":"239","Description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","Payer Specific Negotiated Charge":25648.0},{"Payer":"Clover Health Medicare","MS-DRG":"247","Description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","Payer Specific Negotiated Charge":11064.0},{"Payer":"Clover Health Medicare","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6200.0},{"Payer":"Clover Health Medicare","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7451.0},{"Payer":"Clover Health Medicare","MS-DRG":"292","Description":"Heart Failure And Shock With Cc","Payer Specific Negotiated Charge":4997.0},{"Payer":"Clover Health Medicare","MS-DRG":"308","Description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","Payer Specific Negotiated Charge":6514.0},{"Payer":"Clover Health Medicare","MS-DRG":"309","Description":"Cardiac Arrhythmia And Conduction Disorders With Cc","Payer Specific Negotiated Charge":4240.0},{"Payer":"Clover Health Medicare","MS-DRG":"331","Description":"Major Small And Large Bowel Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":9208.0},{"Payer":"Clover Health Medicare","MS-DRG":"441","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Mcc","Payer Specific Negotiated Charge":10119.0},{"Payer":"Clover Health Medicare","MS-DRG":"442","Description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","Payer Specific Negotiated Charge":5655.0},{"Payer":"Clover Health Medicare","MS-DRG":"455","Description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":26382.0},{"Payer":"Clover Health Medicare","MS-DRG":"460","Description":"Spinal Fusion Except Cervical Without Mcc","Payer Specific Negotiated Charge":25013.0},{"Payer":"Clover Health Medicare","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":10510.0},{"Payer":"Clover Health Medicare","MS-DRG":"481","Description":"Hip And Femur Procedures Except Major Joint With Cc","Payer Specific Negotiated Charge":11526.0},{"Payer":"Clover Health Medicare","MS-DRG":"552","Description":"Medical Back Problems Without Mcc","Payer Specific Negotiated Charge":5385.0},{"Payer":"Clover Health Medicare","MS-DRG":"556","Description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","Payer Specific Negotiated Charge":4696.0},{"Payer":"Clover Health Medicare","MS-DRG":"560","Description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","Payer Specific Negotiated Charge":6048.0},{"Payer":"Clover Health Medicare","MS-DRG":"644","Description":"Endocrine Disorders With Cc","Payer Specific Negotiated Charge":5479.0},{"Payer":"Clover Health Medicare","MS-DRG":"683","Description":"Renal Failure With Cc","Payer Specific Negotiated Charge":5130.0},{"Payer":"Clover Health Medicare","MS-DRG":"690","Description":"Kidney And Urinary Tract Infections Without Mcc","Payer Specific Negotiated Charge":4353.0},{"Payer":"Clover Health Medicare","MS-DRG":"824","Description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","Payer Specific Negotiated Charge":12845.0},{"Payer":"Clover Health Medicare","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":10292.0},{"Payer":"Clover Health Medicare","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":5871.0}],"Inpatient Payer Specific Charge 20":[{"Payer":"GA Ports Authority","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":5178.0},{"Payer":"GA Ports Authority","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":4689.0},{"Payer":"GA Ports Authority","MS-DRG":"158","Description":"Dental And Oral Diseases With Cc","Payer Specific Negotiated Charge":5083.0},{"Payer":"GA Ports Authority","MS-DRG":"189","Description":"Pulmonary Edema And Respiratory Failure","Payer Specific Negotiated Charge":7130.0},{"Payer":"GA Ports Authority","MS-DRG":"191","Description":"Chronic Obstructive Pulmonary Disease With Cc","Payer Specific Negotiated Charge":5236.0},{"Payer":"GA Ports Authority","MS-DRG":"194","Description":"Simple Pneumonia And Pleurisy With Cc","Payer Specific Negotiated Charge":5212.0},{"Payer":"GA Ports Authority","MS-DRG":"215","Description":"Other Heart Assist System Implant","Payer Specific Negotiated Charge":169987.0},{"Payer":"GA Ports Authority","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":6758.0},{"Payer":"GA Ports Authority","MS-DRG":"291","Description":"Heart Failure And Shock With Mcc","Payer Specific Negotiated Charge":7205.0},{"Payer":"GA Ports Authority","MS-DRG":"313","Description":"Chest Pain","Payer Specific Negotiated Charge":4195.0},{"Payer":"GA Ports Authority","MS-DRG":"337","Description":"Peritoneal Adhesiolysis Without Cc/Mcc","Payer Specific Negotiated Charge":9617.0},{"Payer":"GA Ports Authority","MS-DRG":"352","Description":"Inguinal And Femoral Hernia Procedures Without Cc/Mcc","Payer Specific Negotiated Charge":6315.0},{"Payer":"GA Ports Authority","MS-DRG":"378","Description":"Gastrointestinal Hemorrhage With Cc","Payer Specific Negotiated Charge":5795.0},{"Payer":"GA Ports Authority","MS-DRG":"379","Description":"Gastrointestinal Hemorrhage Without Cc/Mcc","Payer Specific Negotiated Charge":3787.0},{"Payer":"GA Ports Authority","MS-DRG":"392","Description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","Payer Specific Negotiated Charge":4466.0},{"Payer":"GA Ports Authority","MS-DRG":"406","Description":"Pancreas, Liver And Shunt Procedures With Cc","Payer Specific Negotiated Charge":34183.0},{"Payer":"GA Ports Authority","MS-DRG":"445","Description":"Disorders Of The Biliary Tract With Cc","Payer Specific Negotiated Charge":6302.0},{"Payer":"GA Ports Authority","MS-DRG":"470","Description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","Payer Specific Negotiated Charge":23344.0},{"Payer":"GA Ports Authority","MS-DRG":"483","Description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","Payer Specific Negotiated Charge":24629.0},{"Payer":"GA Ports Authority","MS-DRG":"519","Description":"Back And Neck Procedures Except Spinal Fusion With Cc","Payer Specific Negotiated Charge":11195.0},{"Payer":"GA Ports Authority","MS-DRG":"520","Description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","Payer Specific Negotiated Charge":7847.0},{"Payer":"GA Ports Authority","MS-DRG":"603","Description":"Cellulitis Without Mcc","Payer Specific Negotiated Charge":4947.0},{"Payer":"GA Ports Authority","MS-DRG":"645","Description":"Endocrine Disorders Without Cc/Mcc","Payer Specific Negotiated Charge":4488.0},{"Payer":"GA Ports Authority","MS-DRG":"682","Description":"Renal Failure With Mcc","Payer Specific Negotiated Charge":8668.0},{"Payer":"GA Ports Authority","MS-DRG":"699","Description":"Other Kidney And Urinary Tract Diagnoses With Cc","Payer Specific Negotiated Charge":6057.0},{"Payer":"GA Ports Authority","MS-DRG":"854","Description":"Infectious And Parasitic Diseases With O.R. Procedures With Cc","Payer Specific Negotiated Charge":12675.0},{"Payer":"GA Ports Authority","MS-DRG":"871","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","Payer Specific Negotiated Charge":10946.0},{"Payer":"GA Ports Authority","MS-DRG":"872","Description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","Payer Specific Negotiated Charge":6095.0}],"Inpatient Payer Specific Charge 21":[{"Payer":"Kaiser","MS-DRG":"101","Description":"Seizures Without Mcc","Payer Specific Negotiated Charge":13947.0},{"Payer":"Kaiser","MS-DRG":"494","Description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","Payer Specific Negotiated Charge":25862.0},{"Payer":"Kaiser","MS-DRG":"535","Description":"Fractures Of Hip And Pelvis With Mcc","Payer Specific Negotiated Charge":15249.0},{"Payer":"Kaiser","MS-DRG":"639","Description":"Diabetes Without Cc/Mcc","Payer Specific Negotiated Charge":7620.0}],"Inpatient Payer Specific Charge 22":[{"Payer":"Peach State Medicaid","MS-DRG":"103","Description":"Headaches Without Mcc","Payer Specific Negotiated Charge":5186.0},{"Payer":"Peach State Medicaid","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":14953.0},{"Payer":"Peach State Medicaid","MS-DRG":"384","Description":"Uncomplicated Peptic Ulcer Without Mcc","Payer Specific Negotiated Charge":5461.0},{"Payer":"Peach State Medicaid","MS-DRG":"472","Description":"Cervical Spinal Fusion With Cc","Payer Specific Negotiated Charge":29540.0},{"Payer":"Peach State Medicaid","MS-DRG":"776","Description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","Payer Specific Negotiated Charge":6948.0}],"Inpatient Payer Specific Charge 23":[{"Payer":"IBG","MS-DRG":"204","Description":"Respiratory Signs And Symptoms","Payer Specific Negotiated Charge":4956.0},{"Payer":"IBG","MS-DRG":"488","Description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","Payer Specific Negotiated Charge":73391.0},{"Payer":"IBG","MS-DRG":"684","Description":"Renal Failure Without Cc/Mcc","Payer Specific Negotiated Charge":3753.0}],"Inpatient Payer Specific Charge 24":[{"Payer":"First Health (Southcare)","MS-DRG":"287","Description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","Payer Specific Negotiated Charge":3030.0}],"Outpatient De-identified Minimum Negotiated Charge":[{"APC":"5012","Description":"Clinic Visits and Related Services","De-Identified Minimum Negotiated Charge":54.0},{"APC":"5021","Description":"Level 1 Type A ED Visits","De-Identified Minimum Negotiated Charge":36.0},{"APC":"5022","Description":"Level 2 Type A ED Visits","De-Identified Minimum Negotiated Charge":69.0},{"APC":"5023","Description":"Level 3 Type A ED Visits","De-Identified Minimum Negotiated Charge":178.0},{"APC":"5024","Description":"Level 4 Type A ED Visits","De-Identified Minimum Negotiated Charge":377.0},{"APC":"5025","Description":"Level 5 Type A ED Visits","De-Identified Minimum Negotiated Charge":477.0},{"APC":"5041","Description":"Critical Care","De-Identified Minimum Negotiated Charge":820.0},{"APC":"5051","Description":"Level 1 Skin Procedures","De-Identified Minimum Negotiated Charge":86.0},{"APC":"5052","Description":"Level 2 Skin Procedures","De-Identified Minimum Negotiated Charge":185.0},{"APC":"5053","Description":"Level 3 Skin Procedures","De-Identified Minimum Negotiated Charge":237.0},{"APC":"5054","Description":"Level 4 Skin Procedures","De-Identified Minimum Negotiated Charge":1349.0},{"APC":"5055","Description":"Level 5 Skin Procedures","De-Identified Minimum Negotiated Charge":2144.0},{"APC":"5061","Description":"Hyperbaric Oxygen","De-Identified Minimum Negotiated Charge":400.0},{"APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","De-Identified Minimum Negotiated Charge":155.0},{"APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","De-Identified Minimum Negotiated Charge":157.0},{"APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","De-Identified Minimum Negotiated Charge":930.0},{"APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","De-Identified Minimum Negotiated Charge":2004.0},{"APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","De-Identified Minimum Negotiated Charge":2704.0},{"APC":"5094","Description":"Level 4 Breast/Lymphatic Surgery and Related Procedures","De-Identified Minimum Negotiated Charge":49802.0},{"APC":"5101","Description":"Level 1 Strapping and Cast Application","De-Identified Minimum Negotiated Charge":115.0},{"APC":"5102","Description":"Level 2 Strapping and Cast Application","De-Identified Minimum Negotiated Charge":206.0},{"APC":"5111","Description":"Level 1 Musculoskeletal Procedures","De-Identified Minimum Negotiated Charge":75.0},{"APC":"5112","Description":"Level 2 Musculoskeletal Procedures","De-Identified Minimum Negotiated Charge":591.0},{"APC":"5113","Description":"Level 3 Musculoskeletal Procedures","De-Identified Minimum Negotiated Charge":1644.0},{"APC":"5114","Description":"Level 4 Musculoskeletal Procedures","De-Identified Minimum Negotiated Charge":3256.0},{"APC":"5115","Description":"Level 5 Musculoskeletal Procedures","De-Identified Minimum Negotiated Charge":5666.0},{"APC":"5116","Description":"Level 6 Musculoskeletal Procedures","De-Identified Minimum Negotiated Charge":5071.0},{"APC":"5151","Description":"Level 1 Airway Endoscopy","De-Identified Minimum Negotiated Charge":143.0},{"APC":"5153","Description":"Level 3 Airway Endoscopy","De-Identified Minimum Negotiated Charge":528.0},{"APC":"5154","Description":"Level 4 Airway Endoscopy","De-Identified Minimum Negotiated Charge":2037.0},{"APC":"5155","Description":"Level 5 Airway Endoscopy","De-Identified Minimum Negotiated Charge":3294.0},{"APC":"5161","Description":"Level 1 ENT Procedures","De-Identified Minimum Negotiated Charge":180.0},{"APC":"5162","Description":"Level 2 ENT Procedures","De-Identified Minimum Negotiated Charge":176.0},{"APC":"5163","Description":"Level 3 ENT Procedures","De-Identified Minimum Negotiated Charge":773.0},{"APC":"5164","Description":"Level 4 ENT Procedures","De-Identified Minimum Negotiated Charge":1082.0},{"APC":"5165","Description":"Level 5 ENT Procedures","De-Identified Minimum Negotiated Charge":1073.0},{"APC":"5181","Description":"Level 1 Vascular Procedures","De-Identified Minimum Negotiated Charge":543.0},{"APC":"5182","Description":"Level 2 Vascular Procedures","De-Identified Minimum Negotiated Charge":910.0},{"APC":"5183","Description":"Level 3 Vascular Procedures","De-Identified Minimum Negotiated Charge":2266.0},{"APC":"5184","Description":"Level 4 Vascular Procedures","De-Identified Minimum Negotiated Charge":1256.0},{"APC":"5191","Description":"Level 1 Endovascular Procedures","De-Identified Minimum Negotiated Charge":1406.0},{"APC":"5192","Description":"Level 2 Endovascular Procedures","De-Identified Minimum Negotiated Charge":2475.0},{"APC":"5193","Description":"Level 3 Endovascular Procedures","De-Identified Minimum Negotiated Charge":4677.0},{"APC":"5194","Description":"Level 4 Endovascular Procedures","De-Identified Minimum Negotiated Charge":49.0},{"APC":"5212","Description":"Level 2 Electrophysiologic Procedures","De-Identified Minimum Negotiated Charge":20650.0},{"APC":"5213","Description":"Level 3 Electrophysiologic Procedures","De-Identified Minimum Negotiated Charge":49.0},{"APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","De-Identified Minimum Negotiated Charge":3077.0},{"APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","De-Identified Minimum Negotiated Charge":5033.0},{"APC":"5231","Description":"Level 1 ICD and Similar Procedures","De-Identified Minimum Negotiated Charge":19155.0},{"APC":"5232","Description":"Level 2 ICD and Similar Procedures","De-Identified Minimum Negotiated Charge":18611.0},{"APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","De-Identified Minimum Negotiated Charge":643.0},{"APC":"5242","Description":"Level 2 Blood Product Exchange and Related Services","De-Identified Minimum Negotiated Charge":1511.0},{"APC":"5301","Description":"Level 1 Upper GI Procedures","De-Identified Minimum Negotiated Charge":516.0},{"APC":"5302","Description":"Level 2 Upper GI Procedures","De-Identified Minimum Negotiated Charge":1292.0},{"APC":"5303","Description":"Level 3 Upper GI Procedures","De-Identified Minimum Negotiated Charge":4056.0},{"APC":"5311","Description":"Level 1 Lower GI Procedures","De-Identified Minimum Negotiated Charge":330.0},{"APC":"5312","Description":"Level 2 Lower GI Procedures","De-Identified Minimum Negotiated Charge":382.0},{"APC":"5313","Description":"Level 3 Lower GI Procedures","De-Identified Minimum Negotiated Charge":1524.0},{"APC":"5331","Description":"Complex GI Procedures","De-Identified Minimum Negotiated Charge":3197.0},{"APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","De-Identified Minimum Negotiated Charge":2567.0},{"APC":"5361","Description":"Level 1 Laparoscopy and Related Services","De-Identified Minimum Negotiated Charge":2425.0},{"APC":"5362","Description":"Level 2 Laparoscopy and Related Services","De-Identified Minimum Negotiated Charge":3952.0},{"APC":"5371","Description":"Level 1 Urology and Related Services","De-Identified Minimum Negotiated Charge":153.0},{"APC":"5373","Description":"Level 3 Urology and Related Services","De-Identified Minimum Negotiated Charge":1523.0},{"APC":"5374","Description":"Level 4 Urology and Related Services","De-Identified Minimum Negotiated Charge":1515.0},{"APC":"5401","Description":"Dialysis","De-Identified Minimum Negotiated Charge":743.0},{"APC":"5412","Description":"Level 2 Gynecologic Procedures","De-Identified Minimum Negotiated Charge":142.0},{"APC":"5414","Description":"Level 4 Gynecologic Procedures","De-Identified Minimum Negotiated Charge":1171.0},{"APC":"5415","Description":"Level 5 Gynecologic Procedures","De-Identified Minimum Negotiated Charge":2093.0},{"APC":"5431","Description":"Level 1 Nerve Procedures","De-Identified Minimum Negotiated Charge":1421.0},{"APC":"5432","Description":"Level 2 Nerve Procedures","De-Identified Minimum Negotiated Charge":3976.0},{"APC":"5441","Description":"Level 1 Nerve Injections","De-Identified Minimum Negotiated Charge":75.0},{"APC":"5442","Description":"Level 2 Nerve Injections","De-Identified Minimum Negotiated Charge":335.0},{"APC":"5443","Description":"Level 3 Nerve Injections","De-Identified Minimum Negotiated Charge":689.0},{"APC":"5461","Description":"Level 1 Neurostimulator and Related Procedures","De-Identified Minimum Negotiated Charge":2520.0},{"APC":"5462","Description":"Level 2 Neurostimulator and Related Procedures","De-Identified Minimum Negotiated Charge":5129.0},{"APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","De-Identified Minimum Negotiated Charge":16291.0},{"APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","De-Identified Minimum Negotiated Charge":10721.0},{"APC":"5471","Description":"Implantation of Drug Infusion Device","De-Identified Minimum Negotiated Charge":21551.0},{"APC":"5481","Description":"Laser Eye Procedures","De-Identified Minimum Negotiated Charge":432.0},{"APC":"5491","Description":"Level 1 Intraocular Procedures","De-Identified Minimum Negotiated Charge":507.0},{"APC":"5492","Description":"Level 2 Intraocular Procedures","De-Identified Minimum Negotiated Charge":3122.0},{"APC":"5503","Description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","De-Identified Minimum Negotiated Charge":1579.0},{"APC":"5521","Description":"Level 1 Imaging without Contrast","De-Identified Minimum Negotiated Charge":53.0},{"APC":"5522","Description":"Level 2 Imaging without Contrast","De-Identified Minimum Negotiated Charge":95.0},{"APC":"5523","Description":"Level 3 Imaging without Contrast","De-Identified Minimum Negotiated Charge":201.0},{"APC":"5524","Description":"Level 4 Imaging without Contrast","De-Identified Minimum Negotiated Charge":208.0},{"APC":"5571","Description":"Level 1 Imaging with Contrast","De-Identified Minimum Negotiated Charge":62.0},{"APC":"5572","Description":"Level 2 Imaging with Contrast","De-Identified Minimum Negotiated Charge":342.0},{"APC":"5573","Description":"Level 3 Imaging with Contrast","De-Identified Minimum Negotiated Charge":336.0},{"APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","De-Identified Minimum Negotiated Charge":308.0},{"APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","De-Identified Minimum Negotiated Charge":399.0},{"APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","De-Identified Minimum Negotiated Charge":1073.0},{"APC":"5594","Description":"Level 4 Nuclear Medicine and Related Services","De-Identified Minimum Negotiated Charge":184.0},{"APC":"5661","Description":"Therapeutic Nuclear Medicine","De-Identified Minimum Negotiated Charge":54.0},{"APC":"5671","Description":"Level 1 Pathology","De-Identified Minimum Negotiated Charge":11706.0},{"APC":"5672","Description":"Level 2 Pathology","De-Identified Minimum Negotiated Charge":54.0},{"APC":"5673","Description":"Level 3 Pathology","De-Identified Minimum Negotiated Charge":114.0},{"APC":"5674","Description":"Level 4 Pathology","De-Identified Minimum Negotiated Charge":119.0},{"APC":"5692","Description":"Level 2 Drug Administration","De-Identified Minimum Negotiated Charge":189.0},{"APC":"5693","Description":"Level 3 Drug Administration","De-Identified Minimum Negotiated Charge":125.0},{"APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","De-Identified Minimum Negotiated Charge":195.0},{"APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","De-Identified Minimum Negotiated Charge":216.0},{"APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","De-Identified Minimum Negotiated Charge":3.0},{"APC":"5731","Description":"Level 1 Minor Procedures","De-Identified Minimum Negotiated Charge":363.0},{"APC":"5732","Description":"Level 2 Minor Procedures","De-Identified Minimum Negotiated Charge":25.0},{"APC":"5733","Description":"Level 3 Minor Procedures","De-Identified Minimum Negotiated Charge":33.0},{"APC":"5734","Description":"Level 4 Minor Procedures","De-Identified Minimum Negotiated Charge":93.0},{"APC":"5735","Description":"Level 5 Minor Procedures","De-Identified Minimum Negotiated Charge":195.0},{"APC":"5781","Description":"Resuscitation and Cardioversion","De-Identified Minimum Negotiated Charge":49.0},{"APC":"5791","Description":"Pulmonary Treatment","De-Identified Minimum Negotiated Charge":114.0},{"APC":"5801","Description":"Ventilation Initiation and Management","De-Identified Minimum Negotiated Charge":444.0},{"APC":"5871","Description":"Dental Procedures","De-Identified Minimum Negotiated Charge":6254.0},{"APC":"N800","Description":"Clinical Diagnostic Lab Services","De-Identified Minimum Negotiated Charge":24.0},{"APC":"N801","Description":"Therapy Services","De-Identified Minimum Negotiated Charge":89.0},{"APC":"N804","Description":"Mammography Services","De-Identified Minimum Negotiated Charge":63.0},{"APC":"N902","Description":"Packaged Services","De-Identified Minimum Negotiated Charge":53.0}],"Outpatient De-identified Maximum Negotiated Charge":[{"APC":"5012","Description":"Clinic Visits and Related Services","De-Identified Maximum Negotiated Charge":1040.0},{"APC":"5021","Description":"Level 1 Type A ED Visits","De-Identified Maximum Negotiated Charge":297.0},{"APC":"5022","Description":"Level 2 Type A ED Visits","De-Identified Maximum Negotiated Charge":668.0},{"APC":"5023","Description":"Level 3 Type A ED Visits","De-Identified Maximum Negotiated Charge":2074.0},{"APC":"5024","Description":"Level 4 Type A ED Visits","De-Identified Maximum Negotiated Charge":2837.0},{"APC":"5025","Description":"Level 5 Type A ED Visits","De-Identified Maximum Negotiated Charge":4109.0},{"APC":"5041","Description":"Critical Care","De-Identified Maximum Negotiated Charge":6477.0},{"APC":"5051","Description":"Level 1 Skin Procedures","De-Identified Maximum Negotiated Charge":2033.0},{"APC":"5052","Description":"Level 2 Skin Procedures","De-Identified Maximum Negotiated Charge":14677.0},{"APC":"5053","Description":"Level 3 Skin Procedures","De-Identified Maximum Negotiated Charge":18846.0},{"APC":"5054","Description":"Level 4 Skin Procedures","De-Identified Maximum Negotiated Charge":8712.0},{"APC":"5055","Description":"Level 5 Skin Procedures","De-Identified Maximum Negotiated Charge":5612.0},{"APC":"5061","Description":"Hyperbaric Oxygen","De-Identified Maximum Negotiated Charge":2733.0},{"APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","De-Identified Maximum Negotiated Charge":2971.0},{"APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","De-Identified Maximum Negotiated Charge":4717.0},{"APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","De-Identified Maximum Negotiated Charge":6287.0},{"APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","De-Identified Maximum Negotiated Charge":7625.0},{"APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","De-Identified Maximum Negotiated Charge":6180.0},{"APC":"5094","Description":"Level 4 Breast/Lymphatic Surgery and Related Procedures","De-Identified Maximum Negotiated Charge":49802.0},{"APC":"5101","Description":"Level 1 Strapping and Cast Application","De-Identified Maximum Negotiated Charge":1318.0},{"APC":"5102","Description":"Level 2 Strapping and Cast Application","De-Identified Maximum Negotiated Charge":772.0},{"APC":"5111","Description":"Level 1 Musculoskeletal Procedures","De-Identified Maximum Negotiated Charge":10867.0},{"APC":"5112","Description":"Level 2 Musculoskeletal Procedures","De-Identified Maximum Negotiated Charge":6058.0},{"APC":"5113","Description":"Level 3 Musculoskeletal Procedures","De-Identified Maximum Negotiated Charge":7626.0},{"APC":"5114","Description":"Level 4 Musculoskeletal Procedures","De-Identified Maximum Negotiated Charge":34068.0},{"APC":"5115","Description":"Level 5 Musculoskeletal Procedures","De-Identified Maximum Negotiated Charge":48105.0},{"APC":"5116","Description":"Level 6 Musculoskeletal Procedures","De-Identified Maximum Negotiated Charge":21626.0},{"APC":"5151","Description":"Level 1 Airway Endoscopy","De-Identified Maximum Negotiated Charge":2413.0},{"APC":"5153","Description":"Level 3 Airway Endoscopy","De-Identified Maximum Negotiated Charge":4717.0},{"APC":"5154","Description":"Level 4 Airway Endoscopy","De-Identified Maximum Negotiated Charge":6287.0},{"APC":"5155","Description":"Level 5 Airway Endoscopy","De-Identified Maximum Negotiated Charge":7203.0},{"APC":"5161","Description":"Level 1 ENT Procedures","De-Identified Maximum Negotiated Charge":13044.0},{"APC":"5162","Description":"Level 2 ENT Procedures","De-Identified Maximum Negotiated Charge":743.0},{"APC":"5163","Description":"Level 3 ENT Procedures","De-Identified Maximum Negotiated Charge":5791.0},{"APC":"5164","Description":"Level 4 ENT Procedures","De-Identified Maximum Negotiated Charge":6287.0},{"APC":"5165","Description":"Level 5 ENT Procedures","De-Identified Maximum Negotiated Charge":8646.0},{"APC":"5181","Description":"Level 1 Vascular Procedures","De-Identified Maximum Negotiated Charge":2675.0},{"APC":"5182","Description":"Level 2 Vascular Procedures","De-Identified Maximum Negotiated Charge":3299.0},{"APC":"5183","Description":"Level 3 Vascular Procedures","De-Identified Maximum Negotiated Charge":7626.0},{"APC":"5184","Description":"Level 4 Vascular Procedures","De-Identified Maximum Negotiated Charge":9895.0},{"APC":"5191","Description":"Level 1 Endovascular Procedures","De-Identified Maximum Negotiated Charge":13366.0},{"APC":"5192","Description":"Level 2 Endovascular Procedures","De-Identified Maximum Negotiated Charge":14451.0},{"APC":"5193","Description":"Level 3 Endovascular Procedures","De-Identified Maximum Negotiated Charge":38863.0},{"APC":"5194","Description":"Level 4 Endovascular Procedures","De-Identified Maximum Negotiated Charge":26655.0},{"APC":"5212","Description":"Level 2 Electrophysiologic Procedures","De-Identified Maximum Negotiated Charge":23443.0},{"APC":"5213","Description":"Level 3 Electrophysiologic Procedures","De-Identified Maximum Negotiated Charge":60772.0},{"APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","De-Identified Maximum Negotiated Charge":14564.0},{"APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","De-Identified Maximum Negotiated Charge":20652.0},{"APC":"5231","Description":"Level 1 ICD and Similar Procedures","De-Identified Maximum Negotiated Charge":50139.0},{"APC":"5232","Description":"Level 2 ICD and Similar Procedures","De-Identified Maximum Negotiated Charge":55638.0},{"APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","De-Identified Maximum Negotiated Charge":3030.0},{"APC":"5242","Description":"Level 2 Blood Product Exchange and Related Services","De-Identified Maximum Negotiated Charge":1511.0},{"APC":"5301","Description":"Level 1 Upper GI Procedures","De-Identified Maximum Negotiated Charge":3406.0},{"APC":"5302","Description":"Level 2 Upper GI Procedures","De-Identified Maximum Negotiated Charge":4717.0},{"APC":"5303","Description":"Level 3 Upper GI Procedures","De-Identified Maximum Negotiated Charge":9430.0},{"APC":"5311","Description":"Level 1 Lower GI Procedures","De-Identified Maximum Negotiated Charge":2795.0},{"APC":"5312","Description":"Level 2 Lower GI Procedures","De-Identified Maximum Negotiated Charge":3684.0},{"APC":"5313","Description":"Level 3 Lower GI Procedures","De-Identified Maximum Negotiated Charge":6287.0},{"APC":"5331","Description":"Complex GI Procedures","De-Identified Maximum Negotiated Charge":9430.0},{"APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","De-Identified Maximum Negotiated Charge":7626.0},{"APC":"5361","Description":"Level 1 Laparoscopy and Related Services","De-Identified Maximum Negotiated Charge":16418.0},{"APC":"5362","Description":"Level 2 Laparoscopy and Related Services","De-Identified Maximum Negotiated Charge":12009.0},{"APC":"5371","Description":"Level 1 Urology and Related Services","De-Identified Maximum Negotiated Charge":398.0},{"APC":"5373","Description":"Level 3 Urology and Related Services","De-Identified Maximum Negotiated Charge":1523.0},{"APC":"5374","Description":"Level 4 Urology and Related Services","De-Identified Maximum Negotiated Charge":4956.0},{"APC":"5401","Description":"Dialysis","De-Identified Maximum Negotiated Charge":1021.0},{"APC":"5412","Description":"Level 2 Gynecologic Procedures","De-Identified Maximum Negotiated Charge":743.0},{"APC":"5414","Description":"Level 4 Gynecologic Procedures","De-Identified Maximum Negotiated Charge":6287.0},{"APC":"5415","Description":"Level 5 Gynecologic Procedures","De-Identified Maximum Negotiated Charge":4775.0},{"APC":"5431","Description":"Level 1 Nerve Procedures","De-Identified Maximum Negotiated Charge":6287.0},{"APC":"5432","Description":"Level 2 Nerve Procedures","De-Identified Maximum Negotiated Charge":20369.0},{"APC":"5441","Description":"Level 1 Nerve Injections","De-Identified Maximum Negotiated Charge":1714.0},{"APC":"5442","Description":"Level 2 Nerve Injections","De-Identified Maximum Negotiated Charge":1938.0},{"APC":"5443","Description":"Level 3 Nerve Injections","De-Identified Maximum Negotiated Charge":2675.0},{"APC":"5461","Description":"Level 1 Neurostimulator and Related Procedures","De-Identified Maximum Negotiated Charge":4691.0},{"APC":"5462","Description":"Level 2 Neurostimulator and Related Procedures","De-Identified Maximum Negotiated Charge":10166.0},{"APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","De-Identified Maximum Negotiated Charge":37484.0},{"APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","De-Identified Maximum Negotiated Charge":62262.0},{"APC":"5471","Description":"Implantation of Drug Infusion Device","De-Identified Maximum Negotiated Charge":29179.0},{"APC":"5481","Description":"Laser Eye Procedures","De-Identified Maximum Negotiated Charge":2127.0},{"APC":"5491","Description":"Level 1 Intraocular Procedures","De-Identified Maximum Negotiated Charge":8117.0},{"APC":"5492","Description":"Level 2 Intraocular Procedures","De-Identified Maximum Negotiated Charge":10988.0},{"APC":"5503","Description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","De-Identified Maximum Negotiated Charge":8097.0},{"APC":"5521","Description":"Level 1 Imaging without Contrast","De-Identified Maximum Negotiated Charge":828.0},{"APC":"5522","Description":"Level 2 Imaging without Contrast","De-Identified Maximum Negotiated Charge":953.0},{"APC":"5523","Description":"Level 3 Imaging without Contrast","De-Identified Maximum Negotiated Charge":4549.0},{"APC":"5524","Description":"Level 4 Imaging without Contrast","De-Identified Maximum Negotiated Charge":1718.0},{"APC":"5571","Description":"Level 1 Imaging with Contrast","De-Identified Maximum Negotiated Charge":2812.0},{"APC":"5572","Description":"Level 2 Imaging with Contrast","De-Identified Maximum Negotiated Charge":6055.0},{"APC":"5573","Description":"Level 3 Imaging with Contrast","De-Identified Maximum Negotiated Charge":9148.0},{"APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","De-Identified Maximum Negotiated Charge":3464.0},{"APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","De-Identified Maximum Negotiated Charge":9583.0},{"APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","De-Identified Maximum Negotiated Charge":9419.0},{"APC":"5594","Description":"Level 4 Nuclear Medicine and Related Services","De-Identified Maximum Negotiated Charge":184.0},{"APC":"5661","Description":"Therapeutic Nuclear Medicine","De-Identified Maximum Negotiated Charge":12510.0},{"APC":"5671","Description":"Level 1 Pathology","De-Identified Maximum Negotiated Charge":11706.0},{"APC":"5672","Description":"Level 2 Pathology","De-Identified Maximum Negotiated Charge":678.0},{"APC":"5673","Description":"Level 3 Pathology","De-Identified Maximum Negotiated Charge":3619.0},{"APC":"5674","Description":"Level 4 Pathology","De-Identified Maximum Negotiated Charge":119.0},{"APC":"5692","Description":"Level 2 Drug Administration","De-Identified Maximum Negotiated Charge":3357.0},{"APC":"5693","Description":"Level 3 Drug Administration","De-Identified Maximum Negotiated Charge":441.0},{"APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","De-Identified Maximum Negotiated Charge":2878.0},{"APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","De-Identified Maximum Negotiated Charge":2918.0},{"APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","De-Identified Maximum Negotiated Charge":7962.0},{"APC":"5731","Description":"Level 1 Minor Procedures","De-Identified Maximum Negotiated Charge":3149.0},{"APC":"5732","Description":"Level 2 Minor Procedures","De-Identified Maximum Negotiated Charge":115.0},{"APC":"5733","Description":"Level 3 Minor Procedures","De-Identified Maximum Negotiated Charge":21996.0},{"APC":"5734","Description":"Level 4 Minor Procedures","De-Identified Maximum Negotiated Charge":790.0},{"APC":"5735","Description":"Level 5 Minor Procedures","De-Identified Maximum Negotiated Charge":743.0},{"APC":"5781","Description":"Resuscitation and Cardioversion","De-Identified Maximum Negotiated Charge":8378.0},{"APC":"5791","Description":"Pulmonary Treatment","De-Identified Maximum Negotiated Charge":28387.0},{"APC":"5801","Description":"Ventilation Initiation and Management","De-Identified Maximum Negotiated Charge":187390.0},{"APC":"5871","Description":"Dental Procedures","De-Identified Maximum Negotiated Charge":6254.0},{"APC":"N800","Description":"Clinical Diagnostic Lab Services","De-Identified Maximum Negotiated Charge":503.0},{"APC":"N801","Description":"Therapy Services","De-Identified Maximum Negotiated Charge":2263.0},{"APC":"N804","Description":"Mammography Services","De-Identified Maximum Negotiated Charge":416.0},{"APC":"N902","Description":"Packaged Services","De-Identified Maximum Negotiated Charge":8166.0}],"Outpatient Payer Specific Charge 1":[{"Payer":"Aetna Medicare","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":101.0},{"Payer":"Aetna Medicare","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":61.0},{"Payer":"Aetna Medicare","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":112.0},{"Payer":"Aetna Medicare","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":254.0},{"Payer":"Aetna Medicare","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":534.0},{"Payer":"Aetna Medicare","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2089.0},{"Payer":"Aetna Medicare","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":1579.0},{"Payer":"Aetna Medicare","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":154.0},{"Payer":"Aetna Medicare","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":275.0},{"Payer":"Aetna Medicare","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":237.0},{"Payer":"Aetna Medicare","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":1356.0},{"Payer":"Aetna Medicare","APC":"5061","Description":"Hyperbaric Oxygen","Payer Specific Negotiated Charge":400.0},{"Payer":"Aetna Medicare","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":507.0},{"Payer":"Aetna Medicare","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1204.0},{"Payer":"Aetna Medicare","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2081.0},{"Payer":"Aetna Medicare","APC":"5111","Description":"Level 1 Musculoskeletal Procedures","Payer Specific Negotiated Charge":142.0},{"Payer":"Aetna Medicare","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1149.0},{"Payer":"Aetna Medicare","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2296.0},{"Payer":"Aetna Medicare","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4988.0},{"Payer":"Aetna Medicare","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9459.0},{"Payer":"Aetna Medicare","APC":"5116","Description":"Level 6 Musculoskeletal Procedures","Payer Specific Negotiated Charge":5071.0},{"Payer":"Aetna Medicare","APC":"5151","Description":"Level 1 Airway Endoscopy","Payer Specific Negotiated Charge":144.0},{"Payer":"Aetna Medicare","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1198.0},{"Payer":"Aetna Medicare","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2420.0},{"Payer":"Aetna Medicare","APC":"5161","Description":"Level 1 ENT Procedures","Payer Specific Negotiated Charge":180.0},{"Payer":"Aetna Medicare","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":3906.0},{"Payer":"Aetna Medicare","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":543.0},{"Payer":"Aetna Medicare","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":1050.0},{"Payer":"Aetna Medicare","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2312.0},{"Payer":"Aetna Medicare","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":3830.0},{"Payer":"Aetna Medicare","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":2475.0},{"Payer":"Aetna Medicare","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":3962.0},{"Payer":"Aetna Medicare","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":8462.0},{"Payer":"Aetna Medicare","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":2488.0},{"Payer":"Aetna Medicare","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"Aetna Medicare","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":6480.0},{"Payer":"Aetna Medicare","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":8646.0},{"Payer":"Aetna Medicare","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":26830.0},{"Payer":"Aetna Medicare","APC":"5242","Description":"Level 2 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":1511.0},{"Payer":"Aetna Medicare","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":678.0},{"Payer":"Aetna Medicare","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":1321.0},{"Payer":"Aetna Medicare","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":652.0},{"Payer":"Aetna Medicare","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":858.0},{"Payer":"Aetna Medicare","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":2579.0},{"Payer":"Aetna Medicare","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":4022.0},{"Payer":"Aetna Medicare","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":6775.0},{"Payer":"Aetna Medicare","APC":"5373","Description":"Level 3 Urology and Related Services","Payer Specific Negotiated Charge":1523.0},{"Payer":"Aetna Medicare","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1453.0},{"Payer":"Aetna Medicare","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":217.0},{"Payer":"Aetna Medicare","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":364.0},{"Payer":"Aetna Medicare","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1004.0},{"Payer":"Aetna Medicare","APC":"5461","Description":"Level 1 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":2542.0},{"Payer":"Aetna Medicare","APC":"5462","Description":"Level 2 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":5233.0},{"Payer":"Aetna Medicare","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":24241.0},{"Payer":"Aetna Medicare","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":434.0},{"Payer":"Aetna Medicare","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":1678.0},{"Payer":"Aetna Medicare","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":3186.0},{"Payer":"Aetna Medicare","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":55.0},{"Payer":"Aetna Medicare","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":98.0},{"Payer":"Aetna Medicare","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":202.0},{"Payer":"Aetna Medicare","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":435.0},{"Payer":"Aetna Medicare","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":177.0},{"Payer":"Aetna Medicare","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":344.0},{"Payer":"Aetna Medicare","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":344.0},{"Payer":"Aetna Medicare","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":309.0},{"Payer":"Aetna Medicare","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":399.0},{"Payer":"Aetna Medicare","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1095.0},{"Payer":"Aetna Medicare","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":55.0},{"Payer":"Aetna Medicare","APC":"5673","Description":"Level 3 Pathology","Payer Specific Negotiated Charge":114.0},{"Payer":"Aetna Medicare","APC":"5692","Description":"Level 2 Drug Administration","Payer Specific Negotiated Charge":3357.0},{"Payer":"Aetna Medicare","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":385.0},{"Payer":"Aetna Medicare","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":238.0},{"Payer":"Aetna Medicare","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":221.0},{"Payer":"Aetna Medicare","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":3.0},{"Payer":"Aetna Medicare","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"Aetna Medicare","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":93.0},{"Payer":"Aetna Medicare","APC":"5735","Description":"Level 5 Minor Procedures","Payer Specific Negotiated Charge":195.0},{"Payer":"Aetna Medicare","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":49.0},{"Payer":"Aetna Medicare","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":32.0},{"Payer":"Aetna Medicare","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":279.0},{"Payer":"Aetna Medicare","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":112.0}],"Outpatient Payer Specific Charge 2":[{"Payer":"Ambetter Exchange","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":360.0},{"Payer":"Ambetter Exchange","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":105.0},{"Payer":"Ambetter Exchange","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":176.0},{"Payer":"Ambetter Exchange","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":462.0},{"Payer":"Ambetter Exchange","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":888.0},{"Payer":"Ambetter Exchange","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2731.0},{"Payer":"Ambetter Exchange","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":6477.0},{"Payer":"Ambetter Exchange","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":596.0},{"Payer":"Ambetter Exchange","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":1355.0},{"Payer":"Ambetter Exchange","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":2413.0},{"Payer":"Ambetter Exchange","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":8712.0},{"Payer":"Ambetter Exchange","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":2740.0},{"Payer":"Ambetter Exchange","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2671.0},{"Payer":"Ambetter Exchange","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1706.0},{"Payer":"Ambetter Exchange","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2300.0},{"Payer":"Ambetter Exchange","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2333.0},{"Payer":"Ambetter Exchange","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2915.0},{"Payer":"Ambetter Exchange","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2068.0},{"Payer":"Ambetter Exchange","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2781.0},{"Payer":"Ambetter Exchange","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4930.0},{"Payer":"Ambetter Exchange","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":15162.0},{"Payer":"Ambetter Exchange","APC":"5151","Description":"Level 1 Airway Endoscopy","Payer Specific Negotiated Charge":2413.0},{"Payer":"Ambetter Exchange","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1355.0},{"Payer":"Ambetter Exchange","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2932.0},{"Payer":"Ambetter Exchange","APC":"5155","Description":"Level 5 Airway Endoscopy","Payer Specific Negotiated Charge":3294.0},{"Payer":"Ambetter Exchange","APC":"5162","Description":"Level 2 ENT Procedures","Payer Specific Negotiated Charge":176.0},{"Payer":"Ambetter Exchange","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":2032.0},{"Payer":"Ambetter Exchange","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":2697.0},{"Payer":"Ambetter Exchange","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":1921.0},{"Payer":"Ambetter Exchange","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":1683.0},{"Payer":"Ambetter Exchange","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":4273.0},{"Payer":"Ambetter Exchange","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":5027.0},{"Payer":"Ambetter Exchange","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":4458.0},{"Payer":"Ambetter Exchange","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":3324.0},{"Payer":"Ambetter Exchange","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":17895.0},{"Payer":"Ambetter Exchange","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":11390.0},{"Payer":"Ambetter Exchange","APC":"5212","Description":"Level 2 Electrophysiologic Procedures","Payer Specific Negotiated Charge":20901.0},{"Payer":"Ambetter Exchange","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":27657.0},{"Payer":"Ambetter Exchange","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":12959.0},{"Payer":"Ambetter Exchange","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":20652.0},{"Payer":"Ambetter Exchange","APC":"5231","Description":"Level 1 ICD and Similar Procedures","Payer Specific Negotiated Charge":44685.0},{"Payer":"Ambetter Exchange","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":39638.0},{"Payer":"Ambetter Exchange","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":3030.0},{"Payer":"Ambetter Exchange","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1355.0},{"Payer":"Ambetter Exchange","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":3524.0},{"Payer":"Ambetter Exchange","APC":"5303","Description":"Level 3 Upper GI Procedures","Payer Specific Negotiated Charge":5270.0},{"Payer":"Ambetter Exchange","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1355.0},{"Payer":"Ambetter Exchange","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":1355.0},{"Payer":"Ambetter Exchange","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":3626.0},{"Payer":"Ambetter Exchange","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":4045.0},{"Payer":"Ambetter Exchange","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":3976.0},{"Payer":"Ambetter Exchange","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":5872.0},{"Payer":"Ambetter Exchange","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":1171.0},{"Payer":"Ambetter Exchange","APC":"5415","Description":"Level 5 Gynecologic Procedures","Payer Specific Negotiated Charge":2093.0},{"Payer":"Ambetter Exchange","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1756.0},{"Payer":"Ambetter Exchange","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":1171.0},{"Payer":"Ambetter Exchange","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":462.0},{"Payer":"Ambetter Exchange","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1171.0},{"Payer":"Ambetter Exchange","APC":"5461","Description":"Level 1 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":3057.0},{"Payer":"Ambetter Exchange","APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":37484.0},{"Payer":"Ambetter Exchange","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":39473.0},{"Payer":"Ambetter Exchange","APC":"5471","Description":"Implantation of Drug Infusion Device","Payer Specific Negotiated Charge":21551.0},{"Payer":"Ambetter Exchange","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":1740.0},{"Payer":"Ambetter Exchange","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":3139.0},{"Payer":"Ambetter Exchange","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":3816.0},{"Payer":"Ambetter Exchange","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":276.0},{"Payer":"Ambetter Exchange","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":344.0},{"Payer":"Ambetter Exchange","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":1094.0},{"Payer":"Ambetter Exchange","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":795.0},{"Payer":"Ambetter Exchange","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":536.0},{"Payer":"Ambetter Exchange","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1071.0},{"Payer":"Ambetter Exchange","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":3507.0},{"Payer":"Ambetter Exchange","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2722.0},{"Payer":"Ambetter Exchange","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2168.0},{"Payer":"Ambetter Exchange","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":6279.0},{"Payer":"Ambetter Exchange","APC":"5661","Description":"Therapeutic Nuclear Medicine","Payer Specific Negotiated Charge":3584.0},{"Payer":"Ambetter Exchange","APC":"5673","Description":"Level 3 Pathology","Payer Specific Negotiated Charge":627.0},{"Payer":"Ambetter Exchange","APC":"5692","Description":"Level 2 Drug Administration","Payer Specific Negotiated Charge":782.0},{"Payer":"Ambetter Exchange","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":176.0},{"Payer":"Ambetter Exchange","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1090.0},{"Payer":"Ambetter Exchange","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":486.0},{"Payer":"Ambetter Exchange","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":7487.0},{"Payer":"Ambetter Exchange","APC":"5731","Description":"Level 1 Minor Procedures","Payer Specific Negotiated Charge":3149.0},{"Payer":"Ambetter Exchange","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":162.0},{"Payer":"Ambetter Exchange","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":458.0},{"Payer":"Ambetter Exchange","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":3947.0},{"Payer":"Ambetter Exchange","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":176.0},{"Payer":"Ambetter Exchange","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":80.0},{"Payer":"Ambetter Exchange","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":1026.0},{"Payer":"Ambetter Exchange","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":351.0},{"Payer":"Ambetter Exchange","APC":"N902","Description":"Packaged Services","Payer Specific Negotiated Charge":1477.0}],"Outpatient Payer Specific Charge 3":[{"Payer":"Amerigroup Medicaid","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":71.0},{"Payer":"Amerigroup Medicaid","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":39.0},{"Payer":"Amerigroup Medicaid","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":108.0},{"Payer":"Amerigroup Medicaid","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":223.0},{"Payer":"Amerigroup Medicaid","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":433.0},{"Payer":"Amerigroup Medicaid","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":942.0},{"Payer":"Amerigroup Medicaid","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":1507.0},{"Payer":"Amerigroup Medicaid","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":164.0},{"Payer":"Amerigroup Medicaid","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":205.0},{"Payer":"Amerigroup Medicaid","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":2346.0},{"Payer":"Amerigroup Medicaid","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":155.0},{"Payer":"Amerigroup Medicaid","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1904.0},{"Payer":"Amerigroup Medicaid","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2939.0},{"Payer":"Amerigroup Medicaid","APC":"5111","Description":"Level 1 Musculoskeletal Procedures","Payer Specific Negotiated Charge":75.0},{"Payer":"Amerigroup Medicaid","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":591.0},{"Payer":"Amerigroup Medicaid","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2116.0},{"Payer":"Amerigroup Medicaid","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4959.0},{"Payer":"Amerigroup Medicaid","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":5944.0},{"Payer":"Amerigroup Medicaid","APC":"5163","Description":"Level 3 ENT Procedures","Payer Specific Negotiated Charge":913.0},{"Payer":"Amerigroup Medicaid","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":5706.0},{"Payer":"Amerigroup Medicaid","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":1073.0},{"Payer":"Amerigroup Medicaid","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2591.0},{"Payer":"Amerigroup Medicaid","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":4510.0},{"Payer":"Amerigroup Medicaid","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":3854.0},{"Payer":"Amerigroup Medicaid","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":605.0},{"Payer":"Amerigroup Medicaid","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":330.0},{"Payer":"Amerigroup Medicaid","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":659.0},{"Payer":"Amerigroup Medicaid","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":3505.0},{"Payer":"Amerigroup Medicaid","APC":"5412","Description":"Level 2 Gynecologic Procedures","Payer Specific Negotiated Charge":204.0},{"Payer":"Amerigroup Medicaid","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":1469.0},{"Payer":"Amerigroup Medicaid","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1571.0},{"Payer":"Amerigroup Medicaid","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":11047.0},{"Payer":"Amerigroup Medicaid","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":949.0},{"Payer":"Amerigroup Medicaid","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":72.0},{"Payer":"Amerigroup Medicaid","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":125.0},{"Payer":"Amerigroup Medicaid","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":864.0},{"Payer":"Amerigroup Medicaid","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":208.0},{"Payer":"Amerigroup Medicaid","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":763.0},{"Payer":"Amerigroup Medicaid","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1188.0},{"Payer":"Amerigroup Medicaid","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1316.0},{"Payer":"Amerigroup Medicaid","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1789.0},{"Payer":"Amerigroup Medicaid","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":283.0},{"Payer":"Amerigroup Medicaid","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":285.0},{"Payer":"Amerigroup Medicaid","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":520.0},{"Payer":"Amerigroup Medicaid","APC":"5732","Description":"Level 2 Minor Procedures","Payer Specific Negotiated Charge":26.0},{"Payer":"Amerigroup Medicaid","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":62.0},{"Payer":"Amerigroup Medicaid","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":141.0},{"Payer":"Amerigroup Medicaid","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":251.0},{"Payer":"Amerigroup Medicaid","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":47.0},{"Payer":"Amerigroup Medicaid","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":134.0},{"Payer":"Amerigroup Medicaid","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":67.0}],"Outpatient Payer Specific Charge 4":[{"Payer":"BCBS HMO","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":227.0},{"Payer":"BCBS HMO","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":231.0},{"Payer":"BCBS HMO","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":432.0},{"Payer":"BCBS HMO","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS HMO","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":1310.0},{"Payer":"BCBS HMO","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":3001.0},{"Payer":"BCBS HMO","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":1961.0},{"Payer":"BCBS HMO","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":432.0},{"Payer":"BCBS HMO","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":1214.0},{"Payer":"BCBS HMO","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":1310.0},{"Payer":"BCBS HMO","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":5612.0},{"Payer":"BCBS HMO","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS HMO","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS HMO","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2747.0},{"Payer":"BCBS HMO","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2747.0},{"Payer":"BCBS HMO","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":4120.0},{"Payer":"BCBS HMO","APC":"5094","Description":"Level 4 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":49802.0},{"Payer":"BCBS HMO","APC":"5102","Description":"Level 2 Strapping and Cast Application","Payer Specific Negotiated Charge":772.0},{"Payer":"BCBS HMO","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS HMO","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4120.0},{"Payer":"BCBS HMO","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":8611.0},{"Payer":"BCBS HMO","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":18071.0},{"Payer":"BCBS HMO","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS HMO","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2747.0},{"Payer":"BCBS HMO","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":5774.0},{"Payer":"BCBS HMO","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS HMO","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS HMO","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":3362.0},{"Payer":"BCBS HMO","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":5149.0},{"Payer":"BCBS HMO","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":5437.0},{"Payer":"BCBS HMO","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":8769.0},{"Payer":"BCBS HMO","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":20476.0},{"Payer":"BCBS HMO","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":20235.0},{"Payer":"BCBS HMO","APC":"5212","Description":"Level 2 Electrophysiologic Procedures","Payer Specific Negotiated Charge":23443.0},{"Payer":"BCBS HMO","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":42696.0},{"Payer":"BCBS HMO","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":13037.0},{"Payer":"BCBS HMO","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":19708.0},{"Payer":"BCBS HMO","APC":"5231","Description":"Level 1 ICD and Similar Procedures","Payer Specific Negotiated Charge":50139.0},{"Payer":"BCBS HMO","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":49213.0},{"Payer":"BCBS HMO","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":1310.0},{"Payer":"BCBS HMO","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS HMO","APC":"5303","Description":"Level 3 Upper GI Procedures","Payer Specific Negotiated Charge":4120.0},{"Payer":"BCBS HMO","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS HMO","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":3119.0},{"Payer":"BCBS HMO","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":5293.0},{"Payer":"BCBS HMO","APC":"5331","Description":"Complex GI Procedures","Payer Specific Negotiated Charge":3197.0},{"Payer":"BCBS HMO","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":6658.0},{"Payer":"BCBS HMO","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":7584.0},{"Payer":"BCBS HMO","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":11798.0},{"Payer":"BCBS HMO","APC":"5401","Description":"Dialysis","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS HMO","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":3393.0},{"Payer":"BCBS HMO","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":20369.0},{"Payer":"BCBS HMO","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS HMO","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS HMO","APC":"5462","Description":"Level 2 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":10166.0},{"Payer":"BCBS HMO","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":47966.0},{"Payer":"BCBS HMO","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS HMO","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS HMO","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":8239.0},{"Payer":"BCBS HMO","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":83.0},{"Payer":"BCBS HMO","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":159.0},{"Payer":"BCBS HMO","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS HMO","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":820.0},{"Payer":"BCBS HMO","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":1090.0},{"Payer":"BCBS HMO","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1090.0},{"Payer":"BCBS HMO","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":1402.0},{"Payer":"BCBS HMO","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1284.0},{"Payer":"BCBS HMO","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1346.0},{"Payer":"BCBS HMO","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":3455.0},{"Payer":"BCBS HMO","APC":"5661","Description":"Therapeutic Nuclear Medicine","Payer Specific Negotiated Charge":2746.0},{"Payer":"BCBS HMO","APC":"5671","Description":"Level 1 Pathology","Payer Specific Negotiated Charge":11706.0},{"Payer":"BCBS HMO","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":419.0},{"Payer":"BCBS HMO","APC":"5673","Description":"Level 3 Pathology","Payer Specific Negotiated Charge":3619.0},{"Payer":"BCBS HMO","APC":"5692","Description":"Level 2 Drug Administration","Payer Specific Negotiated Charge":501.0},{"Payer":"BCBS HMO","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":432.0},{"Payer":"BCBS HMO","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1637.0},{"Payer":"BCBS HMO","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":501.0},{"Payer":"BCBS HMO","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":7720.0},{"Payer":"BCBS HMO","APC":"5731","Description":"Level 1 Minor Procedures","Payer Specific Negotiated Charge":869.0},{"Payer":"BCBS HMO","APC":"5732","Description":"Level 2 Minor Procedures","Payer Specific Negotiated Charge":115.0},{"Payer":"BCBS HMO","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":157.0},{"Payer":"BCBS HMO","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":435.0},{"Payer":"BCBS HMO","APC":"5735","Description":"Level 5 Minor Procedures","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS HMO","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":8378.0},{"Payer":"BCBS HMO","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":559.0},{"Payer":"BCBS HMO","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":144.0},{"Payer":"BCBS HMO","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":1176.0},{"Payer":"BCBS HMO","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":63.0},{"Payer":"BCBS HMO","APC":"N902","Description":"Packaged Services","Payer Specific Negotiated Charge":53.0}],"Outpatient Payer Specific Charge 5":[{"Payer":"BCBS PPO","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":229.0},{"Payer":"BCBS PPO","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":231.0},{"Payer":"BCBS PPO","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":432.0},{"Payer":"BCBS PPO","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS PPO","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":1310.0},{"Payer":"BCBS PPO","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":3001.0},{"Payer":"BCBS PPO","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":1961.0},{"Payer":"BCBS PPO","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":850.0},{"Payer":"BCBS PPO","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":1214.0},{"Payer":"BCBS PPO","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":8479.0},{"Payer":"BCBS PPO","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":3604.0},{"Payer":"BCBS PPO","APC":"5061","Description":"Hyperbaric Oxygen","Payer Specific Negotiated Charge":2067.0},{"Payer":"BCBS PPO","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS PPO","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":4120.0},{"Payer":"BCBS PPO","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":3175.0},{"Payer":"BCBS PPO","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":6180.0},{"Payer":"BCBS PPO","APC":"5101","Description":"Level 1 Strapping and Cast Application","Payer Specific Negotiated Charge":1318.0},{"Payer":"BCBS PPO","APC":"5111","Description":"Level 1 Musculoskeletal Procedures","Payer Specific Negotiated Charge":10867.0},{"Payer":"BCBS PPO","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS PPO","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2747.0},{"Payer":"BCBS PPO","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9374.0},{"Payer":"BCBS PPO","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":17981.0},{"Payer":"BCBS PPO","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS PPO","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2747.0},{"Payer":"BCBS PPO","APC":"5161","Description":"Level 1 ENT Procedures","Payer Specific Negotiated Charge":6254.0},{"Payer":"BCBS PPO","APC":"5162","Description":"Level 2 ENT Procedures","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS PPO","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":1310.0},{"Payer":"BCBS PPO","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":5248.0},{"Payer":"BCBS PPO","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS PPO","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":3878.0},{"Payer":"BCBS PPO","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":6048.0},{"Payer":"BCBS PPO","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":5437.0},{"Payer":"BCBS PPO","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":14451.0},{"Payer":"BCBS PPO","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":19345.0},{"Payer":"BCBS PPO","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":26655.0},{"Payer":"BCBS PPO","APC":"5212","Description":"Level 2 Electrophysiologic Procedures","Payer Specific Negotiated Charge":20650.0},{"Payer":"BCBS PPO","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":49189.0},{"Payer":"BCBS PPO","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":13945.0},{"Payer":"BCBS PPO","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":19708.0},{"Payer":"BCBS PPO","APC":"5231","Description":"Level 1 ICD and Similar Procedures","Payer Specific Negotiated Charge":39181.0},{"Payer":"BCBS PPO","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":49213.0},{"Payer":"BCBS PPO","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":1310.0},{"Payer":"BCBS PPO","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":2691.0},{"Payer":"BCBS PPO","APC":"5303","Description":"Level 3 Upper GI Procedures","Payer Specific Negotiated Charge":4120.0},{"Payer":"BCBS PPO","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS PPO","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":3872.0},{"Payer":"BCBS PPO","APC":"5331","Description":"Complex GI Procedures","Payer Specific Negotiated Charge":4570.0},{"Payer":"BCBS PPO","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":2747.0},{"Payer":"BCBS PPO","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":7155.0},{"Payer":"BCBS PPO","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":12009.0},{"Payer":"BCBS PPO","APC":"5374","Description":"Level 4 Urology and Related Services","Payer Specific Negotiated Charge":3878.0},{"Payer":"BCBS PPO","APC":"5412","Description":"Level 2 Gynecologic Procedures","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS PPO","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":3256.0},{"Payer":"BCBS PPO","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":10918.0},{"Payer":"BCBS PPO","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5461","Description":"Level 1 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":3312.0},{"Payer":"BCBS PPO","APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":37324.0},{"Payer":"BCBS PPO","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":55372.0},{"Payer":"BCBS PPO","APC":"5471","Description":"Implantation of Drug Infusion Device","Payer Specific Negotiated Charge":29179.0},{"Payer":"BCBS PPO","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":1714.0},{"Payer":"BCBS PPO","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":2262.0},{"Payer":"BCBS PPO","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":7121.0},{"Payer":"BCBS PPO","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":96.0},{"Payer":"BCBS PPO","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":159.0},{"Payer":"BCBS PPO","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS PPO","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":820.0},{"Payer":"BCBS PPO","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":1090.0},{"Payer":"BCBS PPO","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1090.0},{"Payer":"BCBS PPO","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":1402.0},{"Payer":"BCBS PPO","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1291.0},{"Payer":"BCBS PPO","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2177.0},{"Payer":"BCBS PPO","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":3455.0},{"Payer":"BCBS PPO","APC":"5661","Description":"Therapeutic Nuclear Medicine","Payer Specific Negotiated Charge":12510.0},{"Payer":"BCBS PPO","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":541.0},{"Payer":"BCBS PPO","APC":"5692","Description":"Level 2 Drug Administration","Payer Specific Negotiated Charge":1881.0},{"Payer":"BCBS PPO","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":432.0},{"Payer":"BCBS PPO","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1791.0},{"Payer":"BCBS PPO","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":501.0},{"Payer":"BCBS PPO","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":7962.0},{"Payer":"BCBS PPO","APC":"5731","Description":"Level 1 Minor Procedures","Payer Specific Negotiated Charge":801.0},{"Payer":"BCBS PPO","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":157.0},{"Payer":"BCBS PPO","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":444.0},{"Payer":"BCBS PPO","APC":"5735","Description":"Level 5 Minor Procedures","Payer Specific Negotiated Charge":743.0},{"Payer":"BCBS PPO","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":8138.0},{"Payer":"BCBS PPO","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":432.0},{"Payer":"BCBS PPO","APC":"5801","Description":"Ventilation Initiation and Management","Payer Specific Negotiated Charge":187390.0},{"Payer":"BCBS PPO","APC":"5871","Description":"Dental Procedures","Payer Specific Negotiated Charge":6254.0},{"Payer":"BCBS PPO","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":169.0},{"Payer":"BCBS PPO","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":1045.0},{"Payer":"BCBS PPO","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":63.0},{"Payer":"BCBS PPO","APC":"N902","Description":"Packaged Services","Payer Specific Negotiated Charge":1170.0}],"Outpatient Payer Specific Charge 6":[{"Payer":"Blue Cross Medicare Advantage","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":99.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":60.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":110.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":245.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":529.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2072.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":2047.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":201.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":269.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":605.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2415.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2289.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4931.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9270.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1174.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":938.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2266.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":2425.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":10739.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":6461.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":8622.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":26294.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":653.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":639.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":855.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":3942.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5371","Description":"Level 1 Urology and Related Services","Payer Specific Negotiated Charge":390.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":244.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1312.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5462","Description":"Level 2 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":5129.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":23756.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":433.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":1644.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":3122.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":53.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":97.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":201.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":427.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":173.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":669.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":535.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1073.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":213.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5673","Description":"Level 3 Pathology","Payer Specific Negotiated Charge":260.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":233.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":216.0},{"Payer":"Blue Cross Medicare Advantage","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"Blue Cross Medicare Advantage","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":39.0},{"Payer":"Blue Cross Medicare Advantage","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":336.0},{"Payer":"Blue Cross Medicare Advantage","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":110.0}],"Outpatient Payer Specific Charge 7":[{"Payer":"Caresource Medicaid","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":159.0},{"Payer":"Caresource Medicaid","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":297.0},{"Payer":"Caresource Medicaid","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":85.0},{"Payer":"Caresource Medicaid","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":222.0},{"Payer":"Caresource Medicaid","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":410.0},{"Payer":"Caresource Medicaid","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":1361.0},{"Payer":"Caresource Medicaid","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":928.0},{"Payer":"Caresource Medicaid","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":113.0},{"Payer":"Caresource Medicaid","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":185.0},{"Payer":"Caresource Medicaid","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":2787.0},{"Payer":"Caresource Medicaid","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":706.0},{"Payer":"Caresource Medicaid","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2094.0},{"Payer":"Caresource Medicaid","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":3119.0},{"Payer":"Caresource Medicaid","APC":"5101","Description":"Level 1 Strapping and Cast Application","Payer Specific Negotiated Charge":326.0},{"Payer":"Caresource Medicaid","APC":"5111","Description":"Level 1 Musculoskeletal Procedures","Payer Specific Negotiated Charge":326.0},{"Payer":"Caresource Medicaid","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1979.0},{"Payer":"Caresource Medicaid","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4553.0},{"Payer":"Caresource Medicaid","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":5666.0},{"Payer":"Caresource Medicaid","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":1302.0},{"Payer":"Caresource Medicaid","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":9145.0},{"Payer":"Caresource Medicaid","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":7395.0},{"Payer":"Caresource Medicaid","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":18611.0},{"Payer":"Caresource Medicaid","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":591.0},{"Payer":"Caresource Medicaid","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":372.0},{"Payer":"Caresource Medicaid","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":502.0},{"Payer":"Caresource Medicaid","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":3110.0},{"Payer":"Caresource Medicaid","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":2859.0},{"Payer":"Caresource Medicaid","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1534.0},{"Payer":"Caresource Medicaid","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":75.0},{"Payer":"Caresource Medicaid","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":1938.0},{"Payer":"Caresource Medicaid","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":80.0},{"Payer":"Caresource Medicaid","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":121.0},{"Payer":"Caresource Medicaid","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":640.0},{"Payer":"Caresource Medicaid","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":210.0},{"Payer":"Caresource Medicaid","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":663.0},{"Payer":"Caresource Medicaid","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1255.0},{"Payer":"Caresource Medicaid","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":897.0},{"Payer":"Caresource Medicaid","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2577.0},{"Payer":"Caresource Medicaid","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":433.0},{"Payer":"Caresource Medicaid","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":282.0},{"Payer":"Caresource Medicaid","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":525.0},{"Payer":"Caresource Medicaid","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":559.0},{"Payer":"Caresource Medicaid","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":33.0},{"Payer":"Caresource Medicaid","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":212.0},{"Payer":"Caresource Medicaid","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":186.0},{"Payer":"Caresource Medicaid","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":29.0},{"Payer":"Caresource Medicaid","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":165.0},{"Payer":"Caresource Medicaid","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":67.0}],"Outpatient Payer Specific Charge 8":[{"Payer":"Choicecare (Humana)","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":286.0},{"Payer":"Choicecare (Humana)","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":109.0},{"Payer":"Choicecare (Humana)","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":184.0},{"Payer":"Choicecare (Humana)","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":472.0},{"Payer":"Choicecare (Humana)","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":905.0},{"Payer":"Choicecare (Humana)","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2237.0},{"Payer":"Choicecare (Humana)","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":184.0},{"Payer":"Choicecare (Humana)","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2512.0},{"Payer":"Choicecare (Humana)","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1478.0},{"Payer":"Choicecare (Humana)","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2251.0},{"Payer":"Choicecare (Humana)","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2237.0},{"Payer":"Choicecare (Humana)","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2251.0},{"Payer":"Choicecare (Humana)","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":6721.0},{"Payer":"Choicecare (Humana)","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":18129.0},{"Payer":"Choicecare (Humana)","APC":"5116","Description":"Level 6 Musculoskeletal Procedures","Payer Specific Negotiated Charge":17350.0},{"Payer":"Choicecare (Humana)","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1966.0},{"Payer":"Choicecare (Humana)","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":4994.0},{"Payer":"Choicecare (Humana)","APC":"5163","Description":"Level 3 ENT Procedures","Payer Specific Negotiated Charge":5791.0},{"Payer":"Choicecare (Humana)","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":3376.0},{"Payer":"Choicecare (Humana)","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":1256.0},{"Payer":"Choicecare (Humana)","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2679.0},{"Payer":"Choicecare (Humana)","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":5712.0},{"Payer":"Choicecare (Humana)","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":4994.0},{"Payer":"Choicecare (Humana)","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":12338.0},{"Payer":"Choicecare (Humana)","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":44413.0},{"Payer":"Choicecare (Humana)","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1966.0},{"Payer":"Choicecare (Humana)","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1966.0},{"Payer":"Choicecare (Humana)","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":2949.0},{"Payer":"Choicecare (Humana)","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":4994.0},{"Payer":"Choicecare (Humana)","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1966.0},{"Payer":"Choicecare (Humana)","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":472.0},{"Payer":"Choicecare (Humana)","APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":17324.0},{"Payer":"Choicecare (Humana)","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":62262.0},{"Payer":"Choicecare (Humana)","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":4335.0},{"Payer":"Choicecare (Humana)","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":387.0},{"Payer":"Choicecare (Humana)","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":547.0},{"Payer":"Choicecare (Humana)","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":533.0},{"Payer":"Choicecare (Humana)","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":1012.0},{"Payer":"Choicecare (Humana)","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":2025.0},{"Payer":"Choicecare (Humana)","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1255.0},{"Payer":"Choicecare (Humana)","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":3464.0},{"Payer":"Choicecare (Humana)","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":8032.0},{"Payer":"Choicecare (Humana)","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":8674.0},{"Payer":"Choicecare (Humana)","APC":"5594","Description":"Level 4 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":184.0},{"Payer":"Choicecare (Humana)","APC":"5673","Description":"Level 3 Pathology","Payer Specific Negotiated Charge":2382.0},{"Payer":"Choicecare (Humana)","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":184.0},{"Payer":"Choicecare (Humana)","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1470.0},{"Payer":"Choicecare (Humana)","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":618.0},{"Payer":"Choicecare (Humana)","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":234.0},{"Payer":"Choicecare (Humana)","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":785.0},{"Payer":"Choicecare (Humana)","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":1881.0},{"Payer":"Choicecare (Humana)","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":237.0},{"Payer":"Choicecare (Humana)","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":1261.0},{"Payer":"Choicecare (Humana)","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":369.0}],"Outpatient Payer Specific Charge 9":[{"Payer":"CIGNA HMO/PPO","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":265.0},{"Payer":"CIGNA HMO/PPO","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":230.0},{"Payer":"CIGNA HMO/PPO","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":382.0},{"Payer":"CIGNA HMO/PPO","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":610.0},{"Payer":"CIGNA HMO/PPO","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":1224.0},{"Payer":"CIGNA HMO/PPO","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2382.0},{"Payer":"CIGNA HMO/PPO","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":3040.0},{"Payer":"CIGNA HMO/PPO","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":426.0},{"Payer":"CIGNA HMO/PPO","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":1454.0},{"Payer":"CIGNA HMO/PPO","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":1727.0},{"Payer":"CIGNA HMO/PPO","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":1884.0},{"Payer":"CIGNA HMO/PPO","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":4283.0},{"Payer":"CIGNA HMO/PPO","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1492.0},{"Payer":"CIGNA HMO/PPO","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1614.0},{"Payer":"CIGNA HMO/PPO","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2044.0},{"Payer":"CIGNA HMO/PPO","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2800.0},{"Payer":"CIGNA HMO/PPO","APC":"5101","Description":"Level 1 Strapping and Cast Application","Payer Specific Negotiated Charge":630.0},{"Payer":"CIGNA HMO/PPO","APC":"5111","Description":"Level 1 Musculoskeletal Procedures","Payer Specific Negotiated Charge":382.0},{"Payer":"CIGNA HMO/PPO","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2046.0},{"Payer":"CIGNA HMO/PPO","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":3704.0},{"Payer":"CIGNA HMO/PPO","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":8361.0},{"Payer":"CIGNA HMO/PPO","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":31514.0},{"Payer":"CIGNA HMO/PPO","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1617.0},{"Payer":"CIGNA HMO/PPO","APC":"5155","Description":"Level 5 Airway Endoscopy","Payer Specific Negotiated Charge":4205.0},{"Payer":"CIGNA HMO/PPO","APC":"5161","Description":"Level 1 ENT Procedures","Payer Specific Negotiated Charge":13044.0},{"Payer":"CIGNA HMO/PPO","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":3000.0},{"Payer":"CIGNA HMO/PPO","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":3067.0},{"Payer":"CIGNA HMO/PPO","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":1494.0},{"Payer":"CIGNA HMO/PPO","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":3299.0},{"Payer":"CIGNA HMO/PPO","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":6359.0},{"Payer":"CIGNA HMO/PPO","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":4651.0},{"Payer":"CIGNA HMO/PPO","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":5819.0},{"Payer":"CIGNA HMO/PPO","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":8704.0},{"Payer":"CIGNA HMO/PPO","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":13710.0},{"Payer":"CIGNA HMO/PPO","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":28676.0},{"Payer":"CIGNA HMO/PPO","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":14564.0},{"Payer":"CIGNA HMO/PPO","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":39916.0},{"Payer":"CIGNA HMO/PPO","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1732.0},{"Payer":"CIGNA HMO/PPO","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":2253.0},{"Payer":"CIGNA HMO/PPO","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1732.0},{"Payer":"CIGNA HMO/PPO","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":1732.0},{"Payer":"CIGNA HMO/PPO","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":4652.0},{"Payer":"CIGNA HMO/PPO","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":5196.0},{"Payer":"CIGNA HMO/PPO","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":5455.0},{"Payer":"CIGNA HMO/PPO","APC":"5415","Description":"Level 5 Gynecologic Procedures","Payer Specific Negotiated Charge":4775.0},{"Payer":"CIGNA HMO/PPO","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":5621.0},{"Payer":"CIGNA HMO/PPO","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":616.0},{"Payer":"CIGNA HMO/PPO","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":615.0},{"Payer":"CIGNA HMO/PPO","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1519.0},{"Payer":"CIGNA HMO/PPO","APC":"5461","Description":"Level 1 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":4691.0},{"Payer":"CIGNA HMO/PPO","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":4007.0},{"Payer":"CIGNA HMO/PPO","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":10988.0},{"Payer":"CIGNA HMO/PPO","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":257.0},{"Payer":"CIGNA HMO/PPO","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":257.0},{"Payer":"CIGNA HMO/PPO","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":623.0},{"Payer":"CIGNA HMO/PPO","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":798.0},{"Payer":"CIGNA HMO/PPO","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":460.0},{"Payer":"CIGNA HMO/PPO","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":848.0},{"Payer":"CIGNA HMO/PPO","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":2669.0},{"Payer":"CIGNA HMO/PPO","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2582.0},{"Payer":"CIGNA HMO/PPO","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2365.0},{"Payer":"CIGNA HMO/PPO","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":6406.0},{"Payer":"CIGNA HMO/PPO","APC":"5661","Description":"Therapeutic Nuclear Medicine","Payer Specific Negotiated Charge":54.0},{"Payer":"CIGNA HMO/PPO","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":54.0},{"Payer":"CIGNA HMO/PPO","APC":"5692","Description":"Level 2 Drug Administration","Payer Specific Negotiated Charge":731.0},{"Payer":"CIGNA HMO/PPO","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":393.0},{"Payer":"CIGNA HMO/PPO","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1742.0},{"Payer":"CIGNA HMO/PPO","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":487.0},{"Payer":"CIGNA HMO/PPO","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":54.0},{"Payer":"CIGNA HMO/PPO","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":54.0},{"Payer":"CIGNA HMO/PPO","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":552.0},{"Payer":"CIGNA HMO/PPO","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":54.0},{"Payer":"CIGNA HMO/PPO","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":382.0},{"Payer":"CIGNA HMO/PPO","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":54.0},{"Payer":"CIGNA HMO/PPO","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":759.0},{"Payer":"CIGNA HMO/PPO","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":340.0}],"Outpatient Payer Specific Charge 10":[{"Payer":"Coventry/Aetna HMO","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":268.0},{"Payer":"Coventry/Aetna HMO","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":245.0},{"Payer":"Coventry/Aetna HMO","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":508.0},{"Payer":"Coventry/Aetna HMO","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":949.0},{"Payer":"Coventry/Aetna HMO","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":1846.0},{"Payer":"Coventry/Aetna HMO","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":245.0},{"Payer":"Coventry/Aetna HMO","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1067.0},{"Payer":"Coventry/Aetna HMO","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1734.0},{"Payer":"Coventry/Aetna HMO","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":3622.0},{"Payer":"Coventry/Aetna HMO","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1008.0},{"Payer":"Coventry/Aetna HMO","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2856.0},{"Payer":"Coventry/Aetna HMO","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":3256.0},{"Payer":"Coventry/Aetna HMO","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":11062.0},{"Payer":"Coventry/Aetna HMO","APC":"5116","Description":"Level 6 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9011.0},{"Payer":"Coventry/Aetna HMO","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1387.0},{"Payer":"Coventry/Aetna HMO","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":1848.0},{"Payer":"Coventry/Aetna HMO","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":3072.0},{"Payer":"Coventry/Aetna HMO","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":3987.0},{"Payer":"Coventry/Aetna HMO","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":4677.0},{"Payer":"Coventry/Aetna HMO","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":13982.0},{"Payer":"Coventry/Aetna HMO","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":10315.0},{"Payer":"Coventry/Aetna HMO","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":6836.0},{"Payer":"Coventry/Aetna HMO","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1387.0},{"Payer":"Coventry/Aetna HMO","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1227.0},{"Payer":"Coventry/Aetna HMO","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":1387.0},{"Payer":"Coventry/Aetna HMO","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":1524.0},{"Payer":"Coventry/Aetna HMO","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":2704.0},{"Payer":"Coventry/Aetna HMO","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":1524.0},{"Payer":"Coventry/Aetna HMO","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":508.0},{"Payer":"Coventry/Aetna HMO","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":1387.0},{"Payer":"Coventry/Aetna HMO","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":3047.0},{"Payer":"Coventry/Aetna HMO","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":301.0},{"Payer":"Coventry/Aetna HMO","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":173.0},{"Payer":"Coventry/Aetna HMO","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":508.0},{"Payer":"Coventry/Aetna HMO","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":1290.0},{"Payer":"Coventry/Aetna HMO","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":1090.0},{"Payer":"Coventry/Aetna HMO","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":949.0},{"Payer":"Coventry/Aetna HMO","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":719.0},{"Payer":"Coventry/Aetna HMO","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":6850.0},{"Payer":"Coventry/Aetna HMO","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":245.0},{"Payer":"Coventry/Aetna HMO","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":2054.0},{"Payer":"Coventry/Aetna HMO","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":530.0},{"Payer":"Coventry/Aetna HMO","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":135.0},{"Payer":"Coventry/Aetna HMO","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":498.0},{"Payer":"Coventry/Aetna HMO","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":3987.0},{"Payer":"Coventry/Aetna HMO","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":245.0},{"Payer":"Coventry/Aetna HMO","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":125.0},{"Payer":"Coventry/Aetna HMO","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":1246.0},{"Payer":"Coventry/Aetna HMO","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":316.0},{"Payer":"Coventry/Aetna HMO","APC":"N902","Description":"Packaged Services","Payer Specific Negotiated Charge":319.0}],"Outpatient Payer Specific Charge 11":[{"Payer":"Coventry/Aetna PPO","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":313.0},{"Payer":"Coventry/Aetna PPO","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":425.0},{"Payer":"Coventry/Aetna PPO","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":681.0},{"Payer":"Coventry/Aetna PPO","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":1363.0},{"Payer":"Coventry/Aetna PPO","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":3497.0},{"Payer":"Coventry/Aetna PPO","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":2033.0},{"Payer":"Coventry/Aetna PPO","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":1156.0},{"Payer":"Coventry/Aetna PPO","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":18846.0},{"Payer":"Coventry/Aetna PPO","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":681.0},{"Payer":"Coventry/Aetna PPO","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1404.0},{"Payer":"Coventry/Aetna PPO","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":4085.0},{"Payer":"Coventry/Aetna PPO","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":3190.0},{"Payer":"Coventry/Aetna PPO","APC":"5101","Description":"Level 1 Strapping and Cast Application","Payer Specific Negotiated Charge":425.0},{"Payer":"Coventry/Aetna PPO","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2516.0},{"Payer":"Coventry/Aetna PPO","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":7019.0},{"Payer":"Coventry/Aetna PPO","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":6587.0},{"Payer":"Coventry/Aetna PPO","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":43083.0},{"Payer":"Coventry/Aetna PPO","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2127.0},{"Payer":"Coventry/Aetna PPO","APC":"5155","Description":"Level 5 Airway Endoscopy","Payer Specific Negotiated Charge":7203.0},{"Payer":"Coventry/Aetna PPO","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":4917.0},{"Payer":"Coventry/Aetna PPO","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":4888.0},{"Payer":"Coventry/Aetna PPO","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":1560.0},{"Payer":"Coventry/Aetna PPO","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":5691.0},{"Payer":"Coventry/Aetna PPO","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":6963.0},{"Payer":"Coventry/Aetna PPO","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":5076.0},{"Payer":"Coventry/Aetna PPO","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":28808.0},{"Payer":"Coventry/Aetna PPO","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":4743.0},{"Payer":"Coventry/Aetna PPO","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":60772.0},{"Payer":"Coventry/Aetna PPO","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":2127.0},{"Payer":"Coventry/Aetna PPO","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":2907.0},{"Payer":"Coventry/Aetna PPO","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":2127.0},{"Payer":"Coventry/Aetna PPO","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":2127.0},{"Payer":"Coventry/Aetna PPO","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":3120.0},{"Payer":"Coventry/Aetna PPO","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":5584.0},{"Payer":"Coventry/Aetna PPO","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":2624.0},{"Payer":"Coventry/Aetna PPO","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":2127.0},{"Payer":"Coventry/Aetna PPO","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":15253.0},{"Payer":"Coventry/Aetna PPO","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":2127.0},{"Payer":"Coventry/Aetna PPO","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":8117.0},{"Payer":"Coventry/Aetna PPO","APC":"5503","Description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","Payer Specific Negotiated Charge":8097.0},{"Payer":"Coventry/Aetna PPO","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":442.0},{"Payer":"Coventry/Aetna PPO","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":658.0},{"Payer":"Coventry/Aetna PPO","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":1266.0},{"Payer":"Coventry/Aetna PPO","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":1142.0},{"Payer":"Coventry/Aetna PPO","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":858.0},{"Payer":"Coventry/Aetna PPO","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1539.0},{"Payer":"Coventry/Aetna PPO","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":6766.0},{"Payer":"Coventry/Aetna PPO","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2092.0},{"Payer":"Coventry/Aetna PPO","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":3756.0},{"Payer":"Coventry/Aetna PPO","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":9419.0},{"Payer":"Coventry/Aetna PPO","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":425.0},{"Payer":"Coventry/Aetna PPO","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":2878.0},{"Payer":"Coventry/Aetna PPO","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":698.0},{"Payer":"Coventry/Aetna PPO","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":264.0},{"Payer":"Coventry/Aetna PPO","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":790.0},{"Payer":"Coventry/Aetna PPO","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":28387.0},{"Payer":"Coventry/Aetna PPO","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":503.0},{"Payer":"Coventry/Aetna PPO","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":1626.0},{"Payer":"Coventry/Aetna PPO","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":416.0}],"Outpatient Payer Specific Charge 12":[{"Payer":"GA Ports Authority","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":1040.0},{"Payer":"GA Ports Authority","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":75.0},{"Payer":"GA Ports Authority","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":125.0},{"Payer":"GA Ports Authority","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":335.0},{"Payer":"GA Ports Authority","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":827.0},{"Payer":"GA Ports Authority","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":1592.0},{"Payer":"GA Ports Authority","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":4809.0},{"Payer":"GA Ports Authority","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1033.0},{"Payer":"GA Ports Authority","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2314.0},{"Payer":"GA Ports Authority","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2704.0},{"Payer":"GA Ports Authority","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2417.0},{"Payer":"GA Ports Authority","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4824.0},{"Payer":"GA Ports Authority","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4401.0},{"Payer":"GA Ports Authority","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":15989.0},{"Payer":"GA Ports Authority","APC":"5116","Description":"Level 6 Musculoskeletal Procedures","Payer Specific Negotiated Charge":21626.0},{"Payer":"GA Ports Authority","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":3932.0},{"Payer":"GA Ports Authority","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":2704.0},{"Payer":"GA Ports Authority","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":2193.0},{"Payer":"GA Ports Authority","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":5303.0},{"Payer":"GA Ports Authority","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":3463.0},{"Payer":"GA Ports Authority","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":11380.0},{"Payer":"GA Ports Authority","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":12360.0},{"Payer":"GA Ports Authority","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1518.0},{"Payer":"GA Ports Authority","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":2992.0},{"Payer":"GA Ports Authority","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1518.0},{"Payer":"GA Ports Authority","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":1696.0},{"Payer":"GA Ports Authority","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":2704.0},{"Payer":"GA Ports Authority","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":3195.0},{"Payer":"GA Ports Authority","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":2277.0},{"Payer":"GA Ports Authority","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":16459.0},{"Payer":"GA Ports Authority","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":335.0},{"Payer":"GA Ports Authority","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1518.0},{"Payer":"GA Ports Authority","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":10721.0},{"Payer":"GA Ports Authority","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":849.0},{"Payer":"GA Ports Authority","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":2277.0},{"Payer":"GA Ports Authority","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":6726.0},{"Payer":"GA Ports Authority","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":251.0},{"Payer":"GA Ports Authority","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":184.0},{"Payer":"GA Ports Authority","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":793.0},{"Payer":"GA Ports Authority","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":723.0},{"Payer":"GA Ports Authority","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":396.0},{"Payer":"GA Ports Authority","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":793.0},{"Payer":"GA Ports Authority","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":1642.0},{"Payer":"GA Ports Authority","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1578.0},{"Payer":"GA Ports Authority","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":9583.0},{"Payer":"GA Ports Authority","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":6189.0},{"Payer":"GA Ports Authority","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1529.0},{"Payer":"GA Ports Authority","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":442.0},{"Payer":"GA Ports Authority","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":6984.0},{"Payer":"GA Ports Authority","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":112.0},{"Payer":"GA Ports Authority","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":416.0},{"Payer":"GA Ports Authority","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":643.0},{"Payer":"GA Ports Authority","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":75.0},{"Payer":"GA Ports Authority","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":1146.0},{"Payer":"GA Ports Authority","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":252.0}],"Outpatient Payer Specific Charge 13":[{"Payer":"Humana Medicare","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":101.0},{"Payer":"Humana Medicare","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":112.0},{"Payer":"Humana Medicare","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":250.0},{"Payer":"Humana Medicare","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":534.0},{"Payer":"Humana Medicare","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2104.0},{"Payer":"Humana Medicare","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":2089.0},{"Payer":"Humana Medicare","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":157.0},{"Payer":"Humana Medicare","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":275.0},{"Payer":"Humana Medicare","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":430.0},{"Payer":"Humana Medicare","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":1356.0},{"Payer":"Humana Medicare","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":511.0},{"Payer":"Humana Medicare","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1204.0},{"Payer":"Humana Medicare","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2081.0},{"Payer":"Humana Medicare","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":3424.0},{"Payer":"Humana Medicare","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":4302.0},{"Payer":"Humana Medicare","APC":"5102","Description":"Level 2 Strapping and Cast Application","Payer Specific Negotiated Charge":206.0},{"Payer":"Humana Medicare","APC":"5111","Description":"Level 1 Musculoskeletal Procedures","Payer Specific Negotiated Charge":470.0},{"Payer":"Humana Medicare","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1149.0},{"Payer":"Humana Medicare","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2296.0},{"Payer":"Humana Medicare","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4988.0},{"Payer":"Humana Medicare","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9459.0},{"Payer":"Humana Medicare","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1198.0},{"Payer":"Humana Medicare","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2441.0},{"Payer":"Humana Medicare","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":3872.0},{"Payer":"Humana Medicare","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":569.0},{"Payer":"Humana Medicare","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":2068.0},{"Payer":"Humana Medicare","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2312.0},{"Payer":"Humana Medicare","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":3830.0},{"Payer":"Humana Medicare","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":2475.0},{"Payer":"Humana Medicare","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":2475.0},{"Payer":"Humana Medicare","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":8477.0},{"Payer":"Humana Medicare","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"Humana Medicare","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":50.0},{"Payer":"Humana Medicare","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":6480.0},{"Payer":"Humana Medicare","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":8646.0},{"Payer":"Humana Medicare","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":26830.0},{"Payer":"Humana Medicare","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":972.0},{"Payer":"Humana Medicare","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":678.0},{"Payer":"Humana Medicare","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":1298.0},{"Payer":"Humana Medicare","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":663.0},{"Payer":"Humana Medicare","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":872.0},{"Payer":"Humana Medicare","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":2079.0},{"Payer":"Humana Medicare","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":2602.0},{"Payer":"Humana Medicare","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":4022.0},{"Payer":"Humana Medicare","APC":"5371","Description":"Level 1 Urology and Related Services","Payer Specific Negotiated Charge":398.0},{"Payer":"Humana Medicare","APC":"5401","Description":"Dialysis","Payer Specific Negotiated Charge":787.0},{"Payer":"Humana Medicare","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1428.0},{"Payer":"Humana Medicare","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":3996.0},{"Payer":"Humana Medicare","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":217.0},{"Payer":"Humana Medicare","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":533.0},{"Payer":"Humana Medicare","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1339.0},{"Payer":"Humana Medicare","APC":"5461","Description":"Level 1 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":2520.0},{"Payer":"Humana Medicare","APC":"5462","Description":"Level 2 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":5233.0},{"Payer":"Humana Medicare","APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":16373.0},{"Payer":"Humana Medicare","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":24241.0},{"Payer":"Humana Medicare","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":434.0},{"Payer":"Humana Medicare","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":1678.0},{"Payer":"Humana Medicare","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":3242.0},{"Payer":"Humana Medicare","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":55.0},{"Payer":"Humana Medicare","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":98.0},{"Payer":"Humana Medicare","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":205.0},{"Payer":"Humana Medicare","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":435.0},{"Payer":"Humana Medicare","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":177.0},{"Payer":"Humana Medicare","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":471.0},{"Payer":"Humana Medicare","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":338.0},{"Payer":"Humana Medicare","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":309.0},{"Payer":"Humana Medicare","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":399.0},{"Payer":"Humana Medicare","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1511.0},{"Payer":"Humana Medicare","APC":"5661","Description":"Therapeutic Nuclear Medicine","Payer Specific Negotiated Charge":617.0},{"Payer":"Humana Medicare","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":278.0},{"Payer":"Humana Medicare","APC":"5673","Description":"Level 3 Pathology","Payer Specific Negotiated Charge":490.0},{"Payer":"Humana Medicare","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":441.0},{"Payer":"Humana Medicare","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":238.0},{"Payer":"Humana Medicare","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":221.0},{"Payer":"Humana Medicare","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"Humana Medicare","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":93.0},{"Payer":"Humana Medicare","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":50.0},{"Payer":"Humana Medicare","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":145.0},{"Payer":"Humana Medicare","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":35.0},{"Payer":"Humana Medicare","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":293.0},{"Payer":"Humana Medicare","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":111.0}],"Outpatient Payer Specific Charge 14":[{"Payer":"PHCS","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":302.0},{"Payer":"PHCS","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":621.0},{"Payer":"PHCS","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":1460.0},{"Payer":"PHCS","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":2837.0},{"Payer":"PHCS","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":4109.0},{"Payer":"PHCS","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":14677.0},{"Payer":"PHCS","APC":"5061","Description":"Hyperbaric Oxygen","Payer Specific Negotiated Charge":2733.0},{"Payer":"PHCS","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2971.0},{"Payer":"PHCS","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1826.0},{"Payer":"PHCS","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1584.0},{"Payer":"PHCS","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4251.0},{"Payer":"PHCS","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":34068.0},{"Payer":"PHCS","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":48105.0},{"Payer":"PHCS","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1410.0},{"Payer":"PHCS","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":2989.0},{"Payer":"PHCS","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":1893.0},{"Payer":"PHCS","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":12073.0},{"Payer":"PHCS","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":38863.0},{"Payer":"PHCS","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":16418.0},{"Payer":"PHCS","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":554.0},{"Payer":"PHCS","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":865.0},{"Payer":"PHCS","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":4549.0},{"Payer":"PHCS","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":1416.0},{"Payer":"PHCS","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":2100.0},{"Payer":"PHCS","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":6055.0},{"Payer":"PHCS","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":9148.0},{"Payer":"PHCS","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":8984.0},{"Payer":"PHCS","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1945.0},{"Payer":"PHCS","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":2918.0},{"Payer":"PHCS","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":177.0},{"Payer":"PHCS","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":377.0},{"Payer":"PHCS","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":348.0}],"Outpatient Payer Specific Charge 15":[{"Payer":"SBG","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":630.0},{"Payer":"SBG","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":75.0},{"Payer":"SBG","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":125.0},{"Payer":"SBG","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":335.0},{"Payer":"SBG","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":643.0},{"Payer":"SBG","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":1979.0},{"Payer":"SBG","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":4304.0},{"Payer":"SBG","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":926.0},{"Payer":"SBG","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":335.0},{"Payer":"SBG","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":748.0},{"Payer":"SBG","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":3195.0},{"Payer":"SBG","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1406.0},{"Payer":"SBG","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2281.0},{"Payer":"SBG","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2704.0},{"Payer":"SBG","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":3486.0},{"Payer":"SBG","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":4525.0},{"Payer":"SBG","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2233.0},{"Payer":"SBG","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":3826.0},{"Payer":"SBG","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":6125.0},{"Payer":"SBG","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":16145.0},{"Payer":"SBG","APC":"5116","Description":"Level 6 Musculoskeletal Procedures","Payer Specific Negotiated Charge":11717.0},{"Payer":"SBG","APC":"5151","Description":"Level 1 Airway Endoscopy","Payer Specific Negotiated Charge":849.0},{"Payer":"SBG","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1875.0},{"Payer":"SBG","APC":"5163","Description":"Level 3 ENT Procedures","Payer Specific Negotiated Charge":1696.0},{"Payer":"SBG","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":2277.0},{"Payer":"SBG","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":2704.0},{"Payer":"SBG","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":1518.0},{"Payer":"SBG","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":1166.0},{"Payer":"SBG","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":5249.0},{"Payer":"SBG","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":3236.0},{"Payer":"SBG","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":4211.0},{"Payer":"SBG","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":10178.0},{"Payer":"SBG","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":25088.0},{"Payer":"SBG","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":12521.0},{"Payer":"SBG","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":55638.0},{"Payer":"SBG","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":643.0},{"Payer":"SBG","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":1518.0},{"Payer":"SBG","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":2612.0},{"Payer":"SBG","APC":"5303","Description":"Level 3 Upper GI Procedures","Payer Specific Negotiated Charge":4056.0},{"Payer":"SBG","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1518.0},{"Payer":"SBG","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":1696.0},{"Payer":"SBG","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":2704.0},{"Payer":"SBG","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":2704.0},{"Payer":"SBG","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":2704.0},{"Payer":"SBG","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":3952.0},{"Payer":"SBG","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":2704.0},{"Payer":"SBG","APC":"5415","Description":"Level 5 Gynecologic Procedures","Payer Specific Negotiated Charge":2233.0},{"Payer":"SBG","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":3578.0},{"Payer":"SBG","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":1161.0},{"Payer":"SBG","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":1030.0},{"Payer":"SBG","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1518.0},{"Payer":"SBG","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":849.0},{"Payer":"SBG","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":2277.0},{"Payer":"SBG","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":7373.0},{"Payer":"SBG","APC":"5503","Description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","Payer Specific Negotiated Charge":2984.0},{"Payer":"SBG","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":251.0},{"Payer":"SBG","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":280.0},{"Payer":"SBG","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":793.0},{"Payer":"SBG","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":723.0},{"Payer":"SBG","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":396.0},{"Payer":"SBG","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":793.0},{"Payer":"SBG","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":2538.0},{"Payer":"SBG","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2474.0},{"Payer":"SBG","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2390.0},{"Payer":"SBG","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":5990.0},{"Payer":"SBG","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":678.0},{"Payer":"SBG","APC":"5673","Description":"Level 3 Pathology","Payer Specific Negotiated Charge":1479.0},{"Payer":"SBG","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":125.0},{"Payer":"SBG","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1602.0},{"Payer":"SBG","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":442.0},{"Payer":"SBG","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":6806.0},{"Payer":"SBG","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":143.0},{"Payer":"SBG","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":328.0},{"Payer":"SBG","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":7017.0},{"Payer":"SBG","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":360.0},{"Payer":"SBG","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":55.0},{"Payer":"SBG","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":873.0},{"Payer":"SBG","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":252.0}],"Outpatient Payer Specific Charge 16":[{"Payer":"United Healthcare","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":199.0},{"Payer":"United Healthcare","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":202.0},{"Payer":"United Healthcare","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":338.0},{"Payer":"United Healthcare","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":539.0},{"Payer":"United Healthcare","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":1080.0},{"Payer":"United Healthcare","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2549.0},{"Payer":"United Healthcare","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":2624.0},{"Payer":"United Healthcare","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":338.0},{"Payer":"United Healthcare","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":1611.0},{"Payer":"United Healthcare","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":1080.0},{"Payer":"United Healthcare","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":7278.0},{"Payer":"United Healthcare","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2379.0},{"Payer":"United Healthcare","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":4717.0},{"Payer":"United Healthcare","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":6287.0},{"Payer":"United Healthcare","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":7625.0},{"Payer":"United Healthcare","APC":"5101","Description":"Level 1 Strapping and Cast Application","Payer Specific Negotiated Charge":338.0},{"Payer":"United Healthcare","APC":"5111","Description":"Level 1 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1621.0},{"Payer":"United Healthcare","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":6058.0},{"Payer":"United Healthcare","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":7626.0},{"Payer":"United Healthcare","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":10300.0},{"Payer":"United Healthcare","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":15336.0},{"Payer":"United Healthcare","APC":"5151","Description":"Level 1 Airway Endoscopy","Payer Specific Negotiated Charge":1621.0},{"Payer":"United Healthcare","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":4717.0},{"Payer":"United Healthcare","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":6287.0},{"Payer":"United Healthcare","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":6287.0},{"Payer":"United Healthcare","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":8646.0},{"Payer":"United Healthcare","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":2675.0},{"Payer":"United Healthcare","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":2675.0},{"Payer":"United Healthcare","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":7626.0},{"Payer":"United Healthcare","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":9895.0},{"Payer":"United Healthcare","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":8802.0},{"Payer":"United Healthcare","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":13997.0},{"Payer":"United Healthcare","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":13386.0},{"Payer":"United Healthcare","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":31662.0},{"Payer":"United Healthcare","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":4717.0},{"Payer":"United Healthcare","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":16388.0},{"Payer":"United Healthcare","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":24103.0},{"Payer":"United Healthcare","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":1080.0},{"Payer":"United Healthcare","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":3406.0},{"Payer":"United Healthcare","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":4717.0},{"Payer":"United Healthcare","APC":"5303","Description":"Level 3 Upper GI Procedures","Payer Specific Negotiated Charge":9430.0},{"Payer":"United Healthcare","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":2795.0},{"Payer":"United Healthcare","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":3684.0},{"Payer":"United Healthcare","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":6287.0},{"Payer":"United Healthcare","APC":"5331","Description":"Complex GI Procedures","Payer Specific Negotiated Charge":9430.0},{"Payer":"United Healthcare","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":7626.0},{"Payer":"United Healthcare","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":9490.0},{"Payer":"United Healthcare","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":9490.0},{"Payer":"United Healthcare","APC":"5412","Description":"Level 2 Gynecologic Procedures","Payer Specific Negotiated Charge":539.0},{"Payer":"United Healthcare","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":6287.0},{"Payer":"United Healthcare","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":6287.0},{"Payer":"United Healthcare","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":12340.0},{"Payer":"United Healthcare","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":1281.0},{"Payer":"United Healthcare","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":2675.0},{"Payer":"United Healthcare","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":2068.0},{"Payer":"United Healthcare","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":6287.0},{"Payer":"United Healthcare","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":225.0},{"Payer":"United Healthcare","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":225.0},{"Payer":"United Healthcare","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":539.0},{"Payer":"United Healthcare","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":457.0},{"Payer":"United Healthcare","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":389.0},{"Payer":"United Healthcare","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":539.0},{"Payer":"United Healthcare","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2743.0},{"Payer":"United Healthcare","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":2743.0},{"Payer":"United Healthcare","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":3290.0},{"Payer":"United Healthcare","APC":"5692","Description":"Level 2 Drug Administration","Payer Specific Negotiated Charge":419.0},{"Payer":"United Healthcare","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":338.0},{"Payer":"United Healthcare","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":2468.0},{"Payer":"United Healthcare","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":547.0},{"Payer":"United Healthcare","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1250.0},{"Payer":"United Healthcare","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":258.0},{"Payer":"United Healthcare","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":284.0},{"Payer":"United Healthcare","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":2675.0},{"Payer":"United Healthcare","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":609.0},{"Payer":"United Healthcare","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":38.0},{"Payer":"United Healthcare","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":936.0},{"Payer":"United Healthcare","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":175.0},{"Payer":"United Healthcare","APC":"N902","Description":"Packaged Services","Payer Specific Negotiated Charge":2743.0}],"Outpatient Payer Specific Charge 17":[{"Payer":"United Healthcare Medicare","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":101.0},{"Payer":"United Healthcare Medicare","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":111.0},{"Payer":"United Healthcare Medicare","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":248.0},{"Payer":"United Healthcare Medicare","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":531.0},{"Payer":"United Healthcare Medicare","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2078.0},{"Payer":"United Healthcare Medicare","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":879.0},{"Payer":"United Healthcare Medicare","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":154.0},{"Payer":"United Healthcare Medicare","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":274.0},{"Payer":"United Healthcare Medicare","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":421.0},{"Payer":"United Healthcare Medicare","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":1349.0},{"Payer":"United Healthcare Medicare","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":2386.0},{"Payer":"United Healthcare Medicare","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":505.0},{"Payer":"United Healthcare Medicare","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1198.0},{"Payer":"United Healthcare Medicare","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1172.0},{"Payer":"United Healthcare Medicare","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":3388.0},{"Payer":"United Healthcare Medicare","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":4318.0},{"Payer":"United Healthcare Medicare","APC":"5101","Description":"Level 1 Strapping and Cast Application","Payer Specific Negotiated Charge":119.0},{"Payer":"United Healthcare Medicare","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1144.0},{"Payer":"United Healthcare Medicare","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2284.0},{"Payer":"United Healthcare Medicare","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4963.0},{"Payer":"United Healthcare Medicare","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9412.0},{"Payer":"United Healthcare Medicare","APC":"5151","Description":"Level 1 Airway Endoscopy","Payer Specific Negotiated Charge":143.0},{"Payer":"United Healthcare Medicare","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1192.0},{"Payer":"United Healthcare Medicare","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2387.0},{"Payer":"United Healthcare Medicare","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":3853.0},{"Payer":"United Healthcare Medicare","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":557.0},{"Payer":"United Healthcare Medicare","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":1561.0},{"Payer":"United Healthcare Medicare","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2300.0},{"Payer":"United Healthcare Medicare","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":3811.0},{"Payer":"United Healthcare Medicare","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":2462.0},{"Payer":"United Healthcare Medicare","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":4074.0},{"Payer":"United Healthcare Medicare","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":8435.0},{"Payer":"United Healthcare Medicare","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":13371.0},{"Payer":"United Healthcare Medicare","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"United Healthcare Medicare","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":6504.0},{"Payer":"United Healthcare Medicare","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":8603.0},{"Payer":"United Healthcare Medicare","APC":"5231","Description":"Level 1 ICD and Similar Procedures","Payer Specific Negotiated Charge":19155.0},{"Payer":"United Healthcare Medicare","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":26696.0},{"Payer":"United Healthcare Medicare","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":1183.0},{"Payer":"United Healthcare Medicare","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":872.0},{"Payer":"United Healthcare Medicare","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":1292.0},{"Payer":"United Healthcare Medicare","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":649.0},{"Payer":"United Healthcare Medicare","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":853.0},{"Payer":"United Healthcare Medicare","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":2033.0},{"Payer":"United Healthcare Medicare","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":2567.0},{"Payer":"United Healthcare Medicare","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":4002.0},{"Payer":"United Healthcare Medicare","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":6742.0},{"Payer":"United Healthcare Medicare","APC":"5371","Description":"Level 1 Urology and Related Services","Payer Specific Negotiated Charge":153.0},{"Payer":"United Healthcare Medicare","APC":"5374","Description":"Level 4 Urology and Related Services","Payer Specific Negotiated Charge":1515.0},{"Payer":"United Healthcare Medicare","APC":"5401","Description":"Dialysis","Payer Specific Negotiated Charge":1021.0},{"Payer":"United Healthcare Medicare","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":2056.0},{"Payer":"United Healthcare Medicare","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1421.0},{"Payer":"United Healthcare Medicare","APC":"5432","Description":"Level 2 Nerve Procedures","Payer Specific Negotiated Charge":3976.0},{"Payer":"United Healthcare Medicare","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":219.0},{"Payer":"United Healthcare Medicare","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":633.0},{"Payer":"United Healthcare Medicare","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":1332.0},{"Payer":"United Healthcare Medicare","APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":16291.0},{"Payer":"United Healthcare Medicare","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":24120.0},{"Payer":"United Healthcare Medicare","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":432.0},{"Payer":"United Healthcare Medicare","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":1670.0},{"Payer":"United Healthcare Medicare","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":3170.0},{"Payer":"United Healthcare Medicare","APC":"5503","Description":"Level 3 Extraocular, Repair, and Plastic Eye Procedures","Payer Specific Negotiated Charge":1579.0},{"Payer":"United Healthcare Medicare","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":54.0},{"Payer":"United Healthcare Medicare","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":98.0},{"Payer":"United Healthcare Medicare","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":201.0},{"Payer":"United Healthcare Medicare","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":433.0},{"Payer":"United Healthcare Medicare","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":176.0},{"Payer":"United Healthcare Medicare","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":342.0},{"Payer":"United Healthcare Medicare","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":336.0},{"Payer":"United Healthcare Medicare","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":308.0},{"Payer":"United Healthcare Medicare","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":590.0},{"Payer":"United Healthcare Medicare","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1089.0},{"Payer":"United Healthcare Medicare","APC":"5661","Description":"Therapeutic Nuclear Medicine","Payer Specific Negotiated Charge":449.0},{"Payer":"United Healthcare Medicare","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":187.0},{"Payer":"United Healthcare Medicare","APC":"5674","Description":"Level 4 Pathology","Payer Specific Negotiated Charge":119.0},{"Payer":"United Healthcare Medicare","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":357.0},{"Payer":"United Healthcare Medicare","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":237.0},{"Payer":"United Healthcare Medicare","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":220.0},{"Payer":"United Healthcare Medicare","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":49.0},{"Payer":"United Healthcare Medicare","APC":"5731","Description":"Level 1 Minor Procedures","Payer Specific Negotiated Charge":363.0},{"Payer":"United Healthcare Medicare","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"United Healthcare Medicare","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":93.0},{"Payer":"United Healthcare Medicare","APC":"5735","Description":"Level 5 Minor Procedures","Payer Specific Negotiated Charge":534.0},{"Payer":"United Healthcare Medicare","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":49.0},{"Payer":"United Healthcare Medicare","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":118.0},{"Payer":"United Healthcare Medicare","APC":"5801","Description":"Ventilation Initiation and Management","Payer Specific Negotiated Charge":444.0},{"Payer":"United Healthcare Medicare","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":30.0},{"Payer":"United Healthcare Medicare","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":239.0},{"Payer":"United Healthcare Medicare","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":111.0},{"Payer":"United Healthcare Medicare","APC":"N902","Description":"Packaged Services","Payer Specific Negotiated Charge":1071.0}],"Outpatient Payer Specific Charge 18":[{"Payer":"Wellcare Medicaid","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":54.0},{"Payer":"Wellcare Medicaid","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":36.0},{"Payer":"Wellcare Medicaid","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":84.0},{"Payer":"Wellcare Medicaid","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":200.0},{"Payer":"Wellcare Medicaid","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":459.0},{"Payer":"Wellcare Medicaid","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":821.0},{"Payer":"Wellcare Medicaid","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":1616.0},{"Payer":"Wellcare Medicaid","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":115.0},{"Payer":"Wellcare Medicaid","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":242.0},{"Payer":"Wellcare Medicaid","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":1697.0},{"Payer":"Wellcare Medicaid","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":3132.0},{"Payer":"Wellcare Medicaid","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1654.0},{"Payer":"Wellcare Medicaid","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":930.0},{"Payer":"Wellcare Medicaid","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2004.0},{"Payer":"Wellcare Medicaid","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":3657.0},{"Payer":"Wellcare Medicaid","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":993.0},{"Payer":"Wellcare Medicaid","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2219.0},{"Payer":"Wellcare Medicaid","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4481.0},{"Payer":"Wellcare Medicaid","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":8165.0},{"Payer":"Wellcare Medicaid","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2037.0},{"Payer":"Wellcare Medicaid","APC":"5161","Description":"Level 1 ENT Procedures","Payer Specific Negotiated Charge":2447.0},{"Payer":"Wellcare Medicaid","APC":"5163","Description":"Level 3 ENT Procedures","Payer Specific Negotiated Charge":773.0},{"Payer":"Wellcare Medicaid","APC":"5164","Description":"Level 4 ENT Procedures","Payer Specific Negotiated Charge":1082.0},{"Payer":"Wellcare Medicaid","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":1097.0},{"Payer":"Wellcare Medicaid","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":1625.0},{"Payer":"Wellcare Medicaid","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":1256.0},{"Payer":"Wellcare Medicaid","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":3724.0},{"Payer":"Wellcare Medicaid","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":4722.0},{"Payer":"Wellcare Medicaid","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":7630.0},{"Payer":"Wellcare Medicaid","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":3480.0},{"Payer":"Wellcare Medicaid","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":5033.0},{"Payer":"Wellcare Medicaid","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":516.0},{"Payer":"Wellcare Medicaid","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":372.0},{"Payer":"Wellcare Medicaid","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":677.0},{"Payer":"Wellcare Medicaid","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":3248.0},{"Payer":"Wellcare Medicaid","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":3169.0},{"Payer":"Wellcare Medicaid","APC":"5374","Description":"Level 4 Urology and Related Services","Payer Specific Negotiated Charge":4956.0},{"Payer":"Wellcare Medicaid","APC":"5412","Description":"Level 2 Gynecologic Procedures","Payer Specific Negotiated Charge":142.0},{"Payer":"Wellcare Medicaid","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":1391.0},{"Payer":"Wellcare Medicaid","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1571.0},{"Payer":"Wellcare Medicaid","APC":"5442","Description":"Level 2 Nerve Injections","Payer Specific Negotiated Charge":560.0},{"Payer":"Wellcare Medicaid","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":507.0},{"Payer":"Wellcare Medicaid","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":67.0},{"Payer":"Wellcare Medicaid","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":116.0},{"Payer":"Wellcare Medicaid","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":585.0},{"Payer":"Wellcare Medicaid","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":310.0},{"Payer":"Wellcare Medicaid","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":364.0},{"Payer":"Wellcare Medicaid","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1116.0},{"Payer":"Wellcare Medicaid","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":664.0},{"Payer":"Wellcare Medicaid","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1025.0},{"Payer":"Wellcare Medicaid","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1652.0},{"Payer":"Wellcare Medicaid","APC":"5672","Description":"Level 2 Pathology","Payer Specific Negotiated Charge":143.0},{"Payer":"Wellcare Medicaid","APC":"5692","Description":"Level 2 Drug Administration","Payer Specific Negotiated Charge":189.0},{"Payer":"Wellcare Medicaid","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":321.0},{"Payer":"Wellcare Medicaid","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":259.0},{"Payer":"Wellcare Medicaid","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":483.0},{"Payer":"Wellcare Medicaid","APC":"5723","Description":"Level 3 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":1814.0},{"Payer":"Wellcare Medicaid","APC":"5732","Description":"Level 2 Minor Procedures","Payer Specific Negotiated Charge":29.0},{"Payer":"Wellcare Medicaid","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":64.0},{"Payer":"Wellcare Medicaid","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":212.0},{"Payer":"Wellcare Medicaid","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":233.0},{"Payer":"Wellcare Medicaid","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":45.0},{"Payer":"Wellcare Medicaid","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":196.0},{"Payer":"Wellcare Medicaid","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":70.0},{"Payer":"Wellcare Medicaid","APC":"N902","Description":"Packaged Services","Payer Specific Negotiated Charge":8166.0}],"Outpatient Payer Specific Charge 19":[{"Payer":"Wellcare Medicare","APC":"5012","Description":"Clinic Visits and Related Services","Payer Specific Negotiated Charge":104.0},{"Payer":"Wellcare Medicare","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":63.0},{"Payer":"Wellcare Medicare","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":115.0},{"Payer":"Wellcare Medicare","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":257.0},{"Payer":"Wellcare Medicare","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":537.0},{"Payer":"Wellcare Medicare","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2152.0},{"Payer":"Wellcare Medicare","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":2290.0},{"Payer":"Wellcare Medicare","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":159.0},{"Payer":"Wellcare Medicare","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":283.0},{"Payer":"Wellcare Medicare","APC":"5053","Description":"Level 3 Skin Procedures","Payer Specific Negotiated Charge":435.0},{"Payer":"Wellcare Medicare","APC":"5054","Description":"Level 4 Skin Procedures","Payer Specific Negotiated Charge":1396.0},{"Payer":"Wellcare Medicare","APC":"5055","Description":"Level 5 Skin Procedures","Payer Specific Negotiated Charge":2144.0},{"Payer":"Wellcare Medicare","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":550.0},{"Payer":"Wellcare Medicare","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":1240.0},{"Payer":"Wellcare Medicare","APC":"5073","Description":"Level 3 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":2144.0},{"Payer":"Wellcare Medicare","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":2539.0},{"Payer":"Wellcare Medicare","APC":"5092","Description":"Level 2 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":4431.0},{"Payer":"Wellcare Medicare","APC":"5101","Description":"Level 1 Strapping and Cast Application","Payer Specific Negotiated Charge":115.0},{"Payer":"Wellcare Medicare","APC":"5102","Description":"Level 2 Strapping and Cast Application","Payer Specific Negotiated Charge":214.0},{"Payer":"Wellcare Medicare","APC":"5112","Description":"Level 2 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1184.0},{"Payer":"Wellcare Medicare","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2365.0},{"Payer":"Wellcare Medicare","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":5138.0},{"Payer":"Wellcare Medicare","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9743.0},{"Payer":"Wellcare Medicare","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1256.0},{"Payer":"Wellcare Medicare","APC":"5154","Description":"Level 4 Airway Endoscopy","Payer Specific Negotiated Charge":2471.0},{"Payer":"Wellcare Medicare","APC":"5165","Description":"Level 5 ENT Procedures","Payer Specific Negotiated Charge":3996.0},{"Payer":"Wellcare Medicare","APC":"5181","Description":"Level 1 Vascular Procedures","Payer Specific Negotiated Charge":559.0},{"Payer":"Wellcare Medicare","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":1085.0},{"Payer":"Wellcare Medicare","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2381.0},{"Payer":"Wellcare Medicare","APC":"5184","Description":"Level 4 Vascular Procedures","Payer Specific Negotiated Charge":3945.0},{"Payer":"Wellcare Medicare","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":2533.0},{"Payer":"Wellcare Medicare","APC":"5192","Description":"Level 2 Endovascular Procedures","Payer Specific Negotiated Charge":4081.0},{"Payer":"Wellcare Medicare","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":8716.0},{"Payer":"Wellcare Medicare","APC":"5194","Description":"Level 4 Endovascular Procedures","Payer Specific Negotiated Charge":13841.0},{"Payer":"Wellcare Medicare","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":6674.0},{"Payer":"Wellcare Medicare","APC":"5223","Description":"Level 3 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":8906.0},{"Payer":"Wellcare Medicare","APC":"5232","Description":"Level 2 ICD and Similar Procedures","Payer Specific Negotiated Charge":27635.0},{"Payer":"Wellcare Medicare","APC":"5241","Description":"Level 1 Blood Product Exchange and Related Services","Payer Specific Negotiated Charge":1206.0},{"Payer":"Wellcare Medicare","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":687.0},{"Payer":"Wellcare Medicare","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":1361.0},{"Payer":"Wellcare Medicare","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":671.0},{"Payer":"Wellcare Medicare","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":883.0},{"Payer":"Wellcare Medicare","APC":"5313","Description":"Level 3 Lower GI Procedures","Payer Specific Negotiated Charge":2105.0},{"Payer":"Wellcare Medicare","APC":"5341","Description":"Abdominal/Peritoneal/Biliary and Related Procedures","Payer Specific Negotiated Charge":2657.0},{"Payer":"Wellcare Medicare","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":4143.0},{"Payer":"Wellcare Medicare","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":6979.0},{"Payer":"Wellcare Medicare","APC":"5401","Description":"Dialysis","Payer Specific Negotiated Charge":809.0},{"Payer":"Wellcare Medicare","APC":"5414","Description":"Level 4 Gynecologic Procedures","Payer Specific Negotiated Charge":2166.0},{"Payer":"Wellcare Medicare","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1471.0},{"Payer":"Wellcare Medicare","APC":"5443","Description":"Level 3 Nerve Injections","Payer Specific Negotiated Charge":689.0},{"Payer":"Wellcare Medicare","APC":"5462","Description":"Level 2 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":5390.0},{"Payer":"Wellcare Medicare","APC":"5463","Description":"Level 3 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":16864.0},{"Payer":"Wellcare Medicare","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":25011.0},{"Payer":"Wellcare Medicare","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":451.0},{"Payer":"Wellcare Medicare","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":1728.0},{"Payer":"Wellcare Medicare","APC":"5492","Description":"Level 2 Intraocular Procedures","Payer Specific Negotiated Charge":3282.0},{"Payer":"Wellcare Medicare","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":56.0},{"Payer":"Wellcare Medicare","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":101.0},{"Payer":"Wellcare Medicare","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":211.0},{"Payer":"Wellcare Medicare","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":448.0},{"Payer":"Wellcare Medicare","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":182.0},{"Payer":"Wellcare Medicare","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":611.0},{"Payer":"Wellcare Medicare","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":348.0},{"Payer":"Wellcare Medicare","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":319.0},{"Payer":"Wellcare Medicare","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":467.0},{"Payer":"Wellcare Medicare","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1316.0},{"Payer":"Wellcare Medicare","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":308.0},{"Payer":"Wellcare Medicare","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":245.0},{"Payer":"Wellcare Medicare","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":227.0},{"Payer":"Wellcare Medicare","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":50.0},{"Payer":"Wellcare Medicare","APC":"5734","Description":"Level 4 Minor Procedures","Payer Specific Negotiated Charge":96.0},{"Payer":"Wellcare Medicare","APC":"5781","Description":"Resuscitation and Cardioversion","Payer Specific Negotiated Charge":448.0},{"Payer":"Wellcare Medicare","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":191.0},{"Payer":"Wellcare Medicare","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":32.0},{"Payer":"Wellcare Medicare","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":169.0},{"Payer":"Wellcare Medicare","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":116.0}],"Outpatient Payer Specific Charge 20":[{"Payer":"Peach State Medicaid","APC":"5021","Description":"Level 1 Type A ED Visits","Payer Specific Negotiated Charge":53.0},{"Payer":"Peach State Medicaid","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":69.0},{"Payer":"Peach State Medicaid","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":178.0},{"Payer":"Peach State Medicaid","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":406.0},{"Payer":"Peach State Medicaid","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":827.0},{"Payer":"Peach State Medicaid","APC":"5041","Description":"Critical Care","Payer Specific Negotiated Charge":820.0},{"Payer":"Peach State Medicaid","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":86.0},{"Payer":"Peach State Medicaid","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":365.0},{"Payer":"Peach State Medicaid","APC":"5071","Description":"Level 1 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":433.0},{"Payer":"Peach State Medicaid","APC":"5072","Description":"Level 2 Excision/ Biopsy/ Incision and Drainage","Payer Specific Negotiated Charge":157.0},{"Payer":"Peach State Medicaid","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":1644.0},{"Payer":"Peach State Medicaid","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":3909.0},{"Payer":"Peach State Medicaid","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":528.0},{"Payer":"Peach State Medicaid","APC":"5182","Description":"Level 2 Vascular Procedures","Payer Specific Negotiated Charge":910.0},{"Payer":"Peach State Medicaid","APC":"5222","Description":"Level 2 Pacemaker and Similar Procedures","Payer Specific Negotiated Charge":3077.0},{"Payer":"Peach State Medicaid","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":331.0},{"Payer":"Peach State Medicaid","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":382.0},{"Payer":"Peach State Medicaid","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":2425.0},{"Payer":"Peach State Medicaid","APC":"5464","Description":"Level 4 Neurostimulator and Related Procedures","Payer Specific Negotiated Charge":13221.0},{"Payer":"Peach State Medicaid","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":101.0},{"Payer":"Peach State Medicaid","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":156.0},{"Payer":"Peach State Medicaid","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":433.0},{"Payer":"Peach State Medicaid","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":281.0},{"Payer":"Peach State Medicaid","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":62.0},{"Payer":"Peach State Medicaid","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1032.0},{"Payer":"Peach State Medicaid","APC":"5591","Description":"Level 1 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":693.0},{"Payer":"Peach State Medicaid","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1086.0},{"Payer":"Peach State Medicaid","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1330.0},{"Payer":"Peach State Medicaid","APC":"5693","Description":"Level 3 Drug Administration","Payer Specific Negotiated Charge":205.0},{"Payer":"Peach State Medicaid","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":195.0},{"Payer":"Peach State Medicaid","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":435.0},{"Payer":"Peach State Medicaid","APC":"5732","Description":"Level 2 Minor Procedures","Payer Specific Negotiated Charge":25.0},{"Payer":"Peach State Medicaid","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":64.0},{"Payer":"Peach State Medicaid","APC":"5791","Description":"Pulmonary Treatment","Payer Specific Negotiated Charge":114.0},{"Payer":"Peach State Medicaid","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":29.0},{"Payer":"Peach State Medicaid","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":89.0}],"Outpatient Payer Specific Charge 21":[{"Payer":"Clover Health Medicare","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":112.0},{"Payer":"Clover Health Medicare","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":274.0},{"Payer":"Clover Health Medicare","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":546.0},{"Payer":"Clover Health Medicare","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":2260.0},{"Payer":"Clover Health Medicare","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2296.0},{"Payer":"Clover Health Medicare","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":4988.0},{"Payer":"Clover Health Medicare","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9459.0},{"Payer":"Clover Health Medicare","APC":"5151","Description":"Level 1 Airway Endoscopy","Payer Specific Negotiated Charge":146.0},{"Payer":"Clover Health Medicare","APC":"5153","Description":"Level 3 Airway Endoscopy","Payer Specific Negotiated Charge":1198.0},{"Payer":"Clover Health Medicare","APC":"5183","Description":"Level 3 Vascular Procedures","Payer Specific Negotiated Charge":2312.0},{"Payer":"Clover Health Medicare","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":2460.0},{"Payer":"Clover Health Medicare","APC":"5193","Description":"Level 3 Endovascular Procedures","Payer Specific Negotiated Charge":13438.0},{"Payer":"Clover Health Medicare","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":50.0},{"Payer":"Clover Health Medicare","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":678.0},{"Payer":"Clover Health Medicare","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":652.0},{"Payer":"Clover Health Medicare","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":858.0},{"Payer":"Clover Health Medicare","APC":"5362","Description":"Level 2 Laparoscopy and Related Services","Payer Specific Negotiated Charge":6775.0},{"Payer":"Clover Health Medicare","APC":"5431","Description":"Level 1 Nerve Procedures","Payer Specific Negotiated Charge":1453.0},{"Payer":"Clover Health Medicare","APC":"5441","Description":"Level 1 Nerve Injections","Payer Specific Negotiated Charge":220.0},{"Payer":"Clover Health Medicare","APC":"5481","Description":"Laser Eye Procedures","Payer Specific Negotiated Charge":438.0},{"Payer":"Clover Health Medicare","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":1678.0},{"Payer":"Clover Health Medicare","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":55.0},{"Payer":"Clover Health Medicare","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":98.0},{"Payer":"Clover Health Medicare","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":211.0},{"Payer":"Clover Health Medicare","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":435.0},{"Payer":"Clover Health Medicare","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":178.0},{"Payer":"Clover Health Medicare","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":344.0},{"Payer":"Clover Health Medicare","APC":"5573","Description":"Level 3 Imaging with Contrast","Payer Specific Negotiated Charge":943.0},{"Payer":"Clover Health Medicare","APC":"5592","Description":"Level 2 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":769.0},{"Payer":"Clover Health Medicare","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1076.0},{"Payer":"Clover Health Medicare","APC":"5721","Description":"Level 1 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":238.0},{"Payer":"Clover Health Medicare","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":221.0},{"Payer":"Clover Health Medicare","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":49.0},{"Payer":"Clover Health Medicare","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":31.0},{"Payer":"Clover Health Medicare","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":359.0},{"Payer":"Clover Health Medicare","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":112.0}],"Outpatient Payer Specific Charge 22":[{"Payer":"First Health (Southcare)","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":302.0},{"Payer":"First Health (Southcare)","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":795.0},{"Payer":"First Health (Southcare)","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":1902.0},{"Payer":"First Health (Southcare)","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":3031.0},{"Payer":"First Health (Southcare)","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":696.0},{"Payer":"First Health (Southcare)","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":8925.0},{"Payer":"First Health (Southcare)","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":3923.0},{"Payer":"First Health (Southcare)","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":587.0},{"Payer":"First Health (Southcare)","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":953.0},{"Payer":"First Health (Southcare)","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":1772.0},{"Payer":"First Health (Southcare)","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":2512.0},{"Payer":"First Health (Southcare)","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":4912.0},{"Payer":"First Health (Southcare)","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":189.0},{"Payer":"First Health (Southcare)","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":264.0}],"Outpatient Payer Specific Charge 23":[{"Payer":"Humana Exchange Plan","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":115.0},{"Payer":"Humana Exchange Plan","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":203.0},{"Payer":"Humana Exchange Plan","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":377.0},{"Payer":"Humana Exchange Plan","APC":"5025","Description":"Level 5 Type A ED Visits","Payer Specific Negotiated Charge":477.0},{"Payer":"Humana Exchange Plan","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":56.0},{"Payer":"Humana Exchange Plan","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":130.0},{"Payer":"Humana Exchange Plan","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":606.0},{"Payer":"Humana Exchange Plan","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":444.0},{"Payer":"Humana Exchange Plan","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":449.0},{"Payer":"Humana Exchange Plan","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":458.0},{"Payer":"Humana Exchange Plan","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":62.0},{"Payer":"Humana Exchange Plan","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":119.0},{"Payer":"Humana Exchange Plan","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":114.0}],"Outpatient Payer Specific Charge 24":[{"Payer":"Kaiser","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":668.0},{"Payer":"Kaiser","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":668.0},{"Payer":"Kaiser","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":1495.0},{"Payer":"Kaiser","APC":"5051","Description":"Level 1 Skin Procedures","Payer Specific Negotiated Charge":1406.0},{"Payer":"Kaiser","APC":"5052","Description":"Level 2 Skin Procedures","Payer Specific Negotiated Charge":1406.0},{"Payer":"Kaiser","APC":"5113","Description":"Level 3 Musculoskeletal Procedures","Payer Specific Negotiated Charge":2775.0},{"Payer":"Kaiser","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":1406.0},{"Payer":"Kaiser","APC":"5491","Description":"Level 1 Intraocular Procedures","Payer Specific Negotiated Charge":1871.0},{"Payer":"Kaiser","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":300.0},{"Payer":"Kaiser","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":95.0},{"Payer":"Kaiser","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":815.0},{"Payer":"Kaiser","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":1397.0},{"Payer":"Kaiser","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":711.0},{"Payer":"Kaiser","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1584.0},{"Payer":"Kaiser","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":8088.0},{"Payer":"Kaiser","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":62.0},{"Payer":"Kaiser","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":2263.0}],"Outpatient Payer Specific Charge 25":[{"Payer":"United Exchange Plan","APC":"5022","Description":"Level 2 Type A ED Visits","Payer Specific Negotiated Charge":114.0},{"Payer":"United Exchange Plan","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":228.0},{"Payer":"United Exchange Plan","APC":"5024","Description":"Level 4 Type A ED Visits","Payer Specific Negotiated Charge":633.0},{"Payer":"United Exchange Plan","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":2504.0},{"Payer":"United Exchange Plan","APC":"5302","Description":"Level 2 Upper GI Procedures","Payer Specific Negotiated Charge":1318.0},{"Payer":"United Exchange Plan","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":55.0},{"Payer":"United Exchange Plan","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":100.0},{"Payer":"United Exchange Plan","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":636.0},{"Payer":"United Exchange Plan","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":442.0},{"Payer":"United Exchange Plan","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":475.0},{"Payer":"United Exchange Plan","APC":"5593","Description":"Level 3 Nuclear Medicine and Related Services","Payer Specific Negotiated Charge":1336.0},{"Payer":"United Exchange Plan","APC":"N800","Description":"Clinical Diagnostic Lab Services","Payer Specific Negotiated Charge":24.0},{"Payer":"United Exchange Plan","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":113.0}],"Outpatient Payer Specific Charge 26":[{"Payer":"Beechstreet","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":2074.0},{"Payer":"Beechstreet","APC":"5301","Description":"Level 1 Upper GI Procedures","Payer Specific Negotiated Charge":3263.0},{"Payer":"Beechstreet","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":234.0}],"Outpatient Payer Specific Charge 27":[{"Payer":"Care Source Exchange","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":583.0},{"Payer":"Care Source Exchange","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":1293.0},{"Payer":"Care Source Exchange","APC":"5522","Description":"Level 2 Imaging without Contrast","Payer Specific Negotiated Charge":195.0},{"Payer":"Care Source Exchange","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":788.0},{"Payer":"Care Source Exchange","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":1449.0}],"Outpatient Payer Specific Charge 28":[{"Payer":"IBG","APC":"5023","Description":"Level 3 Type A ED Visits","Payer Specific Negotiated Charge":352.0},{"Payer":"IBG","APC":"5091","Description":"Level 1 Breast/Lymphatic Surgery and Related Procedures","Payer Specific Negotiated Charge":5626.0},{"Payer":"IBG","APC":"5114","Description":"Level 4 Musculoskeletal Procedures","Payer Specific Negotiated Charge":9786.0},{"Payer":"IBG","APC":"5115","Description":"Level 5 Musculoskeletal Procedures","Payer Specific Negotiated Charge":19813.0},{"Payer":"IBG","APC":"5191","Description":"Level 1 Endovascular Procedures","Payer Specific Negotiated Charge":13366.0},{"Payer":"IBG","APC":"5213","Description":"Level 3 Electrophysiologic Procedures","Payer Specific Negotiated Charge":51553.0},{"Payer":"IBG","APC":"5311","Description":"Level 1 Lower GI Procedures","Payer Specific Negotiated Charge":2094.0},{"Payer":"IBG","APC":"5312","Description":"Level 2 Lower GI Procedures","Payer Specific Negotiated Charge":2382.0},{"Payer":"IBG","APC":"5361","Description":"Level 1 Laparoscopy and Related Services","Payer Specific Negotiated Charge":6221.0},{"Payer":"IBG","APC":"5521","Description":"Level 1 Imaging without Contrast","Payer Specific Negotiated Charge":828.0},{"Payer":"IBG","APC":"5523","Description":"Level 3 Imaging without Contrast","Payer Specific Negotiated Charge":1592.0},{"Payer":"IBG","APC":"5524","Description":"Level 4 Imaging without Contrast","Payer Specific Negotiated Charge":1718.0},{"Payer":"IBG","APC":"5571","Description":"Level 1 Imaging with Contrast","Payer Specific Negotiated Charge":2812.0},{"Payer":"IBG","APC":"5572","Description":"Level 2 Imaging with Contrast","Payer Specific Negotiated Charge":3610.0},{"Payer":"IBG","APC":"5722","Description":"Level 2 Diagnostic Tests and Related Services","Payer Specific Negotiated Charge":530.0},{"Payer":"IBG","APC":"5733","Description":"Level 3 Minor Procedures","Payer Specific Negotiated Charge":21996.0},{"Payer":"IBG","APC":"N801","Description":"Therapy Services","Payer Specific Negotiated Charge":302.0},{"Payer":"IBG","APC":"N804","Description":"Mammography Services","Payer Specific Negotiated Charge":316.0}]}